Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.General InformationDateProject TitleProposed Time Frame (Date of Retreat)Total Amount RequestedSubmitting DepartmentApplicant InformationName of Applicant(s)Project LeadName *Phone NumberEmail Address *Application Completed ByProject DetailsSummarise the issues and relevant background (i.e. the issue, how it has evolved, current situation, how you intend to resolve the issue)Identify all areas impacted by this issue and retreat:Describe the Objective of the project, the desired outcome and how funds will be used; and who will benefit from the outcome.Describe how the retreat aligns with KGH MS’s mission & vision, as well as the strategic goals of the hospital and IH.Are there any environmental factors, regulatory/ethical requirements or legal ramifications to consider?Please identify any other projects that may be affected by this initiative.Describe any assumptions of constraints that have been identified (any factors that are assumed to be true and remain true during this project or anything that will restrict the successful outcome of this project).Please indicate how you will assess the outcome of this retreat. Please advise us if you require assistance to evaluate the outcome of this project.Meeting CostsNumber of physicians involvedNumber of hours per physicianTotal sessional fees at $176.18 / physician $40 impacted the Total meals at $40 / physicianProject lead costs (up to 3 hours worked)Total amount requestedSignatureName of Applicant *Signature Clear Signature Submit
