About Us Advocacy CSHP Network Events Membership Products and Services Programs Resources MY.CSHP.ca  

Programs
Award/Grant Programs
Compounding
CSHP
Research and Education
Fellows Program
Online Education
Residency Training
Printable Version

Programs

Fellows Program

CSHP FELLOW PROGRAM APPLICATION FORM & CRITERIA 2017

Applicants and recommenders can either fax or scan and send the forms via email (preferred) to Pamela Saunders, at psaunders@cshp.ca.

Step 1: Complete the online application form
Step 2: Complete the signature form and fax to 613-736-5660 or email psaunders@cshp.ca (scanned, signed documents) along with an electronic copy of your curriculum vitae to the CSHP National office at no later than July 3, 2017 at 5:00pm EST.
Step 4: Have each recommender complete the recommender form and fax or email to the CSHP National office at 613-736-5660 no later than July 3, 2017 at 5:00 pm EST.

Please respond to all sections of this application.

Applicants should provide a CV in support of application.  A list of publications/presentations is expected but copies of presentations, project proposals, publications, book chapters, or evidence of awards is not appropriate. Electronic submission is required. 

Each application is reviewed / evaluated by members of the Fellows Recognition Committee against the five specific criteria clearly identified in this application form. To be successful, the applicant must take the time to thoroughly and thoughtfully complete this application. The experience of the Committee is that worthy candidates have been unsuccessful due to an incomplete application, often without attention to detail and/or not completed in a timely fashion.  Descriptions should be specific and detailed and not simply “refer to CV” in response to specific criteria. 

Please note, in its evaluation of your application for Fellow status, the Fellows Recognition Committee will consider only the documentation submitted. It is your responsibility to ensure that your application and documentation is complete and presented in a manner that proves your fulfillment of each of the identified criteria. Every applicant is encouraged to perform a self-assessment as well as consulting a recently successful colleague before deciding to submit this application. 

Signature pages to accompany the application may be faxed, or scanned and sent by email (preferred).

Ensure your completed application and all required documentation is submitted no later than July 3, 2017 5pm EST


CSHP FELLOW PROGRAM APPLICATION FORM

Important Instructions before you submit application: Please download the Fellow Program SIGNATURE form (to be completed by candidate) and the Fellow Program RECOMMENDATION form (to be completed by recommender).

Section 1: Personal Information
Name:
Dr. Ms. Mrs. Mr.
CSHP #:  
Active Member Dates From: To:
Honorary Life Member Dates From: To:
APES #:  
Active Member Dates From: To:
Honorary Life Member Dates From: To:
Contact Information
Hospital/Organization Name:
Address:
City:
Province:
Postal Code:
Telephone:
Fax:
E-Mail:
 
Home Address:
City:
Province:
Postal Code:
Telephone:
Fax:
E-Mail:
 
Preferred Mailing Address: Business Residence
 
Section 2: Fellow Criteria
Describe how you fulfill each of the following criteria, being specific and providing examples.  General reference to your curriculum vitae is not adequate; however, your curriculum vitae should be submitted along with your signature form which you will receive after submitting this application form. 
• All Criteria are Mandatory •
Criterion 1: Work Experience
Candidate must have practiced pharmacy for at least 10 years, of which a minimum of five must have been in an organized health care setting.
Describe or list in reverse chronological order, including dates, positions that document your pharmacy practice.  Please include a description of your responsibilities and accomplishments in each of these positions.  The minimum ten years of pharmacy practice must all be fulfilled following a first professional degree.  The minimum five year period in an organized health care setting and the minimum of 10 years of pharmacy practice cannot include time spent as a full-time student in a residency, fellowship or graduate degree program (e.g. Masters, Pharm D or PhD degree).
Position Held Number of years worked
Hospital
Hospital
Hospital
Hospital
Total years worked
Criterion 2: Professional Pharmacy Association Activities
The candidate must be a current active or honorary life member of CSHP or APES. (Participation in APES is accepted as equivalent to participation in CSHP activities.) Candidate must demonstrate support and leadership for the profession through active, current membership and voluntary participation in CSHP for a minimum of five consecutive years. Candidate must show consistent involvement, including leadership, in professional pharmacy association activities.
Describe or list in reverse chronological order (including dates) leadership positions and offices held under the following areas:
(a) Describe your involvement/contributions in CSHP or APES.  Please specify the years for your consistent involvement, which would include ongoing participation such as:
  • Being a member of the national Board, or a national committee or task force.
  • Being a member of a provincial Branch or Chapter committee or task force.
  • Being a member of an affiliated board such as the Canadian Pharmacy Residency Board or the CSHP Research & Education Foundation.
  • Being a representative of CSHP or APES to an affiliated organization such as CCCEP, PEBC, or a provincial organization
Leadership contributions, CSHP/APES
Criterion 3: Practice Excellence
(a) Candidate must have demonstrated sustained practice excellence and have implemented progressive pharmacy program(s):
Sustained is interpreted as a consistent and committed effort to maintain practice focus/excellence on behalf of the profession over a period of 5 years (specified). The purpose of this is to ensure ongoing contributions to the profession versus sporadic, infrequent contributions. Please state the specific area(s) of sustained practice focus/excellence which are over and above the expected professional responsibilities consistent with your position. Please document any further education that applies to the specialty, the number of years in this area and what measures demonstrate how practice excellence has been achieved. This shall involve a description of the implementation of a progressive pharmacy program that has resulted in an improved level of pharmacy practice. Appropriate documentation of the achievement must be submitted. Divide the text of the documentation of the progressive pharmacy program into the following sections, using the headings as described below:
  • Project or Program Title, and
  • Objectives, and
  • Brief supporting background, and
  • Brief description of methods used to implement the program and (where appropriate) to collect data, and
  • Brief summary of the outcome or results, and
  • A description of how the knowledge gained has been translated into practice, and
  • All publications or presentations related to the program
Some examples of new pharmacy programs may include but are not limited to:
  • New or expanded role for the pharmacist (ex: Antibiotic Stewardship)
  • New Seamless Care, Med Rec, Community Care or Home health care service
  • Modernization of drug distribution system  (ex: Oncology Compounding Facility
  • Medication Safety Pharmacist (Institutional, Regional or Provincial)
  • Innovative management system for pharmacy (ex: Senior Technician Role)

Area of Practice Excellence: Additional Education: Years in area: Describe progressive pharmacy program (use headings in criteria)

 

Area of Practice Excellence: Additional Education: Years in area : Describe progressive pharmacy program (use headings in criteria)

 

Area of Practice Excellence: Additional Education: Years in area : Describe progressive pharmacy program (use headings in criteria)

 

Area of Practice Excellence: Additional Education: Years in area : Describe progressive pharmacy program (use headings in criteria)

 

Area of Practice Excellence: Additional Education: Years in area : Describe progressive pharmacy program (use headings in criteria)

 

(b) Describe your involvement in any leadership activities with other professional organizations that have a broad impact on pharmacy practice in hospitals, other collaborative healthcare settings or on pharmacy education.
Leadership contributions in other professional organizations:
Criterion 4: Publications, Presentations, Research
Candidate must have contributed to pharmacy knowledge through publication, presentation, and research.

Please present a complete list of publications, presentations, and research reports, etc. that indicate your contributions to the profession in this area. A minimum of two of the following categories must be met:

(a) Author or co-author of at least five papers/articles (please include a list of all publications) on pharmacy practice in national or international peer-reviewed or refereed* journals (papers must be refereed, i.e., editorials, letters to the editor, abstracts are not applicable). If the article is in-press, please provide confirmation of acceptance. For listings of multiple papers/articles, please highlight or list separately those in peer-reviewed or refereed journals. Do NOT send copies of publications. (Note: * A peer-reviewed or refereed journal is one which asks a selection of experts to pass judgment on a paper prior to publication [i.e., a journal which uses only editorial staff or the same one or two reviewers for all papers is not considered refereed]). Alternately, you could fulfill this category as an author or co-author of a textbook or chapter in a textbook on an aspect of pharmacy (this does not include manuals, formularies, or guidelines used primarily within your hospital; however, it can include those which are widely used throughout the province or the country.) Please provide the complete details for this type of publication, including when it was published and the name of the publisher. Do NOT send copies of books/chapters.

Publications:

(b) Delivery of at least five invited oral presentations on different topics.  Please provide a list of all invited oral presentations that you have delivered.  For each presentation, clearly indicate the title of the presentation, as well as the date, location of meeting, and the name of specific audience or group to whom the presentation was made (i.e. CSHP Professional Practice Conference).

  • Oral presentations must be at provincial, national, or international professional meetings; local or hospital presentations are not acceptable and should not be included on the list.
  • In the list of your oral presentations, clearly specify whether it was delivered to a provincial, national, or international professional meeting.
  • Poster presentations are not acceptable and should not be included.
Invited Oral Presentations (use headings in criteria) :
(c) Principal investigator * in a research project -- please include a brief description of each research project. * The principal investigator (PI) is the person who directs a research project or program. The PI usually writes and submits the grant application, oversees the scientific and technical aspects of the grant, and has responsibility for the management of the research.
Principal Investigator – Research Project
Principal Investigator – Research Project
Principal Investigator – Research Project
Principal Investigator – Research Project
Principal Investigator – Research Project
OR (a) Delivery of at least 10 invited presentations on different topics at provincial, national, or international meetings (poster presentations are not acceptable). Do NOT send copies of presentations.
Invited presentations: (use headings in criteria):
Invited presentations: (use headings in criteria):
Invited presentations: (use headings in criteria):
Invited presentations: (use headings in criteria):
Invited presentations: (use headings in criteria):
Invited presentations: (use headings in criteria):
Invited presentations: (use headings in criteria):
Invited presentations: (use headings in criteria):
Invited presentations: (use headings in criteria):
Invited presentations: (use headings in criteria):
Criterion 5: Educational Activities
Candidates must have demonstrated ongoing commitment to educating health care practitioners, patients and the public.
Please describe activities which demonstrate ongoing commitment over a period of years to educating health care practitioners and the public. A minimum of three (3) of the following or related areas must be met:
(a) Teaching in a health care program (i.e., course coordination or responsibility for at least a 4-5 lecture module at college or university level) for at least 3 years.
(b) Being a preceptor in a health care program (i.e., program or service preceptor for >3 weeks) for at least 3 years.
(c) Routinely creating pharmacy bulletins or newsletters (i.e., >3 per year) for at least 3 years.
(d) Sustained provision of in-service education (i.e., program specific -- diabetic, respiratory, cardiovascular, etc.) for at least 3 years.
(e) Development and delivery of patient education program(s) for at least 3 years.
(f) Other Educational activities (i.e., use of technology)
Criterion 6: Recommendations
Provide the names of at least two (2) recommenders who you have requested to submit confidential recommendations attesting to your contributions as a practitioner and ratings on the attributes list, and who support this application for Fellow status.
Recommenders must use the “Fellow Program Recommendation Form”. (You must download this form below before submitting the online application). Scanned copies of the form are acceptable. Recommenders shall be representative of at least two of the following areas: CSHP Fellows, practitioners, academicians, or administrators. It is encouraged that one of your recommenders includes a current CSHP Fellow and that you do not have a direct reporting staff member as one of your recommenders. Current Fellows Recognition Committee members cannot act as recommenders for Fellow applicants.
Recommender 1:
Recommender 2:

Important Instructions: Please download the Fellow Program SIGNATURE form (to be completed by candidate) and the Fellow Program RECOMMENDATION form (to be completed by recommender).



 

NOTE: Recommenders are to submit confidential recommendations electronically, directly to the Fellows Recognition Committee prior to the application deadline of July 3rd 5 p.m. EST.