HEALTH INNOVATIONS FUND by v7166R

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									SW London Academic, Health and Social Care System

Application for small grants fund 2012

Please note that we would like to maintain electronic records wherever possible and it would be
appreciated if applications were completed and submitted electronically. Please also supply a
regularly used e-mail address for correspondence. Application forms can also be downloaded
from www.swlondonsystem.org

Information about previous small grant funded projects can be found here.

Please check your application carefully and once you are happy with the content, return it to the
general correspondence address (gcahsn@sgul.ac.uk) by Monday 30th April 2012.

Please note that the award of small grants will not be determined until late June, if successful
you will be contacted via e-mail to advise you of the outcome of your application.


1. Lead Applicant (please give your name, position and the organisation that you are
   representing)




2. Details of your sponsoring organisation        Details of partner organisations (if any)




3. Total sum applied for (note that the maximum is a total of £10,000)

£


4. Title of scheme / project



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5. Description of scheme / project (including planned start and end dates)
   (small grant funded projects for Spring 2012 must be completed by December 2013)




6. Key purpose / aims of the scheme or project




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Please tick the borough/s or area/s that your activities will affect:
 1    Sector-wide (all areas)
 2    Croydon
 3    Sutton
 4    Merton
 5    Kingston upon Thames
 6    Richmond upon Thames
 7    Wandsworth




7. Health priorities and need

    a) Which of south west London’s priorities does your scheme target? Supporting
       local QIPP priorities and implementing new models of care (to meet new patient
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      pathways and settings), education and training for health and social care change.




   b) How will the target group benefit? And what evidence exists to support this
      benefit and need?




   c) Has the scheme/project been discussed with GP clusters and/or emerging health
      and wellbeing boards?




8. Does the scheme / project require ethical approval?




9. Please describe how this scheme is innovative and explain what you believe is the
   unique ‘selling point’ of your bid.




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10. Please set out your key outcomes for the scheme / project.




11. How will it be evaluated?




12. How much money have you allowed / built into the budget for the cost of
    evaluation?


                 £                       in total




13. Financial details of grant required (add rows to table if needed)

                                                Amount requested        Alternative finance
                                                                           (state source)
                                                        £                         £
13.1   Employment expenses:
         Basic salary:
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           London weighting:
           Employer’s contribution
           Expected salary increase:
       Subtotal:
13.2   Consumable materials:
       (specify items.):




       Subtotal:
13.3   Other recurrent expenses in detail:



       Subtotal:
13.4   Non-recurrent expenses:



       Subtotal:
            Total Grant Requested:




13.5     If the answer to any of these is yes, please give details in a separate letter

 a. Is any part of your research being supported by any outside
                                                                           YES / NO
    body?
 b. Is this or a related application currently being submitted
                                                                           YES / NO
    elsewhere?
 c. Has this or a similar application been submitted elsewhere
                                                                           YES / NO
    over the past year?
 d. Do you have plans to secure matched funding in order to
    continue the work of this project beyond the term of SW                YES / NO
    London System funding?

14. What is the absolute minimum level of funding that you require in order to deliver
    this project successfully? Answering this question will help us to determine whether we
    may be able to offer your project support even if full funding is not available.




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15. Are there any risks you can identify?
    Consider: financial, health and safety, research governance, media publicity, environmental
    effects, staff views, prospect of successfully recruiting any new staff, availability of
    supplies.




16. Have you allowed for any contingencies in your project to manage these risks?
    Please explain.




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17. Who will project manage the scheme?

By completing these details, you are confirming that this person is willing / able to
manage the scheme.

Name: __________________________________

Job/Role: ________________________________

Address: _________________________________

_________________________________________

_________________________________________


Phone No : ________________________________

E-mail: ____________________________________



18. Who are the lead stakeholders / people involved in this scheme?

Name: __________________________

Job/Role: ________________________

Address: ________________________

E-mail:___________________________

***********************************************
Name: __________________________

Job/Role: ________________________

Address: ________________________

________________________________

E-mail:___________________________

Please note that by completing and submitting this form for consideration, you (the applicant
given in 1) are confirming that to the best of your knowledge and belief the statements on this
form are correct.


Please check your application carefully and once you are happy with the content, return it to the
general correspondence address (gcahsn@sgul.ac.uk) by Monday 30th April 2012.

Please note that the award of small grants will not be determined until May, if successful
you will be contacted via e-mail to advise you of the outcome of your application.
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