SCCM Financial Award Application

SCCM Financial Award Application
Part 1: Applicant Information and Statement of Need
Name

First Name Last Name
Email
example@example.com
Institution
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Background on the organization(s) sponsoring the course:
Description of the project, including goals, target audience, expected outcomes, patient population served, and anticipated number of healthcare professionals who will attend the course:
Statement of need and financial barriers:
Letter of reference from a partnering or intermediary organization supporting the application, if applicable.
Has your insitution held a Fundamental Critical Care Support (FCCS), Pediatric FCCS, FCCS: Obstetrics, or FCCS: Resource Limited course in the past?

Yes No
If yes, please list which course(s) and the course date(s), if known.
Please indicate the profession(s) of clinicians you expect will benefit from this training:

Physician Physician assistant Nurse Pharmacist Respiratory therapist Resident or fellow
Please indicate the specialty(ies) of clinicians you expect will benefit from this training:

Surgeon Anesthesiologist Intensivist Pulmonologist Interventionalist Hospitalist Emergency department clinician Perfusionist Bedside nurse
How many patients at your institution were treated for structural heart disease or critical care in the past 6 months?
How many patients at your institution were treated for structural heart disease or critical care in the past 12 months?
How many patients at your institution were admitted or received in-hospital treatment for cardiac and/or high-risk surgery in the past 6 months?
How many patients at your institution were admitted or received in-hospital treatment for cardiac and/or high-risk surgery in the past 12 months?
How many patients at your institution were treated for COVID-19 in the past 6 months?
Part 2: Award Eligibility
For a course site to be eligible, it must meet the following criteria. Please select one of the following three options if you qualify. *

My healthcare institution is located in the United States and is a federally qualified health center who receives funds from the Health Resources & Services Administration Health Center Program, member of the Indian Health Services, safety net hospital, critical access hospital, community health center, migrant health center, healthcare for the homeless, or a health center for residents of public housing. My healthcare institution is located in a developed or impoverished nation, as identified in the attached list of eligible countries, specifically Africa, Brazil, China, India, and Israel.
Part 3: Course Information and Responsibilities
This application must be received at least 45 days prior to the start of the training. Please provide your anticipated course dates, or a month or quarter if course dates have not been determined.
By submitting this application, the course site agrees to fulfill these responsibilities.
- The course will be run with an SCCM-approved consultant and director and two SCCM-approved instructors to support the training.
- The course site will train participants using the instructor curriculum during the course.
- The course site will return to SCCM pre- and posttest scores for all participants.
- The course site will have all participants complete an SCCM-provided survey after the training is complete and will return the results to SCCM.
- The course site must provide valid email addresses for all participants, who will be contacted one, three, and six months after the course occurs for follow-up.
- The course site will provide a training summary and additional information to SCCM as requested.
- The course site will allow a write-up about the course to be included in SCCM publications.
I agree to all of the above conditions. *

Agree
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