Independent Medical Education (IME) Application Form – External Use

Application Form for funding to provide Independent Medical Education (IME) for the education of Australian healthcare professionals

Before completing and submitting this form, please read the ‘Independent Medical Education guidance document’available on the GSK Australia website [

Please attach to this application a letter on your organisation’s letterhead stationery that requests GSK to consider this application for support. Additional supporting documentation may also be attached if required.

Title of the education initiative:
Total amount of funding requested:
  1. IME provider details

Name of organisation:
Type of organisation:
(Select from drop down box) / Type of organisation /
Description of organisation:
Please include legal structure, purpose and annual revenue. If the organisation provides marketing and independent education services, please attach evidence demonstrating that the educational services are independent e.g. organogram or accreditation certification from a recognised accreditation body that requires independence e.g. RACGP
Is the amount requested more than 25% of your organisation’s annual revenue? / Yes No
If your organisation already receives funding from GSK, would the amount requested and the amount already being received be more than 25% of your organisation’s annual revenue? / Yes No
Contact details of applicant: / Name:
Address:
Email:
Tel:
  1. Conflict of interest declaration

Are any of the officers or beneficiaries of your organisation a government official or affiliated with a government agency?
Yes No
If yes, please provide details of the relevant government or decision-making bodies, and indicate whether you are involved or a member of your family is involved.
Does your organisation, or any of its beneficiaries, have a role making decisions or advising on the regulation of medicines or prescribing policy or funding or the provision of healthcare at a national or international level?
Yes No
If yes, please provide details.
Has your organisation received any pharmaceutical or biotechnology companyor other commercial industry support for educational activities in the chosen disease areas outside of a grant application process?
Yes No
If yes, please provide details.
  1. Education activity proposal

Education proposal is in the following therapy area(s):
Respiratory / Vaccines / Urology / Other:
The focus of the education is in the following disease area(s):
Asthma
COPD / Hepatitis B
Influenza
Malaria
Meningitis
Pertussis
Rabies / Benign Prostatic Hyperplasia / Other:
Is this application in response to a Request for Proposal from GSK?
Yes No
If yes, please provide the title of the education initiative listed on the Request for Proposal briefing document:
Identified healthcare professional education need
  • Please provide an independent, evidence-based assessment that identifies the healthcare professional knowledge, competence and performance gaps, and/or patient health gaps, that exist compared to standards of best practice.
  • Examples of evidence may include expert interviews / testimonials / market research, peer-reviewed published data, nationally recognised papers or anonymised aggregate patient record reviews.
  • Maximum 500 words.

Outline designof educational activity
  • Provide an outline of the proposed educational design and delivery format, including discussion on the use of interactive and innovative formats
  • Outline the process and basis of selection of a representative, independent expert faculty, and how it is proposed to work with the faculty on the development of the agenda and the program content
  • Outline the number and discipline of the proposed target audience and how the initiative will reach this audience.
  • If the education will be accredited, please add details of the accreditation body and if possible attach evidence of previous conduct of accredited educational activities.
  • Please DO NOT provide information relating to the proposed educational agenda, content, or the names of the proposed members of an independent faculty.
  • Maximum 250 words.

Evaluation of educational outcome
  • It is a requirement of GSK that educational activity outcomes are measured through an evaluation of knowledge change.
  • Please outline how the educational outcomes will be measured and highlight the link between the education and the evaluation, how the results will be analysed and communicated.
  • Maximum 250 words.

Howwill best practice be shared
  • Outline any communication strategy of how the education or outcomes will be shared with the wider healthcare professional community.
  • For one-off events, identify proposed strategies to ensure the ongoing availability of the educational activity beyond the initial planned delivery
  • Maximum 150 words.

  1. Budget

Honoraria and faculty expenses may be included. Please note: proposed faculty members must NOT be named.

IME participant travel or out-of-pocket expenses will not be covered.

Budget item / Hourly cost / Hours / Total / Description of expense
Logistics(e.g. venue hire)
$ / $
$ / $
$ / $
Audience generating material and activities (e.g. invitations, leaflets, electronic distribution)
$ / $
$ / $
$ / $
Faculty expenses (e.g. honoraria, travel, accommodation)
$ / $
$ / $
$ / $
Program material development (e.g. webcasts, e-learning modules, slides, publications)
$ / $
$ / $
$ / $
Accreditation fees
$ / $
$ / $
$ / $
Other expenses
$ / $
$ / $
Total proposed budget / $
Additional funding
  • If additional funding has been obtained or is planned to be sought, provide insight into proposed additional funding sources, and sum obtained / being sought.
  • Please document the means by which independence of the educational activity will be maintained. Please confirm that the additional funding arrangements planned will not interfere with theability to comply with GSK’s requirements for Independent Medical Education to be completely free of influence by any funding organisation over agenda, faculty or content.
  • Please include a breakdown of how the funding from the different funding sources, including that from GSK, will bespent.
  • Please provide a copy of the terms and conditions associated with the additional funding.
  • Maximum 500 words.

  1. Declaration

I declare that the information in this form is true, correct and complete to the best of my knowledge.

Name / Signature
Position / Date
Disclosure and reporting declaration
By ticking this box, I agree to meeting GSK transparency and reporting obligationsshould the proposed educational activity be funded by GSK – for more information see ‘Independent Medical Education guidance document’ which is available on the GSK Australia website.
  1. Submission of completed application

Please ensure this form is fully completed before submitting.

Please attach to this application a letter on your organisation’s letterhead, signed by an authorised representative of the requesting organisation, that requests GSK to consider your application for support. Additional supporting documentation may also be attached if required.

Please submit to GSK by emailing a signed pdf copy of the completed application form to:

.

Page 1

Form Version 3.0; Approved June 2018