UNIVERSITY HOSPITAL GENERAL FUND APPLICATION FORM

SUBMISSION DEADLINE: FRIDAY 29TH SEPTEMBER 2017

Please send the completed grant application form to:

Eileen Rock, UHCW Charity, Main Reception, University Hospital, Clifford Bridge Road, Coventry CV2 2DX

Should you require any additional information then please call the Charity Officeon

02476 96 6059 or email:

UNIVERSITY HOSPITAL GENERAL FUND APPLICATION FORM

A: Requested By

Name
Role
Extension Number
Date of Request

B: Speciality Group

Your Group Manager can provide the details required in the table below

Speciality Group Number:
Speciality Group Name:
Group Manager’s Name:
Extension Number:
Commercial Finance Manager’s Name:
Extension Number:

C: Benefits of The Grant

1: For all requests complete the section below:

What would you like the grant for?
State the details for the piece of equipment, facility or patient comfort etc
Name the ward or department that the funding will benefit?
How will this enhance the patient care already provided by UHCW NHS Trust? How many patients will benefit at UHCW each year?

2: For requests of £5,000 and above, please outline how this will support the strategy for your service/department? Your Group Manager will be able to provide you with the details required below

How does this fit into/support the next 1-5 year strategy for the department? (the delivery of the strategy cannot be reliant on the charitable grant)
Why are you applying for a charity grant rather than it being funded by the NHS Trust?
If this is part of a bigger capital project you must give full details including the full value of the project

3.If application is for 1-Pads or similar, please complete the details below:

Please state how many staff will use the equipment (we are unable to fund 1 per person)
Please state the security measures for managing the equipment such as where they will be kept, how they will be logged in and out and who will be responsible for them when with a patient
Please confirm that the equipment will not be taken home and will not be used for personal reasons/tasks

D: Is your request charitable?

Please note we will be unable to provide a grant if request is deemed mandatory/essential to the service or does not have public benefit

This is mandatory/essential to the service (to the NHS or the Operational Development Plan of the Speciality Group) / Yes/No (please delete accordingly)
This has public benefit (benefits the full patient group and does not benefit an individual or group of individuals) / Yes/No

E:

1. Quotes

All applications must be supported by a quote

Item / Quote must be provided by / Attached
ICT Audio and digital equipment / ICT Department / [ ] Yes [ ] N/A
Small Works / Estates Department / [ ] Yes [ ] N/A
Capital Works / Estates Department / [ ] Yes [ ] N/A
Refurbishments / Estates Department / [ ] Yes [ ] N/A
Furniture / Estates Department / [ ] Yes [ ] N/A
Equipment / Please ensure supplier is registered with procurement / [ ] Yes [ ] N/A

2. Cost of the whole project

Please provide full costs for the project (excluding revenue)

Item / Cost exc.VAT
£ / VAT
£ / Total Cost
£
TOTAL

3. Other Funding already secured for this project

Please outline below

Other Funder / Name / Amount contributing
£ / Tick- Evidence Attached
UHCW NHS Trust- Exchequer Code / [ ] signed statement or email from Commercial Finance Manager
Other Organisation / [ ] Letter of confirmation
UHCW Charity Charitable Fund / Complete table below
Total
You must use the full balance of the existing fund in order to apply for a grant from the general fund. To see if there is a charitable fund go to
Name of Charitable Fund:
Fund Number:
Signature of at least one Fund Adviser:
Fund Adviser’s Name

4. Grant Value- Maximum value £10,000

What is the full value of the grant you are applying for?
The charity will fund capital/one off costs only. The NHS Trust is responsible for maintenance, lifecycle and revenue costs / £

F: Revenue Costs:

All revenue and lifecycle costs must be met by your department. Please provide full revenue costs for the project

Item / Cost exc.VAT / VAT £ / Total Cost £
Annual Training
Annual Maintenance
(Estates advise that a figure of 10% of cost is used if a warrantee cost is not available)
Annual Rent
Other
Total

Please pass your application form over to the Commercial Group Manager for your speciality and ask them to complete the next sections

G: Payment Details

If successful the grant will be paid directly to the NHS Trust and you will be responsible for placing the order/purchasing the item in line with their procedures. Please confirm the University Hospitals Coventry and Warwickshire NHS Trust department Z financial code

H: NHS TRUST AUTHORISATION

Before submitting your grant requests to UHCW Charity, you must obtain NHS Trust authority, below. Please refer to your NHS Trust’s Charity Grant Making Application and Expenditure Procedure for details.
I am authorised to give the NHS Trust’s authority for this grant application and I understand that I am signing to confirm
[ ]I am not the person making the request or the authorising Fund Adviser
[ ]I have checked that this request has gone through all the relevant NHS Trust Procedures and has the appropriate
Authority
[ ] I attach the completed Appendix A from the Charity Grant Application and Expenditure Procedure
[ ] I have read the “Terms and Conditions of Accepting a Grant Award” in the UHCW Grant Making Procedure
Document and can confirm that the request meets these requirements and understand that the NHS Trust may
Be required to refund the full value of the grant payment if these conditions are not met
Name/Role
Signature
Date