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
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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
Rationale for the project (what is current state and what is ideal state, what problems have been identified that require improvement): (Limit 1000 words)
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0/1000
Project Goals/Objectives: (Limit 200 words)
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0/200
Project Description (include what the project is, who the main beneficiaries will be, how many people will benefit from this project, etc):
*
Opportunity statement (why is this a good opportunity for CORD, how does this align with CORD mission, how will this help us educate our residents or faculty, and/or further the advancement of emergency medicine education):
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Please describe timeline of project and anticipated date of completion:
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Desired/anticipated project outcome at completion (What would success for this project look like? Presentation? Publication/white paper?)
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Program/Project/Product evaluation plan (how will you evaluate the project to determine whether it met the markers of success?)
*
Resources
Estimate of CORD staff support for this project:
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Requested resources from CORD (if this is more than a $10,000 request, this should benefit at least 25% of the CORD membership)
*
Resources available and approved for project from other sources
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Resources from other sources being sought
*
Is the project recommended/supported by a CORD Committee or Task Force?
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Yes
No
If yes, which Committee or Task Force?
Is this a one time request or is this an ongoing annual request?
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One Time Support Request
Annual Support Request
Please describe any anticipated barriers to completion:
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Budget details: (please attach a budget if requesting financial funding from CORD)
Signature of Project Leader
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: