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Teleflex Medical Education Grant Request Form

Teleflex is committed to supporting genuine medical education that meets defined clinical educational needs. Teleflex medical education grants are governed by the following guidelines:

Teleflex provides cash or in-kind support for accredited medical educational programs or events which promote genuine scientific or educational discourse.
Teleflex does not provide support for speaker honoraria, recreation, entertainment, or food and beverages in connection with medical educational programs or events.
Grants are provided to program or event sponsors, or training institutions. Grants are not provided to individuals.
Teleflex does not control or provide input into educational program content, faculty, or attendees.
Grants are not provided as an inducement or quid pro quo for purchases of Teleflex products.
All grants are provided in accordance with the AdvaMed Code of Ethics on Interactions with Health Care Professionals or other applicable ethical guidelines, and applicable law.

Grant requests should be submitted at least 12 weeks prior to the program/event start date.

Person Responsible For Grant Request

Salutation *

First Name *

Last Name *

Position/Title *

Primary Organization/Facility *

Health System Affiliation (if applicable)

Street Address *

City *

State/Province *

Postal Code *

Mailing/Shipping Address (if different from Street Address)

City

State/Province

Postal Code

Phone *

Fax

Email Address *

Requesting Organization Information

Full legal name of requesting Organization/Facility/Accredited Provider *

Health System Affiliation (if applicable)

Street Address *

City *

State/Province *

Postal Code *

Tax ID Number *

Approved Grant Recipient

If different than Person Responsible for Grant Request, approved grant should be sent to:

Salutation

First Name

Last Name

Position/Title

Primary Organization/Facility

Health System Affiliation (if applicable)

Street Address

City

State/Province

Postal Code

Mailing/Shipping Address (if different from Street Address)

City

State/Province

Postal Code

Phone

Fax

Email Address

Grant Request Details

Request Type (select all that apply) *

Monetary

Product/In-Kind Support

Technician

Cadaveric Tissue

Simulator(s)

Are you Requesting Teleflex as the sole supporter of this activity? * Yes No

If no, please specify additional sources of support:

Needs Assessment

All educational grant requests must include a needs assessment that clearly defines the unmet educational need or gap the activity will address. Please note that the Learning Objectives are not the same as the Needs Assessment; Learning Objectives should support the educational need identified by the Needs Assessment.

What is the identified educational void or gap being addressed through the proposed education?
Indicate whether the education will address a knowledge gap or a practice gap
Describe the specific knowledge gap or practice gap to be addressed
Why has the intended audience been selected as participants for the proposed education?

What are your sources to substantiate your statement that this is an unmet educational need? As available, please provide applicable examples of acceptable sources for a Needs Assessment which may include the following: *

Expert

Expert data may be derived from sources including:

Literature Searches of peer-reviewed medical literature

Advisory Board Feedback (independent of Teleflex)

Expert practitioner/thought-leader interactions
Market Research on Professional Needs

Participant data may be derived from potential sources including:

Focus Panels

Medical education feedback

Survey(s) of the proposed target audience
Observed Data

Observed data may be derived from a number of sources, including:

National and regional data from national research institutes and healthcare professional organizations (CDC, NIH, other)

List the Learning Objectives for the program/event that will help close the gap(s) identified in the Needs Assessment *

Within sixty (60) days of the end of the program/event, provider must submit to Teleflex an evaluation whether and how the program/event met the identified educational needs. *

By checking this box, I acknowledge the educational needs evaluation period.

Previous Teleflex Support

To your knowledge, has the Requesting Organization received grant support in the last two calendar years? * Yes No

If yes, please describe the support type, name of program(s) and the approximate date(s) provided

How many attendees benefited from the previously supported program(s)?

What are the measurable outcomes from the previously supported program(s)?

Monetary Request Detail (if applicable)

Please provide an itemized description of how grant monies will be used and the amount requested for each item:

Proposed Amount ($)	Description
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An accounting detailing the expenditure of grant funds must be submitted to Teleflex within sixty (60) days of the end of the program/event, and any unused funds must be returned to Teleflex at that time.

By checking this box, I acknowledge the expenditure accounting and unused fund requirements.

Disclosure of Funding

State how Teleflex will be disclosed as a source of funding in any written or visual materials for the program *

Product/in-kind Support Request Detail (if applicable)

Product Name/Code	Product Size/Dimensions	Requested Quantity of Product (e.g. 3 each, 2 kits)
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Provider must return all unused in-kind support/product to Teleflex within sixty (60) days.

By checking this box, I acknowledge the requirement to return unused in-kind support/product to Teleflex within 60 days.

Technician Support Request Detail (if applicable)

Number of technicians requested

Documentation To Accompany Request Form

Requesting Organization’s completed and signed W-9 (US) or W-8BEN-E (Canada) *

Agenda and all hand-outs for the program/event *

Needs Assessment or other documentation supporting program/event *

Detailed program/event budget: a detailed budget is required for this request to be reviewed, including fair market value hourly rate and hours of work for any faculty honorarium. *

Signed letter of request on requesting organization’s letterhead *

Accreditation documentation (if applicable)

Open Payments Disclosure

Section 6002 of the Affordable Care Act (also known as the Open Payments or Sunshine Law) requires Teleflex to report to the U.S. Centers for Medicare and Medicaid Services (“CMS”) all payments or transfers of value to physicians and/or teaching hospitals. If Teleflex determines that any grant funding or in-kind support is reportable to CMS, the grant recipient will be required to provide any and all information needed to facilitate proper reporting.