Combined paediatric/adult facilities should submit a joint application form.

Transcription

1 APPLICATION FOR A CYSTIC FIBROSIS CLINIC INCENTIVE GRANT APPLICATION INFORMATION (a) Submission process Please complete the fillable application form, then print it for signatures. After all signatures have been obtained, send the completed form electronically including the budget, statistical information, and progress report to imcintosh@cysticfibrosis.ca by the deadline date. IT IS NOT NECESSARY TO MAIL PAPER COPIES. (b) Deadline for submissions Completed applications and all supporting materials must be received by October 1. APPLICATIONS RECEIVED AFTER THE DEADLINE WILL BE SUBJECT TO A PENALTY EQUAL TO 10% OF THE VALUE OF THE AWARD, FOR THE FIRST YEAR, PLUS AN ADDITIONAL 10% FOR EACH SUBSEQUENT YEAR. THIS PENALTY WILL BE DEDUCTED FROM THE TRAVEL PORTION OF THE AWARD. (c) Funds received from National Support Groups If funds are donated by a National Support Group of Cystic Fibrosis Canada, such as Kin Canada, directly to a Cystic Fibrosis Canada-funded clinic, or to the hospital foundation in the clinic s name, the Board of Directors of Cystic Fibrosis Canada reserves the option to deduct an equal amount from the Clinic Incentive grant. (d) Combined paediatric/adult facilities Combined paediatric/adult facilities should submit a joint application form. (e) Outreach clinics Requests will normally be considered for clinics that sponsor outreach programs and that serve large areas. Clinics requesting such funds should provide a detailed description of their outreach programs, and a detailed rationale for the funding request. Please note that funds are not available in this category to cover the costs of photocopying, telephone expenses, pamphlets, etc. Please see part C.2, Outreach clinic(s). PLEASE REMOVE THIS PAGE PRIOR TO COMPLETING AND SUBMITTING THE APPLICATION FORM.

2 APPLICATION FOR A CYSTIC FIBROSIS CLINIC INCENTIVE GRANT Page 1 of 10 Initial application Renewal application A. GENERAL INFORMATION Name of clinic/ institution Type of clinic Paediatric only Adult only Combined paediatric/adult City and province Date Application is hereby made for a CF Clinic Incentive grant for the period April 1, 2016 March 31, 2017, in the amount of: The figure appearing here should be the same as the TOTAL REQUEST in the Budget summary on page 5 of this application. CF Clinic Director* Name and title Signature Telephone Fax B. INSTITUTIONAL APPROVAL (a) Head of Department responsible for administration and supervision: Name and title Signature (b) Executive of Institution administering grant: Name and title Signature

3 APPLICATION FOR A CYSTIC FIBROSIS CLINIC INCENTIVE GRANT Page 2 of 10 C. PROPOSED BUDGET 1. Clinic personnel supported by Cystic Fibrosis Canada Please provide the following information for all clinic personnel for whom salary support is requested. Note that only one monetary figure is required, and should be indicated as the Subtotal, at the bottom of this list. Clinic personnel and associated physicians for whom no salary support is requested are to be listed later, on page 7 of this application. Name and title CURRENT % of time for CF care REQUIRED % of time for CF care Subtotal: Clinic personnel support*

4 APPLICATION FOR A CYSTIC FIBROSIS CLINIC INCENTIVE GRANT Page 3 of 10 C. PROPOSED BUDGET (cont'd.) 2. Outreach clinic(s) Requests will normally be considered for clinics that sponsor outreach programs and that serve large areas. Please complete sections (a) to (g) for each outreach location; additional pages may be used, and should be inserted following this page. Note that expenses must comply with the reimbursement policy of Cystic Fibrosis Canada (See page 4 of this application for details); please budget accordingly. Be reminded that funds are not available in this category to cover the costs of photocopying, telephone expenses, pamphlets, etc. (a) Outreach location (b) Type of clinic Paediatric only Adult only Combined paediatric/adult (c) Number of clinics per year (d) Driving distance X 40 per kilometre or Air/Rail (e) Number of CF individuals attending each clinic* = (f) CF clinic staff/discipline travelling (g) Estimated expenses for each clinic: Travel Accommodation Meals Other Total (this location) Subtotal: all Outreach clinic(s) Other sources of travel funding and amounts * Please provide explanation for need, where number of patients is fewer than ten.

5 APPLICATION FOR A CYSTIC FIBROSIS CLINIC INCENTIVE GRANT Page 4 of 10 C. PROPOSED BUDGET (cont'd.) Expense policy for Outreach clinic(s) Cystic Fibrosis Canada has guidelines regarding costs associated with Outreach clinics. The guidelines refer to costs associated with travel, accommodation, meals, and certain other expenses, but careful restrictions are placed on expenditures. The maximum claims for meals and mileage are periodically adjusted to reflect shifting costs. Meals: Accommodation: Travel: Meals are limited to $15.00 for breakfast, $15.00 for lunch and $25.00 for dinner. Charges for alcoholic beverages may not be claimed. Cystic Fibrosis Canada allows for reasonable accommodation charges. No incidental expenses charged to the room - including room service, mini-bar, telephone, and entertainment - can be accepted. Cystic Fibrosis Canada will cover travel on its behalf by air, rail, or car. Car mileage may be reimbursed at 40 per kilometre, up to a maximum equal to the lowest applicable advance booking airfare for those dates of travel. Fares should be based on a non-charter carrier, e.g. Air Canada. 3. Travel Where possible, please indicate the specific meetings and/or conferences for which travel funds are requested: Meeting/conference Date Amount requested Subtotal: travel

6 APPLICATION FOR A CYSTIC FIBROSIS CLINIC INCENTIVE GRANT Page 5 of Budget summary Amount requested for clinic personnel support Amount requested for Outreach clinic(s) Amount requested for travel TOTAL REQUEST The figure appearing in the TOTAL REQUEST line should be the same figure that appears on page 1 of this application. Please provide the name, title, and mailing address of the person to whom the quarterly payment cheques should be mailed: Indicate if these details have changed since the last application Yes No Name: Title: Mailing address: CYSTIC FIBROSIS CANADA-FUNDED RESEARCH AND CLINIC GRANTS DO NOT PROVIDE SUPPORT FOR INSTITUTIONAL OVERHEADS AND/OR INDIRECT COSTS OF RESEARCH OR CLINICAL CARE.

7 APPLICATION FOR A CYSTIC FIBROSIS CLINIC INCENTIVE GRANT Page 6 of 10 C. PROPOSED BUDGET (cont'd.) 5. Budget rationale Please provide any additional or supporting information relating to the funding requests made above. Please note that salaries for all personnel should be sought from the host institution, which is supported by government funding. All requests for salary support should therefore be justified. Clinics seeking funds for outreach clinic(s) expenses should provide a detailed description of the outreach programs, or any other initiative for which funds are requested. Additional pages may be used, and should be inserted following this page.

8 APPLICATION FOR A CYSTIC FIBROSIS CLINIC INCENTIVE GRANT Page 7 of 10 D. ADDITIONAL INFORMATION 1. Clinic personnel Please provide a list of all clinic personnel not noted above in part C.1: specifically, non-physicians who are active in the CF clinic but who are funded from sources other than Cystic Fibrosis Canada, and for whom no salary support is being requested: Name and title % FTE in CF clinic Source of support (other than Cystic Fibrosis Canada) 2. Associated physicians Please provide a list of physicians (e.g., gastroenterologists, respirologists, gynaecologists) who play an active role in caring for patients in your clinic. If necessary, an additional page may be inserted following this page. Name and title Area of expertise

9 APPLICATION FOR A CYSTIC FIBROSIS CLINIC INCENTIVE GRANT Page 8 of 10 E. STATISTICAL INFORMATION Type of clinic Paediatric only Adult only Combined paediatric/adult Patient population (a) Total number of patients AS OF JANUARY 1 (b) Number of those patients who have declined consent for the Canadian CF Registry Clinic activity (c) Number of clinical studies your clinic has participated in during the past year (excluding the Canadian CF Registry) Microbiological activity (d) Total number of Burkholderia cepacia complex samples sent to the Canadian Burkholderia cepacia Complex Research and Referral Repository, for clinical diagnostic typing (January 1, 2014 December 31, 2014) F. ACCREDITATION SITE VISIT PROGRAM Clinics that have hosted an Accreditation Site Visit since submitting their last grant application are requested to comment on the resulting report, and its recommendations. Please comment in the space below. If more space is required, additional pages may be used, and should be inserted following this page.

10 APPLICATION FOR A CYSTIC FIBROSIS CLINIC INCENTIVE GRANT Page 9 of 10 G. ADDITIONAL INFORMATION Additional information, covering the points noted below, should be appended to this application. The name of the person making the report, and the period covered by the report, should be clearly indicated. 1. Patient care program (a) Overview This section should note any changes in physical facilities, personnel, admission policies, methods of treatment, medications, clinic events (e.g., CF information days) or other developments of special interest since the date of the previous application. (b) Cooperative relationships Describe current relationships, and any efforts to establish or enhance relationships with: other departments in the medical centre other hospitals in the community private physicians in the community or region government and/or private agencies local chapter of Cystic Fibrosis Canada other (c) Special programs Describe any special programs related to patient care that are not covered elsewhere in this report. In particular, please provide details on any Quality Improvement initiatives undertaken by your clinic team, including proposed objectives, procedures and results. 2. Research program (a) Basic science and clinical investigations completed since last application new projects undertaken since last application currently underway, with a brief report on progress projects discontinued, with reason for termination projects planned for forthcoming year (b) CF program support Provide an overview of any grants held or applied for since the last application (funding sources other than Cystic Fibrosis Canada). Indicate the source of funding, amount, period of grant, and a short project description.

11 APPLICATION FOR A CYSTIC FIBROSIS CLINIC INCENTIVE GRANT Page 10 of 10 G. ADDITIONAL INFORMATION (cont'd.) 3. Publications Please provide full citations for all publications relevant to cystic fibrosis by the Clinic Director and personnel during the year, as well as manuscripts currently in press or in preparation. 4. Education (a) Formal teaching activities professional (e.g., internship, residency, nursing, physiotherapy) lay (e.g., classes for CF parents) (b) Other programs participation in and presentations at meetings, conferences, seminars use or development of visual aids (e.g., films, exhibits) preparation of new educational materials (e.g., manuals for physicians, parents) hosting of visiting physician/s other educational programs 5. Summary Please include any additional information that will further describe the CF program at the clinic. You may comment on the need for and effectiveness of the program, problems experienced during the year, and areas for future development. Any case histories of special interest may also be included.