MITE Academy Scholars Program Application

Questions? Please contact Kathleen Fairfield, MD at FAIRFK@mmc.org or Bob Bing-You, MD MEd, at bingyb@mmc.org.

If you have any technical questions, please contact Elizabeth (Sue) Rose at erose@mmc.org in the Department of Medical Education.

  • Applicant Information

  • Professional Information

  • Mentor Information

  • Enter the name of your mentor

  • Experience and Goals

  • Describe your past and current teaching experience. List chronologically with the current activities first and indicate if the teaching was primarily undergraduate, graduate or continuing medical education. For current activities, please give the approzimate percent (or hours) of your time spent on the teaching activity.
  • What do you hope to gain from involvement in the Academy Scholars Program? What will be the impact on your teaching of medical students and/or residents in the future (including any changes or programs you would like to champion)?
  • What specific medical education topics or areas are of interest to you? Mark all that apply?
  • What are your specific career goals? Where would you like to be in your career in ten years?

  • Documents

  • Your attached description should be no more than 1000 words, approximately 2-3 pages.
    Drop files here or
    Accepted file types: pdf, docx, doc, Max. file size: 128 MB.
    • Please attach your CV and your project mentor's CV.
      Drop files here or
      Accepted file types: pdf, docx, doc, Max. file size: 128 MB.
      • Drop files here or
        Accepted file types: pdf, docx, doc, Max. file size: 128 MB.

          Include letters of recommendation from your mentor and clinical supervisor (e.g., medical director, Department Chief) must include the following statement:

          "In support of this application, I agree that [your name] will be given sufficient release time from clinical duties (0.05 FTE) to attend all Scholar seminars. Clinical schedules will be adjusted accordingly. I have reviewed the submitted budget and agree with the amount of salary support budgeted."

          The letter of recommendation from your mentor should include a description of the mentor's role in your project.

          One additional letter of recommendation may optionally be submitted.

        • This field is for validation purposes and should be left unchanged.
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