Covidien Respiratory and Monitoring Solutions
Grant Request Application
(THIS FORM IS TO BE COMPLETED BY NON-COVIDIEN PERSONNEL ONLY)
If you or your institution is seeking funding from Covidien to support educational activities, please complete and submit this application form, a letter of
request on your institution letterhead, a detailed activity budget, activity agenda, and a W-9 form. All requests must be submitted to the
RMSClinEDGrants@covidien.com inbox a minimum eight (8) weeks before the scheduled educational activity. It is Covidien policy that approvals for
grants will not be awarded unless prior Covidien approval is obtained and supported by the specified documentation below.
All grants go through a stringent review process that is independent of our sales and marketing functions. Grants awarded to institutions by Covidien are
provided without any commitment to purchase, use or recommend use of any Covidien products.
GRANT REQUESTOR INFORMATION
TODAY’S DATE:
PRIMARY CONTACT NAME AND TITLE:
INSTITUTION/ORGANIZATION NAME AND MAILING ADDRESS (street, city, state or providence, postal code, country)
TEL/FAX (country code, area code & extension):
EMAIL ADDRESS:
ACCREDITATION STATUS
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
ACCREDITED
NON-ACCREDITED
INSTITUTION TYPE:
 CME/CE
 JOINT SPONSOR
 OTHER (specify)
COURSE ACCREDITATION:
 ACCME
 AARC
 AANA
 ANCC
 OTHER (specify):
IF ACCREDITED, PROVIDE STATEMENT OF ACCREDITATION FROM THE ACCREDITING INSTITUTION TO
ACKNOWLEDGE SUPPORT OF YOUR PROGRAM:
SUMMARY OF GRANT REQUEST
TITLE OF PROPOSED ACTIVITY:
DATES OF ACTIVITY:
START DATE:
END DATE:
LOCATION OF ACTIVITY:
FORMAT OF ACTIVITY:
 SYMPOSIUM
 GRAND ROUNDS
 WEBINAR
 PRINT
 OTHER (specify):
TOTAL PROGRAM IN US DOLLARS: $
IF REQUESTING PRODUCT DONATION
PRODUCT NAME:
AMOUNT:
DESCRIPTION OF PRODUCT:
**COVIDIEN CAN ONLY DONATE AND/OR LOAN EQUIPMENT FOR QUALIFIED EDUCATIONAL EVENTS**
FINANCIAL SUPPORT REQUESTED FROM COVIDIEN IN US DOLLARS: $
Covidien is committed to protecting the personally identifiable information entrusted to us by our employees, business partners, customers, and by individuals.
PROGRAM DESCRIPTION (include learning objectives, attach additional pages, if necessary):
I certify that the statements herein are true, complete, and accurate to the best of my knowledge.
Signature: __________________________________________ DATE:__/__/____
Covidien Respiratory and Monitoring Solutions
Grant Request Application
(THIS FORM IS TO BE COMPLETED BY NON-COVIDIEN PERSONNEL ONLY)
DESCRIBE THE NEED FOR THIS ACTIVITY (attach additional pages, if necessary):
TARGET AUDIENCE:
NUMBER OF ATTENDEES/PARTICIPANTS ANTICIPATED:
LIST OF POTENTIAL PRESENTERS:
THERAPEUTIC AREAS TO BE DISCUSSED:
ARE YOU REQUESTING RESPIRATORY AND MONITORING SOLUTIONS TO BE THE SOLE SUPPORTER OF THIS
ACTIVITY?
 YES
 NO
IF NO, PLEASE SPECIFY ADDITIONAL SOURCES OF SUPPORT:
IF RELYING ON ADDITIONAL SUPPORT, PLEASE CLARIFY STATUS OF ADDITIONAL SUPPORT (i.e., Confirmed,
Pending Confirmation, etc…):
Has additional request for exhibit/booth space been submitted?
 Yes
 No
IF YES, please specify amount that will go towards booth (which is separate from the dollars associated with the
educational grant support being requested in this form): $ ________.______.
If the sponsorship includes use of a exhibit/booth space you are required to specify the FMV for use of exhibit/booth from
the general conference sponsorship.
HAVE YOU RECEIVED FINANCIAL SUPPORT FROM COVIDIEN IN THE LAST TWO YEARS?
 YES
 NO
IF YES, PLEASE CHECK THE TYPE OF SUPPORT PROVIDED:
 EDUCATIONAL GRANT
 RESEARCH GRANT
 SERVICE AGREEMENT
 SPEAKER ENGAGEMENT
 OTHER (please specify):
IF YES, DESCRIBE THE SUPPORT PROVIDED AND THE APPROXIMATE DATE PROVIDED:
IF THIS GRANT IS APPROVED, TO WHAT INSTITUTION SHOULD THE PAYMENT BE MADE? (include the W-9
form for the institution where the payment should be directed).
Submission of a detailed activity budget is required for this application to be
reviewed.
Covidien is committed to protecting the personally identifiable information entrusted to us by our employees, business partners, customers, and by individuals.
Application Checklist:
ONLY COMPLETE APPLICATIONS WILL BE REVIEWED. A COMPLETE APPLICATION CONSISTS OF THE
FOLLOWING:

COMPLETE AND SIGN THE COVIDIEN RESPIRATORY AND MONITORING SOLUTIONS GRANT
REQUEST APPLICATION FORM

STATEMENT OF ACCREDITATION (ONLY FOR PROGRAMS PROVIDING CME/CE CREDIT)PROVIDE THE STATEMENT OF ACCREDITATION FROM THE ACCREDITING INSTITUTION TO
ACKNOWLEDGE SUPPORT OF YOUR PROGRAM

DETAILED PROGRAM BUDGET- INCLUDE EACH FACULTY HONORARIUM

ROBUST/DETAILED EDUCATIONAL ACTIVITY AGENDA

LETTER REQUESTING COVIDIEN RMS SUPPORT ON INSTITUTIONAL LETTERHEAD

CURRENT, SIGNED IRS W-9 FORM-INFORMATION CORRESPONDING TO INSTITUTION(s)
RESPONSIBLE FOR CONDUCTING THE ACTIVITY.
Application Submission:
PLEASE SUBMIT YOUR COMPLETE APPLICATION ELECTRONICALLY TO: RMSClinEDGrants@covidien.com.
Questions:
SEND QUESTIONS TO COVIDIEN’S RMS GRANT DEPARTMENT: RMSClinEDGrants@covidien.com
WEBSITE: http://www.covidien.com/RMSGrants
Employees of Covidien are not permitted to make any verbal commitments regarding Educational Grant Requests and they do not have the
authority to award Educational Grant Requests. All grant requests go through a review process outlined by Covidien’s Grants and
Compliance Committee (GCC).
All parties associated with a Covidien sponsored Grant Request agree to abide by all requirements of the ACCME
Standards for Commercial Support of Continuing Education and the AdvaMed Code of Ethics on Interactions with Health
Care Professionals.


Submission of a request does not constitute a guarantee of funding.
Previous support on an educational activity does not guarantee future support.
Please sign and attest to the following:






The faculty and content for this program was selected by the institution and was not influenced, in any way, by
Covidien
Covidien did not influence, in any way, the planning/logistics of this event
This program demonstrates genuine educational and scientific value
This grant will be used to pay for/used for appropriate necessities as stipulated in the guidelines
This grant is not tied, in any way, to the purchase or use of Covidien products
Applicant acknowledges full amount may not be awarded and will accept partial funding
Signature: _________________________________________
Date: ___/___/____
Covidien is committed to protecting the personally identifiable information entrusted to us by our employees, business partners, customers, and by individuals.