CALIFORNIA SOCIETY OF HEALTH SYSTEM PHARMACISTS
GRANT REQUEST FORM
CSHP STUDENT CHAPTER GRANTS PROGRAM
Guidelines for Submission and Evaluation of Grant Requests
(Approved by the CSHP Board of Directors 6/15/11)
1. On an annual basis, an amount equal to $5 per pharmacy student membership shall be designated as
restricted Board assets for potential distribution in the form of grants to CSHP student chapters. Grant
amounts per school will be determined by dividing the total received in the prior fiscal year by
number of CSHP affiliated pharmacy school chapters. Grant requests should be submitted through
CSHP student organizations. Requests from individuals will not be accepted.
2. Factors that will be considered in determining whether grant requests will be funded include, but are
not limited to how each proposal:
a. Promotes the profession of pharmacy;
b. Promotes patient care;
c. Supports CSHP’s mission and vision.
Examples of appropriate grant requests include, but are not limited to:
d. Funding to develop, print and provide drug information packets at health fairs;
e. Funding to sponsor Poison Prevention weeks or development of area specific Poison
Prevention Posters;
f. Funding to develop member recruitment material for a CSHP student chapter.
3. The process for submission and evaluation of grant requests shall be communicated to members and
student chapters in the following manner:
a. The President-Elect shall review the process, including all of the factors noted above, at the
Fall Affiliate Chapter Presidents meeting;
b. The Treasurer of CSHP (or designee) will attend a Affiliate Chapter Presidents’ (ACP)
meeting annually in order to in-service the Student Chapter Presidents on the grant proposal
process and guidelines;
c. The same information shall be posted on CSHP’s Web Site, in the affiliate chapters area;
d. The FSL to CSHP student chapters are encouraged to mentor their student chapters to help
them develop their skills in completing CSHP grant proposals. The Treasurer will provide an
example of a completed proposal containing all the required information to assist Board
liaisons with this educational process.
4. All /grant requests must be submitted by October 15 of each year. Late requests will not be
considered.
5. All grant requests must be submitted on the CSHP grant request form (attached).
a. Members of the CSHP Board of Directors may be contacted for assistance in preparing the
grant request form.
b. Requests from individuals will not be accepted.
c. Proposals will only be accepted for future activities. No retroactive funding will be provided.
d. Submission of a proposal to CSHP indicates acceptance of the terms identified in the grant
guidelines.
e. Multiple grants may be submitted and received not to exceed the school chapter’s annual
proportionate share.
f. Completed forms shall be mailed, faxed or emailed to:
CALIFORNIA SOCIETY OF HEALTH SYSTEM PHARMACISTS
GRANT REQUEST FORM
Treasurer
California Society of Health-System Pharmacists
1314 H Street
Suite 200
Sacramento, California 95814-1930
FAX: 916-447-2396
Email: cshp@cshp.org
6. The Treasurer shall mail the grant proposals as well as a grid for ranking the proposals to each Board
member. Each Board member shall rank the proposals according to the provided grid and submit
his/her final ranking to the Treasurer by November 15.
7. The Treasurer shall compile the Board members’ rankings and forward a recommendation, in STP
format, to the Committee on Finance (COF) for action at the December COF meeting. The Treasurer
may recommend partial funding for specific requests.
8. The Committee on Finance shall review these recommendations at its December meeting, and
forward recommendations to the Board of Directors for action at the January Board meeting.
9. At the January Board meeting, the Board of Directors will evaluate which (if any) of the ranked grant
requests will be honored. The Board of Directors may elect not to fund submitted grant requests.
10. All grant applicants shall be notified of the Board’s decision within four (4) weeks via a letter from
the Treasurer.
a. Acceptance letters to grantees that will receive funding will include a copy of the “Grant
Completion Report” to be completed and returned to the CSHP Treasurer to provide a
description of the outcomes resulting from the grant funding for the specific activities
identified in proposal.
b. Denial letters shall include a specific description of the reason the request for funding was
denied.
11. Following approval of a grant, a check in the amount of 75% of the approved amount will be mailed
to the appropriate student chapter. The remaining 25% of the funding will be issued upon receipt by
CSHP of the fulfilled “Grant Completion Report.”
12. Checks will be made payable to the appropriate student chapter, not a specific individual.
13. Funds provided by CSHP for grants are restricted and can only be utilized for the approved
designated activity.
14. No later than six (6) months following receipt of funding, all recipients of CSHP grants shall submit a
status report to the CSHP Treasurer on the utilization and outcomes which resulted from CSHP’s
financial support. Activities that receive grant funding must be completed within 12 months after
receipt of funds or funds returned to CSHP.
15. If only partial funding is utilized, or none of the funding is utilized, the remaining funds are to be
returned to CSHP.
16. The CSHP Board of Directors may choose to utilize the unused funds for the following year’s grant
program.
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GRANT REQUEST FORM
Please complete ALL sections below. Forms MUST be received by October 15th of the year
prior to the planned/proposed project or activity in order to be considered.
Following approval, a check for 75% of the approved amount will be mailed. A check for the remaining
25% will be issued upon submission of a Grant Completion Report, received no later than one year
following receipt of grant. All activities MUST be completed within 12 months of receipt of funds or
funds must be returned to CSHP.
Form submission date:
does NOT include
Amount Requested :$
food/drink/entertainment
(MUST attach copy of
budget/business plan)
Name of CSHP Student Chapter:
Name of Proposed Project/Activity:
Date/Approximate Time of Project/Activity:
Primary Contact Person:
Primary Contact Phone(s)/email:
Secondary Contact Person:
Secondary Contact Phone(s)email:
(submit to CSHP Committee
Person submitting written Completion Report:
on Finance on the outcomes
achieved)
Completion Report Contact Phone(s)/email:
(Due at conclusion of
Date/Approximate Time of Completion Report:
program or 1 year -
whichever comes first)
CRITERIA – Describe how the proposed project will achieve the following:
I. Describe the Project/Activity [please SPECIFY EXACTLY what you plan to do]
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BUDGET - Please estimate expenses, highlighting how the grant will be spent
and attach an itemized budget/business plan to the application.
II. Promote the Profession of Pharmacy: ______________________________________________
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III. Promote Patient Care: ___________________________________________________________
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IV. Support the Mission and Vision of CSHP:
Vision: “Leading Pharmacy Practice in Patient Safety and Medication Therapy Management.”
Mission: “CSHP is a professional society of pharmacists, pharmacy technicians, student pharmacists and
associates who promote the health, safety, and appropriate use of medication therapy for patients and the
public by:
(a) Serving as an organization through which the membership pursues its common professional goals.
(b) Providing leadership for the profession and support for its members.
(c) Advocating for its members before private and public agencies and health care professional
organizations.”
SPECIFIC PURPOSES
The specific purposes and objectives of this corporation are:
(a) To promote rational, patient-oriented medication therapy across the continuum of care.
(b) To foster the optimal and responsible use of medication-related technologies.
(c) To promote pharmacists, and technicians as integral members of the healthcare team in order to allow
full utilization of their clinical skills and knowledge of the medication use process in each healthcare
setting.
(d) To serve as a primary advocate for advancing professional practice, optimizing patient outcomes, and
improving the quality of patient care.
(e) To promote pharmaceutical services that use sound pharmacoeconomic principles.
(f) To advocate the pharmacist's and technician’s value to patients by ensuring that appropriate clinical
services and the medication use process are applied to their benefit.
(g) To promote public health by fostering the optimal and responsible use of medications, including
education for proper use and/or controlled use of medications.
(h) To promote competency in the profession by offering state of the art education and training programs.
V. Describe how the Project/Activity supports the Mission and Vision of CSHP:
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VI. Any Additional Supporting Information: ______________________________________________
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Submit completed form to:
Treasurer
California Society of Health-System Pharmacists
1314 H Street, Suite 200
Sacramento, California 95814-1930
Fax: 916-447-2396 Email: cshp@cshp.org
For OFFICE USE ONLY: Date Rec’d: _____________ Amt Req’d: _____________ Project Appr’d:
Date Appr’d: _____________ Amt Appr’d: _____________ F/U Report
Contact Info:
Contact Info Complete: Budget Rec’d: Date 75% Ck Sent: ___________
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GRANT COMPLETION REPORT
Please complete ALL sections below (use additional pages if needed). Forms MUST be received at
conclusion of program or 1 year - whichever comes first. Report should include outcomes achieved
from the project or activity plus any supporting documentation (written or physical examples).
Following approval, a check for the remaining 25% of the approved grant amount will be issued. All
activities MUST be completed within 12 months of receipt of funds or funds must be returned to CSHP.
(Due at conclusion of
Report submission date:
program or 1 year -
whichever comes first)
Grant Amount Received: $
Name of CSHP Student:
Name of Project/Activity:
Date Project/Activity Completed:
Person submitting Report:
Contact Phone(s)email:
I. Provide a complete description of how the activity or project ((what occurred, overall
outcome and total expenses) please attach final expense report)
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II. Describe how this activity/project promoted the Profession of Pharmacy:
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III. Describe how the activity/project promoted Patient Care:
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IV. Explain how this activity/project supported the Mission and Vision of CSHP:
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V. Other Supporting Information (please provide physical examples whenever possible):
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Submit completed form to:
Treasurer
CSHP,
1314 H Street, Suite 200,
Sacramento, CA 95814-1930
For OFFICE USE ONLY:
Date Rec’d: _____________ F/U Report Contact Info: Date F/U Report: ____________
Date Appr’d: _____________ F/U Report Rec’d: Date 25% Ck Sent: ___________