The American Academy of Pediatrics
Julius B. Richmond Center of Excellence
Julius B. Richmond AAP/FAMRI Visiting Lectureship Program
Application Form
Please type or print legibly. Please use font no smaller than 10 points with at least ½” margin on all pages.
For more information, please refer to the Call for Proposals guidelines.
Primary Contact at Sponsoring Organization
NAME
TITLE (e.g. DO, MD)
Program Name
ADDRESS
CITY
STATE
ZIP CODE
PHONE
FAX
EMAIL
Collaborative Program Host # 1 (if applicable)
NAME
TITLE (e.g. DO, MD)
Program Name
ADDRESS
CITY
STATE
ZIP CODE
PHONE
FAX
EMAIL
Collaborative Program Host # 2 (if applicable)
NAME
TITLE (e.g. DO, MD)
Program Name
ADDRESS
CITY
STATE
ZIP CODE
PHONE
FAX
EMAIL
1
1. Describe the overall goal and objectives of the program.
2. Describe the involvement of pediatric training programs and/or local /regional public health
agencies/health departments in your proposed activities.
3. Describe the extent to which AAP state chapters or equivalent international pediatric
organizations are involved in the proposed activities.
4. Provide brief summaries of the primary applicant organization and your community’s current
tobacco-control activities.
5. Describe your organization’s long-term plans to address tobacco use and secondhand smoke
exposure, and how this award may help you implement these plans.
6. Letters of Support:
Letters from your AAP state chapter, community and state departments of health, communitybased organizations, and pediatric departments will enhance your proposal's success. With this
application, please include (a) 1-page letter(s) of support from any of the aforementioned
organizations.
7. Proposed schedule of activities: Proposed dates: ______________________________
For an example of what these activities might look like, please see
http://www2.aap.org/richmondcenter/pdfs/AAPNews_VisitingLectureships.pdf.
Time
Activity
Target Audience
Day 1
Day 2
2
8. Budget detail and justification of line items (rough estimates, remember not to
include faculty honoraria. See example budget below):
Budget
Air Travel for Visiting
Lecturer
Hotel for Visiting Lecturer
Ground Transportation
Kick-off dinner
Resident Noon Conference
Marketing
Other Resources
Description
Amount
Roundtrip airfare from ATL to SFO
$800
2 Nights
2 Days (cab)
$50 per person for 10 representatives
from UCSF, California AAP Chapter
and Departments of Health
Lunch meeting
Printing of promotional flyers
Printing of brochures and patient
handouts
$400
$100
Total
$645
$350
$500
$205
$3,000
9. How did you learn about the Julius B. Richmond AAP/FAMRI Visiting Lectureship Program?
10. Please list suggested candidates for Visiting Lectureship faculty and brief justification (optional).
1.
NAME
TITLE (e.g. DO, MD)
ADDRESS
CITY
STATE
ZIP CODE
JUSTIFICATION:
2.
NAME
TITLE (e.g. DO, MD)
ADDRESS
3
CITY
STATE
ZIP CODE
JUSTIFICATION:
Signature of Primary Contact ____________________
Date _________________
4