Professional Development Application Form Department of Health Services Research, Management and Policy Step 1 of 2 50% Basic InformationName(Required)Conference/Event Name:(Required)Travel Location(Required) City State / Province / Region AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Purpose of Travel(Required)AcademicResearchReason for Travel. MUST include benefit to UF.Start Date of Travel:(Required) MM slash DD slash YYYY End Date of Travel:(Required) MM slash DD slash YYYY Start Date of Conference/Event:(Required) MM slash DD slash YYYY End Date of Conference/Event:(Required) MM slash DD slash YYYY ExpensesEstimated Cost of Registration (Early Bird):Regular Registration Cost:Estimated Cost of Flight:Luggage Expenses:Expected Cost of Car Rental (per day)How many days do you intend to rent the vehicle?Gas:Reimbursement for personal vehicle or payment for a rental car.Expected Parking (per day)Expected Lyft/Taxi/Uber expensesCost for Meals (per diem)Accommodations (per night)Nights of lodgingWhat hotel do you plan to stay at?Other (please describe):Total Expected Expenses:(Required)Please add up your costs above to produce your total.FundingWhat other funding sources do you have? (Listing additional funding sources does not imply they will be spent but will only document how much is available.)Available IDCs:Available Startup Funds:Available Grants:Other Funding Sources (DO, etc.):What amount of the above funding sources do you intend or are willing to commit to this activity? Justification1. What is your role in attending/what is your position?(Required)2. Will you be presenting a paper/poster/other at this conference?(Required)3. Will students also be attending this conference?(Required)4. How will attending benefit your Career Progression?(Required)5. How does attending this conference align with HSRMP Strategic Initiatives*?(Required)* HSRMP Strategic Initiatives can be found at: S:\hsrmp\Department Resources 6. Please indicate on a scale of 1 to 10 the priority of attending this conference:(Required) 1 2 3 4 5 6 7 8 9 10 (1 = Lowest Priority; 10 = Highest Priority)7. Please provide any additional relevant information.
