CORD Project Request for Support

Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.

CORD Project Request for Support

Please have all information ready to complete the form below. Only complete applications will be accepted.

Files needed for upload to complete the application are:

  • Brief description of project (maximum of 1000 words)
  • Project Leader CV

I.   Title

Title of project: *

II.    Project leader information

Full Name (First Last, Degree) *
Telephone Number: *
Email Address *
Name of Institution: *
Address Line 1 *
Address Line 2 *
City *
State *
Zip Code *

III.   Project Information

Please upload a brief description of your project (maximum of 1000 words) *
Explanation of project objectives: *
How will it benefit CORD, help educate the public, and/or further the advancement of emergency medicine? *

IV.   Time/Costs

Estimate of members' time to be spent on the project: *
Estimate of CORD staff support for project: *
Estimate of project costs and revenues (please itemize): *

V.   Funding Sources

Are other funding sources requested or already approved? *

Clear Selection
If yes, please provide information on any other funding sources that will be used to complete this project:

VI.   CORD Committee and Task Force

We encourage contact and coordination with appropriate CORD Committees and Task Forces.

Is the project recommended/supported by a CORD Committee or Task Force? *

Clear Selection
If yes, which Committee or Task Force?

VII.   Additional Information

Please describe any anticipated barriers to completion: *
Please describe timeline of project and anticipated date of completion: *
Please attach a CV of the Project Leader *
Please describe project distribution methods with CORD membership on outcomes from the project (presentation, publication/white paper, document for posting to Sharepoint, etc.) after completion of the project. *
Typed signature of Project Leader: *
Date: *

Your form submission WILL be encrypted using SSL to ensure your privacy.

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