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

RTT Application

Support for Existing Rural Training Track Programs

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. RTT grants allow a RTT to expand the number of residents above their cap and the usual number of residents in their program.

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.

Residency position must be ACGME approved and in an accredited program. At least 50% of resident time must be in rural hospital and/or clinic.

Rural rotations must comply with all ACGME requirements; supervising physicians must comply with all CMS guidelines.

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 travel stipend

Rural site developmental or administrative or other costs up to $1,000

Residency program developmental and administrative costs up to $1,000

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

List Hospital Site(s):
Name:	Enter hospital name	Contact Information:	Enter hospital contact information
Name:	Enter hospital name	Contact Information:	Enter hospital contact information
Name:	Enter hospital name	Contact Information:	Enter hospital contact information

List Out-Patient Site(s):
Name:	Enter out-patient site	Contact Information:	Enter out-patient site contact information
Name:	Enter out-patient site	Contact Information:	Enter out-patient site contact information
Name:	Enter out-patient site	Contact Information:	Enter out-patient site contact information

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:

What is the duration of resident time at the primary RTT hospital and clinic (7/1/11- 6/30/12)?
Enter primary RTT hospital time:
Enter primary RTT clinic time:

Please describe the curriculum information regarding resident positions for which funding is requested:
Enter description:

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

Percentage estimate of time spent in a rural hospital and/or out-patient site:
Enter % of time in rural hospital:
Enter % of time in out-patient site:

BUDGET ESTIMATE

Please provide dollar estimates to your best ability.

Resident Salary & Benefits
Total Annual Salary & Benefits:
Enter Salary:
Enter Benefits:
Enter TOTAL:
Requested Funds for Salary & Benefits:
Enter Salary Requested:
Enter Benefits Requested:
Enter TOTAL FUNDS Requested:

Resident Travel Stipend (As determined by sponsoring institution per year of residency)
Choose year of residency...

Administration Costs
Residency Program Developmental & Administrative Costs (up to $1,000):
Enter program development costs:
Enter program administrative costs:
Describe Expenses & Itemize Costs:
Enter expenses:
Enter itemized costs:
Residency Site Developmental & Administrative Costs (up to $1,000):
Enter site development costs:
Enter site administrative costs:
Describe Expenses & Itemize Costs:
Enter expenses:
Enter itemized costs:

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