West London Clinical Commissioning Group (WLCCG)

Patient and Public Engagement Grants Programme 2015/16

Application Form

Please only type answers in the boxes provided. The boxes will expand as you type. We expect 1500 words will be sufficient to complete the form. A maximum word count is recommended in some sections for guidance.

When you save this document, please enter the name of your organisation in the document file name. The deadline for submitting applicationsis Monday 10 August 2015at 6.00pm. Please refer to instructions at the end of this form.

A: About your organisation

  1. Name of organisation
  1. Address and contact details of organisation

Address
Main contact person
Phone number
Email
Website
  1. Is your organisation …..

A registered charity? / Yes / No / Charity nr:
A company? / Yes / No / Company nr:
An unincorporated association? / Yes / No
A social enterprise? / Yes / No
  1. When did your organisation start? (year)

  1. Do you have a governing document?
/ Yes / No
  1. How many people are involved in your organisation?

Directors, trustees or management committee members
Volunteers
Full-time staff
Part-time staff
  1. What is the main purpose of your organisation?
  1. What is your annual income?

2012/13 / £ / 2013/14 / £ / 2014/15 / £
  1. Do you have a bank account in the name of your organisation?
/ Yes / No
  1. Do cheques have to be signed by more than one person?
/ Yes / No
  1. If appropriate, are all your relevant people checked by the Disclosure & Barring Service or formerly the Criminal Records Bureau?

Yes / No / Not applicable
  1. If your organisation is already delivering health related projects or services in Kensington & Chelsea, Queen’s Park or Paddington,please outline them briefly here.

Name of project / Brief summary / Funded by

B: About your proposed project

  1. Name of project to be funded
  1. Is your proposed project aimed at a specific community or group of people? If yes, please outline who your project is aimed at. (100 words)
  1. How do you know the project is needed?(150 words)
  1. Please briefly outline the project. Where possible, please be SPECIFIC – for example, how many people will benefit, dates by which the main activities will be done, how the project will be delivered (e.g. existing staff, contractors, and volunteers). Please write no more than one page here.(300 words)
  1. Which outcome(s) will your project deliver?

Outcome / Tick box
Access to primary care is improved
People with long-term conditions are supported
Views are obtained and/or people are able to influence services, primary or hospital care
Diverse communities are supported to take control of their health
  1. The above outcomes support the CCG with its new responsibilities for patient and public engagement:
  • Improving access to primary care and community health services
  • Supporting the North-West London Out-of-Hospital Strategy
  • Engaging patients and/or public in the design of clinical services
  • Gathering patient feedback on services
  • Reducing health inequalities, particularly in deprived/vulnerable communities and empowering local people to improve their own health

How does the proposed project aim to support these responsibilities (250 words)

  1. Please state any additional outcomes you have (if any)
  1. How will you measure these outcomes?
  1. If the project is successful, how do you see it developing after this short period of funding?
  1. Is this a partnership project? If so, please describe how your partnership is structured and what each partner will be responsible for.

SUBMITTING THIS FORM

Please send this form by email to Olivia Leu, Development Officer at Kensington & Chelsea Social Council:

PLEASE ALSO ATTACH:

-Detailed budget for this project

-Your most recent externally examined accounts

If you do not have access to email, please call us on 020 7243 9800 and arrange to hand-deliver your application to our office.Please also call us if you have any questions about the grant scheme or the process.

The deadline for submitting applications is Monday 10th August 2015at 6.00pm.

WLCCG grants 2015-16Page 1 of 4