DWEP Long Form Application

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 taking place in an underserved area by funding MDS faculty participation and/or other meetings 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.

To apply, please complete and submit this application to the MDS International Secretariat. Applications will be reviewed by the MDS Education Committee and selected based on the clarity and completeness of the program proposed, how well the program addresses the educational objectives indicated and how effectively the target audience need is explained.

If you would like to apply for support of faculty airfare only, you may complete the Short Form Application.

* = Required

Applicant Information

Applicant/Primary Organizer Name:*
Applicant Academic/Professional Affiliations:*
Mailing Address:*

City:*
Country:*
Postal Code:*
Telephone:*
Fax:
E-mail:*
Hospital/Host Institution:*
Proposed Meeting Information
Please summarize the factors that qualify your meeting for the developing world education program.*
See the DWEP Policies and Procedures.
May also be uploaded as a separate document at the end of the application.
Official title of the meeting where the MDS faculty will be speaking:*
This course will be presented as:*
Standalone course/workshop (1-2 days)
Conjoined course with a local/regional meeting
Consecutive courses
Number of offerings:*
Location of the meeting:*
Tentative Date(s) Please provide 3 dates:*
    
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 the meeting participant mailing list or e-mail list?*
Yes     No
May MDS provide handouts/bag inserts for each meeting participant?*
Yes     No
Total Amount Requested From MDS (in USD)*
Proposed MDS Faculty
If you would like to recommend an expert speaker(s) from 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 program takes place. Suggested faculty must represent different institutions.

A meeting that is one day may choose to nominate up to three MDS faculty and meetings longer than one day may choose to nominate up to five MDS faculty. In an effort to maintain academic diversity in MDS educational programming, it is preferred that no academic or financial relationship exist between the suggested faculty and the host institution. However, it is understood that some exceptions may apply. Any pre-existing relationship should be disclosed below.
Does your organization have an academic/financial relationship with the suggested faculty?
Yes       No
If yes, please describe the relationship

Please provide the following contact information for the proposed faculty members of the course(s).
A one-day meeting may choose to nominate up to three MDS faculty.

Suggested Faculty 1
Name:
Designation (i.e., MD, DO, PhD):
Company/Organization Name:
Street Address:
City:
State / Province:
Postal Code:
Country:
Phone Number:
E-mail:
Proposed Lecture Topic:
Alternate Faculty 1
Name:
Designation (i.e., MD, DO, PhD):
Company/Organization Name:
Street Address:
City:
State / Province:
Postal Code:
Country:
Phone Number:
E-mail:
Proposed Lecture Topic:
Suggested Faculty 2
Name:
Designation (i.e., MD, DO, PhD):
Company/Organization Name:
Street Address:
City:
State / Province:
Postal Code:
Country:
Phone Number:
E-Mail:
Proposed Lecture Topic:
Alternate Faculty 2
Name:
Designation (i.e., MD, DO, PhD):
Company/Organization Name:
Street Address:
City:
State / Province:
Postal Code:
Country:
Phone Number:
E-Mail:
Proposed Lecture Topic:
Suggested Faculty 3
Name:
Designation (i.e., MD, DO, PhD):
Company/Organization Name:
Street Address:
City:
State / Province:
Postal Code:
Country:
Phone Number:
E-Mail:
Proposed Lecture Topic:
Alternate Faculty 3
Name:
Designation (i.e., MD, DO, PhD):
Company/Organization Name;
Street Address:
City:

State / Province:

Postal Code:
Country:
Phone Number:
E-Mail:
Proposed Lecture Topic:
If the meeting is longer than one day you may nominate up to five MDS faculty.
Suggested Faculty 4
Name:
Designation (i.e., MD, DO, PhD):
Company/Organization Name:
Street Address:
City:
State / Province:
Postal Code:
Country:
E-Mail:
Phone Number:
Proposed Lecture Topic:
Alternate Faculty 4
Name:
Designation (i.e., MD, DO, PhD):
Company/Organization Name:
Street Address:
City:
State / Province:
Postal Code:
Country:
E-Mail:
Phone Number:
Proposed Lecture Topic:
Suggested Faculty 5
Name:
Designation (i.e., MD, DO, PhD):
Company/Organization Name:
Street Address:
City:
State / Province:
Postal Code:
Country:
E-Mail:
Phone Number:
Proposed Lecture Topic:
Alternate Faculty 5
Name:
Designation (i.e., MD, DO, PhD):
Company/Organization Name:
Street Address:
City:
State / Province:
Postal Code:
Country:
E-Mail:
Phone Number:
Proposed Lecture Topic:
Program Audience Information
Please indicate the intended audience of the course.
Specialty/Profession:*
General Neurologists  Movement Disorder Specialists
Physicians In Training Primary Care Physicians
Nurses/Ancillary Health Care Workers
Other   If Other, please specify:*
 
Estimated Number of Attendees:*
Language
The language that the course will be presented in:*
Translation will be needed:*
Yes    No
If Yes, please specify:
Will an interpreter be required?*
Yes    No
Education Objectives
Clearly defined objectives allow prospective participants to select activities which meet their needs. Objectives provide participants with a realistic understanding of the content of the activity, and assist course faculty to focus on the content and methodology of their presentation.


Based on the identified need(s), please list three education objectives, in terms of outcomes that will result from this activity.*


Parkinson and Movement Disorders Curriculum
I am interested in applying to use the Parkinson and Movement Disorders Curriculum as part of the Developing World Education Program content.

Course Design
Please indicate the method(s) of instruction considering the learning objectives and learning style of the intended audience.

Methods of Instruction:
Clinical case presentation and case discussion
Didactic Lecture with question/answer
Lecture using slide sets
Lecture followed by smaller workshops
Interactive seminar using video
Practical workshop

Patient demonstrations
Other - Please specify:
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 Education Committees.

Optional:

  • Pre-test and Post-test. Please note that this method is ideal, however, it will require each faculty member to submit questions for the Pre- and Post-test
  • Six-month follow-up questionnaire.
     
File Uploads
Proposed Meeting Agenda:*

Proposed Meeting Agenda Template
Proposed Program Budget:*

Proposed Program Budget
Proper justification must be provided if the program will generate profit and/or if funding will be requested for program venue or other expenditure. If funds will be raised for the support of the program, all sources and projected income must be reflected in the budget.
 

Applicant CV (English):*

Additional Materials:

Please upload any other supporting materials that you would like to submit with this application.

Developing World Education Program 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 is being proposed.*

The Host/Host organization is responsible for providing comfortable lodging, meals, 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.*

The Host must ensure that a course summary, completed program evaluations and completed Regional Educational Needs Assessment Surveys (where applicable) are submitted to the MDS Secretariat within 60 days of the course date
.*
 

 

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