International Ambassador Program Application

Please fill out the following application. Applications are due December 31, 2022. Awardees will be announced February, 2023.

Should I receive this travel grant, I will attend: *

Yes, I can attend SHEA Spring 2023, April 12-14

No, I cannot attend

First Name/Given Name: *

Last Name/Surname: *

Degree(s): *

Degree(s): Other...

Speciality: *

Street Address: *

City: *

Country: *

E-mail Address: *

Name of Institution: *

Job Title: *

Which population do you serve? *

Number of years working in infection prevention and control: *

Less than 5 years

5-10 years

11-15 years

15+ years

Track: *

Infection Prevention

Antimicrobial Stewardship

Micro/Infectious Diseases

Other...

Track: Other...

Do you chair or actively participate in an Infection Control Committee? *

Infection Control Chair

Infection Control Participant

Not Involved

Have you ever attended a SHEA meeting or IDWeek? *

Yes

No

If yes, list the year(s): *

Have you ever presented an abstract at the SHEA meeting or IDWeek? *

Yes

No

If yes, list the year(s): *

Have you received any prior awards/scholarships or recognitions from SHEA? *

Yes

No

If yes, please list: *

What best describes your current, primary practice setting? *

What best describes your current, primary practice setting? Other...

Please indicate the number of beds in your primary hospital? *

How did you hear about the International Ambassadors Program? *

How did you hear about the International Ambassadors Program? Other...

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International Ambassador Program Application