Engagement Fund Application

Have you reviewed the Pre-Application Funding Package yet?

Please review the Pre-Application Funding Package prior to proceeding with this application. If you have any questions regarding your application process email engagement@smhdrslounge.com

I confirm that I have read, understand and agree to the FE Project Funding Process as outlined in the Funding Package.

Project Information

Project Title

Project Lead

Phone Number

Project Start Date

Project End Date

Funding Amount Requested:

Names of Other Key Participants:

Activity Type

Health System Areas of Impact

Medical Area/Specialty

Issue Statement

Background Information

Objective(s) and Description of Activity

Identify which of the following MOU objectives are most relevant to the activity.

To improve communication and relationships among the medical staff so that their views are more effectively represented.

To prioritize issues that significantly affect physicians and patient care.

To support medical staff contributions to the development and achievement of health authority plans and initiatives that directly affect physicians.

To have meaningful interactions between the medical staff and health authority leaders, including physicians in formal HA medical leadership roles.

Facility Impact

This project would benefit from HA involvement as it requires input, data, implementation, financial or in-kind resources, etc.

I need help finding the appropriate HA contacts.

I am aware of the appropriate HA contacts and have included them below.

Name

Title

Department

Contribution

Engagement Activity Planning

Evaluation Plan

Indicate how you will assess whether the activity’s objectives are being met. How will deliverables be monitored? How and when will data (e.g., indicators) be collected and analyzed?

Please state if you require assistance developing an evaluation plan.

Timeline

Please include your planned milestones with an estimated time frame of accomplishing for each item.

Proposed Budget

Below is the format for which the budget should be submitted in. Feel free to use our online budget tool to assist you in this step of the process. (https://smhdrslounge.com/funding_resources/)

1. Sessional Time

Physicians
$158.97/hr

Number of Individuals

Number of Hours/Person

Sub Total: $

Allied Health
$65/hr

Rate may vary based on profession (more details)

Number of Individuals

Number of Hours/Person

Sub Total: $

Total Sessional Budget: $

2. Meetings

Catering/Food
$30.00/person

Number of Individuals

Number of meetings

Sub Total: $

Meeting Space/Venue
$105/person

Number of Individuals

Number of meetings

Sub Total: $

Accommodation/Travel
$130/person

Number of Individuals

Number of meetings

Sub Total: $

Total Meeting Budget: $

3. Other Items

1. Item

Quantity

Cost

Total: $

2. Item

Quantity

Cost

Total: $

3. Item

Quantity

Cost

Total: $

4. Item

Quantity

Cost

Total: $

SMH | MSA

Engagement Fund

Engagement Fund Application

Have you reviewed the Pre-Application Funding Package yet?

Project Information

Evaluation Plan

Timeline

Proposed Budget

1. Sessional Time

Total Sessional Budget: $

2. Meetings

Total Meeting Budget: $

3. Other Items

Total Other Item Budget: $

Total Budget: $

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