Progress Report

Required fields are marked with *

1. First Name*

2. Middle Initial

3. Last Name*

4. Suffix*

5. Institution at time of award*

6. What is your current Academic Title?*

7. Current Institution if Different than above

8. Current Address*

9. Current Address Line 2

10. Current City*

11. Current State*

12. Current Zip*

13. Current Phone*

14. Current Fax*

15. Current Email*

16. OMSF Award*

17. Other

18. Award Funding Year*

19. Title of the project for which you were funded?

20. What was the dollar amount of funds granted by OMSF?*

21. How many publications have been generated directly or indirectly from your award?*

22. List publications:

23. How many presentations have been generated from your award?*

24. Where have you presented?

25. Have you acquired additional funding or resources as a result of your OMSF Award?*
Yes
No

26. How much additional funding have you acquired as a result of your OMSF Award?*

27. Have there been any patents, copyrights or royalties generated as a result of your Award?*
Yes
No

28. Please list any patents, copyrights, or royalties generated

29. Has your OMSF award impacted your career?*
Yes
No

30. How has your OMSF award impacted your career?

31. Other

32. How has your award impacted the specialty of Oral & Maxillofacial Surgery?*

33. Have other Oral & Maxillofacial Surgeons become involved in your research or education as a result of this award?*
Yes
No

34. What strengths, weaknesses or suggestions do you have in regard to this award?*

9700 W. Bryn Mawr Avenue Rosemont, IL 60018 Phone: 847.233.4304 Fax: 847.678.6254 Email: omsf@aaoms.org