Fellowship Charitable Contribution Request Form
Annual Review of Fellowship Requests
Fellowship Charitable Contribution Criteria
Business Conduct Standard Brochures
Fellowship Q&As

Fellowship Charitable Contribution Request Form
To download a Word version of the Fellowship Charitable Contribution Request Form, click on the link at the bottom of this section.

MSD's charitable contribution request forms are formatted with MicroSoft's form tool. To complete the request form:

• Move to each field that needs to be completed by using the Tab button or a moving your curser to the next field.
• If the field is a box, then just click on the appropriate box to place an "x" in the box.
• If the field is a gray text area (it is empty white space in a printed version of the form), simply start typing in the requested information.
• If you need to unlcok the form to add information that does not have a box or text field: (1) select "View" on the top menu bar, (2) select "Toolbars," (3) select the "Forms" toolbar. Once the toolbar is added, click on the icon that looks like a padlock so it is no longer highlighted. You can then type anywhere on this document. If you click on the padlock again, you may lose the information you entered in a box or text field - so avoid unlocking the document until you have completed all of the form fields and then do not re-lock it.

Submit the form according to the directions on the form. To avoid any delays in reviewing your request, please be sure to complete the request form and provide all of the requested information and documents.

If you have any questions about the request form or MSD's charitable contribution program and practices, send an email to MSD's Charitable Contributions Manager at MSDCharitableContributions@medtronic.com. The current Charitable Contributions Manager's name and phone number are available at the Charitable Contributions home page in the Charitable Contributions Manager Section.

Please read the rest of this page before completing a request form to make sure you have all of the information that you need before you complete the form.

Download Fellowship Charitable Contribution Request Form

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Fellowship Charitable Contribution Criteria
In addition to the criteria that apply to all Customer-Based Charitable Contributions, a Fellowship for which a charitable contribution is requested must also satisfy the following additional criteria:

1. The fellowship is affiliated with an academic medical institution, such as an academic medical center, teaching hospital, or medical school.
   
   
2. The fellowship involves a course of in-depth study and instruction with significant education value for the fellow. The fellowship provides an intellectual environment for acquiring the knowledge, skills, clinical judgment, and attitudes essential to the practice of the applicable sub-specialty.
   
   
3. The fellowship includes appropriate proficiency testing or evaluative processes administered by the recipient and the supervising or testing physician.
   
   
4. The Accreditation Council for Graduate Medical Education, American Osteopathic Association, the Society of Neurological Surgeons, the American Academy of Orthopaedic Surgeons, or another appropriate accrediting body has accredited or otherwise formally recognized the fellowship or the fellowship sponsor has otherwise demonstrated that it is qualified to train physicians (or other health professionals) within the sub-specialty area of the fellowship.
   
   
5. The contribution does not exceed the net anticipated costs of the fellowship based on:
   1. All direct or indirect costs of sponsoring the fellowship, such as fellow's salary, benefits, and medical malpractice coverage,
   2. All direct revenues expected to be generated by the fellow, such as Medicare Graduate Medical Education payments, other graduate medical education payments attributable to the fellow, and any professional billing revenues generated by the fellow to the recipient's or an affiliate's benefit.
      
      
6. Based on the described fellowship content and the fellow's curriculum vitae, the fellowship does not appear merely to be a vehicle for subsidizing the cost of a junior faculty member or an associate physician of the supervising or teaching physician.
   
   
7. The supervising or teaching physician for the fellow is on the faculty of an accredited medical or osteopathic school, board certified in an appropriate medical specialty and sub-specialty (e.g., spinal surgery), and qualified to supervise and train the fellow.
   
   
8. If the recipient is a hospital, the supervising or teaching physician(s) is a member(s) in good standing of the hospital's medical staff.
   
   
9. If the recipient has not already selected the fellow, the selection criteria are appropriate.
   
   
10. If the recipient has already selected the fellow, the fellow is an appropriate choice for the fellowship based on:
    1. The education content of the fellowship.
    2. The fellow's board certification or board eligibility in orthopedic surgery, neurosurgery or another appropriate specialty.
    3. The fellow is not already a junior faculty member of the recipient.

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Business Conduct Standard Brochures
MSD's Compliance Office has "Charitable Contributions Program" and "Fellowships Charitable Contributions" brochures that provide answers to common questions people have about MSD's support of Fellowships and other charitable contributions.

To order the brochure, you need access to MySpineTools.com. If you do not have access, you can ask your local MSD sales representative for the brochure or send an email to MSDCharitableContributions@medtronic.com and ask for one or both of the brochures.

If you have access to MySpineTools.com, the brochure can be ordered on MySpineTools.com by selecting "Resources" from the top navigation bar and then, from the Overview page, select "Click here to order available literature and video for customer use." The brochures are under the Sales Division category. The Item # for the brochures are LITCCBRA for the Charitable Contributions Program brochure and LITFSBR4A for the Fellowship Charitable Contributions brochure.

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Fellowship Q&As
The following Q&As address issues specific to Fellowships. General Q&As about the Charitable Contributions Program are available ar the Charitable Contributions home page at Charitable Contribution Q&As. Q&As about other types of charitable contributions are available by selecting that type of charitable contribution from the menu at the left.

Can MSD fund a Fellowship for a private physician's practice?

No. The Fellowship must be with a non-profit academic medical center, such as a teaching hospital or medical school. A private physician practice also cannot satisfy many of the other Fellowship criteria.

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