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					Health Promotion Board
Workplace Health Promotion Grant
Application Form
Please read the following instructions before completing the application form.


1. The completed application form can be send via fax, email, or by hand to :

     Workplace Health
     Level 4, Adult Health Division
     Health Promotion Board
     3 Second Hospital Avenue
     Singapore 168937
     Fax: 6438 3609
     Email: HPB_Health_at_Work@hpb.gov.sg

2.   An email acknowledgement will be sent to the applicant upon receipt of application.
     Please email HPB_Health_at_Work@hpb.gov.sg if you do not hear from HPB 4
     days after your submission.

3. Prior approval from HPB is required before commencement of project.

4. Successful applicant will receive an in-principal approval letter from HPB.

5. The project must be completed within 12 months from the date of HPB’s in-principal
   approval.

6. At least 80% of the approved Grant amount must be utilised.

7. Reimbursement for approved items will only be made to an applicant upon
   completion of the project. To seek reimbursement, submission of the completed
   reimbursement form with the project report is required.

8. HPB reserves the right to audit successful applicants at any point in time during, the
   1 year after completion of the project to ensure that the grant is used appropriately.




Application from        : ___________________________________
                                (Name of Organisation)

Date of submission      : ____________________________________
                                  (DD/MM/YY)

Received on             : _____________________________________
                                 (for official use only)


Form Updated: 16 April 2012
                                   Name of Organisation: _____________________

            WORKPLACE HEALTH PROMOTION GRANT
                      Application Form
SECTION 1 – APPLICANT DETAILS
i. Organisation

Name

Address

Company Business
Registration No.

Staff Strength

Industry Type               Construction
                              Financial/ Business Services
                              Health/ Education/ Social Services
                              Hotels/ Restaurants
                              Information/ Communications
                              Manufacturing
                              Transport
                              Wholesale/ Retail Trade
                              Others, _______________________________

Singapore HEALTH Award      Nil
status                      Bronze
                            Silver
                            Gold
                            Platinum
                           Year Awarded _______________

How did you come to know    Magazine/ Print Advertisements
about WHP Grant?            Email from Health Promotion Board (HPB)
                            HPB Events
                            HPB Website
                            Singapore National Employers Federation
                            Association of Small and Medium Enterprise (ASME)
                            Others, _______________________________




                                                                                 2
                                          Name of Organisation: _____________________

 ii.Applicant

 He/She will oversee the implementation of the workplace health promotion grant project and will
 serve as the main contact person with HPB.

 Name

 Designation/ Department

 DID/Fax No.

 Email :

 Signature:


iii.Chief Executive Officer (or equivalent)

 Name

 Designation/ Department

 DID

 Email

 Signature


 (Optional) WHP Consultant

 Name of Consultant

 Organisation

 DID

 Email




                                                                                              3
                                            Name of Organisation: _____________________

SECTION 2 – DETAILS OF PROPOSAL

 i. Project Description

 Grant Project Option                                                   Please ‘tick’
 Option 1
 Eligible to newcomer organisations and all SHA recipients
 Option 2
 Eligible to newcomer organisations and SHA(Bronze) recipients
 Project Description
 Project Title

 Project Objectives                 a.
                                    b.
                                    c.
 Time Frame                         Start Date: __________ (dd/mm/yy)
 Project to be completed within     End Date : __________ (dd/mm/yy)
 12 months

ii. Proposal Budget & Interventions

 A. General Health With/Without Targeted Interventions

 (I)     General Health                     Total       Funded         Funded     Name of
         Activities/Services                Amt         By Grant       by         Service
                                            (No GST)    (No GST)       Company    Provider
                                                                       (No GST)
 1

 2

 3

 4

         Total for General Health

 (II)    Targeted Interventions
         *(Please provide proposal on
         Annex A- targeted intervention
         programme)
 1

         Total for Targeted Interventions

 Total




                                                                                             4
                                          Name of Organisation: _____________________



B. Mental Health
(III)   Mental Health                     Total               Name of Service Provider
        Activities/Services               Amt
        *(Please provide an overview of   (No GST)
        the activities/services with
        supporting synopsis/write-ups)
1

2

3

4

Total (Actual Total)

Funded by Grant (Funding total)




                                                                                         5
                                               Name of Organisation: _____________________



ANNEX A
Grant proposal - Targeted Intervention Programme

Applicable only for Grant with Targeted Intervention Programme (Option 1)

Company applied for Grant :

Targeted Intervention Programme:

Service Provider/WHP Consultant :

Total Cost of Programme :

I.    Duration and Monitoring

1.    Duration of Programme :

2.    Frequency of session (e.g. 1hr/wk) :

3     Measurements (e.g. BMI) :
                                                       rd       th
4.    Monitoring (e.g. Baseline, post-programme (3 month, 6/9 month):

II.   Eligibility and Targets

1.    Participants’ eligibility criteria for programme :



2.    Target

      a. Participation rate at end of programme :

      b. Weight loss:

IV    Learning objectives/Outline

1.    Learning objectives



2.    Outline of sessions




V.    Providers (Provide name and related certifications/qualifications of trainers)




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