GRANT SOLICITATION REQUEST FORM
(THIS FORM IS NOT FOR THE SOLICITATION OF EXHIBIT SPACE)
Date Grand Request Packet Submitted to CCEHS:______
Course Information
Title of the Prospective CME Activity:
Course Dates: ______
CME# __ - __ - __
Location of Event: ______
Formal Course or Grand Rounds/Series Event (Circle One)
Number of offerings of this specific activity:
Single ____
Repetitive ____ (list number of programs)
If Grand Rounds, will you be submitting all your grant requests at once? ______
Type of Event:
Live
If live, type of live event
Symposia
Conference
Dinner meeting
Afternoon meeting
Web- or Tele-conference
Enduring material that will be getting CME:
Web
Book
Article
Journal supplement
Monograph
Audio tape or CD
Video tape or DVD
Other,
Please provide the Needs Assessment for this course:
Please Provide the Educational Objectives of this course:
Grant Company Information (Please cut and paste if you need to add more companies)
Company #1
Company Name:
Company Contact/Representative’s
Name:
Title:
Fax Number:
Phone Number:
Email:
Address:
Amount to request: ______
Method of Grant Request (Please check all that apply):
On-Line: Please Provide
--Exact Web Address of the Application/Instructions:
Solicitation Letter: Please Provide
--A copy of the Solicitation Letter
--If letter is to be mailed: Exact name and mailing address of company/representative where grant is to be submitted
--If submitted by email: Exact name and email address of company/representative where grant is to be submitted
--If submitted along with a Paper Application or an On-line application please check here: ______
Paper Application/Form
--Is the application attached to this document?______
--If not how do we obtain a copy?______
Has your organization applied to this company in the past for this course? ______If Yes:
What was the date of the course?______
Did you receive the funding (please list the amount received)? ______
Company #2
Company Name:
Company Contact/Representative’s
Name:
Title:
Fax Number:
Phone Number:
Email:
Address:
Amount to request: ______
Method of Grant Request (Please check all that apply):
On-Line: Please Provide
--Exact Web Address of the Application/Instructions:
Solicitation Letter: Please Provide
--A copy of the Solicitation Letter
--If letter is to be mailed: Exact name and mailing address of company/representative where grant is to be submitted
--If submitted by email: Exact name and email address of company/representative where grant is to be submitted
--If submitted along with a Paper Application or an On-line application please check here: ______
Paper Application/Form
--Is the application attached to this document?______
--If not how do we obtain a copy?______
Has your organization applied to this company in the past for this course? ______If Yes:
What was the date of the course?______
Did you receive the funding (please list the amount received)? ______
Company #3
Company Name:
Company Contact/Representative’s
Name:
Title:
Fax Number:
Phone Number:
Email:
Address:
Amount to request: ______
Method of Grant Request (Please check all that apply):
On-Line: Please Provide
--Exact Web Address of the Application/Instructions:
Solicitation Letter: Please Provide
--A copy of the Solicitation Letter
--If letter is to be mailed: Exact name and mailing address of company/representative where grant is to be submitted
--If submitted by email: Exact name and email address of company/representative where grant is to be submitted
--If submitted along with a Paper Application or an On-line application please check here: ______
Paper Application/Form
--Is the application attached to this document?______
--If not how do we obtain a copy?______
Has your organization applied to this company in the past for this course? ______If Yes:
What was the date of the course?______
Did you receive the funding (please list the amount received)? ______
Are you are offering the companies that provide grants the opportunity to purchase exhibit space, what is the cost of a base unit of exhibit space (i.e. $500 per table top or $1,000 per booth). Please note the cost for exhibiting can not be included in the grant.
Are there any joint sponsors or medical education or any other companies assisting in the production of this CME activity)? If so, please name the companies:
Are you using a source external to your department or the UPMC or the University to plan any part of this activity? If so, please name the organization(s):
Have you notified all your co-course directors, curriculum planning committee membership, and applicable joint sponsors it is prohibited for them to accept, solicit, or manage any commercial support not previously approved by the CCEHS? Yes
Please send as a separate attachment a solicitation letter in a Word document from the course director in collaboration with the division chair and joint sponsor, if applicable. The letter should include an outline of the program, the target audience, expect number of attendees, market area and the treatment area of relevance to the companies he/she is soliciting funds from. Please note joint sponsors are entities external to the departments and divisions of the UPMC and University of Pittsburgh.
Please provide the following information:
· A completed and CCEHS approved marketing material;
· Complete program schedule which includes, topics, assigned speakers, and times
· The date(s), venue, and location
· The target audience
· A preliminary budget containing all anticipated assumptions
Note that applications will not be completed without this information
Please note it is a violation for any pharmaceutical and or medical device manufacturers to sponsor CME activities. This includes many medical services companies, contact CCEHS for a final decision for these interactions.
CCEHS will not jointly certify or co-sponsor educational programming created from entities external to the UPMC or University of Pittsburgh.
Form received by CCEHS on