VISITING PROFESSOR SITE APPLICATION

2017 IRIS LITT VISITING PROFESSOR IN ADOLESCENT HEALTH RESEARCH:

Michael Rich, MD, MPH, FSAHM

Application Deadline: July 8, 2016

I. General Information

A. Name of program or organization applying for visiting professorship: ______

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B. Address: ______

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C. Individual to be contacted: ______

Telephone: (______) ______- ______

Email Address: ______

D. Alternate individual to be contacted: ______

Telephone: (______) ______- ______

Email Address: ______

II. Proposal for Visit:

A. Desired Dates for Visit: ______

Second Choice: ______

Third Choice: ______

0c074c744528f665e2ba62a620d54eef.docx – SAHM Page 1 of 4 B. Topics you would like to have addressed: ______

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C. Proposed Itinerary for Professor (include format: rounds, lectures, informal discussions, etc.)

ACTIVITY COMPOSITION OF AUDIENCE

DAY ONE

DAY TWO

DAY THREE

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III. Additional Information

Please summarize how this visit will enhance the research capacity of your program: ______

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IV. Submit application

Please send completed application to:

Society for Adolescent Health and Medicine One Parkview Plaza, Suite 800 Oakbrook Terrace, IL 60181

Or fax it to +1-847-686-2251, Attn: Ryan Norton

You can also submit your completed application to [email protected]

Please note the following:

1. The Awards Committee will make its selection in July/August 2016.

2. Once the selection process is completed, the actual visit should be coordinated with the recipient program and Dr. Rich directly.

3. The host site awarded the professorship agrees to assume responsibility for travel expenses that exceed $1,500. Society for Adolescent Health and Medicine One Parkview Plaza, Suite 800 Oakbrook Terrace, IL 60181

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