Foundation Fellowship: Final Report - Wisconsin Medical Society

Mission

The mission of the Wisconsin Medical Society Foundation is to advance the health of the people of Wisconsin by supporting medical and health education.

Purpose

The purpose of the Wisconsin Medical Society Foundation Fellowship Program is to offering medical students the opportunity to work under the guidance of a Wisconsin Medical Society member on a health education or research project to advance the health of the people of Wisconsin while providing hands-on experiences working in Wisconsin communities or with specific patient populations to address a health concern, integrating their knowledge of resources available.

Final Reports must be submitted within 60 days of completing your fellowship.

Note: You can save your report and continue later at the bottom of the page.

Name*

First NameLast NameSuffix

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

School Email*

Confirmation EmailA copy of this final report will be sent to the email address entered here.

Where are you enrolled full-time in the next academic year?*

Anticipated graduation*

Date

Are you a student member of the Wisconsin Medical Society?*

YesNo

Project title*

Anticipated start date*

Date

Physician mentor*

Location of project*

Provide an overview of the actual project versus what was proposed in your application:*

What were your personal and professional goals and objectives accomplished compared to those stated in the application:*

List the cooperative organizations/partners:*

Provide a brief statement about how you personally benefited from this fellowship and why it was a valuable experience:*

Please upload copies of materials developed through the fellowship or additional documents to support the project here.

Browse Files

Signed letter from physician mentor

Browse Files

Please upload a signed letter from your physician mentor certifying that the report you submitted is an accurate representation of the fellowship work. Additional comments from the physician or others involved in the fellowship are desired, including comments on the experience of working with a fellow, what was accomplished that might not otherwise have been possible and if he/she would recommend working with another fellow in the future. That letter can be uploaded here.

Upload problems?

Let us know if you were unable to upload your documents with this form. Please understand that your application is incomplete without them and must be sent to the Foundation either by email or U.S. mail.

*

I had problems uploading and will deliver them by email or U.S. mail.My documents uploaded and will be submitted with this form.

Certification

By checking the box below, I certify all of the information provided is complete and accurate to the best of my knowledge. I hereby give the Wisconsin Medical Society Foundation Fellowship Selection Committee permission to share this information, with the exception of my financial information, for the purpose of recruitment, and public relations. Falsification of information may result in termination of any fellowship granted. All application materials become the property of the Wisconsin Medical Society Foundation.

*

Yes, I have read and agree with the statement above and certify this final report complies with the standards outlined above.

Would you like to save and continue later? After clicking Submit, a link to your responses will appear on the screen. Save this link to continue your responses later. Note: all required questions must have a drafted response before clicking Submit.*

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Foundation Fellowship Final Report

Basic information

Project information