EDUCATIONAL GRANT APPLICATION FORM by CBtKR7

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									Eisai, Inc
Medical Affairs Department
Educational Grants
100 Tice Boulevard
Woodcliff Lake, New Jersey 07677

(For Eisai Use Only) TRACKING NO:

                            EDUCATIONAL GRANT APPLICATION FORM
   Requests should be submitted at least 60 days prior to the scheduled program or activity. Requests
 submitted less than 60 days will be reviewed at the committee’s discretion, provided that the scheduled
program or activity does not occur within 45 days of committee review. Requests submitted less than 45
                  days prior to the scheduled program or activity will not be reviewed.

**ALL fields of this Form must be completed. Please submit Form electronically to Eisai’s Professional
Educational Coordinator, eisai_edugrants@eisai.com**

In addition to forwarding this form electronically, create and sign a hardcopy grant request letter and send to
the Professional Education Coordinator (PEC) under separate cover. The request letter must include the
following information:

              o    A statement requesting the funds and a short description of the grant request
              o    Statements declaring to whom the funds should be paid (provide contact and address details).
              o    Tax ID number of the organization
              o    Wet ink signature by the appropriate representative
              o    The subject line of the letter should read as follows: “Subject: Educational Grant Request; <Title
                   of Program>
              o    Include full contact, phone, fax, address and email information.

ACCREDITED PROVIDER/REQUESTING ORGANIZATION INFORMATION:

ACCREDITED PROVIDER:

ADDRESS:




CONTACT NAME:

TELEPHONE # / FAX #:                             P.                            F.

EMAIL ADDRESS:

ACCREDITING COUNCIL:

REQUESTING ORGANIZATION
(complete if different from Accredited
Provider):

ADDRESS:



Please email this form to eisai_edugrants@eisai.com                                    Final Version 3/26/07
                                                                                                               Page 1 of 6
Eisai, Inc
Medical Affairs Department
Educational Grants
100 Tice Boulevard
Woodcliff Lake, New Jersey 07677

(For Eisai Use Only) TRACKING NO:




CONTACT NAME:

TELEPHONE # / FAX #:                             P.                             F.

EMAIL ADDRESS:

THIRD PARTY VENDOR (if
applicable):

ADDRESS:




FINANCIAL ROUTING INFORMATION/PAYEE INFORMATION

    WHO WILL BE RECEIVING                             ACCREDITED PROVIDER
    THE FUNDS:
                                                      REQUESTING ORGANIZATION

                                                      THIRD PARTY VENDOR

    ADDRESS check should be
    mailed to:




    C/O (if applicable)

    TAX ID #:
    TAX STATUS: (For Profit or Not
    for Profit)


                                                PLEASE BE SURE TO INCLUDE:
 HARD COPY GRANT REQUEST LETTER

                                            ! PLEASE NOTE THAT NO REQUEST
                              WILL BE CONSIDERED WITHOUT THIS COVER LETTER




Please email this form to eisai_edugrants@eisai.com                                  Final Version 3/26/07
                                                                                                             Page 2 of 6
Eisai Inc.
Medical Affairs Department
Educational Grants
100 Tice Boulevard
Woodcliff Lake, New Jersey 07677

(For Eisai Use Only) TRACKING NO:


                            EDUCATIONAL GRANT APPLICATION FORM
Therapeutic Area:                          Dementia        GI         Epilepsy       Critical Care      Oncology
Program Title:                        [Insert the full title as it appears in the proposal and on the 1st page of this form]
Program Date:                         [Insert date(s) of program]
Location where Program                [Insert address of location(s)]
will be conducted:
Total Cost of Program:
Requested Amount:                     [Insert amount requested from Eisai]


Program Type:                         [Insert the type of program, e.g. slide presentation, Grand Rounds, etc]


Description of the                    [Insert a 1 paragraph overview of the program describing the method to be used,
Program:                              e.g. “a symposium on the importance of disease management”]


Program Audience                      [Insert the specific target audience(s)]
Estimated # of attendees              [Insert estimated number of attendees for the program]
Program Number(s) and                 [Insert the number of program(s) and duration of each, supported by this grant]
Duration:
Topics of Discussion:                 [Insert topics of discussion]
Learning and Program                  [List the major educational objectives that the program is specifically designed
Objectives:                           to accomplish including information on the disease state, current practices if
                                      applicable, information evidencing any unmet need and providing substantiation
                                      for proposed educational objectives and needs, including relevant literature and
                                      other support, such as evidence-based medicine, practice guidelines and data,
                                      etc.]
Program Agenda:                       [Insert a completed Program Agenda]


Speaker(s):                           [List each individual speaker and attach a brief bio under separate cover.
                                      Also include brief statements on the qualifications of Program Chair and all
                                      presenters and speakers.]



Please email this form to eisai_edugrants@eisai.com                                           Page 3 of 6
Eisai Inc.
Medical Affairs Department
Educational Grants
100 Tice Boulevard
Woodcliff Lake, New Jersey 07677

(For Eisai Use Only) TRACKING NO:

Educational credits (if               [Insert the type and number of credits to be awarded, if applicable]
applicable):

Method of Evaluation:                 [Describe the method(s)that will be used to evaluate the program including
                                      details on pre-, during and post-evaluations]


Methods of                            [Describe the method(s) you intend to use to advertise the program and include
Advertisement:                        preliminary examples of all materials]


Disclosure of Eisai’s                 [Insert how Eisai will be recognized]
recognition:
Budget:                               Attach a FULLY ITEMIZED and DETAILED budget that includes all fees and
                                      totals showing how Eisai funds will be used.
                                      At a MINIMUM this will include: CME accreditation fees, advertising methods
                                      and fees, conference expenses (including meals), course materials (registration
                                      and confirmation), content preparation (including development, production,
                                      syllabus, faculty liaison), faculty expenses (fees, travel and accommodations),
                                      program management fees (overall management, travel and accommodations,
                                      postage, shipping, phone, fax, other), any other line items not included in the
                                      above list that is included in the request for funding.
Other sources of                      [Insert other current organizations and sources of funding for this program only]
Funding:




Please email this form to eisai_edugrants@eisai.com                                        Page 4 of 6
Eisai Inc.
Medical Affairs Department
Educational Grants
100 Tice Boulevard
Woodcliff Lake, New Jersey 07677

(For Eisai Use Only) TRACKING NO:

                         Eisai Inc Educational Grants – Instructions to Requesters
Effective October 2005

Please use the following contact information for all inquiries, completed applications and other correspondence:

Telephone: 201-746-2499
Toll-free: 866-434-1286
Fax number: 732-791-1398
Email: eisai_edugrants@eisai.com
Mail:     Eisai Inc.
          Educational Grants/ <please insert therapeutic area, i.e. dementia, critical care, etc.>
          Medical Affairs Department
          100 Tice Boulevard
          Woodcliff Lake, New Jersey 07677

          Attn: Professional Education Coordinator

All communications relating to Educational Grants must be directed to the Professional Education Coordinator at the address above.


Policy Highlights

Medical Education (ME) Grants supporting high quality activities, educational initiatives and materials which demonstrate the potential to improve
health care provider knowledge, patient care and health outcomes.

The Eisai ME Grant approval process is conducted in accordance with the recommendations and mandates of the Office of the Inspector General,
Compliance Program Guidance for Pharmaceutical Manufacturers, the Accreditation Council for Continuing Medical Education Guidelines, AMA
Gifts to Physicians and the PhRMA Code on Interactions with Healthcare Professionals, internal Eisai policies and other applicable guidelines.

Grant approvals are never related to or otherwise conditioned upon the past, present or future prescribing, purchasing, or recommending of Eisai
products.

All grants are awarded at Eisai’s sole discretion.

         Educational Grants, including Continuing Medical Education (CME), that may be considered for funding include, but are not
          limited to:

         Accredited Educational Activities
         National/regional Symposia
         CME Publications (e.g. monographs)
         Grand Rounds Programs
         Non-promotional Speakers at Sponsored Programs
         Fellowships and Scholarships (only those affiliated with a teaching institution, hospital or medical/scientific association or society and
          commensurate with activities to be performed)
         Third-Party Enduring Materials (i.e. CD-ROM, printed materials, website)

         Types of Requests that WILL NOT be funded by the Eisai Educational Grants Committee include, but are not limited to:

         Payments to individuals for any educational activity
         Charitable contributions
Please email this form to eisai_edugrants@eisai.com                                                             Page 5 of 6
Eisai Inc.
Medical Affairs Department
Educational Grants
100 Tice Boulevard
Woodcliff Lake, New Jersey 07677

(For Eisai Use Only) TRACKING NO:

        Support of promotional activities (e.g. lunch and learns, speaker programs and/or health fairs)
        Support for normal organizational overhead (e.g. standard purchases or staff salaries)
        Support linked to product purchase, pricing or rebate negotiation, or access to formulary
        Consulting, professional or other business arrangements, (e.g. preceptorships, or commercial product booths at educational activities)
        Reimbursement of conference, travel expenses or costs to obtain CME credits for participants or attendees
        Applicants who have received past grant funding, but have not provided required budget reconciliation or returned unused funds for that
         program
        promotional display space or exhibits for grantors
        programs that plan to utilize Eisai personnel as speakers or consultants
        Gifts purchased utilizing grant funds
        Recreational events and entertainment or travel for meeting attendees
        Lavish meals or any meals that are not subordinate to the amount of time spent on educational activities

        Eisai Inc will process only those applications received from the following eligible Educational Grant Requestors and similar such
         organizations:

        ACCME-accredited providers
        National/regional medical/scientific organizations
        Universities or other teaching institutions, hospital s
        Third-party medical education companies that are affiliated with an accredited CME provider

        Ineligible Organizations include, but are not limited to:

        Individual healthcare providers or groups of healthcare providers in private practice
        Organizations that have been previously awarded an Eisai medical education grant but have not provided the required budget
         reconciliation.
        Debarred institutions, organizations or groups
        Requestors involved in any activities related to the promotion of any Eisai products for two (2) years prior to the submission of their grant
         request (see Statement of Independence for details)


Please Note:

        The educational grant requestor is solely responsible and has full control over the content of the activity.
        Eisai’s support of the program must be clearly acknowledged and disclosed to all participants in all grant activities and materials.
        Funds will be provided for all properly completed grant applications and execution of a contract.
        Grants must be used exclusively to fund specific educational programs. Grant requestor's ordinary operating expenses cannot be reimbursed
         under the grant program.
        Grants that offer promotional exhibit or display space to all commercial supporters as part of their overall funding of an educational
         program are permitted, but any portion of the grant intended to pay for promotional exhibit space will be denied and referred to the
         appropriate sales or marketing organization for separate consideration.




Please email this form to eisai_edugrants@eisai.com                                                            Page 6 of 6

								
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