Fellowship Grant Application

Who Should Use This Application

This Fellowship Grant Application is intended for use by Applicant Organizations which are: (i) accredited by the Accreditation Council for Graduate Medical Education (ACGME), or (ii) if located outside of the United States, accredited by a foreign country’s recognized graduate medical education accrediting body. An eligible Applicant Organization is the sponsoring institution (organization or entity) that assumes the ultimate financial and academic responsibility for the accredited clinical orthopaedic fellowship program. Participating clinical sites are not eligible Applicant Organizations unless they are also the sponsoring institution that assumes ultimate financial and academic responsibility of the fellowship program.

Acumed does not provide grants to individual health care professionals (HCPs) or to HCPs in training and does not provide grants that are earmarked for the benefit of individual HCPs or HCPs in training. Accordingly, Acumed will not consider grant requests for individual HCPs or HCPs in training. In addition, this Application should not be used to request grant funding for independent medical educational programs for health care professionals, including congresses, conferences, symposiums, or courses, with or without labs, that are sponsored by professional medical associations, societies, or continuing education providers and academic institution labs. Such requests should be made through the Professional Medical Education Grant Application.

Please see the Guidelines for Fellowship Grant Applications for more information.

Submission Deadline

To manage our budget and to ensure Acumed can fund as many worthwhile programs as possible, we limit the awarding of Fellowship Grants to once per calendar year. To be considered, the completed application, including all required documentation, must be submitted by April 15th. Applications submitted after the April 15th deadline will be held for the following year’s review cycle. Applicants will receive grant notifications by May 30th. If you have any questions, please contact grants@acumed.net.

Other Applications

Professional Medical Education Grant Application is intended to be used for all grant requests for independent medical educational programs for health care professionals, including congresses, conferences, symposiums, or courses, with or without labs, that are sponsored by professional medical associations, societies, or continuing education providers and academic institution surgical skills labs.

Collaborative Research Opportunities is intended to be used for all requests for support towards research proposals and research studies.

Contact Information

All notifications, questions, etc. regarding this grant application will be directed toward the primary contact listed below.

Primary Contact

Secondary Contact

Applicant Organization Information

Click or drag a file to this area to upload.
For Applicant Organizations located outside of the United States that do not have a W-9 or 501(c)(3) tax-exempt IRS Determination Letter, please provide a W-8BEN-E which can be downloaded from the United States Department of Treasury Internal Revenue Service website.
Click or drag a file to this area to upload.
The letter of request must be on the Applicant Organization’s letterhead and is to include the educational goals and objectives of the program, specify the grant amount requested, list all faculty members within the fellowship program, and be signed by an individual with the requisite authority to submit the grant application on behalf of the Application Organization.

Fellowship Program Information

Please provide the following information regarding the orthopedic fellowship program.
Click or drag a file to this area to upload.
This is to include a description of the institution’s method of formal evaluation of faculty, fellows and fellowship program.
Click or drag a file to this area to upload.
This is to include an overview of the educational program, annual curriculum, resources and facilities available to fellows.
Click or drag a file to this area to upload.
This is to include information regarding the research environment for fellows, research requirements for fellows and a list of recent presentations and published papers of fellows.
Click or drag a file to this area to upload.
Core Faculty Members include faculty, other than program directors, who devote at least 15 hours per week to fellow education and administration. Core Faculty Members evaluate the competency domains, work closely with and support the program director, assist in developing and implementing evaluation systems, and teach and advise fellows.
Click or drag a file to this area to upload.
This summary must include the following information for each Core Faculty Member of the fellowship program: (1) name, (2) education, (3) training, (4) years in practice, (5) certifications and board membership, and (6) academic positions held.

Accreditation Status

Click or drag a file to this area to upload.
For programs in the United States, please provide the fellowship program’s most recent ACGME accreditation letter. For programs outside of the United States, please provide the accreditation certification from the recognized graduate medical education regulatory body of the particular country.
If the fellowship program has been accredited for less than (1) one year, please enter “0” above.

Grant Request

Click or drag a file to this area to upload.
This attachment is required to include an itemized budget for the entire fellowship program.

Optional Attachments

Please upload any additional documents, or information that you would like our Grants Committee to take into consideration.
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.

Certifications

This Certification is intended to require the Applicant Organization, Acumed, and their personnel to comply with the laws and regulations applicable to relationships between donors and requestors of grant funding, including but not limited to the federal Anti-Kickback Statute (42 U.S.C. §1320a-7b(b)), state anti-kickback laws and regulations, and the Foreign Corrupt Practices Act of 1977 (15 U.S.C. §78dd-1, et seq.). Acumed reserves the right to modify the requirements of this Certification as Acumed deems appropriate to ensure compliance with state and federal laws and regulations.
(Individual submitting this Grant Application)
I, the Submitter of this Grant Application, certify that to the best of my knowledge all of the following statements are true with respect to the submission of this Grant Application:

  1. I have the requisite authority to submit this Grant Application on behalf of the Applicant Organization.
  2. All information provided in this Grant Application and its attachments is true and accurate as of the date of this Grant Application, and I am unaware of any information or other circumstance that is likely to render any such information false or erroneous. I will promptly notify Acumed in the event that any information provided in this Grant Application and its attachments becomes false or erroneous.
  3. The submission of this Grant Application does not violate the Applicant Organization’s Code of Ethics, Conflict of Interest Policy, or any other policy of the Applicant Organization and does not violate any law or regulation to which the Applicant Organization is subject.
  4. The Applicant Organization, its personnel, and I have not, implicitly or explicitly, solicited the requested grant in exchange for an agreement to purchase, use, order, or recommend Acumed products or as a reward for any prior purchase, use, order, or recommendation of Acumed products. The Applicant Organization, its personnel, and I acknowledge and agree that Acumed’s decision of whether to approve or deny this Grant request is wholly unrelated to any prior or future purchase, use, order, or recommendation of Acumed products. I further acknowledge that any offer to purchase, use, order, or recommend Acumed products in connection with this Grant Application will result in the automatic denial of the Grant request.
  5. No Acumed representative implicitly or explicitly offered a grant to the Applicant Organization, its personnel, or to me to encourage or to reward the prior or future prescription, purchase, use, order, or recommendation of any Acumed product. I understand and acknowledge that any decision to approve a Grant request is determined independently, without regard to the volume or dollar value of any business that may have been or may be potentially generated by the Applicant Organization.
  6. The Applicant Organization, its personnel, and I are not a person (or persons) or organization: (a) excluded from a federal health care program as outlined in Sections 1128 and 1156 of the Social Security Act; (b) debarred by the FDA under 21 U.S.C. 335a; (c) otherwise excluded, suspended, or debarred from contracting with the federal government or participating in a federal health care program; or (d) convicted of or under investigation for a health care-related criminal offense, including any violation described in 42 U.S.C. §1320a-7(a).
  7. The Applicant Organization, its personnel, and I shall comply fully with the U.S. Foreign Corrupt Practices Act (15 U.S.C. §§ 78dd-l et seq.), and any similar laws of any jurisdiction that are applicable to them, including those of the Kingdom of Belgium, the European Union and any other countries in which the Applicant Organization operates, and all countries otherwise having jurisdiction over the fellowship program or the grant requested hereunder (collectively, “Anti-Corruption Laws”).
  8. The Applicant Organization, its personnel, and I represent and warrant that in the event the fellowship is conducted in a foreign country, the award of the grant, the use of grant funds, and the conduct of the fellowship program will not violate any local laws, regulations or ordinances.
  9. The submission of this Grant Application does not guarantee approval of this Grant Application, and if approved by Acumed, Acumed may approve funding at an amount less than what has been requested.
  10. The Applicant Organization shall at all times maintain complete control over the clinical and educational aspects of the fellowship program that is the subject matter of this Grant Application, including but not limited to the selection of individuals to participate in the program, the academic curriculum, and the standards of the program.
  11. If this Grant Application is approved, the Applicant Organization will be required to represent and warrant, in a separate writing, that: (a) the receipt of grant funding will not affect its or its personnel’s’ professional judgment; (b) it will assist Acumed in complying with its reporting duties required by the Physician Payment Sunshine Act and its implementing regulations (42 C.F.R. § 403.900 et seq) as an applicable manufacturer; and (c) Acumed shall have the right to audit the use of grant funds, and the Applicant Organization will provide Acumed with reasonable access to copies of receipts related to the expenditure of grant funding.