FASHP RECOGNITION PROGRAM APPLICATION
2015
INTRODUCTION
Awarding Fellowship in ASHP is one means by which the Society fosters and rewards demonstrated excellence in hospital and
health-system pharmacy. Successful candidates for Fellow status will have made a sustained contribution to ASHP and will
have demonstrated a high level of excellence in health-system pharmacy.
To be eligible for consideration, an applicant must be a current practitioner member of ASHP and have sustained membership
in ASHP for at least ten years, have a record of outstanding service to the profession through active involvement in ASHP, and
at least ten years of professional experience and achievements in hospital and health-system pharmacy from the time of
licensure.
INSTRUCTIONS
Please complete the application in its entirety. The purpose of this application is to establish an objective basis whereby
applicants can be evaluated based on the Fellow criteria. Each application is reviewed by members of the FASHP Recognition
Committee, which recommends to the Board of Directors whether an applicant should be awarded Fellow status.
The FASHP Recognition Committee will base its recommendations solely on the information supplied in this application.
Additional information such as samples of published work, etc. will not be considered. The applicant’s Curriculum Vitae (CV)
is used as a reference document for selected sections of the application and to assist with the Committee’s overall
assessment of the applicant’s qualifications for Fellow of ASHP. To be successful, the applicant must take the time to
thoroughly and thoughtfully complete this application. An incomplete application or insufficient references may serve as a
basis for denial of an application.
Successful applicants demonstrate accomplishments and activities that exceed routine job requirements and reflect a
sustained degree of commitment to health-system pharmacy. It is essential to review the FASHP Application Guidelines
document as it will be used by the Committee in completing its review. The criteria are provided so applicants will be fully
aware of the guidelines used in selecting Fellows. Potential applicants are strongly encouraged to perform a self-assessment
to determine whether or not to proceed with the application process.
In addition to the FASHP Recognition Program Application, a complete submission will include the following:
1.
Curriculum Vitae
2.
Exhibit A – A brief description (200 words or less) of your education, current position and achievements in healthsystem pharmacy. This will be used in announcing and publicizing each of the Fellow recipients. Please use the
format shown in this packet. Examples are also included for your reference.
3.
Exhibit B – A formal-type high-resolution color portrait photograph. Resolution should be no less than 300 dpi
(resolution) and 11 x 14.5 picas (size). Please submit an electronic copy, preferably in jpg or bmp format.
4.
Recommendation Forms - Recommendations from three (3) colleagues (i.e., practitioners, administrators or
academicians) who can attest to your achievement of the Fellow criteria.
All application materials listed above must be received no later than October 1. Please submit all application materials using the
following survey link: http://ashp.az1.qualtrics.com/SE/?SID=SV_38C35VZ5GEin0ot. Additionally, all application materials should
be saved using the following nomenclature: LastName_FirstName_ItemType (e.g., Smith_John_Application, Doe_Jane_CV).
If you have any questions, please contact the Membership Program Manager or Membership Assistant, Office of Member
Relations at Fellows@ashp.org.
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FASHP RECOGNITION PROGRAM APPLICATION
All application materials should be completed by the candidate and submitted no later than October 1 using the
following survey link: http://ashp.az1.qualtrics.com/SE/?SID=SV_38C35VZ5GEin0ot
APPLICANT INFORMATION
Last Name
I.
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First Name
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M.I.
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ASHP ID #
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EDUCATION
In the space below, please list the colleges and universities attended, dates of attendance and degrees earned.
COLLEGE OR UNIVERSITY
DATES OF ATTENDANCE
DEGREE / MAJOR
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II. POST GRADUATE TRAINING
In the space below, please list your residencies, fellowships, etc.
SPECIFIC TYPE OF POST
GRADUATE TRAINING
INSTITUTION
PROGRAM
DIRECTOR / PRECEPTOR
DATES OF
PARTICIPATION
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III. PROFESSIONAL EXPERIENCE (See minimum eligibility requirements and criterion #1 of the additional eligibility requirements.)
In the space below, please list your experience record in health-system pharmacy in reverse chronological order.
EXPERIENCE
DATES
ADDITIONAL COMMENTS
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Please enter a concise, but sufficiently detailed personal statement which addresses your contributions to health-system
pharmacy and why you believe that a level of excellence has been achieved. Suggested maximum length is 500 words.
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IV. PROFESSIONAL ACTIVITIES (See minimum eligibility requirements and criterion #4 of the additional eligibility requirements.)
Sustained Contributions to ASHP
You must be a current practitioner member of ASHP, have sustained membership in ASHP for at least ten years and have a
record of outstanding service to the profession through contribution to ASHP. In the space below, please list your service to
ASHP in reverse chronological order:
ASHP SERVICE:
DATES SERVED
ACTIVITY / SERVICE
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Activities in Other Professional Organizations
In the space below, please list your memberships and activities in other professional associations (i.e., state affiliates),
offices, committees, leadership roles, etc., by organization and dates served.
NATIONAL SERVICE:
DATES
ACTIVITY / SERVICE
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STATE SERVICE:
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ACTIVITY / SERVICE
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STATE SERVICE (CONT):
DATES
ACTIVITY / SERVICE
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LOCAL SERVICE:
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ACTIVITY / SERVICE
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V. PUBLICATIONS (See minimum eligibility requirements and criterion #2 of the additional eligibility requirements.)
In the space below, please list both peer reviewed and non-peer reviewed to include scientific or professional papers,
textbooks or textbook chapters.
PUBLICATIONS
PEER REVIEWED /
NON PEER REVIEWED
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VI. COMMITMENT TO EDUCATION (See minimum eligibility requirements and criterion #3 of the additional eligibility requirements.)
Demonstrate your involvement and commitment to educating practitioners and others through presenting to healthcare practitioners at national, regional or state educational conferences.
Presentations
In the space below, please list presentations to health-care practitioners at national, regional and/or state conferences in
reverse chronological order.
NATIONAL PRESENTATIONS:
TITLE
AUDIENCE
LOCATION
DATE
(MONTH, YEAR)
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REGIONAL PRESENTATIONS:
TITLE
AUDIENCE
LOCATION
DATE
(MONTH, YEAR)
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STATE PRESENTATIONS:
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LOCATION
DATE
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Posters
In the space below, please list your most recent posters presented to health-care practitioners at national, regional and/or
state conferences in reverse chronological order.
ALL POSTERS
TITLE
AUDIENCE
(NATIONAL, REGIONAL, STATE)
LOCATION
DATE
(MONTH, YEAR)
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Please enter a concise, but sufficiently detailed statement which demonstrates your involvement and commitment to
educating practitioners and others through additional activities, such as precepting students or residents, mentoring staff,
educating and training technicians and/or educating the public. Suggested maximum length is 500 words.
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VII. RECOMMENDATIONS
Please note current pharmacy students of the applicant, current ASHP staff, current ASHP Board members and members
of the current FASHP Recognition Committee are not eligible to submit recommendations.
Applications must include recommendations from at least three (3) different colleagues (i.e. practitioners,
administrators, or academicians). These individuals should complete and submit a Recommendation Form
attesting to your achievement of the Fellow criteria. Letters of recommendation may either be submitted
along with your application materials or via email to Fellows@ashp.org.
IMPORTANT
All application materials listed on the application cover page must be submitted no later than October 1. Please submit
all application materials using the following survey link: http://ashp.az1.qualtrics.com/SE/?SID=SV_9yjoFUtOQxAYDm5.
Additionally, all application materials should be saved using the following nomenclature:
LastName_FirstName_ItemType (e.g., Smith_John_Application, Doe_Jane_CV).
If you have any questions, please contact the Membership Program Manager or Membership Assistant, Office of
Member Relations at Fellows@ashp.org.
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Exhibit A Format:
Name, Credentials
Employer(s)
City, State
Education: Degree, School, Year of Graduation [Continue as needed for all advanced degrees, residency training and/or
fellowships. List in chronological order and separate with semicolon. B.S.Pharm. degree may also be included.]
Current positon(s): Title, Employer [Continue as needed for all current positions. Separate with semicolon.]
Practice achievements: Include a brief, third-person narrative (200 words or less) listing your achievements in healthsystem pharmacy (see outline below and included examples).
 Statements of experience
 Involvement in ASHP and/or involvement in ASHP State Affiliate
 Involvement in other pharmacy organizations
 Awards and Honors
Exhibit A Examples:
Linda Y. Radke, B.S.Pharm., Pharm.D., BCPS
Salina Regional Health Center
Salina, Kansas
Heath R. Jennings, Pharm.D., M.B.A., BCPS-AQ Cardiology
Florida Hospital
Orlando, Florida
Education: B.S. in Pharmacy, University of Kansas, 1982; Pharm.D., University
of Kansas, 2004
Education: B.S. in Pharmacy, University of Kentucky, 1997; Pharm.D.,
University of Kentucky, 1998; Pharmacy Practice Residency, University of
Kentucky Medical Center, 1999; Critical Care Pharmacy Residency, University
of Kentucky Medical Center, 2000; M.B.A., Loyola University Chicago Quinlan
School of Business, 2013
Current positions: Clinical Coordinator, Salina Regional Health Center; Adjunct
Assistant Clinical Professor in the Department of Pharmacy Practice, University
of Kansas School of Pharmacy
Practice achievements: Dr. Radke has been active as a leader in promoting
health-system pharmacy at the local, state, national and international levels
both within the profession and to the public. She has been an active member
of the Kansas Society of Health-System Pharmacists (KSHP) for thirty-one
years, including serving as KSHP President in 2005. She was appointed to the
ASHP Commission on Affiliate Relations, serving as Chair in 2011. She has
served as a delegate from Kansas to the ASHP House of Delegates seven times.
She has lectured to pharmacists and pharmacy students at pharmacy
universities in Japan and Thailand and has hosted students from both
countries. Currently, Dr. Radke is the President of the Board of Directors for
the Kansas Council of Health-System Pharmacists (KCHP) Foundation and
serves on a Technician Certification Task Force developing 2014 legislation
that will mandate national certification requirements for technicians in Kansas.
Dr. Radke received KSHP’s Harold N. Godwin Lecture Series Achievement
Award in 2008 and Health-system Clinical Pharmacist of the Year Award in
2002.
Current positions: Director of Pharmacy Services and Director of Graduate
Pharmacy Education, Florida Hospital Orlando
Practice achievements: Dr. Jennings is a leader in hospital services, clinical
pharmacy practice, residency training, and healthcare business strategy
development. He has a passion for practice model advancement and
innovative education, and has actively implemented and expanded programs
that deliver evidence-based patient care, optimize medication-related
outcomes, and advance clinical training in a variety of practice sites. For over
fifteen years, Dr. Jennings has been dedicated to creating pharmacy student
and resident training opportunities, developing novel preceptor-resident
models, and challenging conventional training paradigms. In both community
and academic settings, he has initiated two ASHP Accredited PGY1 residencies,
seven PGY2 residencies, two non-traditional pharmacist training programs,
and hundreds of student practice experiences. Dr. Jennings is active in ASHP
and currently serves as a member of the ASHP Commission on Credentialing.
Prior to this, he served as a member of the ASHP Section of Clinical Specialists
and Scientists (SCSS) Executive Committee, delegate to the ASHP House of
Delegates, and member of the Kentucky Society of Health-System Pharmacists
(KSHP) Board of Directors. He has published in and provides referee services to
a variety of professional journals and is a member of the Editorial Board for
Drug Evaluation. His recognitions include three ASHP Best Practices Awards,
the Kentucky Pharmacist of the Year Award, the Kentucky Hospital Association
(KHA) Quality Award, and The Joint Commission’s Ernest Amory Codman
Award.
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