AMERICAN ACADEMY OF PEDIATRICS
SECTION ON NEUROLOGY and
The Coordinating Center on Epilepsy
VISITING PROFESSORSHIP FOR PEDIATRIC EPILEPSY
APPLICATION FORM
The intent of the visiting professorship is to bring a pediatric neurology expert to a pediatric residency
program via an application process to educate the primary care clinicians and others at the state level
on the issues and needs related to children and youth with epilepsy (CYE). Interested institutions that
possess a pediatric residency program and demonstrate needs regarding pediatric epilepsy (e.g., those
institutions in rural and /or medically underserved areas or which have limited access to an
epileptologist or pediatric epilepsy expert) are encouraged to apply.
The Visiting Professor (VP) will be selected based on the needs of the institution which will include
the capacity to provide care for CYE. Over the course of the two day event, the professor would
conduct lectures, seminars, or rounds with pediatric residents, medical students, and faculty.
What is required of scholarship recipients?
 The recipients must be willing to commit to the following:
 Plan and implement the event no later than August 31, 2016
 Utilize funds available by August 31, 2016
 Provide receipts and other supporting documentation to demonstrate appropriate use of funds
 Communicate in a timely fashion with AAP project staff and speakers, as necessary
 Ensure all event participants complete an electronic evaluation
 Submit a final evaluation and report of the event, as directed by AAP project staff (a standard
template will be provided)
 A maximum of two VPs will be awarded between October 2015-August 2016. The AAP SONu
will oversee the program and provide an honorarium along with reimbursement for travel,
lodging, and meal expenses for up to $890.
Applications should be received by: Friday, February 12, 2016
Email applications to: Linda Rutt at lrutt@aap.org
Fax: (847) 434-8000 to the attention of Linda Rutt
Questions: Lynn Colegrove, lcolegrove@aap.org; Phone: (847) 434-7820
Application Procedure
 Responses to application questions must not exceed stated word limits.
 Include a letter of support from the Program Director of pediatric residency program
Program and Applicant Information
Name of Individual Completing Application:
E-mail address of Individual Completing Application:
Name and address of Applicant Institution:
Program Director:
Advocacy Training Director (if applicable):
Total number of Pediatric Residents
Total number of Medicine/Pediatric Residents (not included in above amount)
Department Chair
Name and Credentials:
Title:
Phone:
E-mail:
Program Director
Name and Credentials:
Title:
Phone:
E-mail:
Needs and Resources
Explain the educational needs (specific to pediatric epilepsy identification, treatment, and/or care) to be
met by the VP.
Describe any existing pediatric epilepsy-related resources within your institution (i.e., do you have a
pediatric epileptologist affiliated with your organization?)
Visiting Professorship Overview and Goals
Statement of educational needs to be met by the visiting professor:
Are there specific epilepsy-related topics that you are particularly interested in?
Describe the overall goal and up to 3 specific, measurable objectives for the VP. Be sure to address
resident training, faculty development, community partnerships, and development of clinician or
patient education resources. (150 word limit)
Overall Goal:
Objective 1:
Objective 2:
Objective 3:
How will the residency program maintain a relationship with the VP after the activities have
concluded? (Combined 300 word limit)
A list of VP is available online (INSERT HYPERLINK). Please select the names of 3 candidates, in
order of preferences. If you don’t have a preference, skip to the next question. If there is a VP not on
the list, please include the name and reason why you select this person.
Preference 1:
Preference 2:
Preference 3:
Other:
Describe the unique skills and experience the VP candidate should bring that will enhance your
community pediatrics and advocacy program.
Community Overview
Describe the community that your residency program serves (e.g. demographics, socioeconomic
indicators, health statistics, number of local pediatricians/health care professionals). (150 word limit)
Describe the barriers (e.g. geographic, cultural, socioeconomic) in this community that impact access
to medical homes and other needed health care services. (150 word limit)
Community Partnerships
What key community partners will be invited to participate in the VP?
(Note: Including all categories is not required, simply state N/A as necessary.)
Community Partner Category
Name/Description
State either
“New” or
“Existing”
Partnership
Community-based organizations
Community health centers
Public health agencies
Community pediatricians in
private practice
Parent/family groups
Other residency programs
Describe the potential impact the VP could have on these partnerships and how will this benefit the
community.
Evaluation
Describe how the immediate outcomes of the VP will be measured (this should align with the
objectives previously stated in this application). (150 word limit)
Describe how the long-term impact of the VP will be measured (this should align with the overall
goals/objectives previously stated in this application). (150 word limit)
Schedule/Scope of Activities
Please provide a complete and detailed program schedule.
Technical Assistance
Primary Contact Pediatrician: