MDS Visiting Professor Program Application

Thank you for your interest in the International Parkinson and Movement Disorder Society's Visiting Professor Program. The Visiting Professor Program is intended to provide an excellent educational opportunity in Movement Disorders education to regions of the world not adequately served by the resources within that region. For more information on the policies, requirements, and structure of the Program, please see the Visiting Professor Program Policies and Procedures available on the MDS website.

If you would like to invite an MDS Visiting Professor to implement an educational 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.

Please complete the following:

* = 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 educational activity for assistance through the Visiting Professor Program. See Visiting Professor Program Policies and Procedures for reference.*
Professorship Program
Please provide three program dates (3 dates) that would be compatible with the program you are proposing:
First Choice:*

Second Choice:*

Third Choice:*
In the event the Visiting Professor(s) could not accommodate any of these three alternatives, would you be willing to consider other dates? *
 Yes       No
Anticipated number of program attendees:*
Based on the identified need(s), please list three education objectives, in terms of outcomes that will result from the program.
Objective 1:*

Objective 2:*

Objective 3:*
Please provide a detailed description and timeline of each day of the Visiting Professor Program you envision to achieve the educational objectives listed above:

When addressing each day of the program, include proposed times for each educational activity, the educational topics, and suggested teaching formats.

Day 1:*

Day 2:*

Day 3:*

Language in which the program will be presented:*

Will translation of program materials be necessary?*
 Yes          No
Will an interpreter be required?*
 Yes          No
  I am interested in applying to use the Parkinson and Movement Disorders curriculum as part of the Visiting Professor Program content.
Program Audience Information
Please identify the target audience of the Visiting Professor Program you are proposing:*
General Neurologists
Primary Care Physicians
Post Doctoral Fellows
Physicians in Training
Researchers
Nurses/Ancillary Health Care Workers
Other   Please specify:
Visiting Professor Information
Suggested Professor 1
Name:
Designation (MD, DO, PhD):
Company/Organization Name:
City:
Country:
E-Mail:
Phone Number:

Alternate Professor 1

Name:
Designation (MD, DO, PhD):
Company/Organization Name:
City:
Country:
E-Mail:
Phone Number:
Suggested Professor 2
Name:
Designation (MD, DO, PhD):
Company/Organization Name:
City:
Country:
E-Mail:
Phone Number:
Alternate Professor 2
Name:
Designation (MD, DO, PhD):
Company/Organization Name:
City:
Country:
E-Mail:
Phone Number:
The suggested Visiting Professor(s) has (have) MDS Membership?
 Yes          No
Does your organization have an academic/financial relationship with the suggested Professor?
 Yes          No
If yes, please describe the relationship:
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 (Ex. Program Brochure) or other supporting materials:
MDS Visiting Professor Program Host Agreement
In person contact provides an invaluable opportunity to discuss collaboration on future Movement Disorder education. As a Host, the MDS Education Committee requests that you meet with the Visiting Professors to discuss what MDS can do to support Movement Disorder education in the region.

I have read the International Parkinson and Movement Disorder Society's Visiting Professor 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 Visiting Professor Program that is being proposed. 
 * The Host/Host organization is responsible for providing comfortable lodging, meals, local transportation, and ensuring the safety of the Visiting Professors while in the host country.
 * MDS agrees to provide airfare for the approved MDS faculty in support of the program according to the Travel Costs section of the Visiting Professor Program Policies and Procedures. 
 * MDS agrees to provide honoraria for the Visiting Professor(s) in the amount of $1,000 USD/program day each.
 * 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 international Secretariat within 60 days of the course date. 
 

 

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