AMERICAN OSTEOPATHIC BOARD OF DERMATOLOGY Operating under the authority of the American Osteopathic Association

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1 APPLICATION INSTRUCTION SHEET RECERTIFICATION DERMATOPATHOLOGY CERTIFICATE OF ADDED QUALIFICATION The American Osteopathic Board of Dermatology (AOBD)/American Osteopathic Board of Pathology (AOBP)/American Osteopathic Association (AOA) will issue a Certificate of Added Qualification in Dermatopathology upon satisfactory application for, and completion of a comprehensive examination. The recertifying examination will be administered at an annual meeting of the American Osteopathic College of Dermatology (AOCD). Application cover sheet, fee, and related documentation must be received by Renee Herron, Administrative Assistant, P.O. Box 493, Kirksville, MO no later than August 1 of the year of the exam. Documentation to be submitted to the AOBD shall include: 1. Completed application form 2. Copy of AOBD or AOBP Board Certificate 3. Copy of AOBD/AOBP Certificate of Added Qualification in Dermatopathology 4. Copy of current State Medical License 5. Copy of current CLIA Laboratory Certificate 6. If the applicant s practice is restricted to pathology/dermatopathology, the laboratory must be accredited by the AOA Healthcare Facilities Accreditation Program (HFAP), College of American Pathologists, JCAHO or equivalent accrediting agency. 7. Letter of good standing from the AOA 8. Letter describing nature of Dermatopathology training 9. Provide evidence of having performed at least 500 dermatopathology cases in a 12 month period prior to submission of application. 10. Provide proof of attendance/completion of a minimum of fifty (50) hours of accredited CME in dermatology or pathology in the 3 years prior to recertification. Thirteen (13) of those hours must have been in dermatopathology. 11. Submit 20 glass slides with reports for the Clinical Assessment Program (CAP). Slides will be reviewed for accuracy and conformity with standard of care. 12. $1, non-refundable fee, made payable to the American Osteopathic Board of Dermatology 13. Signed applicant statement All licenses, memberships and certificates MUST be valid as of the date of the test. 1

2 The above checklist outlines the documents that must be submitted with your application in order to complete your application process. A proctored examination will be administered. The examination will consist of three equally weighted parts: written knowledge, glass dermatopathology slides and dermatology clinical images. Syllabus for the examination is the book Weedon s Skin Pathology, 2010 by Weedon. The syllabus will assist you in focusing your study efforts but does not guarantee that all examination questions will be taken from this reference. Send all materials to: Renee Herron, Administrative Assistant American Osteopathic Board of Dermatology P.O. Box 493 Kirksville, MO Phone: (660) Fax: (660) execdirector@aobd.org 2

3 APPLICATION FOR RECERTIFICATION CERTIFICATE OF ADDED QUALIFICATION IN DERMATOPATHOLOGY NAME A.O.A. NUMBER ADDRESS CITY, STATE ZIP PHONE Please note: It is important to keep your contact information up to date with the AOBD in order to receive important information updates from the AOBD. ENCLOSURES (to be marked by examination committee) 1. Completed application form 2. Copy of AOBD or AOBP Board Certificate 3. Copy of AOBD/AOBP Certificate of Added Qualification in Dermatopathology 4. Copy of current State Medical License 5. Copy of current CLIA Laboratory Certificate 6. If the applicant s practice is restricted to pathology/dermatopathology, the laboratory must be accredited by the AOA Healthcare Facilities Accreditation Program (HFAP), College of American Pathologists, JCAHO or equivalent accrediting agency. 7. Letter of good standing from the AOA 8. Letter describing nature of Dermatopathology training 9. Provide evidence of having performed at least 500 dermatopathology cases in a 12 month period prior to submission of application. 10. Provide proof of attendance/completion of a minimum of fifty (50) hours of accredited CME in 3

4 dermatology or pathology in the 3 years prior to recertification. Thirteen (13) of those hours must have been in dermatopathology. 11. Submit 20 glass slides with reports for the Clinical Assessment Program (CAP). Slides will be reviewed for accuracy and conformity with standard of care. 12. $1, non-refundable fee, made payable to the American Osteopathic Board of Dermatology 13. Signed applicant statement I HEREBY PLEDGE MYSELF TO THE HIGHEST ETHICAL STANDARDS IN THE PRACTICE OF DERMATOPATHOLOGY. DATE I agree to conduct business with AOBD through my provided address. AOBD will conduct business with me through this same account. This includes, but is not limited to, communications related to my board certification status. I give my consent to the AOBD to deliver my examination results electronically to the address I provided on this application. This would replace the paper copy mailed through the U.S. Postal Service. DATE BOARD ACTION: Approved Disapproved Signature: Title: Date: 4

5 APPLICANT STATEMENT I hereby make application to the American Osteopathic Board of Dermatology (AOBD) for examination leading to RECERTIFICATION (CAQ) IN DERMATOPATHOLOGY. This action is made in accordance with and subject to the constitution, bylaws, regulations and requirements of the AOBD and the American Osteopathic Association (AOA). I understand that the certifying examination is a proprietary document of the AOBD and the AOA and that I do not and will not have the right to review the examination or any examination questions at any time prior to or following the administration of the examination. I agree to disqualification from examination or from issuance of certification or to the surrender of such certification as directed by the AOBD and/or the AOA in the event that any of the statements made by me in this application are false or in the event that any of the bylaws, rules, regulations and requirements governing such examinations are violated by me or in the event that I did not comply with any of the provisions of the constitution, bylaws, regulations and requirements of the AOBD and/or AOA. I agree that my professional qualifications, including my moral and ethical standing in the osteopathic medical profession and my competence in clinical skills, will be evaluated by the board and that the board may make inquiry of the persons named in my application and of other persons, such as authorities or licensing bodies, hospitals, program directors or other institutions as the board may deem appropriate with respect to such matters; and I agree that the sources and all information furnished to the board in connection with its inquiry shall be confidential and not subject to disclosure, through legal process or otherwise, to me or to any person acting on my behalf. I agree that the AOBD and the American Osteopathic Association shall be the sole judges of my credentials and qualifications for admission to the examination and for certification. I hereby release, discharge, exonerate and agree to hold harmless the American Osteopathic Association, American Osteopathic College of Dermatology, American Osteopathic Board of Dermatology, their members, examiners, trustees, officers, representatives and agents and free from any action, suit, obligation, damage, expense, claim, demand or complaint by reason of any action they or any one of them may take in connection with this application, such certifying examinations, the grade or grades given with respect to any certifying examination and/or failure of the AOBD to recommend issuance to me of such certification, or the revocation of any certification issued pursuant to this application. It is understood that the decision as to whether my performance on any certification examination qualifies me for certification rests solely and exclusively with the AOBD and the AOA, and that their decision is final. I also agree that the extent of any liability arising out of errors or omissions or other misconduct of the AOBD or the AOA shall be limited to the amount of fees paid to the AOBD and AOA in connection with the board certification process. In the event that any dispute shall arise concerning the certifying examination s content and/or administration, or any other issue relating to the certification process, I understand that the AOA has an administrative appeal process available and I agree to first pursue all available administrative appeals and internal reviews before pursuing any other forms of relief. I further agree that Illinois law, without regard to its provisions concerning conflict of laws, shall apply to the resolution of any dispute that I may have with the AOBD or the AOA. I have this day carefully read and agreed to full compliance with the foregoing. I have hereunto set my hands this day of, 20 ADDRESS PRINT NAME CITY, STATE, ZIP 5