Application for Certification

Advanced Perioperative Transesophageal Echocardiography

(Advanced PTEeXAM)

Certification Requirements and Application

National Board of Echocardiography, Inc.® 1500 Sunday Drive, Suite 102 • Raleigh, NC 27607

Phone: 919-861-5582 • Email: info@echoboards.org Website: www.echoboards.org

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Table of Contents

General Topics Introduction .......................................................................................................................................................................................................................................4

Eligibility ............................................................................................................................................................................................................................................4

Scope of Practice ..............................................................................................................................................................................................................................4

Applying for Advanced PTE Certification ApplyingforCertification ...............................................................................................................................................................................................................5

AdvancedPTEBoardCertificationRequirementsandDocumentation .............................................................................................................................6-7

CertificationInstructions .................................................................................................................................................................................................................8

AdvancedPTEBoardCertificationApplication ...................................................................................................................................................................9-10

ChecklistforAdvancedPTEBoardCertification .....................................................................................................................................................................11

SampleLetter(Requirements4and5–ForPhysiciansWhoCompleted12-MonthClinicalFellowship) ......................................................................12

SampleLetter(Requirements4and5–PracticeExperiencePathway) .................................................................................................................................13

SampleCaseLog(Requirement5–ForPhysiciansWhoCompleted12-MonthClinicalFellowshiporSupervisedTrainingPathway) ...................14

Please check our website at www.echoboards.org for future application deadlines.

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Introduction

National Board of Echocardiography, Inc.®The National Board of Echocardiography, Inc.®(NBE)wasformedinDecember1998.TheNBEisanot-for-profitcorporationestablishedto:

• developandadministerexaminationsinthefieldof PerioperativeTransesophagealEchocardiography,

• recognizethosephysicianswhosuccessfullycompletetheExaminationof SpecialCompetenceinAdvancedPerioperativeTransesophagealEchocardiography(AdvancedPTEeXAM),and

• developaboardcertificationprocessthatwillpubliclyrecognizeasDiplomatesof theNationalBoardof Echocardiography,Inc.® those phy-sicianswhohavecompletedtrainingprogramsorsignificantpracticeexperienceintheperioperativecareof surgicalpatientswithcardio-vasculardiseaseandinadvancedperioperativetransesophagealechocardiography(TEE),asspecifiedinthisapplication,andhaveadditionallypassedtheAdvancedPTEeXAM.

Theexaminationandboardcertificationinadvancedperioperativetransesophagealechocardiographyisnotintendedtorestrictthepracticeof echocardiography. The process is undertaken, rather, in the belief that the public desires an indication from the profession regarding those who have made the effort to optimize their skill in the performance and interpretation of cardiac ultrasound.

Thefirstexaminationinperioperativetransesophagealechocardiographywasgivenundertheauspicesof theSocietyof CardiovascularAnes-thesiologists(SCA)asafieldtestin1997.Anexaminationof perioperativetransesophagealechocardiographywasgivenin1998,againundertheSCA,andannuallysincethenundertheNBE.Physicianswhosuccessfullypassedtheexamwerecertifiedashavingsuccessfullycompletedtheperioperativetransesophagealechocardiographyexamination.Boardcertificationwasnotgrantedsinceapplicantswerenotrequestedtosupply information regarding successful completion of training dedicated to the perioperative care of surgical patients with cardiovascular disease nor completionof specialtraininginperioperativetransesophagealechocardiography.Withamatureandwell-testedexamination,awell-definedbodyof knowledge,publishedtrainingguidelines,andpublishedcontinuingqualityimprovementguidelinestheNBEbeganofferingboardcertificationin2004.

Eligibility

Testamur StatusForlicensedphysiciansnotmeetingthecriteriaforcertification,theNBEwillcontinuetoallowaccesstotheexamination.Thisistoencour-age physicians to test and demonstrate their knowledge of advanced perioperative transesophageal echocardiography based on an objective standard and to allow the medical community the opportunity to recog-nize individuals who elect to participate in and successfully complete a comprehensiveexaminationinadvancedperioperativetransesophagealechocardiography.Thosewhosuccessfullypasstheexamination,willbegrantedTestamurstatusashavingsuccessfullycompletedtheExamina-tion of Special Competence in Advanced Perioperative Transesophageal Echocardiography of the National Board of Echocardiography, Inc.®

CertificationLicensedphysicianswhomeetthecriteriaforcertificationmayapplyforCertificationatthetimeof applicationfortheAdvancedPTEeXAM.Thecertificationapplication,checklist,andallrequireddocumentationcanbesubmittedatanytimebutisnotrequiredtoregisterfortheAdvancedPTEeXAM.

TheCertificationCommitteewillmeettoreviewapplicationsforcer-tification.Applicantswillbenotifiedinwritingof thedecisionof theCommittee.Reviewof applicationforcertificationwillbecontingentonsuccessfulcompletionof theAdvancedPTEeXAM.Applicantswillreceivenotificationof thedecisionof thecommitteewithintheyear.

IndividualswhopreviouslypassedtheAdvancedPTEeXAMmayapplyforcertificationatanypointinwhichtheymeettheclinicalexperiencerequirementsaslongastheirtestamurstatusremainsvalid.

Scope of PracticeTheapplicationof anadvancedperioperativeTEEexaminationistouti-lize the full diagnostic potential of perioperative TEE including direction of the perioperative surgical decision making process.

Important Policy UpdatesRequirement 5 Practice Experience Pathway

Applicant’s that finished core residency training before July 1, 2009:

Applicants must have performed and interpreted at least 300 comprehensive perioperative transesophageal echocardio-gramswithinfour(4)consecutiveyearswithnolessthan50inanyyearandtheseexamsmusthaveoccurrednomorethan10-years prior to application. Additionally, the applicant must have performed and interpreted an average of 50 compre-hensive perioperative transesophageal echocardiograms in the 4-years immediately preceding application. At least 150 of the 300 echocardiograms must be intraoperative. Physicians seek-ingcertificationbythispathwaymusthaveatleast50hoursof AMAcategory1continuingmedicaleducationdevotedechocardiography obtained during the time the physician is acquiringtherequisiteclinicalexperienceinTEE.

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Applying for CertificationWho May Apply?Applicantswhowishtoapplyforcertificationmustholdavalid,unre-stricted license to practice medicine at the time of application. (Geo-graphicalrestrictionsmaybeacceptedandaresubjecttoapproval.Medi-cal restrictions or restrictions to the scope of practice will not be accepted forpurposesof eligibilityforcertification.)Theapplication,checklist,andallrequireddocumentationshouldbesubmittedwiththeapplication.TheCertificationCommitteewillmeettoreviewapplicationsforCertifica-tionandapplicantswillbenotifiedinwritingof thedecisionof thecommittee.Reviewof applicationforcertificationwillbecontingentonsuccessfulcompletionof thePTEeXAM.Applicantswillreceivenotifica-tion of the decision of the committee within 12 months.

The Purposes of Advanced PTE Board Certification• establish the domain of the practice of advanced perioperative

transesophagealechocardiographyforthepurposeof certification,• assess the level of knowledge demonstrated by a licensed physician

practitioner of advanced perioperative transesophageal echocardiogra-phy in a valid manner,

• enhancethequalityof perioperativetransesophagealechocardiog-raphy and individual professional growth in advanced perioperative transesophageal echocardiography,

• formallyrecognizeindividualswhosatisfytherequirementssetbytheNBE, and

• servethepublicbyencouragingqualitypatientcareinthepracticeof advanced perioperative transesophageal echocardiography.

Certification Documentation and InstructionsThe National Board of Echocardiography, Inc.® reserves the right to auditstatedclinicalexperienceandcontinuedprovisionof servicesinperioperative transesophageal echocardiography for the sake of eligibility forboardcertification.

Letters Documenting Training and/or Level of ServiceLetters documenting training and/or level of service from Residency ProgramDirector,theFellowshipTrainingDirector,Directorof Cardio-thoracic Anesthesiology, Cardiothoracic Surgery or Cardiology, Chairs of Anesthesiology,MedicineorSurgery,ortheMedicalDirectorof theEchocardiographyLaboratoryMUSTbetheoriginal notarized letter (no copiesaccepted),MUSTbetypedonappropriateletterhead,andMUSTcontain EXACT numbers of studies performed and interpreted. Ap-plicants with letters not meeting these criteria will not be reviewed. Sample lettersintherequiredformatareonpages12-13thesamplelogonpage14, and on our web site: www.echoboards.org

If applicant is in private practice, the letter documenting level of service must be on appropriate letterhead and should be written by the CEO or President of the practice. If the applicant is the CEO or President of the practice, thelettershouldbewrittenbytheBusinessManager.LetterssignedbytheapplicantwillnotbereviewedbytheCertificationCommittee.

Note: The numbers provided must be in parallel, consecutive years but need not be calendar years. The end of the most recent year for which credit is requested must fall within the 12 months prior to the receipt of the complete application.

Review of Documentation for Board CertificationSinceCertification is dependent on passing theAdvancedPTEeXAM,applicationsforcertificationarereviewedaftertheexaminationhasbeensatisfactorilycompleted.Duetotheexpectedvolumeof applicationsandcomplexityof theprocess,reviewof theapplicationsmaytakeuptooneyear.

Effective Date of Board CertificationCertificationwillberetroactivetothedatethattheExaminationof Spe-cial Competence in Advanced Perioperative Transesophageal Echocar-diography(AdvancedPTEeXAM)waspassedandwillbevalidforten(10)yearsfromthatdate;e.g.if theexamwaspassedin2005boardcertifica-tionwillbevaliduntilJune30,2015.If theexamispassedin2015,boardcertificationwillbevaliduntilJune30,2025.

Non-North American Trained PhysiciansNon-NorthAmericantrainedphysiciansmusthavehadtheequivalentof eachof theapplicablerequirements.Applicationswillbereviewedon a case by case basis to determine the eligibility of the applicant for certification.AlldocumentationmustbesuppliedinEnglish.If originaldocumentationisnotinEnglish,acertifiedtranslationmustbeattachedto each document.

Current License to Practice Medicine:If your medical license does not have an expiration date, you are required to supply ONE of the following:• An original letter from the Medical Council stating your license is

permanent• A original certificate of good standing, dated no more than

12 months prior to date application received

Current Medical Board Certification:Documentation of permission to practice anesthesiology is acceptable documentation.

Specific Training/Experience in the Perioperative Care of Surgical Patients with Cardiovascular Disease: Fellowship PathwayDocumentation must include the inclusive dates of training.

Change in Certification PolicyApplicantsthatfinishedtheircoreresidencytrainingafterJune30,2009,canONLYqualifyforcertificationbycompletingfellowshiptrainingataninstitutionwithanACGMEaccreditedfellowshipprogram. Training obtained during core residency (anesthesiology, internalmedicine,orgeneralsurgery)maynotbecountedtowardthisrequirement.

CanadianandNon-NorthAmericanapplicantsthatfinishedtheircoreresidencytrainingafterJune30,2009,canONLYqualifyforcertificationbycompletingfellowshiptrainingataninstitutionwith a nationally accredited training program in anesthesiology. Applications will be reviewed on a case by case basis to determine eligibilityof theapplicantforcertification.

NOTE: The practice experience pathway will no longer be accepted as an alternative to fellowship training for those that finished their core residency training after June 30, 2009.

Definition of Perioperative TEEPerioperativeTEEisdefinedasaTEEperformed1)intraopera-tive2)postoperativeduringthesamehospitalizationassurgery,or3)preoperativeinpatientshavingsurgeryduringthesamehospitalization.

Note that diagnostic TEEs performed on patients not having a surgical operation, e.g. to rule out thrombus before a cardioversion or ablation, or to rule out a cardiac source of embolus, are not consideredtobeperioperativeandcannotbeusedforcertification.

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Requirement 1. Successful completion of the Examination of Special Competence in Perioperative Transesophageal Echocardiography.

ApplicantsmusthavetakenandpassedthePTEeXAM.

Requirement 2. Current License to Practice Medicine.

Applicantswhowishtoapplyforcertificationmustholdavalid,unre-stricted license to practice medicine at the time of application. (Geo-graphicalrestrictionsmaybeacceptedandaresubjecttoapproval.Medi-cal restrictions or restrictions to the scope of practice will not be accepted forpurposesof eligibilityforcertification.)

Requirement 3. Current Medical Board Certification.

ApplicantsmustbeboardcertifiedbyaboardwhichholdsmembershipintheAmericanBoardof MedicalSpecialties,theAdvisoryBoardforOsteopathic Specialties, the American Association of Physician Special-ists, or Royal College of Physicians and Surgeons of Canada.

Requirement 4. Specific Training/Experience in the Perioperative Care of Surgical Patients with Cardiovascular Disease.

Fellowship Pathway:

Applicants must have a minimum of 12 months of clinical fellowship training dedicated to the perioperative care of surgical patients with car-diovascular disease. Training obtained during the core residency (anesthesiology,internalmedicine,orgeneralsurgery)maynotbecountedtowardthisrequirement.Fellowshiptrainingincardiothoracicor cardiovascular anesthesiology must be obtained at an institution with anACGMEorothernationalaccreditingagencyaccreditedfellowshipincardiothoracic anesthesiology.

Cardiothoracic anesthesiology fellowships in Canada will be accepted only if theyareatleastone(1)yearlongandoccurafterananesthesiologycoreresidencyof five(5)years,andareataninstitutionwithanationallyaccredited training program in anesthesiology.

OR

Practice Experience Pathway:

Applicantsmust have aminimumof 24months of clinical experiencededicated to the perioperative care of surgical patients with cardiovascular disease.Theexperiencemustincludeperioperativecarepersonallydeliveredby the applicant to at least 150 patients with cardiovascular disease per year ineachof thetwo(2)yearsimmediatelyprecedingtheapplication.Trainingobtainedduringcoreresidencymaynotbecountedtowardsthisrequirement.

NOTE: The practice experience pathway will no longer be ac-cepted as an alternative to fellowship training for those that finished their core residency training after June 30, 2009.

Advanced PTE Board Certification Requirements

CERTIFICATION REQUIREMENTS REQUIRED DOCUMENTATION

Requirement 1.

Applicantmustsupplyallrequireddocumentationfortrainingandmaintenanceof skills.Seechecklist(page11)

IndicateYearthatthePTEeXAMwaspassedonapplication.

Requirement 2.

Acopyof currentmedicallicenserenewalcertificatethatshowstheexpi-rationdate.(NonNorthAmericanPhysiciansseepage5)

Requirement 3.

Acopyof currenthighestboardcertificationattained,e.g.Anesthesiolo-gy,CardiovascularDisease,InternalMedicine,etc.(NonNorthAmericanPhysiciansseepage5)

Requirement 4.

Fellowship Pathway:

One of the following:

• Acopyof acertificateof successfulcompletionof fellowshiptrainingdedicated to the perioperative care of surgical patients with Cardiovas-cular Disease.

• A notarized letter typed on appropriate letterhead from the hospital or appropriate departmental Training Director, e.g. Residency Program Director,theFellowshipTrainingDirector,Directorof Cardiotho-racic Anesthesiology, Cardiothoracic Surgery, or Cardiology, Chairs of Anesthesiology,MedicineorSurgery,ortheMedicalDirectorof Echocardiography Laboratory stating the applicant has completed a full 12monthsof clinicaltrainingdedicatedspecificallytotheperioperativecare of surgical patients with cardiovascular disease. This letter must documenttheinclusivedatesof thetraining,aswellastheACGMEprogram number. A summary of the training program activities is recommended. (See Letters Documenting Training and/or Level of Servicepage5andforSampleLetterseepage12)

OR

Practice Experience Pathway:

A notarized letter typed on appropriate letterhead from the hospital or ap-propriate departmental Training Director, e.g. Director of Cardiothoracic Anesthesiology, Cardiothoracic Surgery, or Cardiology, Chairs of Anesthesi-ology,MedicineorSurgery,ortheMedicalDirectorof theEchocardiographyLaboratoryverifyingthenumberof monthsof clinicalexperiencededicatedto the perioperative care of surgical patients with cardiovascular disease, and the number of patients to whom perioperative care was personally delivered bytheapplicantforeachof thetwo(2)yearsimmediatelyprecedingtheapplication. (See Letters Documenting Training and/or Level of Service page5andforSampleLetterseepage13)

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Advanced PTE Board Certification Requirements

BOARD CERTIFICATION REQUIREMENTS REQUIRED DOCUMENTATIONCERTIFICATION REQUIREMENTS REQUIRED DOCUMENTATION

Requirement 5.Supervised Training Pathway: A notarized letter typed on appropriate letterhead from the hospital or appropriate department Training Director e.g. Residency Program Director,theFellowshipTrainingDirector,Directorof CardiothoracicAnesthesiology, Cardiothoracic Surgery, or Cardiology, Chairs of Anes-thesiology,MedicineorSurgery,ortheMedicalDirectorof theEchocar-diographyLaboratoryverifyingcompletionof trainingand/orexperiencein perioperative transesophageal echocardiography and the number of comprehensiveintraoperativeTEEexaminationspersonallyperformed,interpretedandreportedandthenumberof completeexaminationsre-viewed with supervision by the trainee. (See Letters Documenting Train-ingand/orLevelof Servicepage5andforSampleLetterseepage12)Forexaminationsstudiedbutnotperformedbytheapplicant,alogitem-izingeachexaminationincludingthedatereviewed,thediagnosis,surgeryperformed,andthesupervisingfaculty/staff withwhomthefindingswerediscussed.Thelogmustindicatethattheseexamswerestudiedbutnotperformed.(SeeSampleCaseLogonpage14)Note: Do not include any patient information on the log. Logs received with patient information will be returned to the applicant. Only include date reviewed, diagnosis, surgery performed, and with whom the findings were discussed. ORPractice Experience Pathway: A notarized letter typed on appropriate letterhead from the hospital or ap-propriate department Training Director e.g. Residency Program Director, theFellowshipTrainingDirector,Directorof CardiothoracicAnesthesi-ology, Cardiothoracic Surgery, or Cardiology, Chairs of Anesthesiology, MedicineorSurgery,ortheMedicalDirectorof theEchocardiographyLaboratory verifying the number of transesophageal studies performed and interpreted on surgical patients. The letter must state that at least 150 of the 300 transesophageal echocardiograms were intraoperative. (See Let-ter Documenting Training and/or Level of Service page 5 and for Sample Letterseepage13.)ANDAcopyof certificate(s)ordocumentationfromtheinstitutionprovidingCMEcreditsdocumenting50hoursof AMAcategory1CMEdevotedtoechocardiography.Formeetingsnotdevotedonlytoechocardiography,applicantsmustindicateonthecopyof thecertificatehowmanyhourswere devoted to echocardiography.

Requirement 6. ApplicationFeemaybepaidbycheck,Visa,orMasterCardinUSFunds.TheNBEdoesnotacceptAmericanExpressorDiscover.

Requirement 5 Specific Training in Echocardiography.Supervised Training Pathway: Applicantsmusthavehadspecifictrainingorclinicalexperienceinad-vanced perioperative transesophageal echocardiography, including study of 300completeperioperativeTEEexaminationsunderappropriatesupervision.Theseexaminationsmustincludeawidespectrumof cardiacdiagnoses.Of the300examinations,atleast150comprehensiveintra-operativeTEEexaminationsmustbepersonallyperformed,interpreted,andreportedbythetrainee.Forthese150examinations,thesupervisingphysician must be present for all critical aspects of the procedure, and immediatelyavailablethroughouttheprocedure.Thoseexaminationsthatarenotpersonallyperformedbytheapplicantmustbeacquiredandreviewed at an institution where the applicant has performed TEEs under supervision.Documentationof compliancewiththerequirementsof thispathwaymustbeobtainedfromtheinstitutionwheretheexaminationsare performed and must be in a form acceptable to the NBE. Training obtained during the core residency (anesthesiology, internal medicine, or generalsurgery)maynotbecountedtowardthisrequirement.ApplicantsthatfinishedtheircoreresidencytrainingafterJune30,2009,canONLYqualifyforcertificationbycompletingcardiothoracicorcar-diovascularanesthesiologyfellowshiptrainingatanACGMEaccreditedfellowship program.Cardiothoracic anesthesiology fellowships in Canada will be accepted only if theyareatleastone(1)yearlongandoccurafterananesthesiologycoreresidencyof five(5)years,andareataninstitutionwithanationallyaccredited training program in anesthesiology.NOTE: Supervised Training in Perioperative TEE must be com-pleted in two years or less.Definition of Perioperative TEE: PerioperativeTEEisdefinedasaTEEperformed1)intraoperative2)postoperativeduringthesamehospitalizationassurgery,or3)preoperativeinpatientshavingsurgeryduring the same hospitalization. Note that diagnostic TEEs performed on patients not having a surgical operation, e.g. to rule out thrombus before a cardioversion or ablation, or to rule out a cardiac source of embolus, are notconsideredtobeperioperativeandcannotbeusedforcertification.ORPractice Experience Pathway (Certification Policy Change): Applicants must have performed and interpreted at least 300 comprehen-siveperioperativetransesophagealechocardiogramswithinfour(4)con-secutiveyearswithnolessthan50inanyyearandtheseexamsmusthaveoccurred no more than 10-years prior to application. Additionally, the applicant must have performed and interpreted an average of 50 compre-hensive perioperative transesophageal echocardiograms in the 4-years im-mediately preceding application. At least 150 of the 300 transesophageal echocardiogramsmustbeintraoperative.Physiciansseekingcertificationbythispathwaymusthaveatleast50hoursof AMAcategory1continu-ing medical education devoted to echocardiography obtained during the timethephysicianisacquiringtherequisiteclinicalexperienceinTEE.NOTE: The practice experience pathway will no longer be ac-cepted as an alternative to fellowship training for those that finished their core residency training after June 30, 2009.Definition of Perioperative TEE: PerioperativeTEEisdefinedasaTEEperformed1)intraoperative2)postoperativeduringthesamehos-pitalizationassurgery,or3)preoperativeinpatientshavingsurgeryduringthe same hospitalization.

Requirement 6. Application Fee.Advanced PTE Board Certification:ConversiontoBoardCertification: If youpassedPTEeXAM1998-2003 ..........................................$175(USFunds) If youpassedPTEeXAM2004-2015 ................................No Additional Charge

(IncludedinExamfee)

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To Apply for Advanced PTE Certification1. Complete application on pages 9 and 10.

2. Signtheapplicationonpage9.Unsignedapplicationswillnotbeprocessed.

3. Please complete Check List on page 11.

4. Includeallof therequireddocumentationforcertification.

5. Complete the section concerning method of payment.

Advanced PTE Board Certification:

If youpassedPTEeXAM1998-2003 ....................................................$175(USFunds) If youpassedPTEeXAM2004-2015 .......................................... No Additional Charge

(IncludedinExamfee)

TheNBEaccepts check,moneyorder,VISA, andMasterCard.Makechecks payable to National Board of Echocardiography, Inc.® or NBE.

6. Submitapplication,license,andnecessarydocumentationforcertifica-tion to the NBE.

Mail, UPS, or FedEx completed certification application, checklist, documentation and payment to: National Board of Echocardiography, Inc.® 1500 Sunday Drive Suite 102 Raleigh, NC 27607

The NBE recommends that if mail is used you obtain proof of delivery.

Questions? Please visit www.echoboards.org. or call 919-861-5582.

Certification Instructions

Certification Application DeadlinesTheCertificationCommitteewillmeetannuallytoreviewapplications.Applications for Certification are accepted anytime. Please check our website at www.echoboards.org for future application deadlines.

Duetothevolumeof expectedapplicationsandcomplexityof thepro-cess, review of the applications may take up to one year.

Applicantswillbenotifiedof thedecisionof theBoardinwriting.Thedecisionof theBoardwillNOTbegivenoverthetelephone,viafax,orvia e-mail.

Note:IncompleteapplicationswillnotbereviewedbytheCertificationCommittee. If items of documentation are missing, applicants will be notified.Oncealldocumentationhasbeenreceived,thecertificationap-plicationwillbeprocessedforreviewatthenextcertificationmeeting.

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Please fill out the application carefully, accurately, and completely. Please print.

APPLICATIONS THAT ARE NOT SIGNED WILL NOT BE PROCESSED.

Incomplete applications will not be reviewed by the Certification Committee. Faxed applications will not be accepted. Attach completed checklist on page 11 and all required documentation.

See page 8 for certification instructions.

Name ___________________________________________________________________________________________________________________ Last/SurnameFirst(FullName)Middle(FullName)

Degree_____________________________________SocialSecurityNumber(last4digits)_______________Dateof Birth _____________________ (mm/dd/yy)

MailingAddress __________________________________________________________________________________________________________

City ____________________________________________ State _______ Zip________________ Country _________________________________

Address is (please check one): q Home q Business

TelephoneCountryCode*(If outsideUSandCanada) ________________ TelephoneCityCode*(If outsideUSandCanada) ____________________

Business Telephone ___________________________________________ Cell Telephone _______________________________________________

Home Telephone _____________________________________________ E-mail(required) ______________________________________________

Core Residency Training: Institution ______________________________________ Specialty ___________________________ Date Trainning Completed: ________________ (mm/dd/yy)

Application for Advanced PTE Board Certification

Application FeeAdvanced PTE Board Certification:

If youpassedPTEeXAM1998-2003 ...................................$175(USFunds)

If youpassedPTEeXAM2004-2015 ......................... No Additional Charge(IncludedinExamfee)

Refund Policy: No refunds will be made.

Payment Optionsq Check q MoneyOrder q VISA q MasterCard

(The NBE Does Not Accept American Express or Discover)

Name on Card _____________________________________________

Card # __________________________________________________

Exp.Date ________________________________________________

Authorized Signature ________________________________________

Please make sure you have signed this application. Unsigned applications will not be processed.

Please answer the applicable questions on the following page.

I affirm that the information supplied in this application is true and correct.

The NBE reserves the right to request additional information and documentation on all applications.

Signature ________________________________________________ (Original Signature Required)

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FOR OFFICE USE ONLY:

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Please circle the appropriate letter below. Please answer only the questions applicable to you. If you answered these questions on the PTEeXAM application, please disregard.

1. How long have you performed echocardiography in your clinical practice?A. Not yet in practiceB. Less than 1 yearC. 1-2 yearsD. 2-5 yearsE. Morethan5years

2. Which of the following best describes your current professional status?A. Anesthesiologyresidency(PGY2,3,4,orCA-1,-2,or-3)B. Anesthesiologyfellowship(PGY5orabove)C. Staff anesthesiologistD. Other(non-anesthesiology)residencyorfellowshipE. Other(non-anesthesiologist)staff physician

3. Which of the following is your primary clinical area?A. Intraoperative anesthesiaB. Postoperative critical careC. CardiologyD. Surgery

4. How many echocardiograms do you currently perform and interpret each week?A. NoneB. Less than 3C. 3-5D. 6-10E. Morethan10

5 How would you describe your dedicated training in echocardiography?A. No dedicated trainingB. DuringPGY1,2,or3years(Internship,CA-1,orCA-2)C. DuringPGY4(CA-3)D. DuringPGY5orlatertrainingyears(FellowshipinCardiacAnes-

thesia,orCriticalCareMedicine,orothertrainingprogram)E. During time off from clinical practice

6. How long was your dedicated training in echocardiography?A. No dedicated trainingB. Less than 3 monthsC. 6 monthsD. 6 - 12 monthsE. Morethan1year

7. IhavepreviouslytakenthePTEeXAM.

q Yes Date__________________________q No

8. q  I am North American Trainedq  I am Non-North American Trained

Note: If you are Non-North American trained all documentation must be supplied in English. If original documentation is not in English,acertifiedtranslationmustbeattachedtoeachdocument.

9. Where did you graduate from medical school?A. UnitedStatesB. CanadaC. Other

10. What year did you graduate from medical school?A. Prior to 1991 B. 1991 - 1995C. 1996 - 2000D. 2001 - 2005E. 2006 or later

11. In which of the following settings do you spend most of your time?A. Community hospitalB. UniversityhospitalC. VeteransAffairshospital

12.Icompletedorwillcomplete12monthsClinicalTraining/Fellowshipdedicated to the perioperative care of surgical patients with cardiovas-cular disease at the following institution:

Institution ______________________________________________

Director _______________________________________________

DateTrainingCompleted(mm/dd/yy) ________________________

13.IcompletedorwillcompleteFormalEchocardiographyTrainingatthe following institution:

Institution ______________________________________________

Director _______________________________________________

DateTrainingCompleted(mm/dd/yy) ________________________

Mail, UPS, or FedEx completed application, check list, documenta-tion and payment to:

The National Board of Echocardiography, Inc.® 1500 Sunday Drive, Suite 102 Raleigh, North Carolina 27607

Make checks payable to National Board of Echocardiography, Inc.® or NBE.

FAXED, SCANNED, LATE, OR UNSIGNED APPLICATIONS WILL NOT BE ACCEPTED.

INCOMPLETE APPLICATIONS WILL NOT BE REVIEWED BY THE CERTIFICATION COMMITTEE.

To contact our office: Phone:(919)861-5582 E-mail: info@echoboards.org Web site: www.echoboards.org

Note: It is the responsibility of the applicant to verify that all re-quired documentation is attached to the application. The applicant is also responsible for verifying that notarized letters are correct and in the required format.

Please check our website at www.echoboards.org for future application deadlines.

Application for Advanced PTE Board Certification (continued)

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ChecklistNational Board of Echocardiography, Inc.®

Advanced PTE Board Certification

(Complete application on pages 9-10 and submit with documentation.)

Name ___________________________________________________________________________________________________________________ Last/SurnameFirst(FullName)Middle(FullName)

SocialSecurityNumber(last4digits)_________________________________________________Dateof Birth ______________________________

Please check one: q Allrequireddocumentationprovided. q Requireddocumentationtobemailedatalaterdate.

__Requirement 1 EnterYearExamPassed:__________

(If takingAdvancedPTEeXAMin2015enter2015)

__Requirement 2 Copyof CurrentMedicalLicenseRenewalCertificatethatshows

expirationdate.EnterExpirationDate:__________

__Requirement 3 Copyof HighestSubspecialtyMedicalBoardCertificate

__Requirement 4SupplyONEof theFollowing:

FellowshipPathway:

- Acopyof acertificateof successfulcompletionof fellowshiptraining dedicated to the perioperative care of surgical patients with Cardiovascular Disease,

- A notarized letter on appropriate letterhead from the hospital or appropriate departmental Training Director, e.g. Residency Program Director,theFellowshipTrainingDirector,Directorof Cardio-thoracic Anesthesiology, Cardiothoracic Surgery, or Cardiology, Chairsof Anesthesiology,MedicineorSurgery,ortheMedicalDirector of Echocardiography Laboratory stating the applicant has completedfull12monthsof clinicaltrainingdedicatedspecificallyto the perioperative care of surgical patients with Cardiovascular Disease. This letter must document the inclusive dates of the training,aswellastheACGMEprogramnumber.Asummaryof the training program activities is recommended. (See Letters Docu-menting Training and/or Level of Service: Page 5 and for Sample Letterseepage12)

OR

PracticeExperiencePathway:

Note: It is the responsibility of the applicant to verify that all required documentation is attached to the application. The applicant is also responsible for verifying that notarized letters are correct and in the required format.

RETURN THIS CHECKLIST WITH APPLICATION AND DOCUMENTATION TO: National Board of Echocardiography, Inc.®, 1500 Sunday Drive, Suite 102, Raleigh, NC 27607

- A notarized letter on appropriate letterhead from the hospital or appropriate departmental Training Director verifying the number of monthsof clinicalexperiencededicatedtotheperioperativecareof surgical patients with cardiovascular disease, and the number of patients to whom perioperative care was personally delivered by the applicantforeachof thetwo(2)yearsimmediatelyprecedingtheapplication. (See Letters Documenting Training and/or Level of Servicepage5andforSampleLetterseepage13)

__Requirement 5Supervised Training Pathway:- A notarized letter on appropriate letterhead from the hospital or

appropriate department Training Director verifying completion of trainingand/orexperienceinperioperativetransesophagealecho-cardiography and the number of comprehensive intraoperative TEEexaminationspersonallyperformed,interpretedandreportedandthenumberof completeexaminationsreviewedwithsupervi-sionbythetrainee.(ForSampleLetterseepage12)

- Logitemizingeachexaminationstudiedbutnotperformedbytheapplicant including the date reviewed, the diagnosis, surgery per-formed,andthesupervisingfaculty/staff withwhomthefindingswerediscussed.(SeeSampleCaseLogseepage14)

Note: Do not include any patient information on the log. Logs received with patient information will be returned to the applicant. Only include date reviewed, diagnosis, surgery performed, and with whom the findings were discussed.

ORPracticeExperiencePathway:- A notarized letter on appropriate letterhead from the hospital or ap-

propriate department Training Director verifying the number of com-prehensive transesophageal studies performed on surgical patients for eachof thefour(4)yearsprecedingthisapplication(ForSampleLetterseepage13)

AND- Acopyof certificate(s)ordocumentationfromtheinstitution

providingCMEcreditsdocumenting50hoursof AMAcategory1CMEdevotedtoechocardiographyobtained during the time the physician is acquiring the requisite clinical experience in TEE.Formeetingsnotdevotedonlytoechocardiography,appli-cantsmustindicateonthecopyof thecertificatehowmanyhourswere devoted to echocardiography.

12

Sample Letter

ABC Hospital123 Main Street • New York, NY 54321 • (212) 123-5432

Date

National Board of Echocardiography, Inc.® 1500 Sunday Drive, Suite 102 Raleigh, NC 27607

RE: Physician’s Full Name Physician’s Date of Birth Physician’s Social Security Number (last 4 digits) ACGME Program Number

ToWhomItMayConcern:

REQUIREMENT 4 ThisletterconfirmsthatDr.____________________successfullycompletedaminimumof 12monthsof clinicalfellowshiptrain-ing dedicated to the perioperative care of surgical patients with cardiovascular disease at our institution between _______________ and _______________.Thisletterfurtherconfirmsthatfellowshiptrainingwasobtainedataninstitutionwithanaffiliationwithanaccreditedcore residency program.

REQUIREMENT 5 Ourrecordsindicatethat__________hadspecifictraininginPerioperativeTransesophagealEchocardiographyandpersonallyperformed,interpreted,andreported__________comprehensiveintraoperativeTEEexaminationsunderappropriatesupervision.Inaddition,__________ studied under appropriate supervision, but did not perform __________ studies for a total of __________ complete intraop-erativeTEEexaminations.Thesestudiesincludeawidespectrumof cardiacdiagnoses.

Icertifythatthenumberof studiesprovidedaboveareexactnumbersandarenotroundedand/orestimates.

Sincerely,

Name Title (Residency Program Director, Fellowship Training Director, etc.)

Sworn and subscribed to before me on (date): ____________________________________

_______________________________________________________________________ Signature of Notary Public

NOTE: *The EXACT number of studies performed and interpreted MUST be provided. Applications containing approximated and/or rounded numbers will no longer be reviewed by the Certification Committee. Letters MUST be typed on appropriate letterhead and MUST be notarized.

John Doe

(name)(beginning date)

(ending date)

(he/she)

(he/she) (#) (#)(#)

Notary Seal

Advanced PTE Board Certification For Physicians who completed 12 month clinical fellowship dedicated to the

perioperative care of surgical patients with cardiovascular disease (Requirements 4 and 5) Letters must be submitted in this format.

13

XYZ Hospital123 Main Street • New York, NY 54321 • (212) 123-5432

Date

National Board of Echocardiography, Inc.® 1500 Sunday Drive, Suite 102 Raleigh, NC 27607

RE: Physician’s Full Name Physician’s Date of Birth Physician’s Social Security Number (last 4 digits)

ToWhomItMayConcern:

REQUIREMENT 4 ThisletterconfirmsthatDr.____________________isaphysicianpracticinginourhospital.Ourrecordsindicatethat__________has__________monthsof clinicalexperiencededicatedtotheperioperativecareof surgicalpatientswithcardiovasculardiseasebetween__________________ and _____________________________.

Our records indicate that __________ personally delivered perioperative care to __________ patients with cardiovascular disease in 2013 and __________ patients with cardiovascular disease in 2014.

REQUIREMENT 5 In addition our records indicate that __________ performed and interpreted the number of comprehensive perioperative transesophageal echocardiograms per year as follows:

(2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 ### ### ### ### ### ### ### ### ### ###

Icertifythatthenumbersof studiesprovidedaboveareexactnumbersandarenotroundedand/orestimatesandthatatleast150of theperioperative transesophageal echocardiograms performed and interpreted were intraoperative.

Sincerely,

Name Title (Director of Cardiothoracic Anesthesiology, Cardiothoracic Surgery, Medical Director of the Echocardiography Laboratory, President, CEO, etc.)

Sworn and subscribed to before me on (date): ____________________________________

_______________________________________________________________________ Signature of Notary Public

NOTE: *The EXACT number of studies performed and interpreted MUST be provided. Letters documenting training MUST be typed on appropriate letterhead and MUST be notarized. The numbers provided must be in parallel, concurrent years but need not be calendar years. The end of the most recent year for which credit is requested must fall within the 12 months prior to receipt of the complete application.

Sample Letter

Jane Smith

(name)

(date of employment) (end of employment or current date)

(he/she)

(he/she)

(*#)

(*#)

Notary Seal

(*#)

(he/she)

Advanced PTE Board Certification Practice Experience Pathway (Requirements 4 and 5)

Letters must be submitted in this format.

Supervisor/Faculty/Staff Number Date Reviewed Diagnosis Surgery Performed With whom findings discussed

1

2

3

4

5

(continue numbering)

Requirement 5

For Physicians who completed 12 month clinical fellowship dedicated to the perioperative care of surgical patients with cardiovascular disease or who are using Supervised Training Pathway

Supervised Training Perioperative Transesophageal Echocardiography Examinations Studied but NOT performed

DO NOT INCLUDE PATIENT INFORMATION

The Log of Cases Studied but NOT Performed Must Be in This Format

Physician’sFullName _______________________________________________________________________________________________________Physician’s Date of Birth ____________________________________________________________________________________________________Physician’sSocialSecurityNumber(last4digits) __________________________________________________________________________________

Sample Case Log

• •

National Board of Echocardiography, Inc.® 1500 Sunday Drive Suite 102

Raleigh, NC 27607

FIRSTCLASS PRESORTED USPOSTAGE

PAAID PERMIT#1854 RALEIGH, NC