AAAHC Surveyor Part-time Employee Application
It is the policy of this organization to provide equal opportunity to all employees and applicants without discrimination
based on race, color, sex, national origin, religion, marital status, disability, Vietnam veteran status, age, sexual orientation
or other conditions specified in Title VII of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and
the Vietnam Era Veterans Readjustment Assistance Act of 1974.
Instructions
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You can type your responses on the form. Place your cursor on the gray boxes and type as much text as necessary.
Click on the gray outlined boxes for check-marked answers. Use the Tab key to move to the next field.
OR, you can print the form and write in your responses.
We do need your actual signature on the last three pages of the form.
If more space is needed, please attach additional sheets and reference the question being answered.
Submit your application to Julie Haugh, Assistant Director, Surveyor Services, as follows:
• Mail: 5250 Old Orchard Road, Suite 200, Skokie, IL 60077
• Fax: 847-324-7716
• Email: [email protected]
AAAHC’s phone number is 847-853-6060.
Be sure you meet the required qualifications shown below before completing and submitting the
application.
Required Qualifications
• Must be an actively practicing health care professional employed or privileged by an ambulatory health care
organization.
• Must have current or prior direct involvement with the accreditation process in an ambulatory health care organization
accredited by AAAHC.
• Applicants for the AAAHC surveyor position are required to possess a minimum of a bachelor’s degree unless:
1. The applicant has clinical training such as an RN; and/or
2. The applicant is a licensed healthcare professional.
Computer Skills and Usage Required
Surveyors must provide their own laptop computers and be proficient at using them. AAAHC sends a majority of its
communications to surveyors via email, which must be accessed on a continuous basis. In addition, survey reporting is done
electronically and ongoing surveyor education requires viewing webinars and completing quizzes on a computer.
Desired Qualifications
• Clinical credentials
• Graduate or other advanced degree
Surveyor Requirements – make sure you can meet these before submitting an application
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Surveyors are required to conduct a minimum of two surveys per calendar year, comprising approximately three days
per survey including travel and report completion.
Surveys are conducted around the country and, in most cases, travel is required.
Surveyors are required to attend a Surveyor Retraining program every two years.
Surveyors must have regular access to email.
Survey Reports are completed electronically. Surveyors must provide their own laptop computers or tablets, and be
proficient at using them.
Version: 2017
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Documents to Submit with the Application
All applicants
Completed application, including your signature of pages 12-14
Current curriculum vitae or resume or, as applicable, a complete practice and/or job history
A written statement describing why you would like to become a surveyor for AAAHC
How did you hear about this opportunity to become a surveyor?
Have you applied previously for this position?
No
Yes: when?
All health care practitioners – all of the above PLUS:
Current copy of the results of an NPDB Self-Query
• Required of all applicants, including RNs, whom the law would require be reported to the NPDB in the case of an
adverse action, even if the applicant is not currently providing direct patient care.
• Go to www.npdb-hipdb.hrsa.gov and click on “Start a Self-Query.”
• If your employer has queried the NPDB and has a current copy of your results (within the past 90 days), you may
send a copy of that; it does not have to be a SELF-query as long as it is current.
Check here if you have not treated patients for more than 5 years, or have never treated patients.
If so, the NPDB report is not required.
Current copy of state medical or nursing license and any other state licenses (if applicable).
Check here if not applicable
Current copy of Medical Malpractice cover sheet. Check here if not applicable
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Identifying information
Today’s date:
Nickname:
First name:
Last name:
Home information - check here if you want AAAHC to use this as your primary contact information:
Address:
City:
State:
County:
Phone number:
Zip:
Home email:
Is this:
Home
Cell
Nearest airport:
If you are not a U.S. citizen, do you have authorization to work in the U.S.?
Yes
No
N/A
If no, please explain:
Business information.:
Check here if you want AAAHC to use this as your primary contact information:
Organization name:
Organization type (e.g., ASC, student health, medical group practice, etc.):
Organization specialty (e.g., endoscopy, ophthalmology, multi-specialty, family practice):
Your current position:
Address:
City:
Office phone:
Version: 2017
State:
Zip:
Office email:
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If the organization(s) for which you work is accredited, please indicate the accrediting organization(s):
AAAHC
HFAP
JCAHO
Other:
Applicants are required to demonstrate direct involvement with the AAAHC accreditation process in an
accredited ambulatory health care organization.
How many years of experience do you have with the AAAHC accreditation process?
Please describe how you meet this requirement:
Primary hospital affiliation - check here if not applicable:
Name of hospital:
Department:
Address:
City:
Specialty:
State:
Zip:
Status:
Start date (month/year):
Reappointment date (month/year):
Military experience - check here if not applicable:
Branch of service:
Rank:
Length of service: From (year):
To (year):
Licensure - check here if not applicable:
Check all that apply):
MD
APRN – indicate specialty:
DO
________
DPM
RN
DMD
RPh
DDS
Other:
State License number:
State:
Issue date:
Expiration date:
State License number:
State:
Issue date:
Expiration date:
Version: 2017
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Board Certification - check here if not applicable:
Certifying Board:
Original Certification Date (month/year):
Certification Expiration Date (month/year):
Sub-specialty:
Original Certification Date (month/year):
Certification Expiration Date (month/year):
If you have additional board certifications, please make a copy of this page, complete the Board
Certification section and attach to this application.
Other Licenses, Certifications and Fellowships
Please indicate any other certifications (e.g., CASC, CIC, CPHQ), licenses (e.g., LHRM) or fellowships (e.g.,
FACS, FACMPE) that you hold. Do NOT include advanced degrees in this section; instead, include them under
the “Education” section or list them on your resume/curriculum vita. If the designation is not commonly known
outside of your specialty, please include a full description of the designation.
Designation (e.g., LHRM)
Description (e.g., Licensed Healthcare Risk Manager)
Professional Liability Insurance
If you do have liability coverage, as noted on page 1, please attach the Medical Malpractice Face Sheet.
If you do not have this coverage, please explain why:
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Education
Graduate, professional and/or medical school
Institution name:
City:
State:
Start date (month/year):
Degree awarded:
Completion date (month/year):
Foreign medical school graduates: Attach a copy of ECFMG Certificate (if applicable)
Postgraduate training
Check one:
Internship
Residency
Fellowship
Other training
Institution name:
City:
State:
Start date (month/year):
Check one:
Internship
Degree awarded:
Completion date (month/year):
Residency
Fellowship
Other training
Institution name:
City:
State:
Start date (month/year):
Degree awarded:
Completion date (month/year):
Undergraduate education
Institution name:
City:
Start date (month/year):
Version: 2017
State:
Degree awarded:
Completion date (month/year):
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Work history
Starting with your current position, list all employment for the past 5 years. All gaps greater than 6 months
require an explanation. To facilitate the credentialing process, please fill in month and year.
Practice/Employer
City
State
From Month/Year
To Month/Year
/
/
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/
/
/
/
Is your current practice or employment (select all that apply):
With an ambulatory health care facility?
With an organization that owns, operates and/or manages ambulatory health care facilities?
With an organization that provides consulting services to ambulatory health care facilities?
Other – please explain:
Which of the following best describes your involvement with fee-for-service consulting activities (check all
that apply)? Fee-for-service is defined as consulting that results in a customer paying you directly for your
services (if self-employed) or paying your employer for your services (if employed by a consulting organization).
I am not involved with fee-for-service consulting of any sort
I am self-employed as a consultant on a full-time basis
I am self-employed as a consultant on a part-time basis
I provide consulting services through my full-time employment with an organization that provides
consulting services
I provide consulting services through my part-time employment with an organization that provides
consulting services
Other – please describe:
If you are involved with fee-for-service consulting activities, are any of your consulting activities related to
helping organization prepare for accreditation?
Question does not apply because I am not involved with fee-for-service consulting activities
No
Yes – please describe these consulting activities:
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Peer references
Do you currently work with an active AAAHC surveyor?
No
Yes – Name:
Name three peer references who have current knowledge of your clinical and work abilities, ethical character,
and ability to work cooperatively with others. Please complete all contact information.
Reference 1
Name:
Phone:
Credential(s):
Fax:
Address:
Email:
City:
State:
Zip:
State:
Zip:
State:
Zip:
Reference 2
Name:
Phone:
Credential(s):
Fax:
Address:
Email:
City:
Reference 3
Name:
Phone:
Address:
Version: 2017
Credential(s):
Fax:
Email:
City:
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Surveyor privileges
To help provide a peer-based review for all AAAHC surveys, please check your current and any additional
organization types and specialties with which you have experience. Note that there are categories for surgical,
non-surgical and additional specialty areas.
Surgical and Procedural Experience in an Ambulatory Surgery Center - Check all that apply:
Anesthesiology
Bariatric Surgery
Cardiac catheterization
Cardiology
Cosmetic Surgery
Dentistry
Dermatology
Diagnostic imaging
Facial Plastic & Reconstructive Surgery
Gastroenterology
General Surgery
Gynecology
In-vitro Fertilization
Lithotripsy
Neurology
Neurosurgery
Obstetrics
Ophthalmology
Oral/Maxillofacial Surgery
Orthopaedic Surgery
Otolaryngology
Pain Management
Podiatry
Plastic Surgery
Radiation Oncology
Radiology
Urology
Other:
Please provide a brief description of your experience in each area checked above, including number of years of
experience in each setting:
Non-surgical/Primary Care Experience
Settings
Behavioral Health Center
Dentistry
Community Health Center
Emergency Services
Health Plans
Indian Health Center
Medical Group Practice
Medical Home
Medical Oncology Center
Military Health Clinic
Occupational Health Center
Retail Care Center
Student Health Center
Urgent Care Center
Other:
Please indicate related specialties in your selected settings
Behavioral Health
Dentistry
Emergency Medicine
Family Medicine
Gynecology
Internal Medicine
Medical Oncology
Obstetrics
Occupational Medicine
Ophthalmology
Pediatrics
Podiatry
Radiology
Other:
Please provide a brief description of your experience in each area checked above, including number of years of
experience in each setting:
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Other Areas of Expertise:
Administration:
ASC
Endoscopy
Group Practice
Electronic Health Records (EHR)
Health Education/Promotion
Infection Prevention and Control
Life Safety Code Requirements for ASCs
Medicare Conditions for Coverage (CfC) for ASCs
Quality Management and Improvement
Risk Management
Other:
Medical
Nursing
Other:
Please provide any additional information regarding your background and experience in ambulatory practice
settings that may be useful in determining your privileges as a surveyor for the AAAHC:
Survey and travel information
Indicate any day(s) of the week on which you are NOT available to perform surveys:
Monday
Tuesday
Wednesday
Thursday
Friday
Surveys generally require up to 3 days of time, including the survey itself, travel time and completing the survey
report. Surveys can be scheduled throughout the U.S.
How many SURVEYS do you anticipate being able to commit to on an annual basis?
Do you have any limitations that may impact flexibility in travel, i.e., prefer not to fly, distance limitations, etc.?
No
Yes - if yes, please explain:
Please indicate any issues you feel may impact your ability to perform surveys:
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Confidential professional information
Please answer Yes, No or N/A for all questions. If you answer Yes to any of the questions, please provide an
explanation on the following page and include any additional documentation.
• Has your license to practice in any jurisdiction ever been denied, restricted,
limited, suspended (even if the suspension was stayed) or revoked, either
voluntarily or involuntarily?
• Have any complaints/adverse action reports been filed against you with a State
Medical Society, Licensure Board or the National Practitioner Data Bank?
• Has your professional liability insurance coverage ever been denied, canceled,
reduced, limited, not renewed or terminated by action of an insurance company?
• Have any professional liability suits ever been filed against you?
• Have any judgments or settlements been made against you in professional
liability cases?
• Are there any claims pending?
• Have you ever been reprimanded, disciplined, counseled or been subject to
similar action by any state licensing agency with respect to your license to
practice?
• Have you ever been denied hospital privileges or have you ever had any hospital
privileges revoked, suspended (even if the suspension was stayed), reduced or
nonrenewed?
• Have you ever voluntarily relinquished or voluntarily limited any hospital
privileges?
• Have any disciplinary proceedings ever been instituted against you, or are any
disciplinary actions now pending with respect to your hospital privileges or your
license?
• Have you ever received sanctions from a regulatory agency (i.e., CLIA, OSHA,
etc.)?
• Has your board certification ever been suspended or revoked?
• Have you ever been denied certification/recertification, or has your eligibility
status changed with respect to certification/recertification by a specialty board?
• Have you ever been denied, reprimanded, censured, excluded, suspended (even
if the suspension was stayed), debarred or disqualified from participation in
Medicare, Medicaid or any other governmental or quasi-governmental healthrelated program?
• During your internship, residency or fellowship, were you ever suspended,
placed on probation, formally reprimanded, asked to resign, or otherwise not
complete a program?
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
If you answered yes to any of these questions, please provide an explanation below or attach a detailed
explanation.
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Release
I would like to conduct surveys for the AAAHC. I acknowledge that should my application be accepted, I will be
required to participate in a minimum of TWO AAAHC accreditation surveys each calendar year, constituting a
commitment of approximately six days per year. In addition, I understand that for any Medicare Deemed Status
survey that I perform, AAAHC must permit a surveyor to serve as witness if the Centers for Medicare &
Medicaid Services (CMS) takes an adverse action based on accreditation findings of this survey (42 C.F.R.
488.4(b)(3)(v)), and I, therefore, agree to serve as said witness, upon request of AAAHC or CMS.
I hereby certify that the information provided on this application is complete and accurate. I agree to notify
AAAHC of any changes. I authorize AAAHC and its agent to pursue and secure any additional information
pertaining to the verification of information provided in this application.
We require your signature. Please sign below and email, mail or fax this page to 847-324-7716 (you can
email, fax or mail the rest of this form to AAAHC).
Name:
Date:
Signature:
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AAAHC Surveyor Confidentiality and Conflict of Interest Policy
As a surveyor employee and representative of AAAHC, I understand my first and foremost priority when conducting surveys on
behalf of AAAHC is to be an ambassador of AAAHC, an objective fact finder, a reporter of personal observations, as well as an
educator and consultant when appropriate.
In fulfilling this role, I understand that the sole reason I am sent on a survey is to conduct AAAHC business in a professional
manner with integrity and objectivity. Further, it is understood that I remain a representative for AAAHC with the understanding
that under no circumstances may I solicit personal business, or take part in any activities which appear to be in furtherance of any
of my own personal, entrepreneurial endeavors. Surveyors are not to discuss any consulting activities with anyone connected to a
survey until the accreditation decision for that survey has been rendered. It is also understood that all information, including but
not limited to, non-public information submitted on a confidential basis by parties seeking accreditation, schedule lists for future
site visits, survey reports, reports of the internal proceedings and deliberations of AAAHC’s standing and ad hoc committees,
interviews, reports, statements, memoranda and other data used in the course of business are to remain strictly confidential and
will not be disclosed to any other party. To maintain the confidentiality of survey reports, surveyors are not permitted to allow
non-surveyors, or surveyors not assigned to a particular survey, to enter findings from that survey into SurveyLink or other survey
documents such as worksheets.
If I am selected by AAAHC to become a surveyor, I acknowledge that by virtue of my relationship with AAAHC I may obtain or
come into contact with the confidential and proprietary methodologies and techniques (“Confidential Information”) of AAAHC,
of AAAHC subsidiaries, and of AAAHC affiliates, including any program operated or managed by AAAHC or a AAAHC
subsidiary or affiliate, I agree (i) that during the course of my relationship with AAAHC, I shall not conduct nor perform any
activity on behalf of, nor enter into any arrangement or agreement with, any other accreditation organization or any other entity
conducting activities competitive with the activities of AAAHC, AAAHC subsidiaries, AAAHC affiliates, or any program
operated or managed by AAAHC or a AAAHC subsidiary or affiliate (such accreditation organization or entity conducting
competitive activities is referred to herein as a “Competitor”); (ii) not to disclose at any time any portion of such Confidential
Information, either directly or indirectly, to any Competitor or other third party, including that I may not serve as an expert
witness with regard to any aspect of the AAAHC, including but not limited to standards, surveyors and survey processes; and (iii)
that AAAHC may declare me ineligible to conduct surveys, or continue to act as a surveyor, on behalf of AAAHC because of my
relationship with any Competitor, and that such determination is based upon AAAHC’s interest in protecting its legitimate
business interests.
I agree, in good faith:
• To refrain from any activities during the conduct of an AAAHC survey that may be construed as solicitation.
• That I will not undertake any consultative business for personal profit, with any organization for which I have conducted an
accreditation survey, for a period of three years following that survey unless the consultative activity is scheduled or approved
by the AAAHC.
• That for a period of six years after acting as an independent consultant to an organization, I will not perform an accreditation
survey of that organization.
• To refer all questions from organizations that I survey regarding consultants and consultative services to the AAAHC.
I also understand that AAAHC policy and practice warrants that surveyors decline from participating in any surveys of
organizations which may be in direct competition with the surveyors’ business interests, or which bear any significant beneficial
interest to the surveyor or any member of the surveyor’s immediate family. Further, I agree to disclose to AAAHC any personal
relationships I have with known current or recent past (within three years) staff of organizations that I am volunteering to survey
or am asked to survey, so that AAAHC may determine if a conflict of interest exists. If I learn of any type of potential conflict
after accepting a survey assignment, I agree to disclose the potential conflict to AAAHC as soon as I am aware of it.
I have read this statement in its entirety, and I agree to all provisions described herein.
We require your signature - please sign below and fax, email or mail.
Name:
Version: 2017
Date:
Signature:
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Equal Opportunity/Affirmative Action Information
It is the policy of this organization to provide equal opportunity to all employees and applicants without
discrimination based on race, color, sex, national origin, religion, marital status, disability, Vietnam veteran
status, age, sexual orientation or other conditions specified in Title VII of the Civil Rights Act of 1964, Section
504 of the Rehabilitation Act of 1973, and the Vietnam Era Veterans Readjustment Assistance Act of 1974.
The information requested below is voluntary and will be kept confidential.
Date:
First and Last Name:
Check one:
Male
Female
Check one:
White (not Hispanic or Latino)
Asian
Black or African American
Hispanic or Latino
American Indian or Alaskan Native
Native Hawaiian/Pacific Islander
Two or more races
Check if any of the following applies to you:
Vietnam Era Veteran
Disabled Veteran
Referral Source – check any of the following that may apply to you:
Newspaper or newsletter advertisement or article
Surveyor referral
AAAHC website
Other (please specify):
Applicant Signature:
Version: 2017
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