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					                                      Dame Muriel Powell Award
     Dame Muriel Powell was Matron at St George’s Hospital from 1947 to 1969
Please read the guidelines (see over) before completing this application form.

1. PERSONAL DETAILS

Last Name……………………………………… First Names.…………………………………………….

Post held..................................................... Specialty /SDU……………………….............................

Qualifications................................................Work Telephone/bleep No............................................

Work address……………………………………………………………..................................................

E-mail address ..................................................................................................................................

2. DETAILS of RESEARCH / CLINICAL PROJECT

Title of research/clinical project...............………………………………………………………………....

How will this benefit patient care at St George’s Healthcare NHS Trust?

…………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………

Will this research lead to a higher degree? If yes, please complete the rest of section 2.

Name of the degree………………………………Institution awarding the degree…………….............

Name and address of supervisor………………………………………………………...........................

…………………………………………………………………………………………….............................

3. DETAILS OF FINANCE AND STUDY LEAVE (see over for supporting evidence required)

Have you applied to your Service Centre for Study Leave?                                         Yes /No
Have you received funding from the Trust or Service Centre?                                      Yes / No
If yes, how much? .............................................................................................................................
What other sources have you approached? ....................................................................................


AMOUNT REQUESTED FROM THIS COMMITTEE AFTER OTHER FUNDING £……………
(This must be completed for application to be considered)

I understand that if I receive this award I will be expected to produce a brief report for the
St George’s Nurses League and/or give a presentation to a League conference.

Signed…………………………………………… Date ………………………………………….PTO
3. MANAGER’S RECOMMENDATION

Requests for study leave or funding towards academic courses must be signed by the Head of
Nursing.

Please refer to the criteria below to assess suitability of application.

…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………

Signed.…………………………………………….Date ………………………………........................….

Post held............................................................................................................................................


NOTES: Please read as incomplete application forms will not be accepted.

1. Eligibility for the Dame Muriel Powell Award

The following members of staff are eligible to apply to the Committee for financial assistance

           Nurses, Midwives and Health Visitors who are currently on the staff of St George’s
            Hospital NHS Trust and have been employed for a minimum of six months for a piece of
            clinical research or clinical project. It can be made by one person on behalf of a ward or
            departmental team. Only one grant is made per annum and the St George’s Nurses
            League reserves the right not to make an award if there is no suitable applicant.

Academic qualifications will not be funded unless the application demonstrates that it will
benefit the Trust and that the subject of the dissertation has been or will be agreed by
prior negotiation to benefit the service.

2. Application Process

You must first apply to the appropriate Service Centre/Budget Holder for Study Leave and
funding. If this source is unable to fund the study leave or project whether whole or in part, then
an application may be made to this committee. Please state how much you have received from
any other source.

Applicants must demonstrate their own financial and personal commitment.

Please enclose with this form a copy of the study leave application form and all the information
requested in the section on the application process in the accompanying information on the
award.

You may only apply for funds for 1 year at a time if the project is longer than one year.

Send the completed application form and documents to: The Nursing Office, Room 1.032
Grosvenor Wing, St George’s Hospital, London SW17 0QT

3. Payment of Award

If your application is successful you will receive a letter from the secretary of the committee
confirming the amount awarded. You will be required to produce either evidence of expenditure
incurred or an invoice before payment will be made.
FOR OFFICE USE:

Date application received:                       Considered at committee meeting on:                                        Decision:

				
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posted:11/3/2012
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