Course Proposal Form - The Movement Disorder Society



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Developing World Education Program: 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 providing a grant to fund MDS faculty participation and/or other meeting 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.

Please review the following eligibility checklist before proceeding with the application:

□ Waived dues eligibility country. (Visit MDS website)

□ Country for the program is not on the list of U.S.travel warnings.

□ Faculty requested represent different institutions.

□ Program content will be MDS focused.

□ The same host applicant or institution should not have had an Outreach Program (DWEP, VPP or Ambassador) within the past calendar year.

To apply, please complete and submit this application to the MDS International Secretariat. Applications will be reviewed and approved by the Regional Section Executive and Education Committees and the MDS Education Committee (If request is for more than $10,000). Applications will be approved 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 located on the MDS Outreach Education website.

Applicant Contact Information

|Applicant/Primary Organizer Name: |

|Applicant Academic/Professional Affiliations: |

|Hospital/Host Institution Name: |

|Street Address: |

|City: |State/Province: |

|Postal Code: |Country: |

|Phone (Include Country Code): |Fax: |

|E-mail Address: |

Proposed Meeting Information

|Please summarize the factors that qualify your course/meeting for the Developing World Education Program. See the Program Guidelines for |

|reference. May also be submitted as a separate attachment. |

| |

| |

|Official title of the meeting at which the MDS faculty will be speaking: |

|Location of the meeting (must not be on the list of US travel warnings): |

|This course will be presented as: |

| |

|( Stand-alone course/workshop (1-2 days) |

| |

|( Conjoined course with a local/regional meeting |

|Name of the local/regional meeting: ___________________________________________________ |

| |

|( Series of courses |

|Number of offerings: _________________________ |

|Activity Date(s) (Please provide three potential dates if meeting has not been determined: |

|How often is the meeting held? |

|Once Monthly Annually |

| |

|Other (please explain): |

|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 a post meeting mailing or e-mail | YES NO |

|list? | |

|May MDS provide handouts/bag inserts for each meeting participant? | YES NO |

| | |

|TOTAL AMOUNT REQUESTED FROM MDS |US $ |

Proposed MDS Faculty

If you would you like to recommend a movement disorders speaker 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 event takes place. Suggested faculty members must represent different institutions. No academic or financial relationship should exist between the suggested faculty and the Host organization.

Does your organization have an academic/financial relationship with the suggested faculty?

• YES NO

•

Does suggested faculty require a special Visa for travel to the location of the meeting? I yes, please ensure there is enough time to arrange for required visas.

• YES NO

•

A one-day meeting may choose to invite up to two MDS faculty. Two or more days may choose up to four faculty.

|Suggested Faculty 1 |

|Name: |Designation (i.e. MD, DO, PhD) |

|Company/Organization Name: | |

|City: |Country: |

|E-mail Address: |Phone Number: |

|Proposed Lecture Topic: |

|Alternate Faculty 1 |

|Name: |Designation (i.e. MD, DO, PhD) |

|Company/Organization Name: | |

|City: |Country: |

|E-mail Address: |Phone Number: |

|Proposed Lecture Topic: |

|Suggested Faculty 2 |

|Name: |Designation (i.e. MD, DO, PhD) |

|Company/Organization Name: | |

|City: |Country: |

|E-mail Address: |Phone Number: |

|Proposed Lecture Topic: |

|Alternate Faculty 2 |

|Name: |Designation (i.e. MD, DO, PhD) |

|Company/Organization Name: | |

|City: |Country: |

|E-mail Address: |Phone Number: |

|Proposed Lecture Topic: | |

Suggested MDS faculty continued from page 2.

|Suggested Faculty 3 |

|Name: |Designation (i.e. MD, DO, PhD) |

|Company/Organization Name: | |

|City: |Country: |

|E-mail Address: |Phone Number: |

|Proposed Lecture Topic: |

|Alternate Faculty 3 |

|Name: |Designation (i.e. MD, DO, PhD) |

|Company/Organization Name: | |

|City: |Country: |

|E-mail Address: |Phone Number: |

|Proposed Lecture Topic: | |

If the meeting is longer than one day, you may request up to four MDS faculty.

|Suggested Faculty 4 |

|Name: |Designation (i.e. MD, DO, PhD) |

|Company/Organization Name: | |

|City: |Country: |

|E-mail Address: |Phone Number: |

|Proposed Lecture Topic: |

|Alternate Faculty 4 |

|Name: |Designation (i.e. MD, DO, PhD) |

|Company/Organization Name: | |

|City: |Country: |

|E-mail Address: |Phone Number: |

|Proposed Lecture Topic: | |

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:

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: |

| |

|25-50 75-100 100-200 Other: |

MDS Parkinson and Movement Disorders Curriculum

With this application you may also choose to apply for use of the MDS Parkinson and Movement Disorders Curriculum (PMDC) to supplement the lectures of your meeting. The PMDC is an overview of movement disorders and a clinical approach to the evaluation and management of common movement disorders. This curriculum is specially developed for trainees, internists, general neurologists and other clinicians interested in acquiring a basic understanding of movement disorders.

Some additional fees may apply for use of the BMD. For more information please contact MDS Education or visit the PMDC website: .

I would like to apply to use the entire curriculum I plan to translate the slides into ___________________

language.

I would like to apply to use the following topics:

Basal ganglia anatomy and physiology

Phenomenology of Movement Disorders

Etiology and pathogenesis of Parkinson's disease

Diagnosis and differential diagnosis of Parkinson's disease

Management of early Parkinson's disease

Management of Advanced Parkinson's disease

Tremor

Dystonias

Chorea, athetosis and ballism

Myoclonus

Gait disorders

Restless legs syndrome and movement disorders in sleep

Management of MSA, PSP, and CBGD

Tics and Tourette Syndrome

Drug-Induced Parkinsonism (DIP)

Psychogenic Movement Disorders

Learning Objectives

Clearly defined objectives allow prospective participants to select activities which meet their perceived needs. They provide the prospective participant with a realistic understanding of the nature/purpose of the activity, as well as, help course faculty to focus on the content and methodology of their presentation.

Based on the identified need(s), please list three learning objectives, in terms of outcomes that will result from participation in this course.

At the conclusion of this course, participants should be able to:

Describe/List/Discuss/Indicate/Explain/Define/Identify/Recognize (choose the most appropriate verb)

1.

2.

3.

(These objectives should appear in promotional materials and/or activity programs).

Course Design

Please indicate the method(s) of instruction chosen based on compatibility with learning objectives and learning style of the intended audience.

Clinical case presentations and discussions

Didactic lecture with question/answer session

Lecture using slide sets

Lecture followed by small group workshops

Interactive seminar using video

Practical workshop

Patient demonstrations

Other (please specify):

Virtual Professor Program Webinar

• If selected please read and complete the Virtual Professor Program page at the end of this application and also specify what part of your course program will be completed using a Virtual Professor Program Webinar

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.

Application Addendums

□ Proposed Meeting Agenda Template (Page 6)

□ Program Evaluation Template (Page 7)

□ Proposed Program Budget (Page 10)

Application Attachments

□ Applicant CV (English)

□ Proposed Meeting Agenda

□ Proposed Program Budget

o If the program will generate profit, proper justification must be provided.

o If funds will be raised for the support of the program, all sources and projected income must be reflected in budget.

o If funding will be requested for the program venue or other expenditure, proper justification must be provided.

Optional:

□ Draft of promotional material (Ex. program brochure)

□ Other (Please specify):

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.

The Host agrees to deposit the grant money and pay for expenses accrued and/or reimburse faculty upon submission of receipts.

The Host agrees that any money left over from grant money will be used to provide travel grants to local MDS members to attend next International Congress.

The Host must ensure that a course summary, completed budget, completed program evaluations and completed Regional Educational Needs Assessment Surveys (where applicable) are submitted to the MDS Secretariat within 30 days of the course date.

Applicant Signature Date

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Developing World Education Program

Meeting Agenda

Please note that this page has been formatted to assist with the submission of the proposed program. This template may be modified as necessary. If applicable, please specify what portion of the program will be completed using the Virtual Professor Program.

Morning Session

Time Presentation

X: XX - X: XX Introduction

X:-XX - X: XX Title

X:-XX - X: XX Title

X:-XX - X: XX Title

X:-XX - X: XX Break

X:-XX - X: XX Title

X:-XX - X: XX Title

X:-XX - X: XX Lunch

Afternoon Session

X:-XX - X: XX Title

X:-XX - X: XX Title

X:-XX - X: XX Break

X:-XX - X: XX Title

X:-XX - X: XX Closing Remarks

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Developing World Education Program

Participant Evaluation Form

Date:

Location:

Please take time to complete this evaluation form. Your input and comments are essential in planning future educational activities for MDS. To indicate your answers, use the rating scale by circling the number that represents your answer.

ACTIVITY CONTENT AND OBJECTIVES

Please rate your ability to perform the following objectives both prior to participating in the activity and upon

Its completion (circle one): Excellent Above Average Below Poor

Average Average

| |1. Before the activity: |5 |4 |3 |2 |1 | |

| |2. After the activity: |5 |4 |3 |2 |1 | |

| |3. Before the activity: |5 |4 |3 |2 |1 | |

| |4. After the activity: |5 |4 |3 |2 |1 | |

| |5. Before the activity: |5 |4 |3 |2 |1 | |

| |6. After the activity: |5 |4 |3 |2 |1 | |

| |7. Before the activity: |5 |4 |3 |2 |1 | |

| |8. After the activity: |5 |4 |3 |2 |1 | |

| |9. Before the activity: |5 |4 |3 |2 |1 | |

| |10. After the activity: |5 |4 |3 |2 |1 | |

| | | | | | | | |

|Please rate your level of agreement with the following statements |

|Strongly Agree Disagree Strongly |

|Agree Disagree |

|11. |The content of this program is relevant to my practice. |4 |3 |2 |1 |

|12. |Participation in this activity enhanced my professional effectiveness. |4 |3 |2 |1 |

|13. |The science and medical knowledge advanced by this activity will ultimately enhance care |4 |3 |2 |1 |

| |of patients with Movement Disorders. | | | | |

|14. |The audiovisuals were effective. |4 |3 |2 |1 |

|15. |The overall format of this activity was effective. |4 |3 |2 |1 |

|16. |I would like MDS to continue to offer educational activities on this topic. |4 |3 |2 |1 |

COURSE DIRECTOR

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|17. |The course director ensured the activity and its component presentations began and ended |4 |3 |2 |1 |

| |on time. | | | | |

|18. |The course director ensured the faculty adequately addressed the learning objectives of |4 |3 |2 |1 |

| |this activity. | | | | |

|19. |The course director objectively moderated question/answer discussions associated with the |4 |3 |2 |1 |

| |activity. | | | | |

|20. |The course director was free of commercial bias. If no, please comment. |YES |NO |

| | | | |

| | | | |

21. Comments:

FACULTY

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|22. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|23. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|24. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|25. |The presentation was free of commercial bias. If no, please comment. |Yes |No |

26. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|27. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|28. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|29. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|30. |The presentation was free of commercial bias. If no, please comment. |Yes |No |

| | | | |

31. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|32. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|33. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|34. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|35. |The presentation was free of commercial bias. If no, please comment. |Yes |No |

| | | | |

| | | | |

36. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|37. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|38. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|39. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|40. |The presentation was free of commercial bias. If no, please explain. |Yes |No |

| | | | |

| | | | |

41. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|42. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|43. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|44. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|45. |The presentation was free of commercial bias. If no, please explain. |Yes |No |

| | | | |

| | | | |

46. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|47. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|48. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|49. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|50. |The presentation was free of commercial bias. If no, please explain. |Yes |No |

| | | | |

| | | | |

51. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|52. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|53. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|54. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|55. |The presentation was free of commercial bias. If no, please explain. |Yes |No |

| | | | |

| | | | |

56. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|57. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|58. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|59. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|60. |The presentation was free of commercial bias. If no, please explain. |Yes |No |

| | | | |

| | | | |

61. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|62. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|63. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|64. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|65. |The presentation was free of commercial bias. If no, please explain. |Yes |No |

| | | | |

| | | | |

66. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|67. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|68. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|69. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|70. |The presentation was free of commercial bias. If no, please explain. |Yes |No |

| | | | |

| | | | |

71. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|72. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|73. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|74. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|75. |The presentation was free of commercial bias. If no, please explain. |Yes |No |

| | | | |

| | | | |

76. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|77. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|78. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|79. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|80. |The presentation was free of commercial bias. If no, please explain. |Yes |No |

| | | | |

| | | | |

81. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|82. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|83. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|84. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|85. |The presentation was free of commercial bias. If no, please explain. |Yes |No |

| | | | |

| | | | |

86. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|87. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|88. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|89. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|90. |The presentation was free of commercial bias. If no, please explain. |Yes |No |

| | | | |

| | | | |

91. Comments:

| |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|92. |The speaker is knowledgeable and demonstrated appropriate expertise in the subject area. |4 |3 |2 |1 |

|93. |The speaker was clear, concise, and able to keep my attention. |4 |3 |2 |1 |

|94. |The presentation materials were appropriate and effective. |4 |3 |2 |1 |

|95. |The presentation was free of commercial bias. If no, please explain. |Yes |No |

| | | | |

| | | | |

96. Comments:

OTHER COMMENTS

97. What would you like to change in your practice because of this course?

98. The major strengths of this activity were:

99. How would you improve this activity?

100. How did you learn about this activity?

□ 1. Brochure

□ 2. Colleague

□ 3. E-mail

□ 4. Other MDS Course or International Congress

□ 5. MDS website

□ 6. Other organization website

□ 7.Supervisor

□ 8. Other:______________

FEEDBACK TO IMPROVE OVERALL MDS EDUCATION PROGRAM

|The following educational formats are useful to my professional development: |Strongly | | |Strongly |

| |Agree |Agree |Disagree |Disagree |

|101. Live, lecture-style educational activities |5 |4 |2 |1 |

|102. Live, interactive educational activities (skills workshop, video sessions, case studies) |5 |4 |2 |1 |

|103. Printed continuing medical education (CME) materials |5 |4 |2 |1 |

|104. Internet based educational programs (webcasts, teleconference…) |5 |4 |2 |1 |

|105. Smartphone/tablet based educational activities (iPad, iPhone, Android applications) |5 |4 |2 |1 |

|106. Computer based educational programs (DVD, CD-ROM) |5 |4 |2 |1 |

107. I am interested in attending future educational activities on the following topics:

□1 Ataxia

□2 Atypical parkinsonism

□3 Autonomic dysfunction

□4 Basic neuroscience of movement disorders

□5 Blepharospasm/ Hemifacial spasm

□6 Botulinum toxin treatment of movement disorders

□7 Cervical dystonia

□8 Chorea

□9 Clinical neurophysiology

□10 Clinical trial design

□11 Corticobasal degeneration (CBD)

□12 Dystonias

□13 E-Health and movement disorders

□14 Essential tremor

□15 Evidence-based medicine in movement disorders

□16 Eye movement abnormalities in movement disorders

□17 Gait disorders

□18 Genetics of movement disorders

□19 Hospital Management of MD

□20 Huntington’s disease

□21 Integrated and patient-centered care

□22 Movement disorder emergencies

□23 Movement disorders and Internal Medicine

□24 Multiple System Atrophy (MSA)

□25 Myoclonus

□26 Neuroimaging

□27 Neuropathology

□28 Neuropharmacology

□29 Orphan movement disorders

□30 Parkinson’s disease

□30a. Autonomic Dysfunction

□30 b. Biomarkers

□30c. Cognitive impairment

□30d. Motor fluctuations and dyskineseias

□30e. Infusion therapies

□30f. Neurobehavioral complications

□30g. Non-motor complications

□30h. Non-pharmacological therapies

□31 Paroxysmal movement disorders

□32 Pediatric movement disorders

□33 Preclinical models for movement disorders

□34 Progressive Supranuclear Palsy (PSP)

□35 Psychiatric disturbances in movement disorders

□36 Psychogenic movement disorders

□37 Restless leg syndrome

□38 Sleep disorders

□39 Spasticity

□40 Surgery in Parkinson’s disease

□40a Functional neurosurgery (including DBS)

□40b Neurotransplantation and stem cell therapy

□41 Surgery for non-PD disorders

□42 Tardive dyskinesia

□43 Task-specific movement disorders

□44 Tics and Tourette syndrome

□45 Tremor

□46 Wilson’s disease

107. Other:

_____________________________________________

BUDGET FOR DWEP

Course Name:

Location:

Date of Course:

|Income Category |Unit Costs |Units | Projection |Notes |

|Registration Fees |  |  |  |  |

|Members | $ - |0 | $ - |  |

|MDS Junior & Waived Dues Members | $ - |0 | $ - |  |

|Non Members | $ - |0 | $ - |  |

|Subtotal - Registration Fee Income |  |0 | $ - |  |

|Commercial Support |  |  |  |  |

|Unrestricted Educational Grants |  |  |  | |

|Company 1: | $ - |0 | $ - |  |

|Company 2: |  |  | $ - |  |

|Company 3: |  |  |  |  |

|Subtotal - Commercial Support |  |  | $ - |  |

|Grant requested from MDS | | | | |

|TOTAL INCOME |  |  | $ - |  |

| | | | |  |

|Expense Category |Unit Costs |Units |Projection |Notes |

|Marketing |  |  |  |  |

| | | | | |

|Advertising |$0.00 |0 |$0.00 | |

|Postage |$0.00 |0 |$0.00 |  |

|Subtotal - Marketing |  |  | | |

|Meeting Space/Logistics & Planning |  |  |  |  |

|Audio-visual |$0.00 |1 |$0.00 |  |

|Virtual Professor Program |$0.00 |1 |$0.00 |$1,000 budget for AV through VPP if |

| | | | |needed |

|Meeting Room Rental |$0.00 |1 |$0.00 |  |

|Signage: on site |$0.00 |1 |$0.00 |  |

|Subtotal - Meeting Space/Planning |  |  |$0.00 |  |

|Catering |  |  |  |  |

|Breaks |$0.00 |0 |$0.00 |  |

|Lunch |$0.00 |0 |$0.00 |  |

|Dinner |$0.00 |0 |$0.00 |  |

|Faculty Dinner |$0.00 |  |$0.00 |  |

|Sub-total Catering |  |  |$0.00 |  |

|Course Materials |  |  |  |  |

|Course Materials Production |$0.00 |0 |$0.00 |  |

|Subtotal - Course Materials |  |  | | |

|Faculty and Staff Travel Expenses |  |  |  |  |

|Director Honorarium |$0.00 |0 |$0.00 |  |

|Faculty Honorarium |$0.00 |0 |$0.00 |  |

|Faculty Lodging |$0.00 |0 |$0.00 |  |

|Faculty Airfare |$0.00 |0 |$0.00 |  |

|Faculty Expenses |$0.00 |0 |$0.00 |  |

|Staff Travel Expenses |$0.00 |0 |$0.00 |  |

|Bursaries/Travel Grants |$0.00 |0 |$0.00 |to come from regional DWEP fund |

|Subtotal - Honoraria/Travel Expenses |  |  | |  |

| CME/CPD Credit Management and fees | | | | |

|TOTAL EXPENSES |  |  | |  |

|NET GAIN OR (LOSS) |  |  | |  |

Virtual Professor Program

The goal of the Virtual Professor Program is to facilitate the participation of 1or 2 renowned movement disorders experts, who are members of MDS, as virtual presenters. WebEx, a virtual presentation/webinar software, will be utilized for a keynote/plenary lecture during a major regional/local neurological, movement disorders meeting or MDS course

MDS will recognize the efforts of the Virtual Professor with an honorarium of $500 USD and also support the purchase of technology of up to $1,000 USD per Virtual Professor Program. Virtual faculty must also complete a WebEx test/ training session with the MDS Secretariat to ensure proper knowledge of the software and functionality of all technological equipment at least 2 weeks prior to virtual program. For additional details or questions regarding the Virtual Professor Program please contact the MDS Secretariat.

| Technology Summary |

Please indicate the technology you will have available at the location where the Virtual Ambassador Presentation will take place:

( Desktop Computer ( Laptop Computer ( Speakers ( Reliable Internet Connection

( Projector ( Web Cam ( Mouse ( Computer to Projector Connection Cables

( WebEx system requirements

( Other ________________________________________________________________________________________________

| Technology Request |

Please indicate the technology that you are requesting MDS funding for:

( Desktop Computer ( Laptop Computer ( Speakers ( Reliable Internet Connection

( Projector ( Web Cam ( Mouse ( Computer to Projector Connection Cables

( WebEx system requirements

≤ Other ________________________________________________________________________________________________[pic]

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