THE MEATH FOUNDATION

QUALITY IMPROVEMENT FUND

Application Form and Criteria for assessment

Closing date for applications is 12 noon Friday, 30th September 2016

Completed forms must be returned by email to

meathfoundation@amnch.ie

Please ensure that this form, when completed, does not exceed an A4 page

1.1	Lead Applicant

Name
Address for Correspondence
E-mail address
Telephone Number
Mobile Number

Present Appointment

Brief summary of Career ( No more than three lines)

2	Project Sponsor (this must be EMT Directorate Lead)

Name
Position
Contact Number Mobile Number
E-mail

€

3	Grant Requested (to the nearest Euro):

4.1	Title of the Project: _____________________________________________________

4.2	Summary of the project –

(a) Please discuss the originality of this proposal and its relevance to Quality Improvement in the delivery of Patient Care

(b) Please state briefly why this proposal is considered to be particularly suitable for funding by the Meath Foundation under the six dimensions listed in the information provided

5	Details of proposal (use box below only)

6 Quality Improvement / Benefits (use box below only) Please outline: (a) what improvement in quality do you expect to achieve (b) how will this be measured / evaluated (c) will there be any financial benefits?

7	Commencement of the Project (it is advisable that the project is completed within 6 months)

Commencement Date: …………………………………… Expected Completion Date: ……………………………………

8	Previous Funding

Have you received support from the Meath Foundation in the last 3 years -please give details

Date	Project	Amount Awarded	Date report presented to the Foundation

9	Funding Request

9.1	Please provide a detailed break-down of the funding request to include gross costs e.g. VAT and or Employers PRSI etc. along with direct and indirect costs

Details of funding	Costs	VAT	Employers PRSI	Total Costs
Salary / Stipend
Materials /Consumables: (please state item and number)
Use of facilities/equipment
Travel costs/Accommodation
Services/Fees
Other directly allocated costs:
Total

9.2	Salary Payment

If applicable please justify why there is a requirement for additional staff time and indicate how staff time will be recruited and appointed. (It is essential that the cost involved for staff time is agreed with the Human Resources Department.)

9.3	Implementation Costs

Please outline any on-going costs (following implementation of the technology / change)

€
€
€

9.4	Other funding

Please outline any other funding available for this project

Institution	Amount
€
€
€

10	Infrastructure

Please outline the infrastructure that will be utilised in this application

11	Publication and Dissemination

Please outline the proposed plans for publication or other dissemination of the quality improvement on completion of the project.

12	Signature

I have read The Meath Foundation Quality Improvement Fund information and regulations and agree to abide by them.

If funding is made available, I/We

will ensure that The Meath Foundation's contribution to funding this project is suitably acknowledged in all publications/presentations arising from it.

provide The Meath Foundation with a report detailing the project undertaken and the quality improvements achieved.

present the project and the outcomes at The Meath Foundation Research Day and/or The Meath Foundation/Tallaght Hospital Clinical Audit Day

will inform The Foundation of any changes to details set out in the application

Applicant’s signature: _______________________

Date: _____________________

This application must be sponsored and signed by the Applicants Executive Management Team Lead

Sponsors name (EMT Lead): __________________

Sponsors signature: _________________________Date:_______________

Quality Improvement Lead I certify that this application is in line with the Quality Improvement Programme currently in place at Tallaght Hospital Signed: ____________________ Mary Hickey, Quality Lead Date:_______________

Please e-mail the completed application to meathfoundation@amnch.ie

13 Details of collaborators

Please complete this Section if the project involves a co-applicant(s) or other participants.

Co-applicant (1)

Surname	Forename	Title (Dr, Professor etc)

Present appointment

Brief summary of qualifications and career (no more than 3 lines, including principal appointments)

If co-applicant has applied to The Foundation for any funding please give details of the most recent applications

Date of application (month/year)	Title of project	Amount awarded (list € 0 if unsuccessful)

Co-applicant (2)

Surname	Forename	Title (Dr, Professor etc)

Present appointment

Brief summary of qualifications and career (no more than 3 lines, including principal appointments)

If co-applicant has applied to The Foundation for any funding within the last five years, please give details of the most recent application

Date of application (month/year)	Title of project	Amount awarded (list £0 if unsuccessful)