Form Test - Beacon Foundation

APPLICANT DETAILS

Name

Telephone

Profession

Professional Address

Role within the Programme

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

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

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.

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?

Do patients sign a consent form to get
involved in the programme (if so,
please attach)?

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