Facility Engagement Funding Application

If you any have questions or concerns, please feel free to contact us at engagement@msacw.ca.

Project Information

Project Title

Project Lead

Phone Number

Names of Other Key Participants:

Project Start Date

Project End Date

Funding Amount Requested:

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

Health Authority Contact

Name

Title

Department

Contribution

Engagement Activity Planning

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://msacw.ca/funding_resources/

1. Sessional Time

Specialists
$158.97/hr

Number of Individuals

Number of Hours/Person

Sub Total: $

General Physicians
$134.77/hr

Number of Individuals

Number of Hours/Person

Sub Total: $

Allied Health
$70/hr

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: $

Total Other Item Budget: $

Total Budget: $

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. Resource: FE_Evaluation Resource Guide Final_Sept. 2018

Timeline

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

Medical Staff Association of Children's and Women's Hospital

Facility Engagement Funding Application

Project Information

Health Authority Contact

Proposed Budget

1. Sessional Time

Total Sessional Budget: $

2. Meetings

Total Meeting Budget: $

3. Other Items

Total Other Item Budget: $

Total Budget: $

Evaluation Plan

Timeline