Applicant Name:
The John Dystel Nursing Fellowship Program in Multiple Sclerosis
Sponsored by the National Multiple Sclerosis Society
Application Instructions & Form
- This application form may be used for either the 6-month or the 3-month fellowship option. Please indicate, where requested, for which option you are applying. Be sure to complete the appropriate budget page for the option that you have selected.
- The deadline for receipt of a completed application is February 11, 2008 for awards that become effective June 2, 2008. (The NMSS will consider alternate start dates).
- SEVEN copies (original and 6 copies) of the application must be submitted.
- Do not staple the sets, but secure them with rubber bands or paper clips.
- You must submit the application in hard-copy (paper) form. Electronic submissions will not be accepted.
- Do not make any changes in the layout of the forms; use single-spaced format and stay within the margin limitations indicated.
- Use standard size black type (no smaller than 11 point) that can be photocopied; do not use photo reduction.
- Seven copies of any preprints, reprints, or other additional materials must be submitted with the application.
- The application must be submitted accompanied by all supporting documents. Please do not submit your application until you have assembled all references, transcripts and other requested materials.
-Letters of Recommendation: Request that your referees give you an original letter and 6 copies in a SEALED envelope. Submit the sealed envelopes with your application. Do NOT request that the referee send the letter directly to the NMSS.
-Academic Transcripts: Academic transcripts are required. If an institution does not permit issuance of transcripts to you, ask the registrar to send such transcripts directly to the National MS Society, prior to the deadline for receipt of the application. It is preferable, however, that the transcripts accompany your application. Photocopies are acceptable.
- The application cannot be considered for review unless signed by the applicant, the mentor, the financial officer, and the relevant official of the sponsoring institution. “Per” signatures will be disallowed.
- The application and all correspondence relating to it must be received at the Society by February 11, 2008. Please send to: National Multiple Sclerosis Society, 733 Third Avenue, New York, NY10017; Att: Alicia Soto
If you have any questions about the preparation of your application, please contact Alicia Soto at (212) 476-0457 or .
National Multiple Sclerosis Society733 Third Avenue
New York, NY 10017-3288
(212) 986-3240 / (NMSS Use Only)
June 2 2008
Application Number:
John Dystel Nursing Fellowship in Multiple Sclerosis
IMPORTANT: PLEASE INDICATE WHETHER YOU ARE APPLYING FOR THE SIX-MONTH OR THE THREE-MONTH FELLOWSHIP
Name of Applicant
Last Middle First
Degrees
Home Address of Applicant
Street
City State Zip Code -
Telephone ()-Fax ()-
E-mail address
If you cannot be reached at this address through February 2008, please provide an alternative address and expected date of occupancy.
Street Date of occupancy //
City State Zip Code -
Telephone ()- ex: Fax ()-
E-mail address
Name of Mentor
Last Middle First
Degrees Title
Number of years working with MS patients
Address of Mentor
Institution Street
City State Zip Code -
Telephone ()- ex: Fax ()-
E-mail address
Name of Proposed Training Institution
Institution
Department
Address of Proposed Training Institution
Street
City State Zip Code -
Telephone ()-Fax ()-
E-mail address
Name of Medical Director of MS Center/Practice Site
Name
Department
Street
City State Zip Code -
Telephone ()-Fax ()-
E-mail address
Name and Address of Institution’s Financial Officer
Name
Department
Street
City State Zip Code -
Telephone ()-Fax ()-
E-mail address
Name and Address of Nursing Director/Department Chair
Name
Department
Street
City State Zip Code -
Telephone ()-Fax ()-
E-mail address
Make Award Check Payable to:
Six Month Fellowship Budget
Note: Please use this page only if you applying for the 6-month program. Use the following budget page if you are applying for the 3-month program.
The award offered for this fellowship is $44,000, payable to the institution in two installments. The award covers the fellow's salary, fringe benefits, and participation in educational activities; a $4,000 honorarium for the nurse mentor; and indirect costs (not to exceed 10%). The National MS Society will make two payments of $22,000.
Category / AmountSalary for fellow
Fringe benefits package (Please itemize and list associated costs)
Indirect costs (Please itemize and list associated costs)
Other (Please itemize and list associated costs)
Honorarium to Nurse Mentor / $ 4,000
TOTAL / $44,000
Additional support provided to awardee by institution (if applicable)
Comments:
Three-Month Fellowship
Budget
Note:Please use this page only if you applying for the 3-month program. Use the previous budget page if you are applying for the 6-month fellowship.
The award offered for this fellowship is $22,500, payable to the institution in two installments. The award covers the fellow's salary, fringe benefits, and participation in educational activities; a $2,500 honorarium for the nurse mentor; and indirect costs (not to exceed 10%). The National MS Society will make two payments of $11,250.
Category / AmountSalary for fellow
Fringe benefits package (Please itemize and list associated costs)
Indirect costs (Please itemize and list associated costs)
Other (Please itemize and list associated costs)
Honorarium to Nurse Mentor / $ 2,500
TOTAL / $22,500
Additional support provided to awardee by institution (if applicable)
Comments:
Biographical Sketch of Applicant
EducationName and Location of Institution Inclusive Dates Degrees Earned
Academic Honors (include dates)
Professional Experience (begin with most recent position)
Position Employer Name and Location Inclusive DatesBibliographic Citations
Memberships in Professional Organizations
Personal Statement
Describe your long and short-term career goals. Discuss how the fellowship will advance these goals. Describe your personal qualifications for this award. (Please limit to one page).Training Plan
Using the following outline, describe the training plan that you and your mentor have developed to meet the required components of training. Please limit to two pages.
Components of Training:
- Direct, supervised MS patient care
- Exposure to multidisciplinary care
- Didactic activities (including attending lectures, courses, grand rounds, etc.)
- Other
Training Plan (continued)
Recommendations and Transcripts
The following documents MUST accompany this application:
- Three (3) letters of recommendation. Attach in original sealed envelopes.
Name/Title Mailing Address/Telephone
1.
2.
3.
- School Transcripts: Must be attached to this application. Originals or photocopies are acceptable
Name of Institution Address
INFORMATION TO BE PROVIDED BY MENTOR(May attach a CV instead if all information is contained therein)
Name of Mentor / Position/Title
Education
Institution and Location Degree Year Conferred
Professional Experience: List in chronological order previous employment, experience, honors. Please limit to two pages.
Professional Experience (continued)
Mentor’s Bibliographic Citations
Include complete reference and list in chronological order.
Letter of Support from Mentor
The mentor must provide the following information. The mentor letter must be attached to this page.
- A description of the ongoing clinical activities at the MS clinic or practice.
- A description of the multidisciplinary care team.
- An evaluation of the likelihood that the applicant will make a meaningful contribution to MS as a clinician after the fellowship training.
Applicant’s full name and degree(s) / (NMSS use only) Application number
CERTIFICATE OF APPLICANT AND SPONSORING INSTITUTION
By the act of submitting an application for an award, it is agreed by the Applicant and the Institution that: 1) Funds awarded as a result of this request are to be expended for the purpose(s) set forth herein and in accordance with the policies and procedures set forth by the National Multiple Sclerosis Society [the Society]; 2) The information herein is true and complete to the best of our knowledge; 3) The Award may be revoked in whole or in part at any time by the Society, provided that a revocation shall not include any amount obligated previous to the effective date of revocation if such obligation were made solely for the purposes set forth in this application; 4) All reports of activities supported by any award made as a result of this request shall acknowledge such support.
Name / Signature / Date / Office Telephone No.
Applicant / // / ()-
Mentor / // / ()-
Financial Officer / // / ()-