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Call for Applications:

MCW-led Learning Event Support

Eligible MCW faculty serving as learning event hosts are invited to submit the following application to apply for AHW’s Call for Applications: MCW-led Learning Event Support.

The application must be completed and submitted using this online form and no paper or emailed applications will be considered. This application form only supports Plain Text and no text effects such as bold, italics, underlining, bulleting, numbering, etc. will be captured in the form fields in the final submission.

Refer to the Request for Applications (RFA) accessible via the AHW website for additional instructions and requirements.

Applications are accepted on a rolling basis, and will be reviewed on a first come, first serve basis, until available funds have been distributed.

Please note that all fields marked with * are required.

AHW does not discriminate against individuals on the basis of age, race, creed, religion, color, disability, marital status, sex, national origin, ancestry, sexual orientation, gender identity, arrest record, conviction record, membership in the national guard, state defense force or any other reserve component of the military forces of the United States or the State of Wisconsin or use or nonuse of lawful products off MCW’s premises during nonworking hours.

Project Information

Learning Event Title:

Goal Statement - Please provide a brief statement describing the goal of the proposed learning event, including the learning or professional development gap or need that the event aims to address, and the intended health workforce audience that will participate in the event. (maximum 400 characters, including spaces)

Event Start Date:

Event End Date:

For one day events, end date should equal start date.

Where do you anticipate hosting the event? (maximum 500 characters, including spaces)

Budget Request

Total Amount Requested:

(in whole dollars and

not to exceed $5,000 maximum)

Project Team Information

MCW Principal Investigator

MCW School of Medicine Principal Investigator – Project teams must designate one (1) eligible MCW Principal Investigator (PI) to serve as the learning event host. PIs must be full-time or full professional effort MCW faculty with the rank of Assistant Professor, Associate Professor, or Professor. See the Call for Application for MCW PI eligibility requirements. Compliance with fiduciary and reporting requirements are the responsibility of the PI.

MCW PI Contact Information


MCW PI Name, MD/PhD:	First	Middle	Last	Suffix/Credentials

Preferred Name:

For example, enter 'John' if that is your preference rather than Johnathan.

Pronouns:

Title:

Work Phone:

Cell Phone:

Email:

MCW Standing:

Full-time facultyFull-professional effort status

MCW Department:

MCW PI Non-Supplanting Attestation

Attach completed Non-Supplanting Attestation (PDF) here. Please download the template from the AHW website.

Collaborator(s)

Collaborator(s) (highly encouraged) – Please list additional organizations or individuals that are co-hosting the event or supporting event planning and implementation. Collaborators are not subject to MCW PI learning event host eligibility requirements. Please note that the online form is limited to ten collaborators.

Name:	Institution/Organization:

Narrative

Event Description – Describe the following in your response (maximum 2,000 characters, including spaces):

Goal of the learning event including its anticipated impact on health improvement in Wisconsin
The learning or professional development need the event aims to address
List the event learning objectives
How the event content (including speakers, materials, etc.) will help meet the learning goal

Event Participation – Describe the following in your response (maximum 2,000 characters, including spaces):

The Wisconsin-based health workforce audience that will attend the learning event including the fields and MCW faculty, staff, or students represented
The anticipated number of participants

Evaluation and Post-Event Action – Describe the following in your response (maximum 2,000 characters, including spaces)

How the learning event will support participants to apply their learnings to their work
How the event hosts will evaluate participant learning and event objectives

Budget and Budget Justification

Attach completed Budget Workbook (Excel) here. Please download the template from the AHW website.

Attach completed Budget Justification (PDF) here. Please download the template from the AHW website.

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