CMTA Center of Excellence Application

CMTA Center of Excellence Application

Institution (e.g., university, hospital, clinic):

Director's Name(required):

Director's Email:

Director's Phone:

Name of Person Filling Out Form (If other than director):

Email of Person Filling Out Form (If other than director):

Phone Number of Person Filling Out Form (If other than director):

Have you been trained in neurology? If yes, when and where?

Have you done a neuromuscular fellowship? If yes, when and where?

How many CMT patients have you seen clinically in the past 18 months?
01234567891011 or more

Are you a member of the Peripheral Nerve Society (PNS)?
YesNo

Do you attend the annual meetings of the Peripheral Nerve Society?
YesNo

Is your center multi-disciplinary?
YesNo

If yes, what other CMT specialists do you have on staff?

Adult/Pediatric?
Adult OnlyPediatric OnlyBoth Adult and Pediatric

Are you accepting new patients?
YesNo

What are your goals in becoming a CMTA Center of Excellence?

Will you or one of your team members be able to attend an annual CMTA-hosted meeting (most likely virtual) with the other Center of Excellence neurologists?
YesNo

Are you willing to participate annually in a short survey and answer questions about patient statistics?
YesNo

Are you willing to get involved with the local CMTA branch?
YesNo

As a CMTA Center of Excellence, we ask that you give out packets of CMTA information to your patients. Are you willing to do this?
YesNo

Are you willing to have a CMTA volunteer come into clinic to hand out CMTA information packets?
YesNo

Please provide a reference (name and contact information - phone/email) that a member of the CMTA’s Clinical Expert Board can reach out to in regard to your experience and background in the field of CMT:

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