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American Academy for Cerebral Palsy

By Elsie Ross,2014-11-26 12:01
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American Academy for Cerebral Palsy

    American Academy for Cerebral Palsy

    and Developmental Medicine

    Development Grant Application

PROGRAM OBJECTIVES for the Development Grant

    The American Academy for Cerebral Palsy and Developmental Medicine grant program supports the mission of the AACPDM to improve the health and general status of children and adults with cerebral palsy, genetic and developmental disorders, and childhood acquired disabilities through:

    ; Providing financial assistance to like, newly formed organizations for the purpose of developing and presenting a high

    quality educational seminar targeted at increasing the early identification and treatment of individuals with childhood

    acquired disability

    ; Providing resource material and content experts as able, to support the educational content of the proposed seminar.

    ; Promoting attendance to the proposed seminar through the already present AACPDM vehicles (web site, newsletter, and

    possibly the Developmental Medicine and Childhood Neurology journal)

    Organizations should review the overall objectives and mission statement of the AACPDM before applying and be prepared to explain how their proposed meeting supports them.

The Academy seeks out applicant groups that are highly motivated, well organized, and have strongly vested interest in improving

    clinical practice through dissemination of knowledge. The Academy will be sensitive to each granted organization’s need to select

    experts from their own geographical area, and attempt to support content areas with its own experts if requested. Only one application is selected per year for further review. Final funding is contingent upon being able to document significant progress in

    seminar development, and planning for the proposed meeting. This decision is made one year prior to the proposed meeting. Those groups that receive grant funding are expected to:

    ; Maintain communication between the AACPDM during the planning phases of the seminar and respond to Academy and

    International Affairs communications as requested, in a timely manner

    ; Develop and provide a high quality, relevant and accessible educational experience for medical professionals involved in

    the care and management of individuals with cerebral palsy and other childhood acquired disabilities

    ; Ensure that registration fees charged are sensitive to the financial differences among disciplines, and do not serve as a

    barrier to attendance

    ; Provide a final meeting program and a copy of distributed course materials to the Academy either prior to, or directly

    after the event

    ; Provide a certificate of attendance to all participants

    ; List the Academy as a co-sponsoring agency

    ; Provide a financial accounting to the Academy within 2 months of meeting close, as well as a general report of meeting

    objectives and how / if they were met

ELIGIBILITY REQUIREMENTS for Grant Funding

Applicant groups must meet the following requirements:

    ; Must consist of AACPDM members in good standing; societies / groups with few AACPDM members should seek

    sponsorship by a member of the AACPDM who has substantial knowledge of this society’s work and goals

    ; Must be located outside of the United States or Canada, preferably in countries with no like organization.

    ; Must not have applied for and received Grant funding within the last five (5) years.

    ; Must be involved in research or care of individuals with cerebral palsy, developmental disorders, or other childhood

    acquired disability

    ; Must have potential other funding to supplement the project to completion if needed

APPLICATION INSTRUCTIONS for Grant Funding

Before completing this application form please read the instructions carefully. Do not modify, skip, or delete any questions.

    Notation of “not answerable at this time” may be made on all questions you are not yet able to completely answer. However, applications which are more substantial in content have greater chance of being selected, and all questions will need to be fully

    answered before final approval of funding is made.

     Inquiries about this application may be addressed to the Academy office, or directly to the International Affairs Chair. Contact

    information is listed below. You must submit the completed application form and all supplementary sheets ON OR ST, BEFORE August 31two years PRIOR to the estimated meeting date. IE applications requesting funding for a September

    2010 meeting would be due by August 31, 2008.

Applications may be submitted as follows:

    ; via e-mail with attachment of completed application form (minus recommendation form/s) - this should be sent to the

    Academy main office, attn: Tracy Burr, Executive Director tburr@execinc.com with a copy to the International Affairs

    Chair Marek Jozwiak mjsl@poczta.onet.pl

    ; via traditional post (2 copies) to AACPDM 555 East Wells Street, Suite 1100; Milwaukee, WI 53202 Attn: Tracy Burr

    ; via fax to the Academy office, attn: Tracy Burr +1 (414) 276-2146

    Recommendation forms should be sent in the same manner directly to the Academy by the person you asked to complete them.

    This application includes five parts. Any application which is not complete with all five sections will not be considered. They are: 1. General Application 4. Recommendation Forms 2. Speaker biographical data 5. Applicant certification 3. Proposed Budget

APPLICATION REVIEW AND SELECTION CRITERIA for International Scholarships

Applications are reviewed as follows:

     st1. Applications received by August 31 will be checked for completeness. All complete applications will be forwarded to

    the International Affairs Chair during the week of September.

    2. The International Affairs Chair will distribute copies of all forwarded applications to all International Affairs Committee

    members by September 15th.

    3. Applications will be reviewed, discussed and scored by all International Affairs Committee members by September 30th, stwith a final decision postulated no later than October 1.

    4. The selected applicant group / organization will be recommended to the Academy Board members for final approval at

    the October board meeting. th5. A letter notifying the selected organization will be sent directly from the Academy office no later than October 30.

Criteria used in selection of organizations include, but are not limited to the following:

    ; Demonstrated motivation and ability of the applying organization to complete projects

    ; Applying organizations ability to implement knowledge obtained into current practice and disseminate it across a wide

    spectrum of individuals (this may be provided by members of the group be on an individual basis, depending upon

    current environment)

    ; Financial need

    ; Estimated status of medical education and health care provision within the geographical area of the proposed meeting

    ; References and other information submitted in the application

    American Academy for Cerebral Palsy and

    Developmental Medicine

    Development Grant Application

     Before completing this application form please read the instructions carefully. Do not modify, skip, or delete any questions. Notation of “not answerable at this time” may be made on all questions you are not yet able to completely answer. However, applications which are more substantial in content have greater chance of being selected, and all questions will need to be fully answered before final approval of funding is made. Incomplete or late applications will not be considered.

    Name of Applying Organization or Society (if no formal name put “no name”, or list separate contributing groups): _____________________________________________________________________________________________________________________ Names of those on the Organizing Committee:

     __________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE ORGANIZATION REPRESENTING

     __________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE ORGANIZATION REPRESENTING

     __________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE ORGANIZATION REPRESENTING

     __________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE ORGANIZATION REPRESENTING

     __________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE ORGANIZATION REPRESENTING _________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE ORGANIZATION REPRESENTING

    Name of Main Contact Person for this organization:

     __________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE ORGANIZATION REPRESENTING

    Address where mail will reach this person before and during the proposed event:

    NUMBER AND STREET

    CITY / TOWN STATE /PROVENCE

    COUNTRY POSTAL / ZIP CODE

    TELEPHONE FAX

    E-MAIL (WEB-BASED PREFERRED. E.G., HOTMAIL, YAHOO, ETC)

    Secondary contact:

    NAME

    ADDRESS

    TELEPHONE E-MAIL For Office Use Only; App____________ Budget____________ Rec 1____________ Cert___________ Sp Bios___________

    2005 AACPDM Grant Application 1

PROPOSED EVENT INFORMATION

NAME OF EVENT

    NAME OF VENUE (hotel, conference center, etc where it will be held.)

NUMBER AND STREET

CITY / TOWN STATE /PROVENCE

COUNTRY POSTAL / ZIP CODE

TELEPHONE FAX

E-MAIL (WEB-BASED PREFERRED. E.G., HOTMAIL, YAHOO, ETC)

    Proposed dates First choice (month/day/year) Second choice (month/day/year) From To From To

    Mission Statement A mission clarifies the organization’s needs, purpose, and activities (IE what it does and why it does it). It also specifies the philosophy and values that guide it. Please provide a short statement of how this event relates to the AACPDM mission. ______________________________________________________________________________________________________________________________

    Needs Assessment A needs assessment helps determine the needs of a specific group and identifies the actions required to fulfill these needs, primarily for the purpose of program development and implementation. In general, it may help to think in terms of patient’s unmet needs and what education (content and of whom) is required to fulfill them. Information traditionally used for a needs assessment includes peer review, community observation, self assessment, review of current medical practice, review of evidence based medical literature and review of community demographic and morbidity/mortality information. Please provide a statement detailing the major needs identified, and how this was determined. ______________________________________________________________________________________________________________________________

    Target Audience

     What types of professionals will this event be designed to educate? (Content of the meeting should reflect this target audience) Please check all that apply: Orthopedics Neurology Physiatry Developmental Pediatrics General Pediatrics Physical Therapy Occupational Therapy Speech/language Therapy Nursing Psychology Education Parents/individuals with disabilities Other ___________________ Other ___________________

    2006 AACPDM Educational Development Grant Application 2

Meeting Content

     Provide a broad description of the educational content proposed to address the needs identified in the previous section. Include more specific learning objectives for each identified area of need. General definitions are listed below to assist you.

     Identified Need : GENERAL NEED IDENTIFIED THROUGH NEEDS ASSESSMENT

     Learning Objective Expected / Desired Outcome* Outcome Measure* Strategies This is an educational goal This should describe what you This describes how you can This describes how you plan to statement; it should identify expect to see if the objective is determine if what you expect to deliver the information to the who will be taught, what they met. (for example; increased happen does/does not occur. (for target audience it should be will be able to do at the close of multidisciplinary collaboration, example; medical record review, tailored to meet the audience’s this meeting, and how well they improved orthopedic surgery practitioner questionnaire, parent specific needs. (for example; will be able to do it. It needs to outcomes, decreased incidence of report) video clips with audience be a measurable behavior. aspiration, increased numbers of participation in discussion, community ambulators) *note, this column is for your written material, lecture) assistance only in determining *note, this column is for your event effectiveness (see next assistance only in developing page). It is not a requisite for appropriate learning objectives. funding and does not need to be It is not a requisite for funding submitted and does not need to be submitted

     Identified Need: Learning Objective(s): 1. 2. 3. Identified Need: LearningObjective(s): 1. 2. 3. Identified Need: Learning Objective(s): 1. 2. 3. Identified Need: Learning Objective(s): 1. 2. 3. Identified Need: Learning Objective(s): 1. 2. 3.

    Format Describe the overall format proposed for this event including lectures, case studies, workshops, round table discussions, use of handouts, etc.

2006 AACPDM Educational Development Grant Application 3

Participant evaluation of event

    Provide a description of how you propose to evaluate the effectiveness of the event, who will carry this out, and when.

Speaker Profiles Please list your expected speakers and attach a brief biographical paragraph for each one which includes their background, affiliated organizations, and lists their most recent publications. Identify those who have already confirmed their participation. (please put all paragraphs in one document and label as “speaker profiles.your organization’s name”) Confirmed : SPEAKERS:

    Yes No _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

     _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

     _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

     _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

     _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

     _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

     _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

     _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

     _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

     _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

     _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

     _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

     _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

     _________________________________________________________________________________________________ FAMILY NAME FIRST NAME TITLE FIELD OF EXPERTISE

2006 AACPDM Educational Development Grant Application 4

AACPDM Grant Application RECOMMENDATION FORM 1

    SECTION 1 To be completed by applicant group or organization

     Name of organization ______________________________________________________________________________________

     Name of representative for this organization ____________________________________________________________________

    I waive do not waive our right of access to information on this form Names of those on the organizing committee:

APPLICANT’S SIGNATURE

    SECTION II To be completed by an active Academy member of good standing with whom members of the organizing committee

    have worked in the past, or are professionally and personally familiar with.

     1. With whom on the organizing committee are you familiar with, in what capacity, and for how long?

    2. How firm is the person’s and organization’s commitment to their field of work / study?

     3. Do you feel the organization’s cumulative academic and professional development is such as to support their successful formulation of a large educational meeting? Why?

     4. In what way would this meeting contribute to the health and well being of children and adults with cerebral palsy or developmental disorders?

     5. How would you rate the organizing committee’s abilities in the following areas as a group? If you are unable to evaluate an area please leave it blank. Excellent Very Good Average Below Average Clinical knowledge Academic knowledge Leadership Initiative Seriousness of purpose Adaptability Maturity Teaching ability Research generation

    2006 AACPDM Educational Development Grant Application 5

6. Please cite specific examples of how some of those on the organizing committee have demonstrated the qualities listed in question 5.

     7. Do you feel the Ministry of Education, Ministry of Health, local Medical University, local medical professionals or community are willing to support the efforts of the organization in disseminating knowledge obtained at this event? In what way?

     8. Please rate the present English language capability of the organization’s representative as you know it. Superior Good Fair Basic Reading Writing Comprehension (aural) Speaking 9. Additional comments:

     Name _____________________________________________________________ Title and Position ___________________________

     Signed ____________________________________________________________ Date ______________________________________

     Institution __________________________________________________________________________________________________________

     Telephone ________________________ Fax ________________________ E-mail ____________________________________ Please return completed forms directly to the AACPDM office via fax +1 (414) 276-2146 or post. American Academy for Cerebral Palsy and Developmental Medicine 555 East Wells Street, Suite 1100; Milwaukee WI 53202

    2006 AACPDM Educational Development Grant Application 6

    AACPDM Grant Application Budget Estimated Income Number of participants and inscription fees Inscription or registration fees help constitute a portion of the supporting revenue, and can be crucial in determining budgetary needs. An estimated attendance can be calculated using the following: Participation in previous meetings, membership in participating societies, geographic “cachement area” transportation issues, number of specialists in each area. Please note the number of participants should be realistic. The size of the event in and of itself will not increase the chances of support by the AACPDM. A small event in an area of great need may have preference over a larger one. 1. Please estimate the number of participants you are projecting to attend the event: 2. How was this number determined?

     3. Please describe the inscription/registration fee structure which is proposed and how it was calculated. Describe differential fees for students, paraprofessionals, members/non-members, educators, and/or families of children with childhood acquired disability. Please remember that fees charged should be sensitive to the financial differences among disciplines, and not serve as a barrier to attendance.

     4. Using the Organizational Cash Flow Spread Sheet, please list expected or projected income. This should include donations of other organizations, agencies or companies; exhibitor fees; other grants or loans. Potential contributors include health related companies (hospitals, clinics, drug and equipment manufacturers, etc.), universities and educational agencies, government agencies, parent or disability related organizations, medical professional associations and private contributors. (For submission with the initial application please use the first page for notation of all income. It is understood that some items may be moved to pages two or three as time progress) 5. Please list expected or projected gift in kind (donation of product or service in place of cash). Examples include free advertising, providing space, staff, volunteers, food, etc.

Estimated Cost It is understood that cost will be incurred throughout the planning process. However, a rough estimate is required for budget review and meeting planning. In determining cost please consider the following items; conference space, audiovisual cost (renting, staffing), advertising, mailing (estimated target audience, printing/copies cost, envelopes, postage), posters, organizational cost (secretarial support, committee meetings, computers, faxes, etc.), interpreter cost, support for speakers (speaker’s fees, travel, lodging, meals), and price range for hotel rooms in area of meeting. 1. Using the Organizational Cash Flow Spread Sheet, please list expected or projected expense. (For submission with the initial application please use the first page for notation of all expense. It is understood that some items may be moved to pages two or three as time progress)

    2006 AACPDM Educational Development Grant Application 7

ORGANIZATION CERTIFICATION for AACPDM Grant

     I hereby apply for the AACPDM professional meeting development grant as representative of _____________________________. I certify

    that we are eligible to apply, and understand that organizations in the following categories are ineligible (a) those not affiliated with or

    supported by and active AACPDM member; (b) those without high proficiency in spoken English; (c) those who have received this grant

    within the last 5 years; (d) those not directly involved in research or care of individuals with cerebral palsy or developmental disorders. In

    addition, I understand that by accepting this grant we agree to the responsibilities outlined on page one of this application. To my knowledge,

    no statement contained with this application is untrue.

If we receive an AACPDM grant, we agree:

    1. That I am able to participate in technical discussions in English without difficulty, as they relate to the planning of this meeting.

    2. That I will respond to all AACPDM and International Affairs Committee communication as requested, in a timely manner

    3. That I will maintain communication with the International Affairs committee before and during the meeting

    4. That we are responsible for covering all planning and event related expenses above that of the grant amount.

    5. That depending on the tax laws of my home country this grant may be taxable in part or in full. It is our responsibility to

    investigate the tax regulations as they pertain to grant funding

    6. That the planned event will take place within one year of the projected date noted on the initial application.

    7. That we will submit a two to five page report to the International Affairs Committee within two months of the close of this event

    that provides an account of money spent, summarizes the evaluation forms completed by those that attended, give examples of

    how knowledge acquired during the meeting has been put into practice by those that attended, and includes a copy of the final

    event program. Any additional comments for future improvement of the AACPDM grant program would also be greatly

    appreciated.

I understand in signing below that failure to carry out the responsibilities listed above may result in forfeiture of this grant and may

    make both me and my organization liable for the return of payments provided.

NAME OF APPLICANT (PLEASE PRINT)

    SIGNATURE OF APPLICANT DATE

    STOP Before submitting your application please be sure you have completed and included the following:

     1. General Application 4. Recommendation Forms 2. Speaker biographical data 5. Applicant Certification 3. Proposed Budget Spread Sheet

    Upon completion please submit this application as follows:

    ; via e-mail with attachment of completed application form (minus recommendation form/s) - this should be sent to the Academy

    main office, attn: Tracy Burr, Executive Director tburr@execinc.com with a copy to the International Affairs Chair Deirdre

    McDowell d-mcdowell@msn.com

    ; via traditional post (2 copies) to AACPDM 555 East Wells Street, Suite 1100; Milwaukee, WI 53202 Attn: Tracy Burr

    ; via fax to the Academy office, attn: Tracy Burr +1 (414) 276-2146

    2006 AACPDM Educational Development Grant Application 8

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