Facility Engagement Funding Application If you any have questions or concerns, please feel free to contact us at engagement@msacw.ca. Order Number Project Information Project Title * Project Lead * Phone Number * Email * 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 0 Number of Hours/Person 0 Sessional Time Sub Total: $ General Physicians$134.77/hr Number of Individuals 0 Number of Hours/Person 0 Sessional Time Sub Total: $ Allied Health$70/hr Number of Individuals 0 Number of Hours/Person 0 Sessional Time Sub Total: $ Total Sessional Budget: Total Sessional Budget: $ 2. Meetings Catering/Food$30.00/person Number of Individuals 0 Number of meetings 0 Catering Sub Total Sub Total: $ Meeting Space/Venue$105/person Number of Individuals 0 Number of meetings 0 Meeting Venue Sub Total Sub Total: $ Accommodation/Travel$130/person Number of Individuals 0 Number of meetings 0 Accom Travel Sub Total Sub Total: $ Total Meeting Budget: Total Meeting Budget: $ 3. Other Items 1. Item Quantity Cost 1_total Total: $ 2. Item Quantity Cost 2_total Total: $ 3. Item Quantity Cost 3_total Total: $ 4. Item Quantity Cost 4_total Total: $ Total Other Item Budget: Total Other Item Budget: $ Total 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 Eval Plan Timeline Please include your planned milestones with an estimated time frame of accomplishing for each item. Timeline