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					Pfizer Fellowships in Pain Medicine
       Application Template




 MAP Fellowship Application Template – DO NOT MAIL
 All applications MUST be submitted online through
              www.pfizerfellowships.com
2011 Pfizer Fellowship in Pain Medicine
Management of chronic pain continues to be a significant clinical challenge despite the
availability of safe and effective therapies. Pain management is often suboptimal due to
inefficiencies in the healthcare system, difficulties in objectively assessing patient’s pain or pain
tolerance, and concerns with adverse events, tolerance or addiction to available therapies.

Applications are welcome from institutions and programs that take a multidisciplinary approach
to chronic and postoperative pain management and clinical research in pain management.

Program Design
      Two awards for up to $50,000 each, paid over 1 year

Application Deadline
      February 11, 2011

Awards Announced
     April 1, 2011

Funding Begins
     July 2011


Eligibility
Institutions
       Must be an accredited academic institution.

Requirements
     Funding must be used primarily as salary support for the selected fellow, not for
        overhead, indirect, or fringe costs.
     The institution cannot host another recipient of this same award during the proposed term
        as an awardee.

Fellows
      The selected fellow should have relevant experience and be eligible for an appointment
         as a postdoctoral fellow/trainee at a US-based academic medical center.
      At least 50% of the fellow’s time will be devoted to clinical work.
      The selected fellow must be a US citizen or foreign national with permanent US
         residence.

Fellowship in Pain Medicine Application Template                                              1
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
More than 1 application per academic institution may be submitted, provided that each
application is from a different department/division. The applicant cannot be mentored by, nor
have a familial relationship with, a member of the 2011 Academic Advisory Board. The
applicant cannot be awarded if his or her institution will be hosting another recipient of this same
award during the proposed term as an awardee.


Program Requirements
Funding for the Fellowship is paid to the awarded institution. Award payments are disbursed
annually, typically during July, through the term of the award. The institution is responsible for
administering the funds in accordance with its prevailing procedures and policies, and the stated
conditions/stipulations of this Pfizer award.

Use of funding: This Pfizer award is intended primarily for salary support and not for overhead,
indirect, or fringe costs (with the exception of medical, dental, vision, long term disability, life
and AD&D benefits). The total salary and fringe benefits of the award recipients should comply
with institutional and department guidelines. Uses of award funds toward direct expenses
necessary for the awardee’s proper conduct of research (e.g. salary of a technical associate,
purchase of relevant laboratory equipment, etc.) and toward travel expenses to scientific
meetings are also acceptable. This Pfizer award program cannot provide the sponsoring
institution with an allowance for indirect and/or overhead costs.

Annual financial reporting: The institution receiving funding from this Pfizer award must
maintain a separate financial record for each awardee. This record must be available for audit by
Pfizer or its designated agent. Reports of expenditures must be submitted annually to Pfizer at
the conclusion of each academic year, with a final report being submitted after the conclusion of
funding from this award.

Annual progress reports: At least 1 progress report per year and a final report discussing the
awardee's research must be submitted to Pfizer during the period of award funding.

Publications: It is expected that the award recipient will publish and/or present findings from his
or her work done with the support of this award at least once during the term of this award. All
publications and major presentations resulting from work done with the support of this award
shall indicate that the investigator is/was a Pfizer Fellow and that the work is/was supported (in
whole or in part) by a Pfizer Fellowship in Pain Medicine.

Other funding: Applicants are required to disclose all current and pending sources of financial
support (including other Pfizer awards). This Pfizer award cannot be made or continued if the
applicant is the sole beneficiary of, or has principal investigator status on, a research award,
Fellowship in Pain Medicine Application Template                                             2
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
fellowship, career development award, training award, or other equivalent award that is funded
by private sector companies in the pharmaceutical industry or their foundations.

Transferability, forfeiture, and termination: Should the award recipient anticipate changes in
his or her circumstances or situation for reasons including, but not limited to, discontinuation of
the research project, transfer from the designated host/sponsor institution, change in mentorship,
receipt of additional funding, etc, Pfizer must be notified without delay. If forfeiture, temporary
suspension, or termination of the award is desired or warranted by Pfizer, the award recipient,
and/or the sponsor/host institution, a written agreement of the same shall be executed with the
understanding that award funds unexpended at the time of termination may need to be returned
to Pfizer and any unpaid balance of the award may be canceled.

Selection Process
The Fellowship in Pain Medicine award is nationally competitive, and award recipients are
selected by an independent academic advisory board of experts in the field of pain medicine
based on:

Quality of the Proposal:
      Is the proposal innovative, significant, and feasible, and does it have depth?
      Does the proposal reference interdisciplinary knowledge?
      Does the proposal bridge the academic and practice communities?

Quality of the Institution:
      Are the academic and/or research facilities adequate?
      Does this institution have a commitment to pain medicine?

Quality of the Mentor
      Is the proposed mentor exemplary and has he/she made significant contributions to the
          field?




Fellowship in Pain Medicine Application Template                                            3
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
1. Confirmation of Eligibility
Please confirm eligibility by answering the following questions:

                                                                                 True   Not True
The Institution is a US-accredited academic, medical, and/or research
institution.
This fellowship award will be used primarily to pay the salary of the selected
fellow.
This is the only application for the 2011 Pfizer Clinical Fellowship award
from this Institution’s division/department.
The division/department will not be hosting another recipient of a Pfizer
Clinical Fellowship award during the proposed term.
The selected fellow will have relevant experience in the clinical area and be
eligible for an appointment as a postdoctoral fellow/trainee at a US-based
academic medical center.
At least 50% of the selected fellow’s time will be devoted to clinical work.
The selected fellow will be a US citizen or foreign national with permanent
US residence.
I have read and I agree to the requirements of this fellowship award program,
as found in the Program Administration/Stipulations section of the program
description.




Fellowship in Pain Medicine Application Template                                         4
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
2. Institution Information
Primary Institution Name
Department
Division
Address


City
State
Zip
Phone
Website

Secondary Institution Name
(if applicable)
Department
Division
Address


City
State
Zip
Phone
Website




Fellowship in Pain Medicine Application Template                                      5
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
3. Person completing the application/on behalf of (optional):
Salutation
First Name
Middle Initial or Name, if
used
Last Name
Degree(s), Cert(s), if any
Title
Mailing Address
Department
Division
Address


City
State
Zip
Phone
E-mail Address

On behalf of (optional):
Salutation
First Name
Middle Initial or Name, if
used
Last Name
Degree(s), Cert(s), if any
Title
Mailing Address
Department
Division
Address


City
State
Zip
Phone
E-mail Address



Fellowship in Pain Medicine Application Template                                      6
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
4. Mentor Information
Please provide the Primary Mentor's information below.
Salutation
First Name
Middle Initial or Name, if
used
Last Name
Degree(s), Cert(s), if any
Title
Mailing Address
Department
Division
Address


City
State
Zip
Phone
E-mail Address

Primary Mentor's Curriculum Vitae or Biography.
Files submitted must be in PDF, .doc, or RTF format. (max 10 pages)



Letter from Primary Mentor:
Please provide a signed letter that describes the primary mentor’s roles and responsibilities
within the clinical fellowship program including academic, clinical, and research responsibilities
as applicable.
Files submitted must be in PDF, .doc, or RTF format.




Fellowship in Pain Medicine Application Template                                           7
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
Secondary Mentor (optional):
Please provide the Secondary Mentor's information below.
Salutation
First Name
Middle Initial or Name, if
used
Last Name
Degree(s), Cert(s), if any
Title
Mailing Address
Department
Division
Address


City
State
Zip
Phone
E-mail Address

Secondary Mentor's Curriculum Vitae or Biography.
Files submitted must be in PDF, .doc, or RTF format. (max 10 pages)



Letter from Secondary Mentor:
Please provide a signed letter that describes the secondary mentor’s roles and responsibilities
within the clinical fellowship program including academic, clinical, and research responsibilities
as applicable.
Files submitted must be in PDF, .doc, or RTF format.




Fellowship in Pain Medicine Application Template                                           8
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
Co-investigator (if applicable)
Please provide the Co-investigator information below.
Salutation
First Name
Middle Initial or Name, if
used
Last Name
Degree(s), Cert(s), if any
Title
Mailing Address
Department
Division
Address


City
State
Zip
Phone
E-mail Address

Co-investigator’s Curriculum Vitae or Biography.
Files submitted must be in PDF, .doc, or RTF format. (max 10 pages)




Fellowship in Pain Medicine Application Template                                      9
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
5. Division/Department Chair
Please provide the Division/Department Chair's information below.
Salutation
First Name
Middle Initial or Name, if
used
Last Name
Degree(s), Cert(s), if any
Title
Mailing Address
Department
Division
Address


City
State
Zip
Phone
E-mail Address

Division/Department Chair Curriculum Vitae or Biography.
Files submitted must be in PDF, .doc, or RTF format. (max 10 pages)




Fellowship in Pain Medicine Application Template                                      10
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
6. Project Details
Detailed description of the Clinical Fellowship program including academic, clinical, and
research responsibilities and topics (as applicable).

Outline of the proposed rotations/clinical assignments

Files submitted must be in PDF, .doc, or RTF format.




Fellowship in Pain Medicine Application Template                                            11
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
7. Career Development Statement

 Please describe the following:

1. How the fellowship program relates to the career development of the fellow.
2. Detailed description of the mentoring process.
3. Plans for presenting research findings at a professional association meeting or conference. (if
   applicable)
4. Publication plan. (if applicable)

Files submitted must be in PDF, .doc, or RTF format




Fellowship in Pain Medicine Application Template                                           12
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
8. Letters of Support
Please provide a signed letter from the Dean and/or Division/Department Chair (listed above)
confirming institutional support for this fellowship during the entire course of the award. List
additional current and pending sources of financial support for this clinical fellowship (if
applicable).

Files submitted must be in PDF, .doc, or RTF format.




Additional letters of support (optional):
Files submitted must be in PDF, .doc, or RTF format.




Fellowship in Pain Medicine Application Template                                            13
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
9. Other Information

How did you learn about the Pfizer Clinical Fellowship Program?
Please select all that apply.
    Article                   Advertisement      Internet Search
    Colleague                 Conference         Previous Applicant
    Pfizer Representative     Mailing
    Other_______________________
Please enter specifics (eg, name of conference or Pfizer representative, journal where
advertisement ran). (Optional)


Attachments
Files submitted must be in PDF, .doc, or RTF format.
(Optional)


Comments (Optional)




Fellowship in Pain Medicine Application Template                                         14
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com
10. Budget Information

Please provide budget estimate.
Note: Budget needs to total $50,000
Salary
Healthcare Expenses
Technical Associate
Laboratory Equipment
Travel to Scientific
Meetings
Miscellaneous
Total:




Fellowship in Pain Medicine Application Template                                      15
        MAP Fellowship Application Template – DO NOT MAIL
        All applications MUST be submitted online through www.pfizerfellowships.com

				
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