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LMRC- Program Site Interest Form
Thank you for your interest in becoming a site for the Lifestyle Medicine Residency Curriculum!
If you are interested in becoming a site for the LMRC and a Lifestyle Medicine Board Eligible residency for the 2024-2025 residency academic year, please fill out the following form by March 15, 2024. All forms accepted after March 15, 2024 will be eligible for LMRC implementation in the 2025-2026 residency academic year.
Any questions, please contact our team at LMRC@lifestylemedicine.org
Name
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First
Last
Email
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Title and Board Certifications
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Institution Name
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What (if any) medical school are you connected with?
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Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Australia
Canada
France
New Zealand
India
Brazil
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Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Bouvet Island
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong SAR China
Hungary
Iceland
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau SAR China
Republic of North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé & Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St. Barthélemy
St. Helena
St. Kitts & Nevis
St. Lucia
St. Martin
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Outlying Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Which residency program(s) at your institution would like to implement the LM residency curriculum?
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(Please list each one if you have more than one specialty or residency program.)
Total Residents in each specialty
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How many Residents in each specialty will participate in the LM residency curriculum?
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Have you identified Residents in each specialty who would champion the adoption of the LM residency curriculum?
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Yes
No
How many Residents are interested in taking the LM board exam offered by the American Board of Lifestyle Medicine (ABLM) after residency completion?
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How many total Core Residency Faculty are in each specialty?
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How many of these Core Residency Faculty would support the LM residency curriculum? Is the department chair supportive? Is the residency director supportive? Are your associate or assistant chairs and directors supportive? If not, what are your plans to engage them?
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How many total faculty in each specialty are currently board certified in LM and how many additional faculty are qualified and available to teach LM?
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What LM teaching is already in each residency specialty curriculum – who is in charge of the curriculum, who delivers it and how many total hours per month are dedicated to LM teaching?
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How many hours per month are available to support the adoption of the LM residency curriculum in each specialty?
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List the practice sites/clinical sites that are available for LM application with patients for each specialty. (Please briefly describe each clinical site noted in your response.)
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Do the Residency specialties fund other outside curricula for the Residents (ex FEMA training, IHI, LMCC)?
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Yes
No
Please describe and indicate the cost of the curricula adopted. Does your department have funding for curriculum adoption such as this one?
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Anything else you want to add to help us in our selection process?
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