Ontario’s Anesthesiologists Leadership Development Grant

Selection Questionnaire

Thank you for applying to the Ontario’s Anesthesiologists Leadership Development Grant Program. The Selection Questionnaire is designed to obtain information about the individual and the proposed activity. This information will assist the selection committee in selecting finalists. The committee will evaluate applications based only on the content of the application.

General instructions: Answer all the questions to the best of your ability and follow the instructions completely. Be careful not to duplicate your responses. The selection of leadership award recipients will be influenced by the completeness of replies, understandability of submission and legitimacy of the request. The application must be submitted on this form. It is suggested that each nominee retain a copy of their application.

Please email the documents supporting your application to Ontario’s Anesthesiologists, c/o Stephanie Field, Executive Coordinator: info@ontariosanesthesiologists.ca

Applications for the 2025 Ontario’s Anesthesiologists Leadership Development Grant are due by Friday, September 5, 2025.

Administrative Information

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email (preferred)

Email (2nd)

Home Phone

(###)

###

####

Business Phone

(###)

###

####

Cell

(###)

###

####

Years in Practice

Present Leadership Position(s)

Institution of Practice

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Fax

(###)

###

####

Website

http://

Leadership Program/Course Name

Host/Institution

Description

Start Date

YYYY

End Date

YYYY

Grant Amount Requested (up to $5,000 lifetime maximum)

Leadership Development Vision and Goals

What are your leadership development goals and how do they align with the broader needs of anesthesia practice in Ontario? (500 words max)

Feasibility and Plan for Implementation

What key milestones do you plan to achieve during this leadership development process? How will you measure your progress? (500 words max)

What resources (e.g., time, financial, and institutional support) will you require to implement your leadership development plan? Please provide a budget overview and describe how you will integrate this leadership initiative into your daily practice.

Impact on Ontario Anesthesia Practice

What impact do you anticipate your leadership development will have on your anesthesia practice and the field of anesthesia in Ontario? Please provide specific examples of how your development could influence anesthesia practice or the health-care system, and how you plan to engage with key system players (e.g. health-care institutions, professional associations, and government). (500 words max)

Sustainability and Future Leadership Growth

How do you intend to continue your learning and professional growth, and contribute to the growth and development of others, once this leadership development opportunity concludes? (200 words max)

Evidence of Need for Development

What specific leadership challenges or gaps do you currently face in your practice, and how can this leadership development program help address them? (200 words max)

Professional Experience and Readiness

Please describe how your motivation, prior experiences, and career trajectory make you well-suited to participate in this leadership development program. (200 words max)

Alignment with Equity, Diversity and Inclusion

Please outline your commitment to equity, diversity, and inclusion in leadership. Include how you plan to promote inclusive leadership practices, address health-care disparities, and connect with diverse communities. (200 words max)

Additional Information

If you wish to provide additional information (not already stated), please include it here (up to a maximum of 200 words).

Reimbursement

Successful applicants will receive 50% of the award upon commencement of the course and the remaining 50% of the award upon receiving a Summation Report describing the event/course including what was learned, how it will impact present or future leadership roles, and related comments. The Summation Report must be submitted within 60 days of completion of the event to be eligible for the remaining 50% support. Failure to submit a report in this timeframe will result in forfeiture of the remaining amount of the award. Ontario's Anesthesiologists' policy allows up to $1,500 out of a $5,000 scholarship to be used toward accommodation and transportation. Only economy class fares by the most direct and economical routing will qualify. To obtain a full reimbursement, all receipts must be provided. References (Please submit a maximum of two references) Reference 1

First Name

Last Name

Position

Relation to Applicant

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Reference 2

First Name

Last Name

Position

Relation to Applicant

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Attestation and Recommendation (must be completed for consideration)

I certify that my responses are true and factual. I also agree to provide a report within 60 days of the scheduled completion of the activity. Electronic Signature of Applicant

Date

YYYY

Please submit your supporting documents to info@ontariosanesthesiologists.ca.

Leadership Development Grant Application Form

Ontario’s Anesthesiologists Leadership Development Grant

Selection Questionnaire