ABAP Certification App-ABAP

ABAP Certification App

American Board of Adolescent Psychiatry Certification Application Form

Section 1: Introductory Remarks

Dear Colleague:

Congratulations on taking the next step in specialty training and board certification in the field of Adolescent and Young Adult Psychiatry! The current shortage and anticipated future shortage of psychiatrists interested in working with teens and young adults are well known, and identification as a general psychiatrist with specialty board certification in Adolescent and Young Adult Psychiatry will likely enhance your standing among your colleagues in your area. For board-certified general psychiatrists invested in work with adolescents, transitional age youth, and young adults, certification by the American Board of Adolescent Psychiatry offers a way to do this. ABAP certification also demonstrates a commitment to the treatment of adolescents, young adults, and their families.

If you haven't joined or considered joining our host organization, The American Society for Adolescent Psychiatry (ASAP), you may wish to consider joining now. Not only does ASAP offer you opportunities for training, networking, and career advancement, but ASAP members also receive a 25% discount on all ABAP Certification and Recertification Registration Fees! You may learn more by visitng the ASAP Website.

Gregory P. Barclay, M.D., DLFAPA, FASAP | President, American Board of Adolescent Psychiatry

Section 2 - Candidate Guide

Please download this information now. We recommend that you bookmark it for continuing reference as you proceed through the certification application process and beyond.

PLEASE TAKE NOTE: You must complete every question that is marked with an asterisk (*). These are REQUIRED QUESTIONS.

You will NOT be able to upload your application if you leave any of the required questions unanswered!

Please acknowledge below:

I have read the candidate guide and agree with the certification requirements in this guide.

I spend 25% or more of my clinical time treating adolescents, young adults, &/or youth.

I have a microphone and camera set up on my computer.

I have internet service where I will be taking the examination.

I'm aware the professional Proctoring Service will monitor all electronic devices during the test.

I have the ability to pay the Certification Fees online to ASAP, or will mail to ASAP Natl. Office.

I have a non-restricted Microsoft or Mac computer to use for the certification exam.

Section 3 - Additional and Supporting Information for Candidates

Please download and review this information now. We recommend that you bookmark it for continuing reference as you proceed through the certification application process and beyond.

Section 4 - BEFORE YOU BEGIN SECTION 5, please assemble these documents

Gather all of the following documents in a format that is easily uploaded (pdf, word, jpeg, etc). All documents are required before your application will be accepted. Check each box as you gather each document. You will upload the documents later.

Names and contact information for 3 references, or letters already obtained

A copy of your Medical College Diploma(s) or a letter from a school official

A copy of your Residency/Fellowship Diploma(s) or a letter from your training director.

A copy of your current state medical license.

A copy of your current ABPN/AOA/NBPS/RCPCP Certification or official status verification.

A recent headshot photograph, signed at bottom or on back.

Required CME Certificates

Ability and means to pay your $450 application fee in section 7.

Section 5 - Application for Certification in Adolescent and Young Adult Psychiatry

a. Please complete all information fields. Each item in the application must bear an entry; if “none” is applicable, so state. Upload extra sheets for additional data or information; identify the material being furnished and show your name and email address on each uploaded document. Read instructions carefully. If the application is not completed properly, you will be notified and asked to resubmit a completed application.

b. Upload a passport style photograph of yourself, taken within the last two months, signed on the front with a ball-point pen. Photos must be at least 2x2 inches in size, full face, with no hats or scarves to be worn.

c. Submit via the ASAP Website a one-time non-refundable registration fee of $450. All payments are now made electronically. You may use your credit card online via our secure Wix payments platform. Otherwise, you may pay electronically using PayPal. Do not send checks, cash or stamps. All currency must be in US dollars or its equivalent. (Upon admittance to candidacy, the examination fee of $750 will be payable.),

d. Copies of the following documents must be uploaded with this application:

1. Medical school diploma or official statement of valid MD degree from medical school.

2. Current state registration to practice medicine in one state, province or territory.

3. Certificate from the American Board of Psychiatry and Neurology, AOA, NBPS, or RCPCP

e. Reference letters are not required to accompany the submission of the application but must be received at the administrative offices within thirty (30) days of the date of your application. However, if you have reference letters available, please upload them with this application.

First Name

Last Name

Degree

Today's Date

Name and Degree as you would like on your certificate:

If you have ever been known by or used another name (e.g., maiden name) please specify:

Last 4 Digits of Social Security Number (If Non-USA, write "0000")

Address (US & CAN)

Enter your phone number: (Area code) xxx-xxxx (if USA)

Date of Birth

Place of birth

Citizenship

Have you ever been convicted of a felony of misdemeanor (exclude minor traffic violations)?

Yes

If yes, provide explanation here.

Has your license to practice medicine in any US state or Canada ever been suspended, revoked, or restricted? If so, please explain on a separate page (please note ABAP independently verifies all licensing information)

Yes

If yes, provide explanation here:

Has anyone ever filed a complaint against you to any professional board, etc.?

Yes

If yes, please provide an explanation here:

Medical Education - Name and Location of Medical School/College #1

Medical Education - Name and Location of Medical School/College #2 (if applicable, skip otherwise)

Exact Dates of student status (start date-end date) for Medical School/College #1

Exact Dates of student status (start date-end date) for Medical School/College #2 (if applicable, skip otherwise)

Degree conferred by Medical School/College #1 (please upload copy of diploma in last section of this application titled "attachments")

Degree conferred by Medical School/College #2 (if applicable, skip otherwise)

General Psychiatric Training (including internship and residency)- Name and location of Training Program #1 (please upload copy of certificate in last section of this application titled "attachments")

General Psychiatric Training (including internship and residency)- Name and location of Training Program #2 if applicable, otherwise, please skip (please upload copy of certificate in last section of this application titled "attachments")

General Psychiatric Training - Dates of training (start to finish) for Program #1 (please explain any gaps in training)

General Psychiatric Training - Dates of training (start to finish) for Program #2 (please explain any gaps in training) - skip if not applicable

If not presently Board Certified in General and/or Child/Adolescent Psychiatry, please provide a detailed explanation here and attach any substantiation at the end of this application.

Board Certification in General Psychiatry (ABPN/NBPS/AOA/RCPCP) - Date of (re)Certification

Board Certification in General Psychiatry (ABPN/NBPS/AOA/RCPCP) - Certificate Number (please upload copy of certificate in last section of this application titled "attachments")

Subspecialty Post Residency Psychiatric Training, Including Fellowship Training (please upload copy of certificate in last section of this application titled "attachments"). If not applicable, please skip this section.

Dates from start to finish of Post-Residency Training listed above

State/Province in which you have your primary medical license. (please upload copy of license in last section of this application titled "attachments") comment

Primary medical license number

Primary medical license expiration date:

States/provinces of additional currently active medical licenses and expiration dates (if applicable)

Continuing Medical Education (CME) Category I Credit hours in Adolescent/Transitional Age Youth Psychiatry. If CME certificates and/or your Option A transcript are available at this time, upload them at end.

Option A: 36 hours of "ABAP-Pre-approved Core Curricululm Category I CME"

Option B: 36 hours of self study Category I CME relevant to Child/Adolescent/YoungAdult Psychiatry

List all subspecialty certifications (ABPN/RCPCP, etc.) with latest certificate number: (please upload copy of certificate in last section of this application titled "attachments"), If not applicable, please skip this section.

At present, what percentage of your professional time is devoted to clinical activities in adolescent and/or transition age psychiatry?

less than 25% (please attached a written rationale for exception to 25% prerequisite)

greater than 25%

Please list Medical and Scientific Societies in which you hold membership. Please indicate offices held. (May upload list if preferred in last section of this application titled "attachments")

Please list current medical staff and/or consulting appointments. Please include academic appointments, if applicable.

List papers and/or books published in the field of adolescent or transition age youth psychiatry. (May attach list if preferred in last section of this application titled "attachments")

How did you learn of this opportunity?

If you chose option 6 above (Referral by ABAP Certified Dr. or Colleague), please identify them below so we can thank them! If you checked #10 above, please describe below:

Applicants are able to take the online examinations on demand whenever they wish within these sequence open dates. Examinees are typically notified of their results during June or December accordingly. Those who do not take the exams during their assigned sequence open dates will automatically be moved to the next cohort sequence once only. Requests to extend beyond this may be considered for extraordinary circumstances and must be made in writing to ABAP before the expiration of the second assigned sequence period or else the examinee's application will be voided and the exam fee refunded (note: the application fee is non-refundable). Please indicate your initial sequence preference below:

The ABAP Certification examinations are administered to cohorts based to allow time for statistical analysis and revision between administrations. Cohort selections are typically Spring (February 1-May 31) and Fall (August 1-November 30)

Section 6 - Letters of Recommendation

List the names and addresses of three (3) individuals who have agreed to furnish references on your behalf. Each should be acquainted with and attest to your professional reputation in adolescent and/or transition age youth psychiatry. Two (2) of the references must be psychiatrists. No reference may be a member of the American Board of Adolescent Psychiatry or Executive Committee of the American Society for Adolescent Psychiatry. It is the applicant’s responsibility to contact the individuals for the reference letters. ABAP will reach out via email (if email addresses are provided below) 10-14 days after any application is received to any listed references who have not submitted their letters. Applicants will be informed within 21 days of submission if any reference letters have not been received.

NOTE: We have simplified this process by creating an online form that your references may complete and submit directly to our office in lieu of formal letters to be typed, mailed, faxed, or scanned and emailed! The link can be copy-and-pasted from this application and emailed directly to your reference.

Here is the link

Reference #1 - Name, email address, contact phone number, and mailing address

Reference #1 - choose one answer

I have uploaded a letter of recommendation (please do this in last section titled "attachments")

I have requested my reference to submit a traditional letter of recommendation within 30 days

I have requested that my reference utilize the on-line form and have emailed them the link to access

Reference #2- Name, email address, contact phone number, and mailing address

Reference #2- choose one answer

I have uploaded a letter of recommendation (please do this in last section titled "attachments")

I have requested my reference to submit a letter of recommendation within 30 days

I have requested that my reference utilize the on-line form and have emailed them the link to access

Reference #3- Name, email address, contact phone number, and mailing address

Reference #3 - choose one answer

I have uploaded a letter of recommendation (please do this in last section titled "attachments")

I have requested my reference to submit a letter of recommendation within 30 days

I have requested that my reference utilize the on-line form and have emailed them the link to access

Section 7 - Affirmation and Attestation

Note: Your signature grants ABAP permission to list my name and post my photo in its directory and online Diplomate Showcase once/if successfully certified. You may retract this permission at any time by contacting us in writing.

DISABLED CANDIDATES: The American Society for Adolescent Psychiatry (ASAP) wishes to ensure that no individual with a disability is excluded, denied services, or otherwise treated differently from other candidates because of the absence of auxiliary aids and services.If you need any of the auxiliary aids or services identified in the Americans with Disabilities Act (ADA), please notify the ASAP administrative office at the time you submit your application via the electronic online submission form we offer. Provisions will be made for those candidates that identify their needs in advance of the examination, and whose claim of disability under ADA is substantiated by ASAP. Without advance notification the availability of such services on-site cannot be guaranteed. Note: A letter from a medical professional documenting any disability and need for accommodations is required.

I will require assistance to take the examination. I will submit the form required using the link above.

yes

I hereby make this application to the American Board of Adolescent Psychiatry, for the issuance to me of a certificate of Qualification in Adolescent and Transition Age Youth Psychiatry and for examination relative thereto, all in accordance with and subject to its rules and regulations. I hereby release, discharge and exonerate the American Board of Adolescent Psychiatry, The American Society for Adolescent Psychiatry, its directors, officers, members, examiners, representatives and agents from any action, suits, obligations, damages, claims or demands arising out of, or in connection with, this application, the grade or grades given with respect to the examination or the failure of the Board to issue to me such certificate. It is understood that the decision as to whether my examination qualifies me for a certificate rests solely and exclusively in the Board and that its decision is final.In support of this application, I certify that all the statements made herein or associated herewith are true, complete, and correct to the best of my knowledge and belief and are made in good faith.

Your Signature

Your non-refundable application fee of $450 is now due. Please submit payment electronically

Note: Active (current year's dues fully paid) members of The American Society for Adolescent Psychiatry (ASAP) are eligible for a registration fee discount. If you are an ASAP member, please check the appropriate response below.

Regarding my non-refundable application fee:

I have submitted payment of $450 electronically per above

If the $450 application fee is waived, I have uploaded a copy of the official waiver I received

I am an active, dues fully paid, ASAP member. Please bill me electronically for my discounted fee

If paying electronically, please upload a copy of your electronic receipt (received via email) here (hint: open the email receipt, "save to pdf", save the pdf to your hard drive, then upload the pdf here).

Section 8 - Attachments

What follows are upload options for 10 images (photos) followed by 10 pdf documents.

You may use as few or as many of each as you wish.

If you have a non-supported type of attachment, or more than 10 PDF's and/or 10 images, please attach them to an email and send to our executive office (americanboardadolescentpsych@gmail.com)

Please upload the following with this application - check each as you do so. Failure to upload the documents will delay your application processing.

Headshot Photograph

Medical training diploma or official statement of valid MD degree from medical college/university.

Current primary state license to practice medicine in one state, province or territory.

Board Certification Certificate of ABPN, AOA, NBPS or FRCP

Category I CME Certificates supporting required training hours (per section 2)

$450 non-refundable application fee electronic payment receipt (if not attached in section 7)

Copy of a current valid photo ID (passport, driver's license, state ID card)

Documentation of Completion of General or Child/Adolescent Psychiatry Residency Training

Please upload the following if applicable

3 reference letters if available and not submitted indepdently

Certificate of Fellowship or advanced post-residency training

List of Publications pertinent to Adolescent and TAY psychiatry

List of Professional and Medical Societies I am a member of or officer in

Additional Continuing Education Documents

Upload Image File

Upload PDF File

It is time to submit your application!

If you did not include any documents, please describe below, and email them as soon as possible to americanboardadolescentpsych@gmail.com Note: Incomplete applications are not processed until all requested materials are submitted.