Eligibility Criteria for HHS Foundation Family Grants

To fund items outside HHS budgets (eg. Specialized furnishings and equipment):

1. Patient and staff items that cannot be met by other sources. 2. Projects or items that will enhance the workplace environment. 3. Enhancement of internal health programs offered by Hamilton Health Sciences.

Most grants awarded are up to $2,000, although larger requests may be considered.

Ineligible: The following will not be considered, but may be accessed through other sources: 1. Conferences/workshops. (For more information contact ext. 46020, Clinical Practice and Education). 2. Health professional development and research. (Through separate calls for applications). 3. Fax machines, digital cameras, printers, laminators, telecommunications equipment and other computer equipment. 4. Books, publications, manuals, and pamphlets. 5. Single use items (such as bus/taxi vouchers, food vouchers etc.) or items that require ongoing expenses. 6. Ice machines. 7. Staff recognition parties. 8. Televisions (NEW). 9. Psychological testing materials.

Application Procedure: IMPORTANT NOTE: EACH REQUEST MUST BE ON A SEPARATE FORM

1. Complete the Application Form: Include a brief description of the item/project; highlight why it is required, including its priority level (to be filled out by Program Director / AVP). The cost breakdown including taxes must be included (attach quote). All required signatures are mandatory. Applications that do not include this information will not be considered. 2. Submit FOURTEEN copies of your application to the Foundation office, 40 Wellington Street North by January 29, 2010. 3. Submissions that do not meet the eligibility criteria will not be considered. 4. All equipment requests must be in compliance with building stipulations and must be supported and serviced by HHS Building Services employees. 5. Successful applicants must submit approved purchase requisitions prior to June 30, 2010. 6. Departments that receive grants are required to submit a three-paragraph report confirming the staff and patient benefit for the item that was implemented on their unit by December 31, 2010. If appropriate, a photograph or quotes can be included. 2009 HHS FOUNDATION FAMILY GRANTS APPLICATION A complete application must include ALL required signatures, a description of the project/item, cost breakdown (incl. taxes) and priority rating. Applications that do not include this information will not be considered. Remember: FOURTEEN copies of your application are due in the Foundation Office, 40 Wellington Street North by January 29, 2010. IMPORTANT NOTE: EACH REQUEST MUST BE ON A SEPARATE FORM

Application Check List:

Description of Item/Project

Price Quotation attached

Applicable Taxes

Priority Level

All Required Signatures

SECTION I

______Program/Department Name and Title Of Person Completing This Form

______HHS address Telephone Extension

Name and Location of Principal Beneficiary if Other Than Applicant

______

of 3 SECTION II - Equipment Attach price quote, including ALL taxes, shipping and delivery. ALL requests for equipment must have specific item cost and taxes confirmed with the Purchasing Department. Description of Equipment:

______

______$ ______1 of 3 SECTION III - Capital Improvement Attach price quote, including ALL taxes, shipping and delivery. Applications must be signed by the Capital Development Site Leader. Please send signature requests to the appropriate Site Lead: Hamilton General & Chedoke Sites - Cris Robinson at [email protected] Henderson Site - Cathy Lovett at [email protected] McMaster Site - Anita Lamond at [email protected]

Description of capital improvement:

______

______$ ______

______Signature of Capital Development Site Leader Date

SECTION IV - Furniture Requests Attach price quote, including ALL taxes, shipping and delivery. Applications must be signed by the Capital Development Site Leader. Please send quotation and signatures requests to the appropriate Site Lead: Hamilton General & Chedoke Sites - Cris Robinson at [email protected] Henderson Site - Cathy Lovett at [email protected] McMaster Site - Anita Lamond at [email protected]

Requests for quotations will not be accepted after January 11, 2010. The furniture quotations are based on HHS standards.

Description of furniture:

______

______$ ______

______Signature of Capital Development Site Leader Date Page 2 of 3 SECTION V - Description/Comments: Information that will assist the Selection Committee (eg. rationale; Who will use equipment? How does it add value to patient or work environment area? How will people benefit? (eg. Quality of life)

______2 of

SECTION VI - Priority Rating Program Directors / AVP’s are asked to prioritize each request as follows: (circle one)

1. Absolutely essential for program function/cannot work without this item (patient/staff safety issue)

2. Important for program function

3. Desirable for program function

SECTION VII - Signatures IMPORTANT NOTE: To be signed AFTER forms are completed.

The application must be endorsed by Vice-President or Assistant Vice-President AND Program Director.

______Signature of Program Director Date

______Signature of Vice-President or Assistant Vice-President Date

______Signature of Person Completing Application Date