The Queen’s Nursing Institute

and

Burdett Trust for Nursing

Fund for Innovation and Leadership2017

Application form

Improving care, enhancing leadership

Closing date: Thursday 24th November 2016

Guidance notes accompany this application form. Please make sure that you have read theseprior to completing your application,to ensure that your project meets the required criteria.

Please ensure that you complete all sections of the application form and submit anelectronic copy (in WORD document format) of your application to: Aga Kusmierz, Practice Development Administrator,

If you have any queries or would like to talk through your project idea before commencing or submitting an application, please contact Anne Pearson, Director of Programmes on 020 7549 1400 or email to

Check list: Please tick below to indicate you have collated all relevant documents required:

Application form
Manager’s letter of support
CV (one for each applicant)
Amount of funding required: / £
Name of lead applicant who must be directly involved in delivering the project
this will also be the main contact person for all correspondence
Please confim that you have read the Fund for Innovation and Leadership guidance accompanying this form
Signature of all applicant(s)
Name of Lead applicant Co-applicants will also need to include contact details- please photocopy or repeat this page to do so.
Address for correspondence
Telephone number / Mobile
Email / NMC Registration pin number
Please confirm that your DBS (Disclosure and Barring Service) check is current
Position held and professional qualifications
Name of employing organisation
Address of employing organisation
Please confirm that your employing organisation has safeguarding policies in place for children, young people and vulnerable adults
Name of Supporting manager
Address of Supporting manager

Please complete all sections

The size of the following tables are for guidance only- as this is a word document, the table will expand to accommodate text.

Project title:
What is the aim of your project? (100 words maximum)
Please provide an outline summary of your project and why you want the support of the Queen's Nursing Institute.
What is the rationale for your project?
Why do you want to undertake the project? A review of relevant information and evidence of need to support the proposal should be included.
What makes your project Innovative? What is new, exciting or different?
In what way does your project reflect local and/or national public health targets?
What are the project objectives?
Are the project objectives SMART?(Specific, Measurable,Achievable, Realistic,Timely)
How do you plan to implement your project?
This should clearly detail the plans for implementation including timescale for each activity. It is expected that the project will be undertaken and completed in a one-year period.
Which indicators will you use to monitor your project?
How will you ensure that the project remains on track?
How do you plan to evaluate your project?
Evaluation process should be clearly outlined and relate to the proposed aims and outcomes.
Short and long term outcomes should be included.
Do you anticipate any challenges in the implementation or delivery of your project?
Please indicate how you might address them.
What level of user involvement has there been in the development of this project? Please detail user involvement. If no user involvement was there a particular reason for this?
What are the health outcomes you are hoping to achieve for your patients?
Please detail how you expect clients/patients to benefit from your project.
How many clients/patients do you expect will gain from this project?
Is the project multi disciplinary/multiagency?
Detail disciplines and their expected involvement.
Have your colleagues expressed support for your project?
How do you plan to disseminate the results of your project? How are you going to let others know about your work?
How easily would your project transfer to other areas?Will others be able to learn from this work?
How much funding do you require?
Realistic and detailed breakdown of costing (or estimates) must be included. Any other sources of funding obtained should be clearly identified, including from your employer.
Is ethical approval required? Yes No
Please circle. If ethical approval is required there must be evidence that this is being sought. Funding will not be given to successful applications until approval has been confirmed.
Where did you hear about Queen’s Nursing Fund for Innovation programme?
Information received at conference / Which conference?
Queen's Nursing Institute website / Other website (please state)
Article in journal (please state journal) / Adverts (please state)
Other (please state)

Data protection:

Your privacy is important to us, and we will NOT pass your details to any third party. The Queen's Nursing Institute will use the information provided on the application form to process the proposal and manage any grant awarded. We will also use the information to communicate with you on issues which we feel may be of interest to you. By providing us with your information, you consent to us using it for the purposes outlined above.

CURRICULUM VITAE

Co-applicants will also need to include a CV- please photocopy or repeat this page to do so

Name
Current role – please summarise current responsibilities
Professional qualifications
Previous employment history (last three posts)
Personal statement in support of your application(maximum 500 words)

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