Grant Application Form
Project Title
Healthcare Organisation and Full Address
Name/ Contact details for Individual Requester on behalf of Healthcare Organisation* / Name:
Email:
Contact phone number:
Project Goal / Briefly describe how this project will improve patient care
Project Plan / Please outline the proposed methodology and key stages/milestones of your planned approach. Please include details of responsible roles required to carry out the project, e.g. in house staff, external service providers.
Evaluation Measures and Metrics / What measures and metrics will you use to evaluate the success of the project
Ensure robust plan to capture baseline and end of project metrics e.g.
· Change in number of patients registering in the Practice for support with a Quit Attempt
· Change in Practice level Quit Rate
Please note Pfizer must not receive any patient identifiable information
Educational Sustainability / How will the project support ongoing patient management and care?
Start and End Date
Requested Support from Pfizer / Please indicate total monetary sum being requested from Pfizer and provide a full breakdown of how the funding will be spent* e.g.
· Number of additional clinics to be provided
· Hourly rates of required personnel
· Costs of Consumables
· Number and cost of educational materials to be printed
If any additional non-monetary support is required please detail here.
*Please note funding for institutional overheads will not be provided
PP-GIP-GBR-2062 IPCTD Grant Application Form Date of prep June 2017
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*Your data will be held on a database controlled by Pfizer Limited (Ramsgate Road, Sandwich, Kent CT13 9NJ, UK) and used for the purpose of assessing your application. Only Pfizer (i.e., Pfizer Limited, Pfizer Inc. and other Pfizer Group companies (http://www.pfizer.com/)), Pfizer Alliance Partners (i.e., other companies which co-promote medical products with Pfizer) and information and communication technology services providers working with Pfizer, will have access to your information to design, implement and control Pfizer initiatives in the area of medical and educational goods and services and/or provide technical support to the database. The database and these recipients may be located within the EU or outside (where privacy legal standards may not be equivalent to those applicable in the EU). We will always employ appropriate technical security measures to protect your personal information and to ensure that it is not accessed by unauthorised persons. You may access or update your data or withdraw this consent by emailing us at: . Please use the reference “Pfizer Email Programme” in any communication to us.