APPLICATION FORM
Application deadline
31 May 2015
XOVA is sponsored by Novartis Pharmaceuticals and Alcon, a Novartis company
Excellence in Ophthalmology Vision Award (XOVA)
Application form
Thank you for your interest in the XOVA.
What is the XOVA?
XOVA is an award program sponsored by Novartis Pharmaceuticals and Alcon. It provides funding, in the form
of a grant, of up to €50,000 to eye care specialists, including trainees and specialist nurses, with the support of
their responsible institutions who have devised non-profit, sustainable initiatives that are expected to have a
significant impact on unmet health needs in the fields of ophthalmology and optometry.
Who should apply?
XOVA applications from ophthalmologists, optometrists and allied eye healthcare professionals, including
those in training, will be considered. Applications should be made on behalf of an organization, which should
endorse your application. If your application is successful, Novartis Pharmaceuticals and Alcon will execute a
grant agreement with the organization.
For details of last year’s successful applicants, please visit www.XOVAprogram.org.
What are the main criteria for the XOVA?
Proposed initiatives must demonstrate a clear impact on improving the quality of eye care, as well as longterm viability. While initiatives do not have to be sustainable from the outset, they must have the goal of
becoming self-funded after a defined period. Initiatives must be at a relatively advanced stage of planning (or
already in progress) with outcomes projected within two years. Please note that the XOVA is NOT a scientific
research grant.
Who judges the XOVA?
The XOVA committee comprises expert representatives from multiple international institutions of eye health.
They will consider all short-listed applications in spring 2015. Members of the XOVA committee may not apply
for the XOVA. Final decisions relating to the 2015 XOVA winners will be made by the XOVA committee,
following which the XOVA winners will be notified and listed on www.XOVAprogram.org. Novartis
Pharmaceuticals and Alcon will sponsor the attendance of one winning applicant (per grant awarded) to
accept their award during a ceremony at a European ophthalmology congress in late 2015.
How do I apply for the XOVA?
Please complete each part of the application form in English. By selecting File > Save As, save the form to your
computer desktop. This will allow you to return to the form as many times as you wish without losing any
work. Once the form is complete, please email it to XOVA@bm.com, or print and mail your form to the postal
address shown on the next page. Application forms will only be accepted if all fields are completed. You will
receive an email receipt of your application within 48 hours of it arriving with us. If you do not receive an
email, please contact the XOVA coordinating team at XOVA@bm.com.
For more information, an FAQ page is available at www.XOVAprogram.org and definitions are provided of
specific terms used throughout the form.
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Excellence in Ophthalmology Vision Award (XOVA)
Application form
Can you provide me with feedback on a previous unsuccessful XOVA application?
As in past years, we’re unable to provide feedback on individual submissions. Winners will be notified by email
within several weeks of the application deadline.
If your application was not selected last year, we encourage you to reapply. Every year, we receive a large
volume of inspiring entries and are only able to fund a limited number. We know you share our commitment
to making a difference in the fields of optometry and ophthalmology and we look forward to learning more
about your project in 2015.
Please email the completed application form to XOVA@bm.com, or post it to:
XOVA coordinating team
Burson-Marsteller
Attn: Christian Petrovic
Level 6 South, Central St Giles
1 St Giles High Street
London WC2H 8AG
UK
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Excellence in Ophthalmology Vision Award (XOVA)
Application form
Section 1. Your details
a) Name:
b) Title/position:
c) Organization* with whom the grant agreement would be made:
d) What is the relationship between you and the organization*?
e) Has this organization* endorsed your application?
Yes ☐ No ☐
f) Your mailing address:
g) Email:
h) Telephone:
i) How did you hear about XOVA?
*Organization: Your associated organization can be an academic institution, such as a university or teaching
hospital, a non-governmental or not-for-profit organization, a registered charity, or a hospital or clinic.
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Excellence in Ophthalmology Vision Award (XOVA)
Application form
Section 2. Your project
a) Your project title:
b) Will your initiative be run on a not-for-profit† basis? Yes ☐
No ☐
c) In what country(ies) will your initiative take place?
d) Is your initiative already established, or is it in the planning stages?
i) Already established ☐
In planning ☐
ii) If your project is already established, when did it first start?
iii) If your project is still in the planning stages, when will you be ready to begin?
e) What is the expected total duration of your initiative? If applicable, please include the time your project has
already been running.
f) Have any projects, similar to yours, already demonstrated that the initiative works? Please leave blank if you
are unaware of any similar projects.
g) How will your project be managed, and by whom? Please include details of any relevant qualifications or
experience.
h) If your application is successful, you will be required to submit regular reports on the progress and
achievements of your project. Will you be able to provide your first report at the beginning of 2016?
Yes ☐
No ☐
†Not-for-profit: XOVA actively encourages self-sustaining projects; however, your initiative should not set out to
generate profits to be used for personal or corporate gain.
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Excellence in Ophthalmology Vision Award (XOVA)
Application form
Section 3. Funding your project
a) What level of XOVA funding does your project require?
€10,000 ☐
€20,000 ☐
€30,000 ☐
€40,000 ☐
€50,000 ☐
Please tick only one box. Please note that management of the project must be factored into this proposal – no
project management support will be provided by Novartis Pharmaceuticals or Alcon. Novartis Pharmaceuticals
and Alcon support is limited to the grant provided.
b) How will this funding be allocated?
Equipment and consumables
€0.00
Travel and accommodation
€0.00
Training costs
€0.00
Administrative costs
€0.00
Staffing costs
€0.00
Building and venue costs
€0.00
Other (please specify):
€0.00
€0.00
€0.00
€0.00
€0.00
€0.00
€0.00
€0.00
TOTAL
€0.00
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Excellence in Ophthalmology Vision Award (XOVA)
Application form
Section 3. Funding your project (continued)
c) Please briefly justify each aspect of your proposed budget (approximately 300 characters
per funding category).
d) Please indicate at what stage of your project the XOVA funding will be spent (e.g. at project start,
at 12 months, etc.).
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Excellence in Ophthalmology Vision Award (XOVA)
Application form
Section 3. Funding your project (continued)
e) What is the total budget required to implement your project?
If you require extra funding (beyond the XOVA grant) to implement your project:
i) Please state how much funding you have already secured, and from what source.
ii) If you have not yet raised all of the additional funds that you will need, please detail how you intend
to raise this money.
Please note: If your application is short-listed, a more detailed budget may be requested for consideration by
the XOVA judging committee.
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Excellence in Ophthalmology Vision Award (XOVA)
Application form
Section 4. Précis/Abstract (5,000 characters, including spaces)
Please provide a clear overview of your proposed initiative.
If you use abbreviations, please define at first use.
a) Introduction (20%) Please include:
• Unmet health needs‡ your initiative aims to address
• Estimated number of people who will benefit from your project
• If applicable, what facilities/equipment you already have, and why they are no longer suitable
for use (if you intend to replace them using the XOVA funding)
b) Please list the aims of your project (10%)
c) Please outline how you will evaluate the success of your project (10%)
‡Unmet health need: A health problem or issue not being resolved or addressed.
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Excellence in Ophthalmology Vision Award (XOVA)
Application form
Section 4. Précis/Abstract (continued)
d) Description of how your initiative will be executed (50%). Please outline:
• Steps you will take in implementing your initiative (if it is not already established)
• Work you propose to undertake, with an approximate time frame
e) Please outline how you will ensure that the impact of your project will be sustained (10%)
Section 5. Photography and/or videos
a) Please include a short video and/or a series of photographs (or links to these assets online) to accompany
your application. Please ensure that photos and video are of high-quality.
Videos and photographs can offer the XOVA judging committee:
• An inside look at the status of your project, facilities and populations you seek to help
• An introduction to members of the team
• An opportunity to share your vision and passion for the project
• A depiction of the unmet health need you are addressing
Please note that by submitting this form you authorize Novartis Pharmaceuticals and Alcon, as well as its affiliate entities, to use your name and center/hospital/practice
affiliation name in regard to accessing your application and using the provided information and multimedia materials when publicizing the winners of the XOVA program. This
includes, but is not limited to, use in press materials, promotional materials, at promotional events, Novartis Pharmaceuticals’ and Alcon owned websites, and other media
forms, on a worldwide basis in perpetuity.
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Excellence in Ophthalmology Vision Award (XOVA)
Application form
Please save your form and either email it to XOVA@bm.com, or mail it to XOVA coordinating team at the
address on page 2.
Data Privacy Statement: When you apply for the XOVA, you accept that the Sponsors (Novartis Pharmaceuticals, located in Basel Switzerland, and
Alcon, located in Fort Worth, Texas, USA), Burson-Marsteller headquartered in New York, New York (who manage the XOVA program), and the
XOVA judging faculty (ophthalmology experts located in countries around the world who are members of the ACUITY advisory program) will use
the information you provide on your application form to select the XOVA winner, and to contact successful applicants. Once the program is
concluded for a particular year, if you have not been selected, your personal information will be deleted. By submitting this application you permit
Novartis Pharmaceuticals, Alcon, Burson-Marsteller and the judging faculty to use your personal information as described, and to transfer the
information between themselves as required.
We would like to store your email address in order to keep you up to date with any XOVA program news, such as notifying you when the award
opens for applications each year. Your email address will not be used for any other purposes. If you do not wish to receive emails about XOVA,
please tick this box: ☐
If you wish to opt out of receiving emails at any time in the future, please email XOVA@bm.com with the word ‘REMOVE’ in the email subject
header, and your email address will be removed from the mailing list.
February 2015
GLO/LUC/00319
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