MEMBER GRANT APPLICATION
GRANT APPLICANT INFORMATION
Applicant's Full Name, Degree(s)
Applicant is a:
Physician
Resident Physician
Medical Student
Applicant's Texas Medical License Number or NPI
Applicant's E-mail
example@example.com
Applicant's Phone Number
Format: (000) 000-0000.
Applicant's Specialty
Applicant's Primary Place of Employment/School
Has the applicant ever applied for or been awarded an HCMS grant?
Yes
No
Full Names of Other Physicians Involved in the Project/Program
PROJECT/PROGRAM OVERVIEW
Program Title
Requested Amount (not to exceed $2,500) $
Program History
New Program (Never Implemented Before)
New Component to Existing Program
Original Start Date of Existing Program:
Name of lead of Existing Program:
Program Timeline (related to work funded by this grant)
Start Date:
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Month
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Day
Year
Date
End Date:
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Month
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Day
Year
Date
Brief Program Summary. Be sure to include the problem being addressed and the proposed solution (maximum 500 characters).
ALIGNMENT WITH HAM MISSION
How does this program align with the mission, vision and goals of Houston Academy of Medicine (maximum 500 characters)?
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Which of the following does the program address? Check all that apply.
Access to Care
Physician Wellness
Health Equity
Practice Innovation
Medical Education or Mentorship
Public Health or Community Outreach
Advocacy or Policy-Related Education
Physician Autonomy
Workforce Development
Other
What is the geographical location of those who will benefit from this program (cities, counties, states)?
What is the role of HCMS members or staff in the program, if any?
IMPACT AND OUTCOMES
Why is this program needed?
Who will benefit from this program and how?
Estimated number of people the program will reach:
Age range of people the program will reach:
How the target population will benefit:
What measurable outcomes are expected? Include metrics such as number served, cost savings, access improvements, education delivered, etc.
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How will success be evaluated?
FEASIBILITY AND SUSTAINABILITY
Describe the activities involved in carrying out the program.
Detail by month the major steps in program planning, implementation and evaluation.
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What resources, partnerships or staffing will support this work?
List at least two measurable program goals and the outcomes will be evaluated.
Goal 1:
How Goal 1 will be evaluated:
Goal 2:
How Goal 2 will be evaluated:
Other Goals (optional):
If applicable, describe other ways it will be known if the program is successful or not.
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Provide detailed budget and justification of how grant funds will be used.
Explain the total funding, staffing and other needs that must be satisfied in order for this to program to occur and how these will be secured.
APPLICANT EXPERIENCE, CAPACITY AND COLLABORATIONS
Briefly describe your relevant experience or qualifications to carry out this program (maximum 500 characters).
Have you received similar grants in the past? If yes, describe the outcomes.
List all organizations that play a role in planning, carrying out, or evaluating this program and, briefly, their specific role.
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ACKNOWLEDGEMENT AND SIGNATURE
HCMS will not consider incomplete grant applications nor grant requests for projects/programs that take place prior to the funding decision dates (this does not include planning activities). Your employer, medical school or university might have requirements in place to obtain pre-approval to apply for grant funding. Confirm that you have received the necessary approval to apply. Any awarded grants will be funded electronically through ACH only. Applicants awarded a grant will be required to provide brief, periodic updates related to the program/project outlined in this application. Grant activities are intended to advance a broader public benefit, and any benefit to individual members is merely incidental to that overarching purpose. HCMS reserves the right to withhold further payments or demand repayment if it determines that grant funds were used in a manner inconsistent with the approved purpose outlined in this form.
I have read the above, understand and agree.
Applicant Signature
Date
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Month
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Day
Year
Date
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