Please complete the application form in full. Onlyapplications providing required information will be considered by the committee for grant award. Please be specific by including a quote, photos and examples where appropriate. Submissions are due bymidnight April 30th, 2018. Electronic (PDF only)applications can be emailed to . Please limit applications tothree per email.If you have any questions regarding the formatting please call 902 334-1546.

A) Identify Category of submission(choose One Category, only):

Patient comfortsPatient/family education

Patient/family furnishingsPatient recreation/activities

B) Have you considered the following items:

Does your item(s) meet infection control standards?

Have you explored other sources of funding i.e. department funds, other Foundation Funds

Have you checked alternate sources for furniture and equipment i.e. stores

Have you included quotes for your specific item?

Have you considered the safety of your item i.e. glider chair?

C) Total amount requested $ (Do not include HST, shipping or installation)

Note: Certain items may have an award limit cap. Please see Application, P. 4 (Budget).

D) Project Title: A one line summary of the specific use of the item[s] requested):

E) Main item(s) requested on attached Budget Form (e.g. blanket warmer, recliner):

1) Contact Information

Department applying for grant:

QEII Building and floor/room #:

Name of person responsible for project coordination:

Email: Internal phone number:

Internal mailing address:

Name of Health Services Manageror Director: Phone:

(per approval signature below)

Signature of Health Services Manager orDirector:

Name of Director: Department of Director:

2) Project Details

A) Intended use: Describe in detail how the funds will be used and why.

B) Potential impact on patients and/or families and number of patients/families this will affect?

C) List the individuals and their job titles thatassisted with this submission and are supportive of the project.

D) Additional information for the Adjudication Committee:

3) Budget Form (do not include HST, please attach quotes)

Please list specific items requested, description, number of items requested, cost of each item.
Item / Brief Description / Number of Items / Cost per Item / TOTAL Cost of Each Item(s)

TOTALcostof all itemsrequested - $ .

PLEASE NOTE:

  1. Grant awards will be limited to $5,000, with the exception of the following items which are capped at the amounts shown:

ITEM / AWARD LIMIT CAP
Bariatric chairs
(For Family and Waiting Rooms, only) / $612 (500 lb. capacity)
$1,367 (700 lb. capacity)
Bedside Chairs / $2045
Recliners / $1158
Waiting Room Furniture / $4,478
  1. Applications requesting an amount greater than the amounts indicated above will be considered for the capped amount, only.
  2. Applications requesting an amount greater than $5,000 will not be considered for funding.

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