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

Rural Rotation 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. Rural rotation grants support existing graduate medical education programs to offer rural rotations.

Eligibility Requirements

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

Any Wisconsin residency program in family medicine, general surgery, internal medicine, obstetrics, pediatrics or psychiatry 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

Rural Rotations must:

Comply with ACGME resident duty hours and supervision requirements and with CMS guidelines for supervisors overseeing care, care participation and billing

Be credit-worthy experience for individual’s resident program, begun after 6/30/10; be a clinical experience of at least 8 (continuous or cumulative) weeks; and involve a minimum of 60% of resident’s time in the rural setting

Be in a hospital that is located in a rural area or in a clinic staffed by physicians who admit patients to a hospital located in a rural area.

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

Resident salary and benefits

Resident work-related food costs

Travel stipend

Resident housing

Administration or other costs

RESIDENCY PROGRAM INFORMATION

Your Name:	Prefix…	Enter First Name	Enter Last Name
Today’s Date:	Choose today’s date...
Program Director’s Name:	Prefix...	Enter First Name	Enter Last Name
Program Director’s Email:	Enter email address
Program Director’s Phone:	Enter phone number	Best Time to Contact:	Choose or type...
Program Name:	Enter program name
Location (Program):	Enter program location
Sponsoring Institution:	Enter sponsoring institution
Location (Sp. Inst.):	Enter sponsoring institution location
Accreditation:	Date:	Enter date...	Duration:	Enter duration

ROTATION INFORMATION

Rotation Description:
Enter description:

List Rotation Site(s): May include hospitals, clinics, and out-patient sites: Please provide name, contact information, and a brief description of each site.
Name (Site 1):	Enter name	Contact Information:	Enter contact information
Description:	Enter description
Name (Site 2):	Enter name	Contact Information:	Enter contact information
Description:	Enter description
Name (Site 3):	Enter name	Contact Information:	Enter contact information
Description:	Enter description
Name (Site 4):	Enter name	Contact Information:	Enter contact information
Description:	Enter description
Name (Site 5):	Enter name	Contact Information:	Enter contact information
Description:	Enter description
List Community Population(s): How many people live in each community?
Community Name:	Enter community name	Population:	Enter population
Community Name:	Enter community name	Population:	Enter population
Community Name:	Enter community name	Population:	Enter population

Distance, in miles, from nearest community with population greater than 20,000:
Community Name:	Enter community name
Population:	Enter population	Distance in Miles:	Enter # of miles

Name of Primary Preceptor at Site (If not the Program Director):
Enter name of primary preceptor:

Board certification verification and year of most recent certification?
Board certified?	Enter year of most recent certification?

What is the Rotation Duration?
Enter rotation duration:

Please describe how rotation weeks are configured:
Enter description:

Please describe any longitudinal and/or non-sequential elements:
Enter description:

Please describe any time that residents will be away from the rural site:
Enter description:

BUDGET ESTIMATE

Please provide dollar estimates to your best ability.

Resident Salary & Benefits
Total Annual Salary & Benefits:
Enter salary & benefits:
Enter time on rotation:
Enter final estimate for salary & benefits:

Resident Housing
Total Housing Costs:
Enter lodging ($ amount):
Enter plan for housing and cost:

Resident Meals
Total Meal Costs:
Enter food ($ amount):
Enter plan for work related meals and cost:

Resident Transportation Costs
Estimated number of educationally necessary trips required by RTT curriculum:
Enter estimated # of trips:
Miles per Trip:
Enter # of miles per trip:
Total travel amount (E.g.: Trips x Miles x $0.485 = $ amount):
Enter total amount:

Administration Costs
Administrative Costs:
Enter administrative expenses ($ amount):
Describe expenses & itemize costs

Other Expenses
Other Expenses:
Enter other activities, if any, for which supplemental compensation is proposed:

FINANCIAL PARTICIPATION BY THE RURAL SITE

Describe expenses that will be undertaken by the residency program and/or its partnering hospital, clinical practice or community to support this rotation.

Expense Description:
Enter expenses:

ATTESTATIONS

1. *Program actively recruits UWSMPH & MCW graduates:

Yes

No

2. *Complies with ACGME accreditation requirements:

Yes

No

3. *Supervising physicians will adhere to CMS guidelines:

Yes

No

4. *If funding is granted, no additional funding will be received for same purpose, unless GME caps have been exceeded:

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