DHMC Palliative Care Peer Observership Program Application Form

PROGRAM SCHEDULEThe program is being offered 7 months of the year over a two‐year period:2010 – Sept, Oct, and Nov2011 – Feb, Mar, Apr, May, Sept, Oct and Nov2012 – Feb, Mar, Apr and MayThe program will be offered the last two weeks of each month in session, with the exception of Novemberwhen it will be offered one week earlier in the month to avoid Thanksgiving week.The program is offered in one or two week blocks. The latter is offered in two contiguous weeks and presentsmore time for in depth clinical exposure and consolidation.A maximum of 2 clinicians will be accepted into the program at any one time. Where possible, visits in pairs(i.e., two clinicians from the same program) are highly recommended. Capacity is limited. Early application isencouraged.TUITION AND FEESDue to the generous support from Jane’s Trust, there are no tuition fees for this educational program.However, successful applicants will be required to provide a $300 commitment fee at the time that PeerObservership dates are confirmed. The full amount of this fee will be refunded upon successful completion ofthe program. Any un‐refunded monies will be added to the travel stipend fund for other candidates.Successful applicants are fully responsible for all travel, meals and accommodation expenses. They are alsoresponsible for making their own arrangements. A listing of local accommodations and dining options isavailable upon request.TRAVEL STIPEND AWARDSAs part of the supporting grant, Jane’s Trust has allocated modest funds to assist participants who wouldotherwise have difficulty doing so. The primary focus of these stipends is support for clinicians andadministrators who are charged with developing new or enhancing existing Palliative Care Programs withintheir organizations. Preference will be given to applicants from smaller rural hospitals (under 50 beds) andparticularly critical access hospitals.ACKNOWLEDGEMENTFunding for this two‐year DHMC Palliative Care Service Peer Observership Program for Clinical Colleagues inNorthern New England is generously provided by Jane’s Trust.FOR MORE INFORMATIONFor more information on the Peer Observership Program, the Application Procedure, Scheduling or the TravelStipend Awards contact Yvonne Corbeil at Yvonne.J.Corbeil@Hitchcock.org or 603‐650‐5402.DHMC Palliative Care Peer Observership Program – September 2010 to June 2012 3http://www.cancer.dartmouth.edu/education/palliative_observership.shtml

4. Briefly describe your organization:5. Does your organization/institution have an existing Palliative Care Program?Y N _ If yes, describe briefly:If no, is one being planned? Y N _ If yes, describe current plans:6. Please provide the following additional documents:(Note – documents may arrive separately)a. CVb. Letter of support from CEO of your organizationc. Letter of support from your Medical Director (for physicians),Nursing Director (for nurses) or appropriate Department Head for other disciplines7. This application is for:The ONE week program The TWO week program ___8. Preference for scheduling: (Note – see Program Schedule section for options)1 st Choice:2 nd Choice:3 rd Choice:Additional comments re scheduling availability:9. Do you plan to attend with a colleague? Y N _If yes, please provide name: ______________________(Note – a complete separate application from this individual is required)Applicant’s Signature :Date:(Note – electronic signature acceptable for electronic submission)DHMC Palliative Care Peer Observership Program – September 2010 to June 2012 5http://www.cancer.dartmouth.edu/education/palliative_observership.shtml