Project Funding Agreement Project Funding Agreement 1. Project title: * 2. Physician name: * 3a. Department: * AnesthesiaCritical CareDiagnostic ImagingEmergencyFamily PracticeMedicineObstetrics /GynecologyPathologyPediatricsPsychiatrySurgery 3b. Division (if applicable): ENTFamily Practice with ObstetricsGeneral SurgeryHospitalistsInternal MedicineMidwiferyOphthalmologyPalliative CarePlastic SurgeryUrologyVascular SurgeryOther 3b. Division (if applicable): 4. Email: * 5. Phone(s): (xxx-xxx-xxxx) * The Richmond Hospital Physician Society (RHPS) wants to support the successful outcomes of your project.Please check that you understand and agree to the terms of the Project Funding Agreement below: Checkboxes You have read, signed and will adhere to the RHPS Conflict of Interest Policy (click here to view the policy). You will submit progress reports at the quarter and mid-points of your project. Your funding gate will be released upon receipt of these reports (click here to view the form). All project claims must be submitted within 3 months of the meeting/activity date. Any claims outside the 3-month window will not be processed as per Facility Engagement policy. Under the discretion of the RHPS Working Group and Executive, your project budget may be reduced if the project is underspent by the mid-point of your project. From time to time, you will be asked to verify claims made against your project. During or after completion of your project, you may be asked to submit profiles of your project for the RHPS newsletter, website, and/or Annual Report. You may also be asked to present your work at an RHPS event. Upon completion of your project, you will be asked to submit an Activity Impact Assessment (click here to view the form). Signed Physician Lead name: * Date: * Signature signature keyboard Clear Submit If you are human, leave this field blank.
