/ FORM / Doc. # / Rev # / MED.003.F1 / 0
Medical Education Grant Requests Form / Effective Date / 29NOV2016
Page / 1of7

We would like to solicit the support of Portola for the following educational program:

Program Details:

Title:

Date(s):
Venue:

**A copy of the request letter on institutional letterhead, proposed agenda, or program brochure must be submitted with application (draft acceptable).**

Statement of Program Objectives:

Brief description of the program:

Target Audience(s):

Physicians / Nurses / Pharmacists / Other / Other
Expected Number of Participants:

Is this activity expected to be presented more than once? No Yes

If “yes”, please provide justification for educational need for multiple presentations:

Amount of Funding Requested (USD):

/ $

**A copy of the proposed budget must be submitted with application.**

Will there be other supporters of this program?

/ Yes / How many? N/A / No

Comments:

Accreditation:

Is this program certified for credit by the ACCME or another recognized accrediting body?

No Yes

If “yes”, please provide information on organization and credit:

Name: / No. of Hours:
Address: / Category of Credit:

**Accreditation statement, including number of approved hours, must be included.**

Requirements for Portola Funding of Educational Grants(Funding Requires Agreement to All of the Following Criteria)
Provider must indicate that they agree to all of the following criteria.
# / Criteria / Yes
1 / Statement of Purpose
The proposed support is for educational purposes only and not for promotion of the company’s products directly or indirectly.
2 / Control of Content and Selection of Presenters and Moderators
The provider will be solely responsible for control of content and selection of presenters and moderators.
3 / Selection of Audience
The Provider is responsible for selection of the audience for the program.
4 / Disclosures
The Provider will ensure meaningful disclosure to the audience, at the time of the program, of
(a) Portola funding, and
(b) any significant relationship between the Provider and Portola (e.g., grant recipient) or between individual speakers or moderators and Portola.
5 / Ancillary Promotional Activities
There will be no promotional activities permitted in the same room or obligate path as the Provider’s activity, and no product advertisements will be permitted in the program room.
6 / Objectivity and Balance
The Provider will make every effort to ensure that data regarding Portola products or competing products are selected objectively and presented with favorable and unfavorable information and balanced discussion of prevailing information on the product(s) and/or alternative treatments. Additionally, the Provider will ensure that the activity is focused on educational content and is free from influence or bias and that the title of the activity fairly and accurately represents the scope of the presentation. Furthermore, if a discussion of Portola products constitutes a substantial portion of the program, such discussion shall be limited to the FDA-approved uses of such products.
7 / Limitations of Data
The Provider will ensure, to the extent possible, meaningful disclosure of limitations on data (e.g., ongoing research, interim analyses, preliminary data, or unsupported opinion).
8 / Opportunities for Discussion
The Provider will ensure that opportunity exists during the program for meaningful questions and scientific debate, if applicable.
9 / Independence of Sponsor in the Use of Contributed Funds
Provider agrees that:
(a)Funds will be in the form of an educational grant made payable to the Provider.
(b)All other support associated with the program (e.g., distributing brochures, preparing slides) must be given with the full knowledge of the Provider.
No other funds from Portola will be paid to the program director, faculty or others involved in the program (e.g., additional honoraria, extra social events).
10 / Disclosures
The provider agrees (1) to acknowledge educational support from Portola in program brochures, syllabi, and other program materials, and (2) to furnish to Portola a report concerning the expenditure of the funds provided (i.e., reconciliation will be provided after the activity).
11 / Reconciliation
After the program, Provider will agree to provide Portola a report in the form provided that contains any payments and items of value provided to healthcare providers, including physician speaker payments, expenses, and funds provided to teaching institutions.
12 / Refund
Provider agrees to refund any unused grant funds to Portola after the program.
13 / Independent Medical Education (IME) Agreement
For IME grants, Provider agrees that any grant is subject to the terms of Portola’s IME agreement that is a condition of payment of any grant award.
Provider must answer all of the following questions.
1 / Is this grant related to any other grant that has been submitted to Portola (e.g., annual program, supplemental amount)?
Yes No
If yes, please explain how:
2 / What percentage of the recipient organization’s total educational budget, including this grant request, has been received from Portola during the current fiscal year?
3 / Does this program have multiple supporters? Yes No
If yes, who?
Total amount of support from other supporters?
4 / What is the percentage of total budget for this program requested from Portola?
100% Other:
5 / Program location (city, state, country):
6 / Program venue (e.g., name of hotel):
7 / Program language: English Other:
8 / Will enduring program materials be created? Yes No
If yes, please describe:
9 / Exclusion List Verification:
Does your organization appear on any of the following lists? Yes No
(i)FDA Debarment List:
(ii)OIG Exclusion List: or
(iii)Excluded Parties List:
Date sanctions lists checked:
Provider must answer all of the following questions.
10 / What amount of funding has this organization received from Portola in the past 3 years?
11 / Is the applicant organization (s) a distinct legal entity with separate personnel from any entity performing sales and marketing activities for Portola?
Yes No If no, please explain:
Checklist: Have you attached the following documents?

Grant request letter on institutional letterhead stating grant is restricted to a specific educational purpose

/ Yes

Needs Assessment summarizing justification for program

/ Yes

Program agenda or brochure (describing purpose, date, time, place, and event title)

/ Yes

Detailed budget

/ Yes

IRS W-9 Form

/ Yes

Accreditation statement or certificate

/ Yes

Additional Information:

Please use the space below to include any additional comments related to your application.

Payee Information:

Institution: / Primary contact:
Address: / Title:

**If payee is not the CME provider, a statement from the CME provider identifying the “remit to” details must be included.**

Requestor Information (if not the same as above):

Name: / Institution:
Title: / Address:
Phone:
Fax:
Email:
Certification

The above information and any other supporting information attached is, to the best of my knowledge, a complete and accurate description of my/our request for educational support from Portola for this activity. I understand that if the request is approved, Portola funding will be in the form of an educational grant and that my/our acceptance of the grant does not constitute a solicitation, receipt, offer, payment, or remuneration for: 1) referring business payable under Medicare or Medicaid; or,
2) purchasing or ordering products or services payable under Medicare or Medicaid.

Name: / Title:
Signature: / Date:

**Please submit application materials via email to .**

FOR INTERNAL PORTOLA USE ONLY
1 / Grant amount recommended:
2 / Program Type: / Live
Enduring
Web-based
Multi-media
Other
3 / Exclusion List Verification: / Verify that organization does not appear on:
(i)FDA Debarment List: ;
(ii)OIG Exclusion List: ; or
(iii)Excluded Parties List:
Date sanctions lists checked:
4 / Verification: Are there proposed speakers or organizers that are currently Portola employees or paid consultants?

CONFIDENTIAL