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Applicant Information
Institution/Medical School:
Address:
 
City:
State:
Zip Code:
Phone:
Fax:
Primary Contact / Principal Investigator/Program Director:
Primary Contact Email Address:
Secondary Contact:
Secondary Contact Email Address:
Program and Institution Information
I. A history of success in producing academic geriatric faculty. Successful recruitment of geriatrics fellows and the pursuit of research/academic career training by a portion of them:
I.1  How many clinical ( typically 1st year) fellowship slots is your program approved for?
I.2  How many 1st year fellows do you currently (2006-2007) have?
I.3 How many fellows (including 2006-2007) have you trained in the past 5 years?
I.4  How many of your fellows over the past 5 years go on to a second year (or more) "advanced fellowship"  or other transitional position at your institution?
I.5 How many of your fellows over the past 5 years have been offered full-time faculty positions in academic medicine?
II. Leadership and depth of faculty (basic science, clinical and multidisciplinary):
II.1  How many full-time physician junior faculty are in the geriatric medicine department, division, or section? (Do not count professional staff, adjunct, or non-faculty clinicians)
II.2  How many full-time physician senior faculty are in the geriatric medicine department, division, or section? (Do not count professional staff, adjunct, or non-faculty clinicians)
II.3  How many full-time non-physician faculty are in the geriatric medicine department, division, or section? (Do not count professional staff, adjunct, or non-faculty clinicians)
II.4  How many full-time professional staff (typically PhDs) are in the geriatric medicine department, division, or section?
III. The existence of a geriatrics department, division or section:
III.1 What is the structure of your geriatrics unit?  (Department? Section? To whom does the Principal Investigator/Program Director report?) (Limit your answer to 50 words)

  
III.2 Please select the category that best describes your geriatric program's annual budget for the current academic year (2006-2007).

IV. Demonstrated success in obtaining competitive research funding:
IV.1 What is your annual average external funding budget over the past five years, in dollars?
IV.2 Please list major awards the geriatrics and gerontology programs have received. Include awards such as Hartford pre-CoE type awards, Hartford CGNE awards in nursing, Hartford/RAND Interdisciplinary grants, Reynolds Center educational awards, Pepper, GRECC,  or similar awards. (Limit your answer to 100 words)

  
IV.3 What is your NIH funding rank?
V. Access to excellent geriatric clinical facilities across the continuum of care:
V.1 Please list the major geriatric medicine clinical facilities available for training. (Limit your answer to  100 words)

  
V.2 What other clinical or training venues might be available for future programming with the CoE? ( This may include schools of nursing, pharmacy, allied health, social work or other clinical professions. Limit your answer to 100 words)

  
V.3 What other non-clinical programs or units have strong ties to the geriatrics program? (This may include programs in the social sciences, public health, business school, or other non-clinical units. Limit your answer to 100 words)

  
VI. A strong and visible commitment to geriatrics by the institution:
VI.1 What has the institution done to support the geriatric medicine department, division, or section?

  
VII. Letter of Intent:
VII.1 Project Title
VII.2 Amount requested, in dollars?
VII.3 Amount of match anticipated, in dollars?
VII.4 Anticipated source of matching funds. (Limit your answer to 50 words.)

  
VII.5  Please use this space to paste a narrative that is responsive to the Call for Proposals. Why should your program be considered for funding as a Hartford Center of Excellence in Geriatric Medicine and Training?  Who will lead the Center? What are the measurable goals and objectives of the Center? How will the program build on current strengths to increase the number and quality of faculty in geriatrics? Describe the institutional capacity for research and educational leadership training. Demonstrate junior faculty productivity. What programs are proposed to further enhance geriatrics training across the institution? (Limit your answer to 1500 words)

  

Please review information carefully before submitting document, as you will not be able to return for further editing.

Applicants will be notified by March 23, 2007 if an invitation to submit a full proposal will be extended. Thank you for your interest in the Hartford CoE program.