North Carolina Chapter of the American College of Physicians, P. 3

North Carolina Chapter of the American College of Physicians, p. 3

Application – Education Innovation Grant Program 2017-2018

Application

NC-ACP Education Innovation Grant Program 2017-2018

Section I

Project Lead: / Credentials: MD, DO,
Male Female / Date of birth: / NC medical license no.:
Preferred mailing address ( business or home) / City, State, Zip / Business Telephone
Preferred email / Fax / Cell Phone
Current residency program or medical school / Est. project completion date
Residency Program Director or Medical Student Clerkship Director / Director’s phone / Director’s email
Department Coordinator / Coordinator’s phone / Coordinator’s email
Additional Project Team Members
Name / Credentials / Email address
MD, DO,
MD, DO,
MD, DO,
MD, DO,

Section II – Details of the proposal

Project Title
Outline of the problem (Why is this topic important? Why are you interested in studying this topic?)
Project summary (What are the planned interventions? What are your anticipated results? What do you hope to achieve?)
How does this project relate to the NC ACP Chapter’s long-term strategic goals (check all that apply)
Delivery of Quality Patient Care
Reform of Health Care Delivery System
Excellence in Education
NC Chapter, ACP: Leader and Unifier of the Internal Medicine Community in North Carolina
Time schedule: The grant period is from July 2017 through January 2019. Following the grant period, any unused project funds shall be returned to the NC ACP.
Grant amount requested (max $2500)
$

Section III

Personal Statement: Please indicate how this grant, if funded, will help your career development. Outline your expected career path and how this aligns with the NC ACP Education Innovation Grant Program objectives and criteria. (500 words max.)

Section IV – Detailed anticipated budget for proposed project period

Personnel / Amount
Name or entity / Role in project
Total cost for personnel / $
Material & Supplies / Amount
Devices, equipment, extension to existing equipment, material rental, supplies, etc.
Total cost for material / $
Other Expenses / Amount
Itemize below
Total cost for other expenses / $

Section V

If selected for participation in the program, the grantee agrees to the record keeping and reporting requirements as outlined in the program overview, and to conduct herself/himself professionally according to the principles of medical ethics, and to be governed by the Bylaws of the North Carolina Chapter of the American College of Physicians.
Applicant’s signature: / Date:
Program Director’s signature: / Date:

To be considered for the 2017-2018 grant year, submit the following by June 30, 2017:

1.  Completed application form

2.  Primary applicant’s CV

3.  Completed W-9 form of the recipient organization (IRS W-9)

Submit by email, mail or fax to:

NC-ACP, PO Box 27167, Raleigh, NC 27611 | Fax: 919-833-2023 |