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Application for theAmerican Academy of PediatricsSection on Infectious DiseasesS. MICHAEL MARCY VISITING PROFESSOR PROGRAMName of hospital & academic affiliation (if applicable): ________________________Program Director Name: _________________________ Email: _______________Department Chair Name: ________________________ Email: _______________Name for contact: _______________________________ (if other than those above)Title/Position: __________________________________Address: ______________________________________City: ________________ State: ________ Zip: _______________Phone: ______________ FAX: _________________ E-mail: ___________________Completion of each section of the application will allow the Evaluation Committee to fully understand the needs of your institution and your plan for the visiting professor. Incomplete applications will not be considered.Estimated expected attendees (number): Pediatric Residents: ___ Faculty/Attending Physicians: ___Medical students: ___ Other (i.e. Community Physicians, Allied Health /Mid Level Providers): _____Please select 3-5 areas of strongest educational need from the drop down boxes below. This information will allow the visiting professor to better tailor his/her talks to best meet the needs of your institution:#1 Choose an item.Describe why this is a need: #2 Choose an item.Describe why this is a need: #3 Choose an item.Describe why this is a need: #4 Choose an item.Describe why this is a need: #5 Choose an item.Describe why this is a need: Other, please specify: Enter Text Here How many full and part-time infectious diseases physicians are on staff at your institution?Adult infectious diseases physicians: ____Pediatric infectious diseases physicians: ____What kinds of regular educational programs (i.e. grand rounds, case conferences, resident lectures, etc.) does your institution have?Type of ProgramFrequencyAverageAttendance*Percent of Attendees fromOutside Institution**Grand RoundsCase ConferencesNoon LecturesRounding with ResidentsOther (please specify)*Average attendance-Please include medical students, residents, faculty and community physicians. **Percentage of the attendees from outside of the institution such as community physicians.Has your institution had a visiting professor for ID in the last 3 years? Choose an item.Please indicate your top two preferences for a Visiting Professor from the list provided: 1. _____________________2. _____________________Provide a proposed itinerary indicating the proposed schedule of activities in which the Visiting Professor will participate during 1-2 days including grand rounds, rounding with residents etc. Applications without a proposed itinerary will not be considered.Enter text here or attach in separate documentPlease use the space below to provide any additional information regarding how the VPP would benefit your institution.Enter text here or attach in separate documentIf selected for a Visiting Professorship, the Visiting Professor will then work with your institution to identify specific topics and determine a mutually convenient time for the visit to take place. ___________________________________________ ___________________Signature of Dept. Chair or Residency Program Director Date Please return by mail, email, or fax to: Dana BrightSenior Manager, Immunization InitiativesAmerican Academy of Pediatrics 345 Park Boulevard Itasca, Illinois 60143Phone: (630) 626-6271 Fax: (847) 434-8000 E-mail: dbright@The Visiting Professor Program is supported by Section Funds ................
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