Physiatric Research Consulting Program Site Visit Form

Name(Required)

First Last

Title(Required)

Institution(Required)

We are currently a:(Required)

PM&R Department

PM&R Combined Department

PM&R Division

Other

Our department currently conducts at least some research.(Required)

Yes

Work Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Telephone(Required)

Work Email Address(Required)

Department Research Background Information(Required)

Max. file size: 128 MB.

Letter from Department Chair, requesting the visit, outlining expectations(Required)

Max. file size: 128 MB.

Letter of commitment from Dean and expected involvement in process

Max. file size: 128 MB.

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