Leonard P. Rome CATCH Visiting Professorships
2015-2016 Application
Application Procedure
1. Responses to application questions must not exceed stated word limits.
2. Attachments must include and are limited to the following:
 Visiting Professor candidate’s curriculum vitae
 Letter of support from the AAP Chapter President
 Letter of support from the Chapter CATCH Facilitator
 Letter of support from Program Director of pediatric residency program
 Letter of support from 1 community partner that will participate in the activities
3. Application and required attachments must be submitted by e-mail to cpti@aap.org by
12:00 pm Pacific/2:00 pm Central/3:00 pm Eastern on Wednesday, July 8, 2015.
You will receive an e-mail confirmation of receipt of your application materials by
Friday, July 10. If you do not, contact jdonnelly@aap.org.
Program and Applicant Information
Pediatric Residency Program:
Program Director:
Advocacy Training Director (if applicable):
Primary Applicant
Member of both national AAP and state chapter?
Yes
Name and Credentials:
Title:
Phone:
E-mail:
Co-Applicant (optional)
Name and Credentials:
Title:
Phone:
E-mail:
Community Pediatrics Topic/Title for Visiting Professorship:
Visiting Professor (VP) Candidate
Name and Credentials:
Title & Institution:
1
No
Complete Address:
Phone:
E-mail:
Is your Chapter CATCH Facilitator aware of this application submission?
Yes
No
Is this application seeking support for an existing collaborative that has previously received
Yes
No
a Rome CATCH Visiting Professorship?
If yes, please contact Jeanine Donnelly at jdonnelly@aap.org or 800/433-9016, ext. 7397 to
discuss eligibility and application requirements.
Residency Program
1a. Provide a brief summary of the current training activities in community health and
advocacy in your residency program.
1b. Please describe the area(s) you plan to strengthen via this Visiting Professorship and
the potential impact the Visiting Professorship could have.
(Combined 300 word limit)
Visiting Professorship Overview and Goals
2. Describe the overall goal and up to 5 specific, measurable objectives for the Visiting
Professorship. Be sure to address resident training, faculty development, and community
partnerships. (150 word limit)
Overall Goal:
Objective 1:
Objective 2:
Objective 3:
Objective 4:
Objective 5:
3a. Describe the unique skills and experience the VP candidate possesses that will enhance
your community pediatrics and advocacy program.
3b. How will the residency program maintain a relationship with the Visiting Professor
after the activities have concluded?
(Combined 300 word limit)
2
4. One role of Chapter CATCH Facilitators is to share the CATCH program and its
opportunities during the Visiting Professorship. Describe how your CATCH Facilitator
will contribute to the Visiting Professorship. (150 word limit)
Community Overview
5. 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)
6. 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)
7. The mission of CATCH is to support pediatricians to collaborate with their communities
so that all children have access to needed health services and a medical home. Demonstrate
how the proposed program will draw upon this mission to address the described access
barriers. (150 word limit)
Community Partnerships
8. What key community partners will be invited to participate in the Visiting
Professorship?
(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
Other
9. Describe the impact the Visiting Professorship could have on these partnerships and how
this will benefit the community. (150 word limit)
3
Evaluation
10. Describe how the immediate outcomes of the Visiting Professorship will be measured.
This should align with the objectives previously stated in this application. (150 word limit)
11. Describe how the long-term impact of the Visiting Professorship will be measured. This
should align with the overall goals/objectives previously stated in this application.
(150 word limit)
Budget and Activities
Budget
$4,500 maximum – Please refer to the Application Guidelines for more information.
Note: Complete rows as necessary for your proposed program – some rows may remain blank.
Expense
Honorarium
Description/Formula
Visiting Professor (Check one)
$1,000 total for 2-day program or
$2,000 for 3-day program
Total
4
$ Amount
Schedule of Activities
Please refer to the sample schedule included in the Application Guidelines.
Note: Complete rows as necessary for your proposed program – some rows may remain blank.
Theme
Activity/Discussion Topic
Day 1
Day 2
Day 3
(optional)
5
Target Audience