Residency Expansion Program

Resident Community Healthcare Impact Project Grant Program

REGISTRATION INFORMATION

First Name:

Last Name:

Credentials:

Other Credential:

Mailing Address:

City

State

Zip Code

Phone No.:

Email:

Residency Program:

PGY:

PGY Other:

Resident Project Leader Primary Contact:

First Name:

Last Name:

Name of Community Health Outreach Project:

Location of Project Impact (Zip Code):

Describe the Location of Project Impact:

Other:

PLEASE LIST UP TO FOUR (4) OTHER PROJEXCT TEAM MEMBERS AND THEIR RESPECTIVE INFORMATION

Resident Project Leader above will be the primary contact for RIG communications

Team Member No. 1:

First Name:

Last Name:

Credentials:

Other Credential:

PGY:

Email:

Team Member No. 2:

First Name:

Last Name:

Credentials:

Other Credential:

PGY:

Email:

Team Member No. 3:

First Name:

Last Name:

Credentials:

Other Credential:

PGY:

Email:

Team Member No. 4:

First Name:

Last Name:

Credentials:

Other Credential:

PGY:

Email:

TERMS AND CONDITIONS:

We understand that if awarded a Community Health Outreach Mini Grant through this program that we will participate in the RIG Summit, April 2025 (Friday program preceding Reaseach Day) as well as present a poster or oral presentation at PAFP Research Day, April 2025:

We understand that if awarded a Community Health Outreach Mini Grant through this program that we will fulfill all project deliverables (including monthly calls, Research Day, final report, budget reconciliation):

ADDITIONAL PROJECT INFORMATION

Project Abstract (350 Words Max.):

Project Budget (Upload Workbook, Excel File, etc.):

Uploaded % ( ) Total
Uploaded files: % () Total files:
Uploading file:
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WARNING: Due to security issues in place on Apple iOS devices, uploading files could be problematic. General use PC and other computer devices should work just fine. Please contact Molley Talley to make other arrangements as necessary.

Community Health Outreach Project Definition: community health outreach is a temporary, mobile project that invovles the collaboration of a community to undertake its purposeful health intervention of reaching a population facing health risks.

For the purposes of this mini-grant program, "community" includes residency program teams comprised of residents, faculty and others, colloaborating with the community they serve to target an identified health need and make a positive impact on the health within that community.

Identified Community Health Need Addressed with this Project:

Source of Community Health Needs Assessment Referenced Above:

Any Additional Information or Comments: