Training & ResearchGrants Programme Application Form

(Please read the guidelines before completing)

Name of Applicant:
Job Title:
Ward/Dept/Organisation:
Address:
Telephone Number:
Mobile Number:
E-mail Address:
Normal Working Hours
(if we need to contact you)
Project Title & Commencement Date

THE PROPOSAL

1.Please describe your training or research proposal in detail (use a separate sheet if required):
2.Have we funded similar training or research for you before? If yes, please give details below. / Yes / No
3.How will this training or research benefit children / young people / families?
4.How will these benefits be assessed?
5.Please explain why NHS will not fund this project and why you have applied to ECHC for funding? Have you sought funding from any other source, if so, please give details?
6.Do you agree to your details being used in/ provide details of a case study forECHC marketing materials? / Yes / No

THE COSTS

7.Total cost of project (including VAT). Please attach quotation (if applicable):
(Please note VAT does not apply to medical equipment purchased by ECHC)
Net Amount / VAT Amount / Total
£ / £ / £
8.Total Amount sought from ECHC:
Net Amount / VAT Amount / Total
£ / £ / £
9.Detail any recurring revenue implications (i.e. increased consumables / maintenance charges):
10.Is this project to be funded by a particular donation? If yes, please give details. / Yes / No
11.After your training or research is complete you will be required to provide a report on the outcomes and how you have shared what you have learnt with other colleagues. Please confirm you agree to do this? / Yes / No
12.After your training or research is complete you may be asked to present the outcomes to ECHC staff and other clinicians. Please confirm you agree to do this if asked? / Yes / No
13.Do you agree to accredit ECHC in any published works resulting from this funding? / Yes / No

ENDORSEMENTS

Applicant’s Signature:
Date:

Head of Department:

Signature:
Print:
Date:

Associate Divisional Medical Director, or

Chief Nurse, RHSC (or equivalent for your area)

Signature:
Print Name:
Date:

I can confirm that NHS Lothian – Acute Operating Division, will fund any additional revenue consequences arising from the project as noted at item 9.

Strategic Programme Manager, or

Service Manager (or equivalent for your area)

Signature:
Print Name:
Date:

For Projects Outwith NHS Lothian

I can confirm that on-going revenue consequences will be funded by:

Name of Organisation:
Signed by Head of Organisation:
Print Name:
Date:

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