Award: Supporting individuals to take control of their care
Thank you for entering this award, below are the questions you will be asked when
you click on the ‘enter a submission’ link on our website. We would suggest you
complete this offline version first, once you are satisfied you have answered the
questions to the best of your ability, complete the online form. If you have any
charts, data, photographs etc. you want to add to your submission, please zip the
files and then give it the same name as the title of your submission. Then email
them to Karen@giraffehealthcare.co.uk before 2nd June 2016.
If you have any questions, please don’t hesitate to contact Karen Mitchell at
Karen@giraffehealthcare.co.uk
1. What is the title of your submission? (max 25 words)
2. Please provide contact details for the person responsible for the submission
Name
Job Title
Organisation
Email
Contact No
3. Is this an individual submission or is it on behalf of a team?
(Yes/No)
4. If a team please give names and positions of team members
Name
Job Title
Organisation
Next member of the team…
5. Please tick one of the boxes below which describes who has led your
submission. (Please note this award is only open to patient groups,
healthcare professionals and healthcare organisations)
Healthcare Professional
Healthcare Organisation
Patient Group
6. Please provide a reference with contact details for you and your team.
Name
Job Title
Organisation
Email
Contact No
7. Please provide a short description of your initiative (max 80 words)
8. Does your initiative meet an unmet need?
Yes/no
9. If so what and how? (200 words plus uploads)
10. What is its key benefit for individuals and what does it empower them to do,
that they couldn’t before? Please evidence this. (max 200 words plus ability
to upload charts and visuals)
11. Provide evidence that your initiative benefits individuals and enables them to
better self-manage their condition, health and wellbeing and evidence of
improve patient experience, care and outcomes in practice. (max 300 words
plus uploads)
12. Have patients and public been involved in the development, research and
user testing of your initiative?
Yes / no
If yes please give details. (150 words plus uploads)
13. Is your initiative capable of mass and cost effective take up? (200 words plus
uploads)
14. Why is it going to make a big contribution to sustainable healthcare?
And on what scale? e.g. What are potential savings/ improvements and what
would they be if scaled up? (max 250 words plus uploads)
15. Is there anything else you would like to add to support your award? (max 200
words)
16. The bursary of up to £3,000 must be used for the benefit of the NHS and / or
patients and can be used for either travel# or research†. Please specify how
you plan to use the bursary to benefit the NHS and/or patients. (150 words)
17. If you need to supply any charts of data or evidence to back up your
submission, please email Karen@giraffehealthcare.co.uk, making sure the
files are zipped and the name of the file is the same as your submission title.
Yes, I will be emailing back up data
No, I will not be emailing back up data
You will then be asked to agree or disagree with the statement below.
By allowing this submission to be submitted, I confirm that I have permission
from all members of the Team, that we can use their image in the awards
brochure if your entry has been selected as a finalist (tick Box)
*Recipients of the awards must acknowledge that AbbVie is required by the
ABPI Code to document and publically disclose certain transfers of value
made to health professionals, healthcare organisations and patient
organisations, and these include information about the payments or other
transfers of value that will be provided through these awards. Recipients may
have signed or be asked to sign a separate consent declaration in this regard.
#
Travel bursaries are for healthcare professionals or members of staff at a
healthcare organisation to attend a suitable medical or scientific education
meetings (such as conferences, symposiums, congress, training, workshops/
seminars), under the following conditions and in accordance with the ABPI
Code and AbbVie Global Requirements:
• There is a legitimate educational need fulfilled through the attendance of
the event and this will benefit patients and/or the NHS.
• The primary purpose of the event must be scientific or medical and
educational in nature.
Transfers of Value related to the Sponsorship of HCPs to educational events
are subject to ABPI Transparency Reporting requirements. In accordance
with ABPI requirements, consent to disclose payments must be confirmed in
writing by the HCP prior to the public disclosure of any sponsorship related
transfer of value.
†Research grants can be provided to healthcare organisations and must
enhance patient care, or benefit the NHS and maintain patient care.