Credentials Review Evaluation Form – 2007
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EQUINE CREDENTIALS REVIEW
Equine Dental Specialty EVALUATION FORM
Complete the shaded boxes
Applicant
Reviewer
A. Credentials Application Form Type of Training Program Full Residency Part-Time Residency Advanced Standing Form dated sand signed, photo Yes No included? Check list section completed? Yes No Comments:
Any Publications or Radiograph Sets Yes No submitted as ‘Originals’? If Yes, which items? Comments on Application Form:
C, D. Vet School Diploma, License C. Veterinary school diploma included? Yes No Comments: D. Current veterinary license included? Yes No Comments:
E. Curriculum Vitae Curriculum vitae included in coherent Yes No format? Comments: Professional activities clear from CV? Yes No Comments: Any unexplained time gaps in CV? Yes No Comments: One-year internship or equivalent prior Yes No to starting veterinary dental training Comments: program? (Required for all residencies) Nature and content of formal courses Yes No satisfactory? Comments:
Nature/duration of informal training Yes No sufficiently documented? Comments: If a Part-Time candidate, is Yes No documentation of dental/veterinary Comments: dental training in addition to Direct Diplomate Supervision included? Overall comments on CV: F. Specialist Training Documentation of completion of Anesthesia Yes No specialist training (40 hours each in Radiology Yes No anesthesia, radiology and surgery) in Surgery Yes No acceptable format (Pre-Approval If no, what is missing or incorrect? certificates or completed ARS forms)?
G. Direct Diplomate Supervision and Clinical Experience Supervision requirement documented Yes No (48 weeks)? (not required for Advanced Standing) If no, what is missing or incorrect? Total 78 weeks clinical experience? Yes No (not required for Advanced Standing) If no, what is missing or incorrect? H, I. Charts, Equipment, Supplies Oral-dental record charts currently Yes No used by candidate Pre-Approved or If no, what is missing, unclear or incorrect? charts included and are satisfactory? Comments: (Not required for Residents) Veterinary dental equipment and Yes No supplies Pre-Approval certificate If no, what is missing, unclear or incorrect? included, or list and photographs Comments: included are satisfactory in content and format? (Not required for Residents)
J. Publication Items One MAJOR and one MINOR Major publication publication submitted as Pre-Approved Pre-Approved Submitted as Original certificates or as ‘Original’ undergoing Minor publication blinded review if submitted with Pre-Approved Submitted as Original application. Comments:
K. Radiograph Set Submitted as Pre-Approval certificates Pre-Approved Submitted as Original or as ‘Original’ undergoing blinded (result of blind review pending) review if submitted with application. Comments: L. Case Log 500 minimum caseload documented in Yes No DMS online log in AVDC format? If no, what is missing, unclear or incorrect? Cases recorded in correct category, no Comments: multiple visits for same treatment, maximum of three categories per case? Total number of cases and breadth of Yes No caseload indicates acceptable veterinary If no, what is missing, unclear or incorrect? dental activity? Comments: MRCL cases all logged within last six Yes No years? Comments: MRCL cases – trainee status. 50% as Yes No ‘primary dentist assisted by Diplomate’ Comments: (PDA) in each MRCL category? MRCL Diplomate Review Forms for Yes No MRCL cases logged since last TSS If no, what is missing, unclear or incorrect? Annual Report are included and Comments: appropriate? Overall, caseload is acceptable? Yes No Comments:
M. Additional Materials (optional) Comments:
N. Supervisor Report Form Certification of completion of training Yes No NA program by Residency Program If no, what is missing, unclear or incorrect? Director or Mentor is satisfactory? Comments: Any negative or questionable Yes No comments made by Supervisor? Comments: O. Letters of Reference Are at least two confidential letters of Yes No reference included, including one from If no, what is missing, unclear or incorrect? the Resident’s Supervisor? Comments: Do the writers state their relationship/ duration of contact with the candidate, and are the writers qualified to give an informed opinion of the candidate? Do the writers support this candidate’s application, and overall, are the letters satisfactory as a recommendation for AVDC membership?
P. Cadaver Procedure Log - optional Comments:
Q. TSS Annual Report Reviews Comments or questions after reading Comments: the most recent TSS Annual Report reviews (included in DMS file list)?
R. ‘Seven cases’ Validation This material will be sent to you via Yes No DMS. If no, what is missing, unclear or incorrect? Is the material satisfactory (sufficient Comments: detail, accurate, and content matches entry in case log)?
Summary of Application Is the sum of the formal and informal Yes No training satisfactory? Format of application package is Yes No satisfactory? Dental caseload satisfactory? Yes No Charts, equipment and supplies Yes No satisfactory? Publications satisfactory? Yes No Review results pending Radiograph sets satisfactory? Yes No Review results pending Supervisor report satisfactory? Yes No Letters of reference satisfactory? Yes No ‘Seven cases’ validation satisfactory? Yes No OVERALL RECOMMENDATION Candidate is APPROVED for Yes No Recommendation pending the admission to AVDC examination result of case report or radiograph set review. Comments: Reviewer’s name Date review completed and forwarded to Credentials Committee chair