Education Exchage Program Application...

Thank you for your interest in the Education Exchange Program of the American Burn Association. The Education Exchange Program provides financial support for occupational therapists, physical therapists, registered nurses and other non-physician ABA members to visit other burn centers to gain added clinical expertise in burn care.

Following, please find an application form to be completed by each person applying for funds under the Exchange Program. The application must be received in the Education Committee Chairperson’s office three months prior to the program. Please return the completed form to the Education Committee chair by clicking submit and submit requested supporting documentation via email to Karen.Kowalske@UTSouthwestern.edu. All documents will be circulated to committee members for review. The total maximum award is $1,000 ($1,500 if more than two weeks are spent at the sponsoring institution).

Please include a brief note with your application, which should:

1. Provide a brief description of the purpose of your visit.
2. State your reason for choosing the specific burn unit.
3. Explain why you feel you should be awarded the grant.

In addition, two letters of reference and a letter from the medical director of the sponsoring institution are required.

If you are awarded an ABA Education Exchange Program stipend, it is understood that the grant may not cover all the costs you may incur in fulfilling the program requirements. After all incurred expenses have been paid; please submit a list of these paid expenses for reimbursement to the American Burn Association Central Office at 625 North Michigan Avenue, Suite 2550, Chicago, IL 60611. Also, a brief report of your activity, particularly highlighting the experience gained by this program, must be forwarded along with your request for reimbursement to the Central Office.

 

Name:
Street Address 1:
Street Address 2:
City, State, Zip:
ABA Membership #:
Place of Employment:
Phone:
Address:
City, State, Zip
Work Specialty:
Degree Held:
Year Granted:
Where Obtained:
Name of Dept. Director.
Address:
Tel.
Names and Addresses of Two Persons Submitting Letters of Recommendation
Name #1:
Address #1:
City, State, Zip #1:
Name #2:
Address #2:
City, State, Zip #2:
Specialty for which application for study is being submitted:
Previous experience within specialty listed above:
Is this the first application you have made for the ABA Education Grant?



If no, list year of application:
Choice of Host Institution
A:
B:
Itemized List of Estimated Expenses
Expenses:
If a grant is awarded, will the funds be used by persons in addition to yourself?



If yes, list names and addresses
Name #1:
Address #1:
City, State, Zip #1:
Name #2:
Address #2:
City, State, Zip #2:
Explain why you would like a grant to be awarded to you and what you expect to gain from the experience:

 



The American Burn Association Web site contains general information for burn care professionals. The ABA Web site is not intended to respond to requests for medical information, and the ABA is unable to respond to requests regarding personal medical concerns related to burn injuries. Your physician is the best source for information related to initial treatment, ongoing care, and follow-up issues for burn injuries. If you do not have a physician, please contact the physician referral service at your local burn center or hospital. © copyright 2005 American Burn Association