2. Complete REQUIRED Attachments
You will have to complete all required documents PRIOR to starting the application process. You will have 60 minutes to complete your application. You will NOT be able to save the work you do on the online application form.
2. A. Signed Letter of Request
You MUST complete, SIGN and upload this Letter of Request (not required to be on letterhead for ETHICON).
2. B. Budget Template (Sample Budget)
You may use your own budget or complete the sample budget template provided.
Budget should be for the entire program (not just the portion for which you are requesting funding).
The budget must include the following details (where applicable):
• Meals - provide breakdown of cost per meal, per attendee/faculty/speaker.
• Faculty travel costs - provide breakdown of airfare, transportation and lodging per speaker, per day/night
• Honoraria - provide breakdown per speaker
2. C. Program information/Agenda/Objectives & Needs Assessment (Sample Document)
1. Agenda: must include date, time, title & description of presentation
2. Needs Assessment and Objectives: explain unmet educational needs and why the course content satisfies those needs. Objectives should be learner-based.
2. D. Other - REQUIRED Information Form for ETHICON
This form contains additional information that is REQUIRED in order to process your grant request. It includes Payee information, accreditation statement (for CE/CME) and requested products and shipping information (if applicable).
2. E. CE Provider Questionnaire
This form is not required for ETHICON Educational Grant requests. This space can be used to upload one additional attachment (e.g. Needs assessment)
2. F. Educational Partner Questionnaire (used to upload the Certificate of Separation – CE/CME only, if applicable)
Required for institutions utilizing 3rd Party program development.
If you don’t require a Certificate of Separation you can use this space to upload one additional attachment.
2. G. W-9 Form
EP-0162-09-12/10