Interest Form and Questionnaire for the Board and Nominating Committee

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2024/2025 Board of Directors and Nominating Committee Interest Form

Stop Snoring Fast

To participate, please complete this form and ensure all required documents are attached by the deadline. It’s essential to familiarize yourself with the Conflict of Interest Policy prior to volunteering. Note that only voting members are eligible to serve on the Board of Directors.

Nominee Checklist:

1. Log into your member profile and verify that your affiliations, contact details, and diversity, equity, and inclusion information are current and complete.
2. Upload the following documents:
   • CV, Resume, or Biographical Sketch

Section 1: Personal Information

• Prefix (Required):
  Dr. / Miss / Mr. / Mrs. / Ms. / Prof. / Rev.
• First Name (Required):
• Middle Name:
• Last Name (Required):
• Suffix:
• Phone (Required):
• Email (Required):
• Institution/Practice Name (Required):
• Primary Specialty (Required):
  • Pulmonary Medicine
  • Pediatrics
  • Family Practice
  • Neurology
  • Internal Medicine
  • Dentistry
  • Psychiatry
  • Psychology
  • Child Neurology
  • Otolaryngology
  • Research
  • Pediatric Pulmonary
  • Nursing
  • Anesthesiology
  • Other
• Practice Type (Required):
  • Academic
  • Federal Health System
  • Private Practice
  • Non-Academic Hospital / Health System

Patient Demographics

• Patient Mix:
  Please indicate the percentage of your patients who are adults vs. pediatric:
  • Adults (%): __ (Required)
  • Pediatrics (%): __ (Required)

Sleep Disorders

• Sleep Disorders Mix:
  Estimate the percentage of your work that involves treating the following sleep disorders:
  • Sleep Related Breathing Disorder (%): __ (Required)
  • Central Disorders of Hypersomnolence (%): __ (Required)
  • Sleep Related Movement Disorders (%): __ (Required)
  • Circadian Rhythm Sleep-Wake (%): __ (Required)
  • Parasomnias (%): __ (Required)
  • Insomnia (%): __ (Required)
  • Other (%): __ (Required)

Payer Mix

• Payer Mix:
  If known, please provide your estimated payer mix:
  • Medicare (%): __
  • Medicaid (%): __
  • Private Payer (%): __
  • Other (%): __

Certification and Experience

• Are you Board Certified in Sleep Medicine? (Required)
  • Yes
  • No
• AASM Leadership Experience:
  • Are you an AASM Fellow? (Required)
    • Yes
    • No
  • Have you ever served as Chair of an AASM committee/task force/panel/course? (Required)
    • Yes
    • No
  • If yes, how many times? (Required):
  • Please share a brief overview of your leadership activities within the AASM (300-word maximum) (Required):

Licensing Disclosures

• State Medical Licensing Board Disclosures:
  • Have any disciplinary actions been threatened, initiated, or are any pending against you by a state licensure board? (Required)
    • Yes
    • No
  • If yes, please describe:
  • Has your license to practice in any state ever been denied, limited, suspended, or revoked, diminished, not renewed, relinquished (voluntarily or involuntarily), or are any proceedings currently pending which may result in such actions? (Required)
    • Yes
    • No
  • If yes, please describe:

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Take care to fill out all sections accurately and ensure that your responses reflect your experiences and qualifications.