ASL Application for Class of 2027-2028

Please have the following prepared to upload with your application. Please save all documents together for upload as one PDF. (a second upload is available, if needed)

1. Current curriculum vitae
2. Statement of Department Chair Commitment and Support Download form
3. A separate cover letter from your chair stating what they expect the value of your participation will be to the university/or institution
4. A personal statement (limited to two pages) indicating why you want to participate in this course, a statement of agreement to complete course requirements, and how you intend to use the knowledge and skills gained from this experience
5. If you have applied before, a statement of what you have accomplished since your last application

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* 1. First Name:

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* 2. Last Name:

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* 3. Degree(s):

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* 4. Academic Rank:

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* 5. Contact Information:

Institution *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 6. My local mentor will be:

Local Mentor's Name:

Local Mentor's Email Address:

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* 7. Local mentor role:

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* 8. Which of the following roles do you currently hold at your institution? Check all that apply.

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* 9. In what ways have you developed curricula and/or generated education research?

Curricular development and implementation at my institution

Dissemination of curricula I developed beyond my institution (please describe below)

Education research that has led to a manuscript in a peer-reviewed journal

Education research that I presented as an abstract at a meeting

PI or co-PI of a funded educational project grant

Other, please describe:

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* 10. In what ways have you done clinical research?

	Yes	No
Publication of a clinical, basic, or translational science research article in peer-reviewed journals	Publication of a clinical, basic, or translational science research article in peer-reviewed journals Yes	Publication of a clinical, basic, or translational science research article in peer-reviewed journals No
PI or co-PI of a funded clinical, basic, or translational science research grant	PI or co-PI of a funded clinical, basic, or translational science research grant Yes	PI or co-PI of a funded clinical, basic, or translational science research grant No

Other:

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* 11. Please describe your contributions to educational scholarship. In your response, include examples such as curriculum development, innovative teaching methods, assessment tools you have created, educational research or publications, mentoring activities, or leadership roles in educational programs.

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* 12. In what ways has your teaching been honored?

No teaching award yet

A teaching award as a resident

A teaching award as a faculty member

The APGO Excellence in Teaching Award, given at my institution

The CREOG Faculty Teaching Award, given at my institution

The APGO Humanism in Teaching Award, given at my institution

A teaching award on a national or regional level (not including the APGO and CREOG awards listed above).

Other, please describe:

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* 13. Which APGO meetings have you attended in the last five years?

Martin L. Stone, MD, Faculty Development Seminar

Susan M. Cox, MD, Clerkship Directors’ School

CREOG & APGO Annual Meeting

None of the above

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* 14. Upload your CV here (required):

Please save all other documents together for upload as one PDF. (a second upload is available, if needed)
1. Statement of Department Chair Commitment and Support Download form
2. A separate cover letter from your chair stating what they expect the value of your participation will be to the university/or institution
3. A personal statement (limited to two pages) indicating why you want to participate in this course, a statement of agreement to complete course requirements, and how you intend to use the knowledge and skills gained from this experience
4. If you have applied before, a statement of what you have accomplished since your last application

ASL Application for Class of 2027-2028

Question Title

* 1. First Name:

Question Title

* 2. Last Name:

Question Title

* 3. Degree(s):

Question Title

* 4. Academic Rank:

Question Title

* 5. Contact Information:

Question Title

* 6. My local mentor will be:

Question Title

* 7. Local mentor role:

Question Title

* 8. Which of the following roles do you currently hold at your institution? Check all that apply.

Question Title

* 9. In what ways have you developed curricula and/or generated education research?

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* 10. In what ways have you done clinical research?

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* 12. In what ways has your teaching been honored?

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* 13. Which APGO meetings have you attended in the last five years?

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* 14. Upload your CV here (required):

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* 15. Upload other combined documents (required):

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* 16. Additional upload, if needed.