DWEP Short Form Application
Developing World Education Program: Short Form Application – Faculty Airfare Only
Thank you for your interest in the International Parkinson and Movement Disorder Society's (MDS) Developing World Education Program. The goal of the Developing World Education Program is to support a local movement disorders education meeting/ course happening in an underserved area by providing a grant to fund MDS faculty participation and/or other meeting costs as approved by MDS. For more information on the policies, requirements, and structure of the Program, please see the Developing World Education Program Policies and Procedures available on the MDS website.
Please review the following eligibility checklist before proceeding with the application:
□Waived dues eligibilitycountry. (Visit MDS website)
□City/Country for the program is not on the list of U.S.travel warnings.
□Faculty requested represent different institutions.
□Program content will be MDS focused.
□The same host applicant or institution should not have had an Outreach Program (DWEP, VPP or Ambassador) within the past calendar year.
This Short Form Application is intended to facilitate participation of from one – four approved MDS faculty at an education activity by sponsoring airfare (or ground transportation, if appropriate) to the activity. MDS willsupport the cost of business class airfare for faculty to and from the host country if these flights equal or exceed six hours. If the flights are under six hours, faculty will receive economy class flights. MDS payment of airfare costs will be made directly to the faculty upon completion of the course. If an MDS-designated travel agent is used, payment will be made directly to that agent.
If you would like to apply for support for additional aspects of a meeting beyond faculty airfare please complete the Developing World Education Program - Long Form Application available on the MDS Outreach Education website.
Applicant Contact InformationApplicant/Primary Organizer Name:
Applicant Academic/Professional Affiliations:
Hospital/Host Institution Name:
Street Address:
City: / State/Province:
Postal Code: / Country:
Phone (Include Country Code): / Fax:
E-mail Address:
Proposed Activity Information
Please summarize the factors that qualify your meeting for the Developing World Education Program. See the Program Guidelines for reference. May also be submitted as a separate attachment.
Official title of the meeting at which the MDS faculty will be speaking:Location of the meeting(must not be on the list of US travel warnings):
Please provide date(s) of the meeting:
How often is the meeting held?
Once Monthly Annually
Other (please explain):
Will continuing education credit be offered for this meeting? / YES NO
If yes, which type of credit? (CME, CPD, Nursing):
May MDS have one-time access to a post meeting mailing or e-mail list? / YES NO
May MDS provide handouts/bag inserts for each meeting participant? / YES NO
Program Audience Information
Please identify the target audience of the Developing World Education Program you are proposing:
General Neurologists Primary Care Physicians Post-Doctoral Fellows
Physicians in Training Researchers Nurses/Health Professionals
Other:
Language and Course Design
Language in which the program will be presented:Will translation of program materials be necessary? / YES NO
Will an interpreter be required? / YES NO
Anticipated number of program participants:
25-50 75-100 100-200 Other:
Will the Virtual Professor Program be used?
*If selected please read and complete the Virtual Professor Program Technology Summary at the end of this application and also specify what part of your course program will be completed using a Virtual Professor Program Webinar / YES NO
MDS International Parkinson and Movement Disorders Curriculum
With this application you may also choose to apply for use of the MDS International Parkinson and Movement Disorders Curriculum (PMDC) to supplement the lectures of your meeting. The PMDC is an overview of movement disorders and a clinical approach to the evaluation and management of common movement disorders. This curriculum is specially developed for trainees, internists, general neurologists and other clinicians interested in acquiring a basic understanding of movement disorders.
Some additional fees may apply for use of the PMDC. For more information please contact MDS Education or visit the BMD website:
I would like to apply to use the entire curriculum I plan to translate the slides into ______language
I would like to apply to use the following topics:
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DWEP Short Form Application
Basal ganglia anatomy and physiology
Phenomenology of Movement Disorders
Etiology and pathogenesis of Parkinson's disease
Diagnosis and differential diagnosis of Parkinson's disease
Management of early Parkinson's disease
Management of Advanced Parkinson's disease
Tremor
Dystonias
Chorea, athetosis and ballism
Myoclonus
Gait disorders
Restless legs syndrome and movement disorders in sleep
Management of MSA, PSP, and CBGD
Tics and Tourette Syndrome
Drug-Induced Parkinsonism (DIP)
Psychogenic Movement Disorders
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DWEP Short Form Application
MDS Faculty Information
If you would you like to recommend a movement disorders speakerfrom your region ideally suited to address the educational needs of your proposed program in the preferred language of the target audience, you may do so here. This recommendation will be evaluated among other potential regional candidates.As per the Developing World Education Program Policies and Procedures, when more than one faculty is sponsored, not more than one half of sponsored faculty may come from beyond the region in which the event takes place. Suggested MDSfaculty members must represent different institutions.No academic or financial relationship should exist between the suggested MDS faculty and the Host organization.
Does your organization have an academic/financial relationship with the suggested faculty?
YES NO
Does suggested faculty require a visa for travel to the location of the meeting? If yes, please ensure there is enough time to arrange for required visas.
YES NO
A one-day meeting may choose to invite up to two MDS faculty.
Suggested Faculty 1Name: / Designation (i.e. MD, DO, PhD)
Company/Organization Name:
City: / Country:
E-mail Address: / Phone Number:
Proposed Lecture Topic:
Alternate Faculty 1
Name: / Designation (i.e. MD, DO, PhD)
Company/Organization Name:
City: / Country:
E-mail Address: / Phone Number:
Proposed Lecture Topic:
Suggested Faculty 2
Name: / Designation (i.e. MD, DO, PhD)
Company/Organization Name:
City: / Country:
E-mail Address: / Phone Number:
Proposed Lecture Topic:
Alternate Faculty2
Name: / Designation (i.e. MD, DO, PhD)
Company/Organization Name:
City: / Country:
E-mail Address: / Phone Number:
Proposed Lecture Topic:
If meeting is longer than one day, you may choose to invite up to four faculty.
Suggested Faculty 3Name: / Designation (i.e. MD, DO, PhD)
Company/Organization Name:
City: / Country:
E-mail Address: / Phone Number:
Proposed Lecture Topic:
Alternate Faculty 3
Name: / Designation (i.e. MD, DO, PhD)
Company/Organization Name:
City: / Country:
E-mail Address: / Phone Number:
Proposed Lecture Topic:
Suggested Faculty 4
Name: / Designation (i.e. MD, DO, PhD)
Company/Organization Name:
City: / Country:
E-mail Address: / Phone Number:
Proposed Lecture Topic:
Alternate Faculty 4
Name: / Designation (i.e. MD, DO, PhD)
Company/Organization Name:
City: / Country:
E-mail Address: / Phone Number:
Proposed Lecture Topic:
Activity Evaluation
As with all of its educational activities, the International Parkinson and Movement Disorder Society will evaluate the effectiveness of this course through a compulsory Participant Evaluation Form. This form measures the knowledge of each participant, both prior to and after the course. Specifically, this evaluation form includes questions that gauge participants' intake of the identified learning objectives, assess general course content, and requests participants to rate each speaker on their presentation. Additionally, this evaluation measures whether the science and medical knowledge advanced by the activity will ultimately enhance the care of patients with Movement Disorders.
The following methods will be employed to measure the outcome(s) of the course:
Participant Evaluation Form
It is the responsibility of the host and MDS faculty to ensure that evaluation forms are completed by course attendees. Following the course, all completed evaluations are to be sent to the MDS International Secretariat for tabulation. In turn, the MDS International Secretariat will provide the evaluation results to the Host, MDS faculty members, as well as MDS and Regional Section Executive and Education Committees.
Application Addendums
□Proposed Meeting Agenda Template (page 7)
□Program Evaluation Template (page 8)
□Virtual Professor Program Technology Summary (Page 11)
Application Attachments
□Applicant CV (English)
□Proposed Meeting Agenda
Optional:
□Draft of promotional material (Ex. program brochure)
□Other (Please specify):
Host Agreement
I have read the MDS Developing World Education Program Policies and Procedures and acknowledge the following:
The Host must adhere to the Policies and Procedures that have been outlined with regards to the Developing World Education Program that I am proposing.
The Host/Host organization is responsible for providing comfortable lodging and accommodations, local transportation, and ensuring the safety of the MDS faculty at the cost of the Host, while in the host country.
MDS agrees to provide airfare for the approved MDS faculty in support of the program according to Travel Costs section of the Developing World Education Program Policies and Procedures and to provide $1000 honoraria for each faculty for the course.
The Host must ensure that thecompleted program evaluations and completed Regional Educational Needs Assessment Surveys (where applicable) are submitted to the MDS International Secretariat within 30 days of the course date.
Applicant Signature Date
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DWEP Short Form Application
Developing World Education Program
Please note that this page has been formatted to assist with the submission of the proposed program. This template may be modified as necessary.If applicable, please specify what portion of the program will be completed using the Virtual Professor Program.
Morning Session
TimePresentation
X: XX - X: XX Introduction
X:-XX - X: XXTitle
X:-XX - X: XXTitle
X:-XX - X: XXTitle
X:-XX - X: XXBreak
X:-XX - X: XXTitle
X:-XX - X: XXTitle
X:-XX - X: XXLunch
Afternoon Session
X:-XX - X: XXTitle
X:-XX - X: XXTitle
X:-XX - X: XXBreak
X:-XX - X: XXTitle
X:-XX - X: XXClosing Remarks
Developing World Education Program
Participant Evaluation Form
Program Title> | <Date Location>
Please take time to complete this evaluation form. Your input and comments are essential in planning future educational activities for MDS. To indicate your answers, use the rating scale by circling the number that represents your answer.
ACTIVITY CONTENT AND OBJECTIVES
Complete (circle one) the rating of each objective before and after the activity. / Excellent / Above Average / Below Average / Poor1. / <Learning Objective 1>; / Before the activity: / 4 / 3 / 2 / 1
After the activity: / 4 / 3 / 2 / 1
2. / <Learning Objective 2>; / Before the activity: / 4 / 3 / 2 / 1
After the activity: / 4 / 3 / 2 / 1
3. / <Learning Objective 3>; / Before the activity: / 4 / 3 / 2 / 1
After the activity: / 4 / 3 / 2 / 1
Please rate your level of agreement with the following statements: / Strongly Agree / Agree / Disagree / Strongly Disagree
4. / The content of this program is relevant to my practice. / 4 / 3 / 2 / 1
5. / Participation in this activity enhanced my professional effectiveness. / 4 / 3 / 2 / 1
6. / The science and medical knowledge advanced by this activity will ultimately enhance care of patients with Movement Disorders. / 4 / 3 / 2 / 1
7. / The handouts were useful. / 4 / 3 / 2 / 1
8. / The audiovisuals were effective. / 4 / 3 / 2 / 1
9. / The overall format of this activity was effective. / 4 / 3 / 2 / 1
10. / I would like MDS to continue to offer educational activities on this topic. / 4 / 3 / 2 / 1
< Host Name> / Strongly Agree / Agree / Disagree / Strongly Disagree
11. / The course director ensured the activity and its component presentations began and ended on time. / 4 / 3 / 2 / 1
12. / The course director ensured the faculty adequately addressed the learning objectives of this activity. / 4 / 3 / 2 / 1
13. / The course director objectively moderated question/answer discussion associated with the activity. / 4 / 3 / 2 / 1
14. Comments:
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DWEP Short Form Application
<Faculty Name 1> / Strongly Agree / Agree / Disagree / Strongly Disagree15. / The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. / 4 / 3 / 2 / 1
16. / The speaker was clear, concise, and able to keep my attention. / 4 / 3 / 2 / 1
17. / The presentation materials were appropriate and effective. / 4 / 3 / 2 / 1
18.. Comments:
<Faculty Name 2> / Strongly Agree / Agree / Disagree / Strongly Disagree19. / The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. / 4 / 3 / 2 / 1
20. / The speaker was clear, concise, and able to keep my attention. / 4 / 3 / 2 / 1
21. / The presentation materials were appropriate and effective. / 4 / 3 / 2 / 1
22. Comments:
<Faculty Name 3> / Strongly Agree / Agree / Disagree / Strongly Disagree23. / The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. / 4 / 3 / 2 / 1
24. / The speaker was clear, concise, and able to keep my attention. / 4 / 3 / 2 / 1
25. / The presentation materials were appropriate and effective. / 4 / 3 / 2 / 1
26. Comments:
<Faculty Name 4 / Strongly Agree / Agree / Disagree / Strongly Disagree27. / The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. / 4 / 3 / 2 / 1
28. / The speaker was clear, concise, and able to keep my attention. / 4 / 3 / 2 / 1
29. / The presentation materials were appropriate and effective. / 4 / 3 / 2 / 1
30. Comments:
COMMENTS31. The major strengths of this activity were:
32. How did you learn about this activity?
1. Brochure
2. Colleague
3. E-mail
4. Other MDS Course or International Congress
5. MDS website
6. Other organization website
7. Other:______
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DWEP Short Form Application
FEEDBACK FOR THE IMPROVEMENT OF
MDS EDUCATIONAL ACTIVITIES
Rate your preference for the educational modality / Strongly Agree / Agree / Disagree / Strongly Disagree33. / Live, lecture-style educational activities / 4 / 3 / 2 / 1
34. / Live, interactive educational activities / 4 / 3 / 2 / 1
35. / Printed continuing medical education (CME) materials / 4 / 3 / 2 / 1
36. / Online, Web-based CME / 4 / 3 / 2 / 1
37. / CD-ROM based CME / 4 / 3 / 2 / 1
38. / Audio/video tape CME / 4 / 3 / 2 / 1
39. I am interested in attending future educational activities on the following topics:
1 Ataxia 10 Gait disorders19 Sleep disorders
2 Basic neuroscience 11 Huntington’s disease20 Spasticity
3 Blepharsopasm12 Myoclonus21 Tardive dyskinesia
4 Brain stem function13 Neuropharmacology22 Tics and Tourettes
5 Chorea14 Neurosurgical therapy23 Tremor
6 Dysphonia15 Neurotransplantation and 24 Wilson’s disease
7 Diagnosis & treatment of stem cell therapy
Movement Disorders16 Parkinson’s disease
8 Dyskinesia17 Psychogenic Movement Disorders
9 Dystonic disorders18 Restless legs syndrome
40 What questions in your practice do you have that you aren’t getting answers to?
41. What challenges do you have in your practice that you would like MDS to address?
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DWEP Short Form Application
Virtual Professor Program
The goal of the Virtual Professor Program is to facilitate the participation of 1 to 2 renowned movement disorders experts, who are members of MDS, as virtual presenters. WebEx, a virtual presentation/webinar software, will be utilized for a keynote/plenary lecture during a major regional/local neurological, movement disorders meeting or MDS course
MDS will recognize the efforts of the Virtual Professor with an honorarium of $500 USD and also support the purchase of technology of up to $1,000 USD per Virtual Professor Program. Virtual faculty must also complete a WebEx test/ training session with the MDS Secretariat to ensure proper knowledge of the software and functionality of all technological equipment at least 2 weeks prior to virtual program. For additional details or questions regarding the Virtual Professor Program please contact the MDS Secretariat.
Technology SummaryPlease indicate the technology you will have available at the location where the Virtual Ambassador Presentation will take place:
Desktop Computer Laptop Computer Speakers Reliable Internet Connection
Projector Web Cam Mouse Computer to Projector Connection Cables
WebEx system requirements
Other ______
Technology RequestPlease indicate the technology that you are requesting MDS funding for:
Desktop Computer Laptop Computer Speakers Reliable Internet Connection
Projector Web Cam Mouse Computer to Projector Connection Cables
WebEx system requirements
Other ______
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