World Institute of Pain – FIPP Board of Examination

Board of Examination

FIPP Examination Application for Certification
as Fellow of Interventional Pain Practice
(FIPP)

This application must be completed in its entirety. Attached, enclosed, or forwarded materials will not be accepted in lieu of the application. Supplemental documentation may be sent as requested or required. You may save a draft of this application at specified points in the application, and login to complete it before submission.

SECTION 1 - NAME/ADDRESS

Full legal name is required. If last name is a multiple or hyphenated name, insert that in the Last Name/Surname/Family Name space.
Mailing address should be where you want to receive ALL materials from WIP.

 
FULL LEGAL NAME
Last Name/Surname/Family Name:  
First Name:   
Middle Name1 (if applicable):  
Middle Name2 (if applicable):  
Medical degree:  
If Other Medical Degree, please enter:  
Do You Have a PhD?:    NO   YES
Other professional degrees (please specify, separated by commas):  
 
MAILING ADDRESS:
Address Line 1:  
Address Line 2:  
City/Township:  
State/Province:  (Enter NA if not applicable)
Postal Code:  
Country:  
 
CONTACT INFORMATION:
E-mail address:  
Daytime telephone number:  
Mobile telephone number:  
FAX number:  
If unavailable, message may be left with (list the name and relationship of person to you, and contact number if different than above):  
 
IDENTIFYING CHACTERISTICS (for statistical purposes only):
Date of Birth:  (mm/dd/yyyy)
Gender:    MALE   FEMALE  
Please upload a 2" x 3" photo of yourself in jpg or jpeg format:    Click browse to locate photo on your computer.
 
 
SECTION 2 - EDUCATION

List in chronological order (oldest earned first) all completed undergraduate, medical school, and approved specialty training.
Applicants must have satisfactorily completed a four-year ACGME-accredited residency training program that included
specialization in pain management.

 
UNDERGRADUATE:
Name of Institution:  
City/State/Province/Country:  
Dates of Attendance (from month/year to month/year):  
Date of Graduation (month/year):  
Degree Earned:  
 
MEDICAL SCHOOL:
Name of Institution:  
City/State/Province/Country:  
Dates of Attendance (from month/year to month/year):  
Date of Graduation (month/year):  
Degree Earned:  
 
OTHER POST GRADUATE WORK (if applicable):
Name of Institution:  
City/State/Province/Country:  
Dates of Attendance (from month/year to month/year):  
Date of Graduation (month/year):  
Degree Earned:  
 
RESIDENCY:
Name of Institution:  
City/State/Province/Country:  
Dates of Attendance (from month/year to month/year):  
Date of Completion (month/year):  
Specialty:  
 
SECOND RESIDENCY (if applicable):
Name of Institution:  
City/State/Province/Country:  
Dates of Attendance (from month/year to month/year):  
Date of Completion (month/year):  
Specialty:  
 
FELLOWSHIP:
Name of Institution:  
City/State/Province/Country:  
Dates of Attendance (from month/year to month/year):  
Date of Completion (month/year):  
Specialty:  
Subspecialty:  
 
OTHER (if applicable):
Name of Institution:  
City/State/Province/Country:  
Dates of Attendance (from month/year to month/year):  
Date of Completion (month/year):  
Specialty:  
Subspecialty:  
 
 
SECTION 3 - LICENSURE AND CERTIFICATIONS
 
LICENSURE:
 
List all ACTIVE medical licenses & medical regulatory authority registrations you hold. Each must be valid and unrestricted. Please upload a digital JPG copy of each license.

If your license expires before the FIPP examination you are applying for, you must provide a copy of the renewed license prior to final eligibility decision.

NOTE: If you do not have a valid, unrestricted, and current license to practice medicine in your country, you do NOT meet the eligibility requirements.

You may choose to mail copies of your License(s) in lieu of uploading digital images by checking the associated box(s) below.


 
LICENSE NUMBER 1:
State, Parish, Province or Equivalent Issue:  
License/registration Number:  
Date of Original Issue:  
Expiration Date:  
Please upload a copy of your license 1 in jpg or jpeg format:  
I prefer to mail a copy of this license:    YES
 
LICENSE NUMBER 2 (if applicable):
State, Parish, Province or Equivalent Issue:  
License/registration Number:  
Date of Original Issue:  
Expiration Date:  
Please upload a copy of your license 2 in jpg or jpeg format:  
I prefer to mail a copy of this license:    YES
 
LICENSE NUMBER 3 (if applicable):
State, Parish, Province or Equivalent Issue:  
License/registration Number:  
Date of Original Issue:  
Expiration Date:  
Please upload a copy of your license 3 in jpg or jpeg format:  
I prefer to mail a copy of this license:    YES
 
BOARD CERTIFICATION (or Equivalent):
 
To be eligible, you MUST be certified in your primary specialty by a member board of the American Board of Medical Specialties (ABMS) or equivalent postgraduate medical specialty certification authority in your country.
 
Are you currently board certified by a member of the ABMS or equivalent? (yes/no)  YES - ABMS   YES - Equivalent   NO
If NO, you do not meet the eligibility requirements for admission to the FIPP examination.
 
If YES to EQUIVALENT, identify and describe in the space provided, and include the date(s) of equivalent certification/recertification:
 
If YES to BOARD CERTIFICATION by a member of the ABMS, please select from the following list of General and Subspecialty Certificates, and indicate the date of original certification and last recertification:   General                                         Subspecialty
   
If Other chosen above, please define:           
Original Certification Date:           
Last Recertification Date (if applicable):           
 
OTHER SPECIALTY CERTIFICATIONS:
 
Have you received other specialty certifications pertaining to your practice of medicine? If so, please select all that apply in the drop-down menu, and define others not listed. To select more than one, hold down the Crtl key while clicking choices.
Other Specialty Certifications not in list above (if applicable):
If more than 1, please separate with commas.
 
 
SECTION 4 - CLINICAL PRACTICE EXPERIENCE
 
Effective on the date of this application, you must have been engaged in the clinical practice of pain medicine for at least 12 months after completing a formal residency training program.

If you have successfully completed a pain fellowship training program that lasted 12 months or longer, you may count the fellowship training as equivalent to 12 months of clinical practice in pain medicine.
 
Total number of years in practice after residency:
Does this number include a 12 month pain medicine fellowship?:  YES   NO  
Your professional practice setting is (check all that apply):
If Other selected above, please specify:
What percentage of your clinical practice is in the field of pain medicine? : %
        If less than 100%, list the remaining practice efforts and percent of each to total 100%: %
 
List all practical experience in reverse chronological order (current position first, oldest last):

   Name of current institution/practice affiliation:
   Your title/position:
   Dates of experience (month/year to present):
 
   Name of previous institution/practice affiliation 1:
   Your title/position:
   Dates of experience (month/year to month/year):
 
   Name of previous institution/practice affiliation 2:
   Your title/position:
   Dates of experience (month/year to month/year):
 
   Name of previous institution/practice affiliation 3:
   Your title/position:
   Dates of experience (month/year to month/year):
 
   Name of previous institution/practice affiliation 4:
   Your title/position:
   Dates of experience (month/year to month/year):
 
If additional appropriate work history is available, please enter it here (3500 characters max):
 
 
SCOPE OF PRACTICE:
 
Fill out this chart based on a one-month period that would be representative of your personal clinical practice in pain medicine. Please note that what is provided here will be the basis of your procedural examination. A certain number of interventional procedures are expected for you to be eligible. This must be completed and attested to by the applicant.
 
Total number of individual (different) patients you see in one month:
 
Number of procedures or services you provide in one month for each of the following evaluation, management or procedural areas of your practice.
 
  Outpatient Visits, New Patient
  Outpatient Visits, Established Patient
  Inpatient Consultations
  Peripheral nerve block procedures
  Stellate Ganglion Block
  Facet block (intra-articular or median branch block)
  Intravenous infusion trial (e.g., lidocaine, phentolamine)
  Epidural steroid injection (cervical, thoracic, lumbar, caudal)
  Lumbar Sympathetic Block
   a. Single dose
   b. Indwelling catheter
  Epidural/intrathecal drug delivery system implantation
   a. Tunneled epidural catheter
   b. Patient-controlled external pump to reservoir/valve/catheter implant
   c. Programmable drug administration pump implantation
  Peripheral nerve stimulation generator implant/revision
  Spinal cord stimulation (SCS) electrode insertion/revision (percutaneous)
  Lumbar Discography Procedure
  Lumbar Communicating Ramus
  Cryotherapeutic or RF techniques
  Epidural or subarachnoid neurolysis (alcohol, phenol)
  Trigeminal gangliolysis (RF/Chemical)
  Sphenopalatine gangliolysis
  Brachial plexus or sciatic block and catheter placement
 
 
I hereby affirm that I have correctly and completely filled in the information above, the data is representative of my personal clinical practice experience in a one-month period of time, and I understand that my practical examination will include some of these procedures.        I AFFIRM.
 
 
SECTION 5 - RECOMMENDATIONS
 
Indicate in the spaces below the names of the physicians whom you will ask to write letters of recommendation. The form entitled Requirement of Ethical and Professional Standards, which is available in WORD format at this location, must be completed by at least two practicing physicians and submitted by them directly in accordance with the instructions printed on the form.
 
 
Reference Name 1:  
Degree  
Title/Institution:  
Address Line 1:  
Address Line 2:  
City/Township:  
State/Province:  (Enter NA if not applicable)
Postal Code:  
Country:  
 
 
Reference Name 2:  
Degree  
Title/Institution:  
Address Line 1:  
Address Line 2:  
City/Township:  
State/Province:  (Enter NA if not applicable)
Postal Code:  
Country:  
 
 
CREDENTIALS QUESTIONAIRE
 
Please check boxes below. If "yes" chosen, please give full details in the space provided at the end of the questions. Number your explanation to correspond with the question number.
 
1.    Has you license to practice your profession in any jurisdiction ever been limited, suspended, revoked, denied, or subjected to probationary condition, or have proceedings toward any of those ends ever been instituted against you? :  
 
    NO   YES
2.    Have your clinical privileges at any hospital or healthcare institution ever been limited, suspended, revoked, not renewed, or subject to probationary conditions, or have proceedings toward any of these ends ever been instituted or recommended against you by a standing medical staff committee or governing body? :  
 
    NO   YES
3.    Has your medical staff membership status ever been limited, suspended, revoked, not renewed, or subject to probationary conditions, or have proceedings toward any of these ends ever been instituted or recommended against you by a standing medical staff committee or governing body? :  
 
    NO   YES
4.    Have you ever been sanctioned for professional misconduct by any hospital, healthcare institution, or medical organization? :  
 
    NO   YES
5.    Have you ever been convicted of a felony relating to the practice of medicine or one that relates to health, safety, or patient welfare? :  
 
    NO   YES
6.    Do you presently have a physical or mental health condition that affects or is reasonably likely to affect your professional practice.? :  
 
    NO   YES
7.    Do you have or have you had a substance abuse problem that affects or is reasonably likely to affect your professional practice?:  
 
    NO   YES
8.    Have there been any malpractice judgments or settlements filed or settled against you in the last five years? :  
 
    NO   YES
 
If YES chosen for any question above, please give full details in the space provided here. Number your explanation to correspond with the question number. (3500 characters max):
 
 
 
DECLARATION AND CONSENT
 
I hereby apply for certification offered by WIP-FIPP Board of Examination subject to its rules. I understand that the WIP-FIPP Board of Examination may use information accrued in the certification process for statistical purposes and for evaluation of the certification program. I further understand that WIP-FIPP Board of Examination will treat any patient information I submit confidentially. I understand that WIP reserves the right to verify any or all information on this application, and that if I provide any false or misleading information, or otherwise violate the rules governing the WIP-FIPP Board of Examination's certification, so doing may constitute grounds for rejection of my application, revocation of my certification, or other disciplinary action.

I recognize the sole and absolute discretion of WIP-FIPP Board of Examination to determine my qualifications to receive and to retain a certificate issued by WIP, and to have my name included in any list or directory in which the names of diplomats of WIP-FIPP Board of Examination are published. I further agree to indemnify and hold harmless individually and collectively the officers, directors, committee members, employees, appointed examiners, and agents of WIP, including its FIPP Board of Examination (hereinafter, the "above-designated parties") for any decision or action made in good faith in connection with this application, the examination, the score or scores given with respect to any examination, the refusal of WIP-FIPP Board of Examination to issue me a certificate, or the revocation of my certificate.

I understand and agree that in the consideration of my application, the WIP-FIPP Board of Examination may review and assess my moral, ethical, and professional standing (including but not limited to any information regarding any disciplinary action related to the practice of medicine by any state licensing agency or any institution in which I have practiced or have applied to practice medicine). I agree that the WIP-FIPP Board of Examination may make inquiry of such persons inspection of such records, and copies of such materials as WIP-FIPP Board of Examination deems appropriate with respect to my moral, ethical, and professional standing. I consent and agree that WIP-FIPP Board of Examination may investigate allegations against me, provided, however, that should WIP-FIPP Board of Examination wish to revoke my credential or otherwise administer discipline against me based on any allegations, that WIP-FIPP Board of Examination agrees to first give me an opportunity to rebut such allegations. I understand and consent that in the event WIP-FIPP Board of Examination presents me with allegations that WIP need not advise me of the identity of the individuals who have furnished adverse information concerning me and that all statements and other information furnished to WIP-FIPP Board of Examination in connection with such inquiry may be maintained between the disclosing parties and WIP and not subject to examination by me or by anyone acting on my behalf. I agree to cooperate fully and promptly in the event of any review by the WIP-FIPP Board of Examination of my eligibility for initial or continued certification. Without limiting the generality of the foregoing, I understand and agree that any individual or institution providing information to the WIP-FIPP Board of Examination regarding my fitness for certification shall be absolutely immune from civil liability arising from any act, communication, report, recommendation, or disclosure act, communication, report, recommendation, or disclosure is performed or made in good faith and without malice. I hereby authorize WIP-FIPP Board of Examination to supply a copy of this Declaration and Consent, which has been executed by me, to any individual or institution from which it requests information relating to me. I expressly give permission to WIP-FIPP Board of Examination to obtain information regarding my moral, ethical and professional behavior from any individual or institution that could reasonably be expected to have such information. Further, I authorize the WIP-FIPP Board of Examination and the above-designated parties to communicate any and all information relating to my WIP-FIPP Board of Examination application and any review thereof including but not limited to pendency or outcome of disciplinary proceedings to governmental licensing and other authorities, hospital or healthcare institutions, employers, and others.

I understand that I must keep my license to practice medicine active and I attest that it is currently active. I attest that I am not currently under any restriction or consent decree from any medical licensing authority or under any court orders. I attest that I will notify WIP-FIPP Board of Examination immediately should any of the following events occur: 1) change in my license status; 2) any past or future conviction related to the conduct of my practice or for any crime relating to medical practice, health, safety or patient welfare; or3) being placed on probation by my licensing board or by any court-ordered probation.

I have read the Bulletin of Information and understand and agree to abide by the policies of the WIP-FIPP Board of Examination and its FIPP Board of Examination. I understand that the WIP reserves the right to refuse admission to the certification examination if I do not have the proper identification, or if administration has begun. If I am refused admission for any of these reasons or fail to appear at the test site, I will receive no refund of the application or examination fees and there will be no credit for future examinations. I authorize the WIP-FIPP Board of Examination and its agents at my assigned test site to maintain a secure and proper test administration in their discretion. In this regard, the WIP-FIPP Board of Examination may relocate me before or during the examination. I will not communicate with other examinees in any way. I understand that I may only seek admission to sit for the WIP certification examination for the purpose of seeking WIP-FIPP Board of Examination certification, and for no other purpose. Because of the confidential nature of the WIP-FIPP Board of Examination Examination, I will not take any examination materials from the test site, reproduce the examination materials, or transmit the examination questions or answers in any form to any other person.

I understand that review of the adequacy of examination materials will be limited to providing hand scoring. If I do anything which is not authorized or which is prohibited by the WIP-FIPP Board of Examination in connection with any WIP-FIPP Board of Examination certification examination, I understand that my examination performance may be voided, and such activity may be the subject of legal action. In a case where my examination performance is voided, I will receive no refund of the allowable application or examination fees and there will be no credit for any future examination. I expressly waive all further claims of examination review.

I pledge myself to the WIP-FIPP Board of Examination Ethical Standards and the highest ethical standards in the practice of Pain Medicine. I understand that if I receive WIP-FIPP Board of Examination certification, it will be my responsibility to remain in compliance with all WIP standards for certification, to keep my certification current and to submit a valid renewal application and fee within sixty (60) days of my certification expiration date. I understand that to maintain FIPP certification, I need to maintain an active membership in WIP-FIPP Board of Examination.

I have used all reasonable diligence in preparing and completing this application. I have reviewed this completed application and, to the best of my knowledge, I aver that the information contained herein and in the attached supporting documentation is true, correct, and complete.

 
 
I hereby affirm that I have read the entire recital above and I unconditionally agree to all of its declarations and concurrently give my full consent to abide to each and every actionable clause therein.        I AFFIRM.
 
 

 

 

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