The 26th Forum for Behavioral Science in Family Medicine
Downtown Chicago: September 15-18, 2005

This award recognizes an innovative approach to behavioral science instruction in family medicine. The 2005 Award will be the 18th, the 8th since the award was posthumously named after Gabriel Smilkstein, MD, respected family physician and educator. To be considered, teaching innovations must address an aspect of clinical family practice, be in use presently, and must:

• encourage integration of knowledge, skills and attitudes
• be generalizable to other residency settings
• have measurable outcomes

Examples of past awards include a training program for drug abuse and alcoholism, a block rotation in behavioral and counseling skills, and brief consultation techniques for integrating a family-centered approach into routine office encounters.

Eligibility: Applicants who have been selected to present a seminar or workshop about the teaching innovation will be eligible for the award. Previously submitted materials may be resubmitted for consideration.

To apply:
(1) Complete both the award application on the next page and the seminar or workshop application form, also attached.
(2) Submit both forms (5 copies each) by mail to the Forum at the address below by no later than March 21, 2005. Faxed forms will not be accepted.

Selection process: The Planning Committee will forward award applications that accompany accepted presentations. These nominees will be reviewed by an independent panel of judges. The award will be announced and presented at the conference.

Award application deadline is March 21, 2005.

Application

Title of innovation: ______________________________________________________

Innovator(s) / implementor(s) and titles:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Family medicine program: ________________________________________________

Address: _____________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Phone: ___________________________ E-mail: _____________________________

Describe innovation: (program, objectives, methodology, techniques, etc., including setting, resident/patient population, etc. Attach additional pages if needed).

Length of time innovation in practice:

Evaluation or feedback mechanisms employed:

Other uses, variations, etc.:

Return application (5 copies) to:

Mary Ellen Radjenovich
Medical College of Wisconsin
Department of Family and Community Medicine
8701 Watertown Plank Road
Milwaukee, WI 53226-0509