Application Deadline: November 1, 2019
Applicant:	(1) Complete pages 1 and 2.

(2) Give pages 3 and 4 to your program director to complete and sign.

Name: Click here to enter text. FMR Program: Click here

Address:Click here

Office Phone:Click here Cell Phone: Click here Email:Click here Fax: Click here

Month/year hired as Behavioral Science faculty: MM/YYYYHours per week spent as faculty*? Hrs/Wk

*hours committed to teaching residents/medical students including seeing patients with learners, administrative responsibilities and teaching prep

Number of Behavioral Science faculty in your program (including applicant):Click here

Number of residents in each class. 1st year: # 2nd year :# 3rd year: Click here to enter text.

Underrepresented in Medicine Scholarship:
The STFM Foundation is offering scholarships to cover the fellowship registration fee for two underrepresented in medicine participants.

To apply please identify your race from the following list (check all that apply):
☐ American Indian/Alaska Native ☐ Black/African American ☐ Hispanic/Latino ☐ Native Hawaiian/Pacific Islander

The BFEF fellowship is a faculty development program and requires dedicated time towards creation and completion of an educational scholarly project and attendance at two national conferences:

2020 STFM Annual Conference May 1-6, 2020 in Salt Lake City, Utah (registration included in fellowship fee)

The Forum for Behavioral Science, September 9-12, 2020, in Chicago (registration included in fellowship fee)

Fellows will have a guaranteed slot to present their poster at the next STFM Annual conference (2021 STFM Annual Conference April 30-May 5, 2021 New Orleans, LA.) (funded by your program).

You will collaborate with your program director to identify departmental behavioral science educational needs. Based on that, you will complete a Professional Learning Contract which includes a plan to address those needs. The benefits to your department are that you will:

Complete an educational scholarly project, and national poster presentation at the STFM Annual Conference

Develop a curriculum that meets the most current guidelines mandated by the ACGME

Find a professional home with a diverse array of behavioral scientists

Begin a lifetime of mentoring from peers, colleagues and national experts.

The review committee will give priority to applicants who will have been in their faculty position for at least one year at the start of fellowship (i.e., May 1, 2020).

TO BE ANSWERED BY THE APPLICANT:

In order for us to understand you and your learning needs, please answer the following questions (500-word maximum per question).

How do you see your participation in the STFM Behavioral Science/Family Systems Educator Fellowship enhancing your ability to serve effectively as a Behavioral Science/Family Systems educator?

Click here to enter text.

Define three curricular needs you have recognized that could be tied to your program/organization’s needs.

Click here to enter text.

Please describe your scholarly interests, commenting on current and previous activities as well as where you see your growth opportunities in scholarly work.

Click here to enter text.

I, the undersigned, am dedicated to making the most of this opportunity to participate in the fellowship. I have read and understood these requirements.

Jane Doe

Date

To complete your application:

1. Save this file as follows: lastname.bfef.app2020

2. Save a copy of your cv with the following file name: lastname.bfef.cv.2020

3. Save your program director’s application pages as follows: lastname.bfef.pd.2020

4. Send all documents to:

Kim Sevedge at ksevedge@stfm.org

For questions contact Melissa Abuel at mabuel@stfm.org

PROGRAM DIRECTORS: PLEASE COMPLETE THIS SECTION (Page 3 and 4)

The BFEF fellowship is a faculty development program and requires dedicated time towards creation and completion of an educational scholarly project and attendance at two national conferences:

2020 STFM Annual Conference May 1st -May 6th , in Salt Lake City, UT (registration included in fellowship fee)

The Forum for Behavioral Science, September 9-12, 2020, in Chicago (registration included in fellowship fee)

Fellows will have a guaranteed slot to present their poster at the next STFM Annual conference (2021 STFM Annual Conference April 30-May 5, 2021 New Orleans, LA.) (funded by your program).

Your behavioral science faculty will collaborate with you as program director to identify departmental behavioral science educational needs. Based on that, your faculty will complete a Professional Learning Contract which includes a plan to address those. It is expected that dedicated time for fellows' scholarly work will be a part of their Learning Contract.

The benefits to your department are that your behavioral science faculty will:

Complete an educational scholarly project, and national poster presentation at the STFM Annual Conference

Develop a curriculum that meets the most current guidelines mandated by the ACGME

Find a professional home with a diverse array of behavioral scientists

Begin a lifetime of mentoring from peers, colleagues and national experts.

TO BE ANSWERED BY THE PROGRAM DIRECTOR

Please respond to the following questions in 300 words or less:

1. Why do you believe that your faculty member is a good candidate for the STFM Behavioral Science/Family Systems Educator fellowship?

Click here to enter text.

2.What benefits will your program be likely to realize as a result of this faculty’s participation in the Behavioral Science/Family Systems Educator fellowship (ex. create new curriculum, enhance existing curriculum, replace longstanding curriculum)

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I understand that it is expected that my faculty member will be able to:

☒Have dedicated time to work on the fellowship’s scholarly project

☒Attend the 2020 and 2021 STFM Annual Spring Conferences

☒Attend the 2020 Forum for Behavioral Science

I, the undersigned, am dedicated to making the most of this opportunity for my Behavioral Science Educator to participate in the fellowship. I fully intend to provide the resources necessary to support my faculty member’s participation in this fellowship.

Program Director name

Today’s date

Email

PLEASE RETURN THIS FORM TO YOUR FACULTY MEMBER TO SEND IN WITH THEIR APPLICATION.