Grant Application Form s2

January 1, 2013

Toulouse

In order for our Board of Directors to come to a decision regarding your grant application, we would be grateful if you could complete the document attached in detail.

GRANT APPLICATION FORM

Content of File:

· Form 1: "Project summary"

· Form 2: Criteria for grant approval if the center offers therapeutic education

· Form 3: cost and financial assessment

· Note: the follow-up form (4) will be completed at a later stage so as to assess the way the grant is used

Files (forms 1, 2, 3) must be returned (signed by hand and with company stamp) to the following address:

Docteur Chantal SEGARD

FONDATION POUR LA DERMATITE ATOPIQUE: RECHERCHE ET EDUCATION

Hôtel-Dieu Saint Jacques –2, rue Viguerie – 31 000 TOULOUSE

….

GRANT APPLICATION FORM

Form 1

"Project summary"

Project Title :………………………………………………………………………………….

Project summary :

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

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

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

Project Manager (contact name) :

· Name:……………………………………………………………………………

· Function: ………………………………………………………………………...

· Company or society leading the project:………………………………………….

· Address: ………………………………………………………………………….

· Telno:

· Fax:………………………………………………………………………………..

· Emailaddress:

List of public or private partners:

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

Duration of project:…………………………………………………………………………….

Signature of Project Manager + company or organization stamp:

Form 2

Criteria for grant approval if the Center offers therapeutic education

Approval of Hospital Director Obtained □ In progress □

Health professionals involved in project (list of their names and positions):

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

……………………………………………….…

PTE (Patient’s Therapeutic Education) Guidelines written by department:

Yes □ No □

Type and frequency of session:

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

Education tools used (or currently being developed):

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

Planned evaluation Yes □ No □

Specify if yes……………. ………………………….……………….……………………..

Number of patients considered per year: …………….….…………………………….………

Form 3

Cost and finance assessment

Cost estimation (Euros including VAT):

1. Staff costs: …………….… €

2. Operation costs: ………… €

3. Equipment costs: ……………… €

TOTAL PROJECT COST: ………… €

GRANT APPLICATION AMOUNT: …………….. €

OTHER FINANCIAL SOURCES*: ……………………. €

· Applications in progress (public or private organizations):

o ……………………………………………..…….

o ………………………………………………...…

· Funding obtained (amounts and origin):

o …………………………………………………..

o …………………………………………….…….

Signature and stamp of Project Manager

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

Form 4

Follow-up form

● Number of patients per year:

Number of patients evaluated for PTE / Number of patients, session 1 / Number of patients, session 2 / Number of patients, session 3

● PTE evaluation: means and results:

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

● Development tools: Yes □ No □

Specify which tools if yes:

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

● Evaluation of actual annual cost per Center:

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

* Patient education assessment

FONDATION POUR LA DERMATITE ATOPIQUE: RECHERCHE ET EDUCATION

Siège social: Hôtel-Dieu Saint Jacques –2, rue Viguerie - 31 000 TOULOUSE

Tel: 00 33 5 63 58 98 10