Project Request for Support
Please have all information ready to complete the form below. Only complete applications will be accepted. Files needed for upload to complete the application are: Brief description of project (maximum of 1000 words) and the Project Leader CV
Title of Project:
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Project Leader Information
Full Name
*
First Name
Last Name
Degree
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Institution
*
Program Name
Institution Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please attach the CV of the project leader
*
Project Information
Brief Description of your Project (maximum 1,000 words):
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0/1000
Explanation of Project Objectives:
*
How will it benefit CORD, help educate the public, and/or further the advancement of emergency medicine?
*
Time/Cost
Estimate of members' time to be spent on the project:
*
Estimate of CORD staff support for project:
*
Estimate of project costs and revenues (please itemize):
*
Funding Sources
Are other funding sources requested or already approved?
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Yes
No
If yes, please provide information on any other funding sources that will be used to complete this project:
CORD Committee and Task Forces
We encourage contact and coordination with appropriate CORD Committees and Task Forces.
Is the project recommended/supported by a CORD Committee or Task Force?
*
Yes
No
If yes, which Committee or Task Force?
Additional Information
Please describe any anticipated barriers to completion:
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Please describe timeline of project and anticipated date of completion:
*
Please describe project distribution methods with CORD membership on outcomes from the project (presentation, publication/white paper, document for posting to Sharepoint, etc.) after completion of the project.
*
Signature of Project Leader
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: