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VDFP Communications Submission Form
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1.
Submission heading:
(Required.)
*
2.
Is the request free of pharmaceutical/industry funding and is not a business?
(Required.)
Yes
No
*
3.
Submission information:
Please check all that apply.
(Required.)
This is an opportunity to improve family doctors’ wellness and job satisfaction
This opportunity supports family doctors’ ability to meet their patients’ needs
This is an opportunity to affirm the value of family doctors and amplify their voice and experience
The topic of this request will benefit from Family Practice representation
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4.
I have read the
submission guidelines
and confirm that my submission aligns with VDFP policy
(Required.)
Yes
No
*
5.
Purpose of submission:
Please select all that apply
(Required.)
Primary care research or engagement [MUST be formally approved by a university research ethics board and free from pharmaceutical/industry funding]
Job posting
Promoting an event
Promoting a clinic or service
Educational opportunity (non-CME)
Soliciting representation for a committee
Seeking member perspective
6.
Communications headline:
*
7.
Submission summary:
(
4 sentences max
.)
(Required.)
8.
Link to full information:
9.
Desired publication date:
*
10.
Submitter contact information
(Required.)
Name
Company
Email Address
Phone Number
11.
Message to the reviewer (
optional
)
