Proposal Application

Use this form to submit your application to produce content for the Residency Curriculum Resorce. Fields shaded in green are required. Click here to view instructions.

Lead Author

First Name:

Middle Name:

Last Name:

Title:

Degree:

Membership (check all that apply):

AFMRDSTFM

Residency Program or Medical School Affiliation:

Address Line 1:

Address Line 2:

Address Line 3:

City:

State:

Zip Code:

Please provide this information so we can contact you to update your curriculum as needed. We will try your primary email address first.

Email Address:

Alternate Email Address:

Phone Number:

Cell Phone Number:

Co-Authors (if any)

First Name:

Middle Name:

Last Name:

Degree:

Residency Program or Medical School Affiliation:

First Name:

Middle Name:

Last Name:

Degree:

Residency Program or Medical School Affiliation:

Disclosures

For all authors, list financial arrangements and affiliations with organizations that may have a direct interest in the subject matter.

Curriculum Proposal

Core Topic:

Topic:

0 words Lead Author Biosketch (125 word max.):

Learning Objectives:

Curriculum Description (400 words max.):

0 words Describe how you would teach the session and how it would flow. Include the time spent on each section.

Type of Session:

Curriculum Format (e.g., PowerPoint, Keynote, video, interactive module):

Authors will be provided PowerPoint templates, Word templates, and style guidelines.

Teaching Tools You Would Use (e.g., illustrations, video, case studies):

Related Topic If your preferred topic is already assigned, would you consider a related topic in the same area?

YesNo

Understandings (you must check all boxes)

	I understand that in addition to a “presentation,” I am must create a quiz and a facilitator guide.
	I understand that I will be required to update my curriculum on a periodic basis.
	I understand that I must own or have written permission to use any graphs, charts, photos, videos, etc. that I include in my curriculum.

NOTE: Make sure you have a copy of your proposal before you submit this application. Once your application has been submitted you will not be able to retrieve it.

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