Medical Toxicology Subboard Nomination Form

Nominees will be asked to update their demographic information in the ABEM portal.

Last Name

First Name

Professional Photo (optional)

Upload a professional photo here or email to SReed@abem.org, if you choose to.

Drop your files here

City/State

Email Address

Phone Number

Current Position

Continuing Certification

Click here to attest that you are participating in Medical Toxicology Continuing Certification.

Are you actively participating in ABEM Continuing Certification?

Description of Current Practice in Medical Toxicology

(e.g., poison center, in-patient, out-patient, teaching, research, etc. Please include practice setting, percentage of time spent in Medical Toxicology, and description of Medical Toxicology clinical work.)

ABEM Volunteer Experience (if applicable)

Item Writer

Item Writer Dates

Oral Examiner

Oral Examiner Dates

Other ABEM Volunteer Experiences

Other Volunteer Appointments (please specify)

Statement of Interest

Please provide a statement of interest in serving on the Medical Toxicology Subboard. Why do you want this opportunity?

Send me a copy of my responses

Report Abuse