Building Trust Through Diversity, Health Care Equity, and Inclusion in Internal Medicine Training

Letter of Intent Submission Form

Applicant Information

*Please note that this application will need to be submitted in one session.

First Name *

Last Name *

Title *

Institution *

Address *

Phone (xxx) xxx-xxxx *

Email *

Principal Investigator (PI) of the project *

PI Address *

PI Phone (xxx) xxx-xxxx *

PI Email Address *

As a PI, are you (check all that apply)

ACP member

AAIM member

Certified by ABIM

Proposal Information

Project Title *

Brief Description of Project - to include overview of goals, objectives and sustainability after funding period ends (300 words or less) *

0/300 words

Describe the primary outcome of your project (150 words or less) *

0/150 words

Describe the potential generalizability of the project to other settings (150 words or less) *

0/150 words

Type of Grant Application Seeking *

Large grant ($20,000 total for up to two years)

Small grant ($2,500 or $5,000 grant for one year)

If you are accepted to submit a full proposal, would you like coaching as you develop your project proposal? *

Yes

No

Do you commit to particpating in a learning network with other grantees? *

Yes

No

Do you commit to submitting a final report once the project is completed? *

Yes

No

The following demographic questions are used to understand the diversity of submitters. If you do not wish to disclose this information, please select “Prefer not to answer” from the list of options. Selecting “Prefer not to answer” will not affect the evaluation of your proposed project.

I identify my race/ethnicity as (select all that apply):

*

I identify my gender as: *

This grant program is sponsored by the American Board of Internal Medicine, ABIM Foundation, Alliance for Academic Internal Medicine, American College of Physicians, and the Josiah Macy Jr. Foundation.