ASSFN Volunteer Application
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1.
First Name
(Required.)
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2.
Last Name
(Required.)
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3.
Credentials
(Required.)
MD
MS
MPH
DO
PhD
RN
PA
BS
BA
Credential not listed (please specify)
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4.
Email Address
(Required.)
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5.
Professional Title
(Required.)
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6.
Institution/Organization
(Required.)
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7.
Are you currently an ASSFN member?
(Required.)
Yes
No
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8.
What is your professional background?
(Required.)
Physician, attending
Physician, fellow
Physician, resident
Medical student
Nurse Practitioner
Physician Assistant
Registered Nurse
Research scientist
Engineer
Other (please specify)
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9.
What are your areas of expertise? (select all that apply.)
(Required.)
Addiction Medicine
Basic Science Research
Clinical Guidelines
Ethics
Medical Education
Neurology
Neurosurgery
Hospice and Palliative Care
Internal Medicine
Pain Medicine
Pain Management
Palliative Medicine
Radiology
Other (please specify)
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10.
Which areas of committee service are you most interested in?
(Required.)
1st choice
2nd choice
3rd choice
4th choice
5th choice
Research
1st choice
2nd choice
3rd choice
4th choice
5th choice
Education
1st choice
2nd choice
3rd choice
4th choice
5th choice
Member Engagement
1st choice
2nd choice
3rd choice
4th choice
5th choice
Advocacy and Policy
1st choice
2nd choice
3rd choice
4th choice
5th choice
Website and Social Media
1st choice
2nd choice
3rd choice
4th choice
5th choice
11.
Elaborate on your areas of interest, ranked above.
12.
I want to be contacted for short term volunteer opportunities. Check all that apply.
Social Media Ambassador
Abstract Reviewer
Newsletter Author
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13.
What ideas or initiatives would you like to share as a committee member?
(Required.)
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14.
If any, what related committee experience do you have with ASSFN or other societies?
(Required.)
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15.
For committee service, time requirement is on average 2 hours per month. Members are expected to attend most meetings, held via Zoom, and participate in committee activities. Are you able to meet this commitment?
(Required.)
Yes
No
Not Sure
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16.
Please upload your CV (DOC/DOCX or PDF Format) into Google Drive, Dropbox, or OneDrive and provide us with the URL.
(Required.)
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17.
I agree to the ASSFN Volunteer Values:
Mutual respect, Confidentiality, Accountability, Professionalism, Innovation, Duty to act in interest of organization.
(Required.)
Yes
No