Teaching Scholars Program - Application Form

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Section 1 - General Information

Faculty Rank:

Enter Faculty Rank

School / College:

Enter school info

Department Name:

Enter Department.

Clinical Responsibilities and Location:

Enter Responsibilities.

Current Teaching and/or Educational Administrative Responsibilities

Enter Teaching

Number of Years at AMC or other academic medical/healthcare institution:

Enter Number of Years

Section 2 - Application Questions

Instructions: Please provide a thoughtful response to each question below. You are allowed a maximum of 500 words per question.

1. What (if any) previous education or training (resulting in degree, certificate, or other recognition) have you had in teaching, educational scholarship, or leadership? Name and briefly describe the program.

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2. What personal / professional goals do you expect to achieve through participation in TSP?

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3. Briefly describe an idea you have for a medical / education research project or a curriculum development project and what your role would be in the project.

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4. Explain / Describe how your project idea (described in #3) was generated. Include information on any funding or support you have and what major obstacles you anticipate in development and implementation of the idea. Indicate if you an identified mentor for this project (provide their name and contact information) and what your relationship is with this person. Note that having an identified mentor prior to entry is not required, and we will gladly work with you to identify an appropriate project and / or career mentor.

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Section 3 - Letter of Committment from Supervisor

Please upload files in PDF or DOCX format only.

Upload signed letter from Department Head:

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Section 4 - Current CV

Upload current CV / resume:

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Complete all fields before submitting.