Special Workshop Request Form Special Workshop Request Form Special Workshop Request Form First Name * Last Name * Department/Program * Email * Workshop Genre * AssessmentCoachingEducational ScholarshipFeedbackMitigating BiasSelf and/or Peer ObservationTeachingWho the Academy Serves and Educator Development ProgrammingOther Workshop Genre If other, please provide the topic Audience * Faculty Residents Fellows Pre-clinical students Clinical students Goals of the Workshop: What are you hoping to learn, gain, and/or achieve from this workshop? * Logistics: Provide some details about the session that would be ideal for scheduling this workshop (rough date range, day of the week, time of day, virtual or in-person, number of participants, etc.) * Additional Information: Provide any additional information that would be helpful. If you are human, leave this field blank. This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Submit Δ