BMS-Pfizer Alliance - Grant Application Form
Project Title
Healthcare Organisation Name and Address
Name/ Contact details for Individual Requester on behalf of Healthcare Organisation* / Name:
Email:
Contact phone number:
Project Goal / Briefly describe how this project will improve patient care
Project Plan / Please outline the proposed methodology and key stages/milestones of your planned approach. Please include details of responsible roles required to carry out the project, e.g. in house staff, external service providers. If you have consulted with patients regarding the need for your project or design of the project please include this information. Please include details of how prepared/ready your organisation is to support this project
Evaluation Measures and Metrics / What measures and metrics will you use to evaluate the success of the project
Ensure robust plan to capture baseline and end of project metrics including measurement of patient feedback or impact where appropriate e.g. change in time to confirmed VTE diagnosis
Please note the BMS-Pfizer Alliance must not receive any patient identifiable information
Impact of initial phase / How many patients will be helped by this initial project ?
Sustainability / How will the project support ongoing patient management and care?
Scalability / Should it prove successful, how might this project be scaled up to help more patients ?
Sharing the learning points / Please detail any publication plan, and plans for local or wider dissemination
Start and End Date
Requested Support from BMS-Pfizer Alliance / Please indicate total monetary sum being requested from BMS-Pfizer Alliance~, upto a maximum of £20,000, and provide a full breakdown of how the funding will be spent*
· Number of additional clinics to be provided
· Hourly rates of required personnel
· Costs of Consumables
· Number and cost of educational materials to be printed
If any additional non-monetary support is required please detail here.
*Please note funding for institutional overheads will not be provided
~If successful the contract for MEGS will be with Pfizer Ltd on behalf of the BMS-Pfizer Alliance
Please note that if the BMS-Pfizer Alliance are not in receipt of a signed contract within 8 weeks of receipt of the contract, the funding offer will be rescinded and the funding re-allocated
How did you hear about this funding opportunity ? / Print journal
Electronic journal
Other (please specify)
To contact Pfizer for any other purpose, including adverse event reports or medical information requests, please call 01304 616161
*Your data will be held on a database controlled by Pfizer Limited (Ramsgate Road, Sandwich, Kent CT13 9NJ, UK) and used for the purpose of assessing your application. Only Pfizer (i.e., Pfizer Limited, Pfizer Inc. and other Pfizer Group companies (http://www.pfizer.com/)), Pfizer Alliance Partners (i.e., other companies which co-promote medical products with Pfizer) and information and communication technology services providers working with Pfizer, will have access to your information to design, implement and control Pfizer initiatives in the area of medical and educational goods and services and/or provide technical support to the database. The database and these recipients may be located within the EU or outside (where privacy legal standards may not be equivalent to those applicable in the EU). We will always employ appropriate technical security measures to protect your personal information and to ensure that it is not accessed by unauthorised persons. You may access or update your data or withdraw this consent by emailing us at: . Please use the reference “Pfizer Email Programme” in any communication to us.
PP-GIP-GBR-2097IPCA Grant Application Form Date of prep June 2017