Application Website: http://www.fammed.wisc.edu/wi-rural-physician-program

Rural Education Development Funding Application

Instructions

Step 1: Please read the information below.

Step 2: Fill out the form in its entirety at: http://www.fammed.wisc.edu/wi-rural-physician-program.

Step 3: Use the Save As function to save a copy of this document.

Step 4: Once completed, submit via email to Program Coordinator Wilda Nilsestuen at: wilda.nilsestuen@fammed.wisc.edu.

Funding Goals

The goal of the WRPRAP program is to prepare future physicians for practice in rural Wisconsin. This funding is designed to support existing programs to develop and promote sustainable resident education (Graduate Medical Education) in rural areas. Collaboration between residency programs and rural health partners (rural hospitals, health systems and clinicians) is encouraged.

Eligibility Requirements

Eligibility Requirements for participating in this grant program are defined in the WRPRAP guidelines.

Any Wisconsin program in or organization supporting family medicine, general surgery, internal medicine, obstetrics, pediatrics or psychiatry graduate medical education which meets eligibility criteria may apply.

“Rural” = community of fewer than 20,000 at least 15 miles from any community of 20,000 or more

Preference accorded to programs actively recruiting graduates of Wisconsin School of Medicine and Public Health and Medical College of Wisconsin.

See www.fammed.wisc.edu/rural/applications-funding for full details, including expenses for which WRPRAP funding may be requested

Eligible Funding Requests

Maximum award is $35,000 with justification for specific costs

Fundable expenses include:

Faculty and/or staff salary and benefits

(where no other external funding or in-kind support is received for this purpose)

Transportation costs

(At prevailing University of Wisconsin Department of Family Medicine rate)

$1,000 is available for rural site development, administrative, or other costs or a combination of these

Software or other enhancements will be considered (e.g., educational equipment, software) that are required for the implementation of the rural educational experience

PRINCIPAL APPLICANT INFORMATION

Your Name:	Prefix…	Enter First Name	Enter Last Name
Today’s Date:	Choose today’s date...
Your Email:	Enter email address
Your Phone:	Enter phone number	Best Time to Contact:	Choose or type...

PARTNERS

List any Graduate Medical Education Programs participating in this application:
Name / Organization:	Enter name / organization	Contact Information:	Enter contact information
Name / Organization:	Enter name / organization	Contact Information:	Enter contact information
Name / Organization:	Enter name / organization	Contact Information:	Enter contact information

List any/all hospitals, health systems, or clinicians participating in this application:
Name / Organization:	Enter name / organization	Contact Information:	Enter contact information
Name / Organization:	Enter name / organization	Contact Information:	Enter contact information
Name / Organization:	Enter name / organization	Contact Information:	Enter contact information

List any/all additional partners participating in this application:
Name / Organization:	Enter name / organization	Contact Information:	Enter contact information
Name / Organization:	Enter name / organization	Contact Information:	Enter contact information
Name / Organization:	Enter name / organization	Contact Information:	Enter contact information

PROPOSAL

With this grant what activities would be facilitated? What is their intended scope? Attachment: If you wish to provide supplemental information please attach a .doc or a .pdf file, no more than 20 pages.
Enter description:

What is the anticipated outcome of the proposed initiative? In particular, how will the project lead to enhanced Graduate Medical Education activities in rural areas in Wisconsin? Please explain.
Enter description:

What is the timeline for this project? Please provide start dates, potential end dates, and any intermediary dates of importance:
Enter description:

BUDGET ESTIMATE

Please provide dollar estimates to your best ability.

Salary & Benefits
Identify each person and/or position: Please include the percent time involved in project activities, the rate of financial compensation, any added costs, including benefits, and the duration of involvement. (E.g.: Physician X earns $100/ hour & he/she will work on the project for a total of 12 hours/ month for 6 months = $7,200)
Enter description:
Enter final estimate for salary & benefits:

Travel Costs
Describe travel necessary to achieve project goals: Please include an estimate of total mileage.
Enter description:
Total travel amount (E.g.: Trips x Miles x $0.485 = $ amount):
Enter total amount:

Equipment &/or Supplies
Include only those specifically needed for this project. For major items, please provide costs based on actual research of intended purchase.
Describe equipment:
Describe supplies:

Administration Costs
Describe administrative costs necessary to achieve goals:
Describe expenses:
Total requested administrative expense funding ($ amount):
Grand total requested ($ amount):

Other Resources
(To be considered must be defensible as central to the project for which you are requesting funding).
Enter description:

FINANCIAL PARTICIPATION BY THE RURAL SITE

Describe expenses or in-kind contribution of resources: This includes expenses or in-kind contributions of resources by the principal applicant and/or its partner to support this project.

Expense or In-kind Contribution of Resources Description:
Enter description:

ATTESTATIONS

Resources requested do not supplant existing funding: *

Yes

No

If you have responded “NO” to any of the above attestations, please explain below:
Explain:

Please let WRPRAP know how you discovered our funding opportunities.
Choose or type...

Application Website:

http://www.fammed.wisc.edu/wi-rural-physician-program