THE DAVID FEAR FELLOWSHIP NOMINATION FORM The David Fear

							                                  THE DAVID FEAR FELLOWSHIP

                                         NOMINATION FORM

The David Fear Fellowship award supports Continuing Education activities such as Continuing Education
leadership courses, site visits, attendance at Continuing Education meetings, etc.

Candidate Information

Name of Nominee: _____________________________________________________________

Organization: _________________________________________________________________

Position: _____________________________________________________________________

Address: _____________________________________________________________________

Telephone: (   ) _______________________ Fax: (       ) _______________________________

E-mail: _______________________________________________________________________


Nomination Information

Name of Nomination: ___________________________________________________________

Organization: _________________________________________________________________

Position: _____________________________________________________________________

Address: _____________________________________________________________________

Telephone: (   ) _______________________ Fax: (       ) _______________________________

E-mail: _______________________________________________________________________
Information Required:

Please provide the following documentation:

   •   The nominee must indicate, in a 1-2 page letter, his/her interest in continuing education, and in what
       ways the expertise acquired by the Fear Fellowship support will be utilized
   •   The letter must be accompanied by one or more letters of support, from departmental chairs, other
       faculty members, or from community-based health professionals
   •   Once the professional development activity has occurred, the fellow will report back to a meeting of the
       CEPD Leaders and Directors Group and/or in another forum, eg. at an Education Rounds
   •   It is not anticipated that the fellowship award will cover all expenses, and may be matched by other
       funds, either personal or departmental
   •   Support for this fellowship will be a maximum of $3,000, available in a one year period, derived from
       University of Toronto sponsorship fees and the Academic Development Fund in Continuing Education
       and Professional Development
   •   The fellow is obliged to acknowledge the University of Toronto David Fear Fellowship in relevant
       presentations, publications, as appropriate

Nominations can be submitted to the foundation, by ________________ in several ways:

  by Fax: (416) 971-2722
  by E-mail: ce.med@utoronto.ca
  by mail:    Continuing Education, Faculty of Medicine, University of Toronto
              500 University Avenue, Suite 650
              Toronto, ON M5G 1V7