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Center to Center Pilot Application

Thank you for your interest in the International Parkinson and Movement Disorder Society’s (MDS) Center to Center Program. The Center to Center Program is intended to support underserved regions across the globe where there is a relative lack of appropriate education, skills and tools to diagnose, treat and manage Parkinson’s disease and other movement disorders. Underserved countries have significant challenges in accessing education and skills to impact clinical practice in the field of Parkinson’s disease and movement disorders. The main goal is to improve the ability of neurologists in underserved regions to diagnose and treat patients with movement disorders by creating a collaborative MDS Center to Center Program between an expert center (Mentor Center) and a center in an underserved region (Mentee Center) that wants to develop capacity to treat Parkinson’s disease and movement disorder patients.

The application is a joint process, which should be performed cooperatively between the Mentor Center and Mentee Center sites. Both centers should be located in the same MDS region (i.e. Pan-American (PAS), European (ES) or Asian and Oceanian (AOS)). Applicants from Africa may consider joint applications with Mentor Centers in ES or AOS regions. Mentor Centers should be a center of expertise in Movement Disorders (defined as having Movement Disorders trained neurology specialists on staff). Mentee Centers should be from an underserved country and would like to access the experience of a Mentor Center’s expertise to get more practical clinical training and experience in Movement Disorders. Once a cooperative partnership has been identified, please complete and submit this application to the MDS International Secretariat at education@ by July 15, 2018.

Before submitting an application, please read carefully the outline of the MDS Center to Center Program, to become familiar with its goals and requirements. Applications will be reviewed by the MDS Education Committee. If eligible, selection will be based on program feasibility (including ability to travel, infrastructure for training, technical prerequisites for tele-education, shared language, etc.), quality of training for the mentees at the Mentor and Mentee Centers, as well as the current need and future potential of the Mentee Center.

Please review the following eligibility checklist before proceeding with the application:

□ Program content is Movement Disorders focused

□ Invited mentor and mentees must be MDS members or become MDS members

□ Mentor and Mentee Centers have received approval from their administration to participate

□ For the Mentor Center, the mentor understands his/her role as the project coordinator in implementing the curriculum and timeline, program execution and evaluations, including regular reporting to MDS

□ For the Mentee Center, there are at least two neurologists who would be interested in being specifically trained on Movement Disorders and intend to practice at the Mentee Center for the next 4 years

□ Mentor and Mentee Center sites are not on the list of U.S. travel warnings

|Mentee Center - Applicant Contact Information |

|Applicant Name (may be the head of the department or one of the mentees): |

|Applicant Academic/Professional Affiliations: |

|Hospital/Host Institution (Center) Name: |

|Street Address: |

|City: |State/Province: |

|Postal Code: |Country: |

|Phone (Include Country Code): |Fax: |

|E-mail Address: |

Statement of Need/Opportunity (max 1/2 page)

|Summarize the factors that qualify your Center for participation as a Mentee Center in the MDS Center to Center Program. |

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|Mentor Center - Applicant Contact Information |

|Applicant Name: |

|Applicant Academic/Professional Affiliations: |

|Hospital/Host Institution (Center) Name: |

|Street Address: |

|City: |State/Province: |

|Postal Code: |Country: |

|Phone (Include Country Code): |Fax: |

|E-mail Address: |

Description of Program (max 3 pages)

I. Mentor Center Information

|Describe why you consider this Center to be a center of expertise including number of cases per year, number of Movement Disorders specialists|

|at the Center, local organization of clinical care for Movement Disorders, teaching experience, etc. |

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|What qualifies the neurologist to be a mentor and project leader? |

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|Add CV of mentor as addendum 1 (max 2 pages). |

II. Mentee Center Information:

|Describe what you hope this program will do for the Mentee Center including the description of the current organization, the potential to |

|treat sufficient numbers of patients with Movement Disorders and the expected long-term impact of the program? |

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|Are there a minimum of two neurologists that the Center would like to be trained specifically in Movement Disorders? |

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|Add CV of applicant and each mentee as addendum 2 (max 2 pages per CV). |

III. Feasibility of the Program

|What is the common language that the staff and patients will speak at both sites? |

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|Will there be any potential language barriers? |

|Describe the ease of travel including travel time between the Mentor and Mentee Centers, any visa restrictions, lodging accommodations, etc. |

|Describe the potential and infrastructure for tele-education between the two sites. |

|Describe the curriculum content and how you plan to implement and execute. |

|What is the availability of the mentor and the mentees to have the time commitment to participate in this program? |

IV. Site approvals

|What administrative and legal approvals have you received from the Mentor Center and the Mentee Center to pursue this program? (Provide a |

|support letter from the head of the department / administrator of both the Mentor and Mentee Center as addendum 3 and 4.) |

V. Support

|Is their any financial support or in-kind donations available to support mentor and mentees during the program (Lodging, meals, |

|transportation, etc.)? (Note: The mentor will generally have a quarterly, 2-day visit at the Mentee Center, and 2 mentees will be at the |

|Mentor Center for four weeks each year) |

VI. Other

|Please add anything else you’d like to share as to why you should be chosen as a Center in the program. |

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