New Activity Application Form - Vernon Physician Society

Members of the medical staff at Vernon Jubilee Hospital with hospital privileges can apply for funding support for physician led activities through the Doctors of BC’s Facility Engagement Initiative.

If you are ready to submit a full project proposal please use the form below. Our Program Director will arrange for your proposal to be reviewed by the VJHPS Executive and Working Group, who may suggest amendments or pass a motion to approve your activity.

(If your project is still an idea and you would like to connect with someone who could help you to make it fly, use our Quick and Easy Project Submission form instead to get things started.)

Your Name

Your Email

Your Phone

Activity Name

Expected Timeframe to complete the project

Total Funding Amount Requested

Name of Other Key Participants

Project Summary(What problem are you trying to solve?)

Objective(s)(What will be improved? What are your expected outcomes?)

Approach/Methodology (How you will accomplish your objectives?)

Identify which of the following MOU objectives are most relevant to this activity(Select all that apply)

To prioritize issues that significantly affect physicians and patient care.

To improve communication and relationships among the medical staff so that their views are more effectively represented.

To support medical staff contributions to the development and achievement of health authority plans and initiatives that directly affect physicians.

To have meaningful interactions between the medical staff and health authority leaders, including physicians in formal Interior Health medical leadership roles.

Evaluation Plan(How will you measure your project’s success? How and when will data be collected and analyzed?)

Facility Impact (List the facility areas that the activity would impact (e.g. medical areas, departments, health authority operational areas)

Interior Health Engagement (Any proposed activity involving patient care, flow, environment, data analytics, allied health, or resources would benefit from early consultation with IH.)

I need help finding the appropriate HA partners

My collaborative HA partners/dyads are:

Budget(Provide details including proposed physician sessional hours, the rate is $158.97 per hour.)

I need help with figuring out a budget.

Special Provisions(Are there any regulatory requirements, ethical considerations, or legal ramifications that should be considered?)

Milestones(Indicate significant achievements during the timeline of the activity and approximate dates they will be achieved)

Agreement

I will submit quarterly reports (online form available) to update on my project status.

I agree

I understand that funding for this project is only available for 12 months after approval.

I agree

I have received written approval from my Department Head for this work.

I agree
Not applicable

I will do a brief presentation to the VJHPS Working Group upon completion of my project.

I agree