Form Test APPLICANT DETAILS Name Email Telephone Profession Professional Address Role within the Programme PROGRAMME OUTLINE Name of Program Proposed geographical location Description of program: Include evidence base (Attach Business Plan as a separate document) Upload Document Is this a new programme? Y/N YesNo If no, please state the outcomes of the current programme List of intended beneficiaries What are the inclusion and exclusion criteria? Please state how you will notify potential beneficiaries of this program FUNDING (€) State the total of the funding requested If this program is funded by multiple sources, please include the name of the funding body and percentage contribution. RESPONSIBILITY Has a data protection impact assessment been completed to ensure the patient’s (data subject/person) personal data is projected at all times? Where appropriate, has this programme been approved by the local Research Ethics committee? YesNo Do patients sign a consent form to get involved in the programme (if so, please attach)? YesNo Please state any potential conflict of interest in the personal involved in this program or the institutions/Industries involved in this program. Signature of Beneficiary Date Δ