Patients First Program Application

Full Name *

First Name Last Name

Title *

Department *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number

E-mail *

AHRA Member?

Yes No

How did you hear about this grant opportunity?

Organization Name *

My organization is *

IDN/health system single-site hospital single-site imaging center

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Which patient population will this program target? *

Pediatrics Overall patient care

What type of program is your single-site hospital or imaging center hoping to fund with the grant?

A program that improves the safety and comfort of pediatric imaging. A program that improves overall patient care and safety in imaging. A program focusing on oncology imaging.

What type of program is your IDN/health system hoping to fund with the grant?

A program that improves overall patient care and safety in imaging implemented across the IDN/hospital system. A program that improves cybersecurity in imaging implemented across the IDN/hospital system.

Title for this program: *

In fewer than 800 words, describe your organization’s plan for creating and implementing the program. Please highlight how your program will improve patient care and safety in diagnostic imaging by a) reducing radiation dose; b) improving patient understanding of the process; c) improving patient comfort; and/or d) improving the overall clinical pathway. Describe the shape the program will take (traditional program, staff training, seminar or another format), main objectives/goals, timing and anticipated outcome. *

0/800

For IDN/hospital systems only: In fewer than 500 words, describe specifically how yourprogram will be implemented across the entire IDN/hospital system, including the plan toensure quality, consistency and compliance across the entire hospital system.

0/500

In less than 100 words, describe how the “best practices” learned from the program can be shared with across the hospital system for IDNs or with other facilities for single-site hospitals and imaging centers. *

0/100

Additional information/comments.

Senior Management support: (required, upload letter below)
In less than 100 words, describe your show of support for the program.

Do you have additional files/documents that you feel would be helpful in your application? You can attach the files below. (optional)

Upload Attachment

Upload a File

*I certify this application contains no misrepresentations or falsifications and this information istrue and correct to the best of my knowledge. I understand that any false statements madeherein will void this application and I will be ineligible for support from Putting Patients FirstProgram. I have read the eligibility requirements and certify that I and my facility are eligible forthis grant. I also certify that I understand and agree to the funding overview, judging, timingand program criteria as stated in this application. *

*Required or application will not be processed.

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Administrator Section

Organization Section

Program Overview