Next Generation Award
for Adolescent Substance Use Prevention
Application Form: 2015-16
Instructions:
Eligibility:

Physicians who have been accepted into or have applications being considered by an ABAMF-accredited
Addiction Medicine fellowship for training starting in 2015.

Preference given to physicians who have completed residencies in Pediatrics, Family Medicine, Internal Medicine,
or Obstetrics-Gynecology, or a fellowship in Adolescent Medicine. But physicians of any specialty who are
committed to addressing substance use among youth are encouraged to apply.
Training Requirements to be Completed under the Award:

Fellows will complete at least 1 elective rotation (160 hours or more) addressing prevention and early intervention
for adolescents and young adults.

Fellows will acquire skills in the delivery of Screening Brief Intervention and Referral to Treatment (SBIRT) in
clinical settings, teaching SBIRT to other health care professionals, and implementing SBIRT on a sustainable
basis in health care delivery systems.

Fellows will attend at least one professional meeting at which they will conduct a training session for 15 or more
other physicians in Screening Brief Intervention and Referral to Treatment (SBIRT) for adolescents and young
adults.
Application forms should be completed jointly by the prospective Fellow and their Fellowship Program
Director:

Personal Statement (Completed by Fellow).

Educational Goals & Objectives specific to prevention / early intervention for adolescents and young adults
(Completed by Fellow & Program Director).

Description of rotation(s) and any other elements (eg, conferences, didactics, continuity care experiences)
addressing the Fellow’s goals & objectives. Identify faculty mentor(s). (Completed by Fellow & Program
Director).
Award Criteria: The Award is for individuals who have a strong interest in health care for adolescents and young adults,
coupled with a desire to use their addiction medicine training in service to this population and to share their
knowledge and skills with other health professionals so they can do likewise. Awards will be made on the basis of:


The candidate’s:

Commitment to pursuing a career that includes prevention and early intervention for adolescents
and young adults.

Potential to become a future leader.

Planned outcomes for the fellowship experience.
The fellowship program’s ability to provide an educational experience in adolescent prevention and
early intervention that meets the candidate’s goals and objectives.
Questions? Please contact the ABAM Foundation National Center for Physician Training in Addiction Medicine:
AddictionMedicine@buffalo.edu
Application Form
Next Generation Award for Adolescent Substance Use Prevention
Please complete this form and return
1 copy via email to: addictionmedicine@buffalo.edu
1 copy (signed) to:
Andrew Danzo
ABAM Foundation National Center for Physician Training in Addiction Medicine
University at Buffalo Dept. of Family Medicine
77 Goodell Street, Suite 220
Buffalo, NY 14203
Attach:
1) Candidate CV
2) Two (2) Letters of Recommendation (e.g., residency program director, residency faculty member, clinical
supervisor)
3) Fellowship Program Director Letter, confirming:

fellowship’s commitment to meet the applicant’s educational objectives, as described in the
application;

fellowship’s commitment to supporting the applicant’s attendance at a professional conference to
train other physicians in adolescent SBIRT.
Fellowship Name:
Candidate Information:
Name:
Address:
Telephone:
E-mail:
Citizenship:
Medical School:
Degree:
Year Graduated:
Residency Program:
Year Graduated:
Board certification(s):
State(s) in which licensed to practice medicine:
Current position, employer/institution:
Awards / Honors:
(please expand box as necessary):
Service & Leadership: Please list any community, academic or other volunteer activity you consider relevant
(expand box if necessary):
Personal Statement:
Please describe your career goals and interest in substance use prevention and early intervention for
adolescents and young adults (expand box as necessary, up to maximum 500 words):
Educational Goals & Objectives:
The following is to be completed by the Fellow (input from the Program Director):
Please describe specific educational objectives relevant to your youth-oriented career interest (expand box as
necessary, up to 500 words):
Proposed Training Experience:
The following is to be completed by the Program Director (with input from the Fellow): Description of
rotation(s) and any other elements (eg, conferences, didactics, continuity care experiences) designed to meet
the fellow’s goals & objectives. Identify faculty mentor(s), clinical training sites, hours. Explain how the
experience will be integrated into the fellowship curriculum as a rotation (required or elective) for future fellows.
(expand box as necessary, up to 1,000 words):
Budget:
Budget should be based on the Proposed Training Experience, described above. No part of the award may be
used for institutional facilities and administrative costs, also referred to as indirect and overhead costs.
Budget Justification:
Describe how the award funds will be allocated to meet the Fellow’s goals & objectives. (expand box as
necessary):
Signatures:
____________________________________________________
Award Candidate (fellow)
__________________
Date
____________________________________________________
Fellowship Program Director
__________________
Date