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 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

This Short Form Application is intended to facilitate participation of up to three approved MDS faculty at an education activity by sponsoring airfare (or ground transportation, if appropriate) to the activity. MDS will support 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 host this program in your country, 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 for additional aspects of a meeting beyond faculty airfare please complete the Developing World Education Program - Long Form Application.

* = Required

Applicant Contact Information

Applicant/Primary Organizer Name:*
Applicant Academic/Professional Affiliations:*
Hospital/Institution Name:*
Street Address:*

City:*
Postal Code:*
Country:*
Phone (include country code):*
Fax:
E-Mail:*
Statement of Educational Need

Please summarize the factors that qualify your meeting for the Developing World Education Program.*
See MDS Developing World Education Program Policies and Procedures. May also be uploaded as a separate document at the end of the application.
Proposed Activity Information
Official title of the meeting at which the Faculty will be speaking:*
Please provide the location of the meeting:*
Please provide the date(s) of the meeting:*
How often is the meeting held? (annually, monthly, etc):*
Will continuing education credit be offered?*
Yes    No
If yes, which type of credit? (CME, CPD, nursing)*
May MDS have 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
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  - Please specify:
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:*
MDS Faculty Information
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:
A one-day meeting may choose to invite 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 request 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:
Phone Number:
E-Mail:
Proposed Lecture Topic:

Alternate Faculty 4

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 5
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 5
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:
Program 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.

Application Templates

File Uploads
Please include the following with your application:
Your current CV (English):*
Proposed Meeting Agenda including lecture topics, dates and times.*
Optional:
Draft of promotional material (e.g., Program Brochure) or other supporting materials:
MDS 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 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.

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

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