Application Number:

Application for South London Small Grant 2017

Please note that we would like to maintain electronic records wherever possible and it would
be appreciated if applications were completed and submitted electronically. Please also supply
a regularly used e-mail address for correspondence.

Information about previous Small Grant funded projects can be found here.

Please check your application carefully and once you are happy with the content, return it to
the general correspondence address (hin.southlondon@nhs.net) by 28th June.

Please note that the award of funding will not be determined until after July 31 st. You will be
contacted via e-mail to advise you of the outcome of your application and if successful will be
invited to the award event and an introductory meeting. You will be expected to provide regular
update reports and participate in the HINs dissemination and promotion activity. Further details
can be found in the Small Grant Guidance document.

1. Title of scheme / project

2. Lead Applicant (please give your name, position and the organisation that you are
representing, including correspondence postal address, preferred e-mail address and a
telephone number that we can contact you)

Name:
Position:
Address:

Email:
Contact Number:

3. Details of your sponsoring organisation Details of partner organisations

4. Total sum applied for (note that the maximum is a total of 10,000)

Page 1 of 6
5. Description of scheme / project. 800 words

6. Timescales (including start and end date) and key milestones. 600 words

7. Key purpose / aims of the scheme or project. 600 words

8. Please set out your key outcomes for the scheme / project. 600 words

9. Please describe how this scheme is innovative and explain what you believe is the
unique selling point of your bid. 600 words

10. Health priorities and need

a) Does your application meet any of south Londons priorities, if so which ones?
Supporting and fostering innovation in service and practice, Innovative approaches to
developing the workforce, Addressing the gaps identified in local STPs and the NHS
Five Year Forward View, Enabling spread and adoption and Evaluation of the success
and impact of current initiatives

Page 2 of 6
 b) How will the target group benefit? What evidence exists to support this benefit
and need? 500 words

c) If relevant, has the scheme / project been discussed with Clinical Commissioning
Groups (CCGs), other local commissioners and Health and Wellbeing Boards?

11. Does the scheme / project require ethical approval?

12. How will your project be evaluated? 500 words

13. How much money have you allowed / built into the budget for the cost of evaluation?

in total
14. Please describe your plans for sharing the learning / dissemination. 500 words

15. Financial details of grant required (add rows to table if needed)

Amount requested Alternative finance

(state source)

14.1 Employment expenses:
Basic salary:
London weighting:
NI
Superannuation
Subtotal:
14.2 Consumable materials:
(specify items.):

Page 3 of 6
 Subtotal:
14.4 Non-recurrent expenses:

Subtotal:
Total Grant Requested:

15. If the answer to any of these is yes, please give details in the space beneath so that
your application can be fully considered

a. Is any part of your research being supported by any outside

body?
b. Is this or a related application currently being submitted
elsewhere?
c. Has this or a similar application been submitted elsewhere over
the past year?
d. Do you have plans to enable the sustainability of this project
beyond the term of the grant funding?

16. What is the absolute minimum level of funding that you require in order to deliver this
project successfully? Answering this question will help us to determine whether we may
be able to offer your project support even if full funding is not available.

17. Please identify any risk factors that may affect the delivery of the project
Consider: financial, health and safety, research governance, media publicity, environmental
effects, staff views, prospect of successfully recruiting any new staff, availability of supplies.

Page 4 of 6
18. If you answered Yes to the above, could you please indicate how you have allowed
for any contingencies in your project to manage these risks? Please explain.

19. Who will project manage the scheme?

By completing these details, you are confirming that this person is willing / able to
manage the scheme.

Name:

Job/Role:

Address:

Phone No:

E-mail:

20. Who are the lead stakeholders / people involved in this scheme?

Name:

Job/Role:

Address:

E-mail:

***********************************************
Name:

Job/Role:

Address:

Page 5 of 6
E-mail:

Please note that by completing and submitting this form for consideration, you (the
applicant given in 1) are confirming that to the best of your knowledge and belief the
statements on this form are correct.

Please check your application carefully and once you are happy with the content, return it to
the general correspondence address (hin.southlondon@nhs.net) no later than June 28th.

Please note that the award of Small Grants will not be determined until July 31 st at the
earliest, and you will be contacted via e-mail to advise you of the outcome of your
application.

Page 6 of 6