SOT ToxScholar Outreach Grant Report

FUTURE appreciates your report from your ToxScholar visit. This information is important to summarize the impact of the program and inform future activities. If you were awarded funding, your reimbursement will be processed after submission of this report.

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* 1. Contact Information for ToxScholar.

First Name

Last Name

Affiliation

Email address

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* 2. If there was an additional ToxScholar, please provide information for that speaker.

First Name

Last Name

Affiliation

Email address

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* 3. Information about the visit.

Institution Visited

Date of Visit

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* 4. How were the students recruited for the event?

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* 5. Any tips for making arrangements with the campus contact?

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* 6. Description of the first talk or event (audience, format of meeting, type of talk, etc.).

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* 7. Number attending first event.

Undergraduate students

Graduate students

Faculty

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* 8. Description of additional presentations or events (if applicable).

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* 9. Number attending second event.

Undergraduate students

Graduate students

Faculty

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* 10. Most important outcomes of the visit.

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* 11. Feedback from students and host on value of the visit is required. Include comments received verbally or through other means.

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* 12. Aspects you would change to improve outcome.

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* 13. Other comments or suggestions.

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* 14. Did you receive any other funding or support for the visit? If so, provide source and amount.

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* 15. If you were allowed to collect attendance list(s), upload it here. Please include the name and email for students and faculty; include the date of graduation for the students (mo/day/year). This information is critical for SOT to establish communication with the attendees.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

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* 16. Upload a pdf of the SOT reimbursement form and copy of receipts here.

PDF, PNG, JPG, JPEG file types only.

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* 17. List the materials used in the visit. Upload files containing promotional materials, your slides, or other materials that would be of interest to FUTURE in Questions 18-20).

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* 18. A. Upload additional materials you'd like to include in your report; use a descriptive name for the file.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 19. B. Upload additional materials you'd like to include in your report; use a descriptive name for the file.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 20. C. Upload additional materials you'd like to include in your report; use a descriptive name for the file.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 21. Do you have photos taken during the ToxScholar visit (with permission from those who are included) for SOT use in any or all media?

Yes. Please email medium or large resolution photos to Betty Eidemiller, or upload them in the spaces above.

Thank you for making the ToxScholar visit and for submitting your report. Please send a message to Betty Eidemiller so that FUTURE will know that your report is submitted.