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VAFP Family Medicine Practice Transformation Grant Initiative Application

Funding Goal: To support family physicians and their care teams in enhancing the patient experience and/or delivering the highest level of care to patients.

This grant opportunity is available to all active and resident members of the VAFP. The maximum grant amount that will be awarded is $2,500 and grant requests may be awarded all or a portion of the requested amount. If your application is accepted for an award, you must submit a report on how the funds were used within one year of the award receipt.

Please complete the following noting the word counts.

Question Title

* Please Check the Practice Transformation Function(s) this Project Supports:

Patient access

Patient experience of care

Transitions and coordination of care

Team based care

Quality

Other (please describe)

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* Title of the Project:

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* Description of the Project: (300 words or less)

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* Target Population:

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* Problem/Need Statement:(300 words or less):
Please include data and supporting information.

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* Goal, Objective, Activity, Desired Outcome: (300 words or less)
For each goal, identify corresponding objective(s) and activity that help achieve the goal. Objectives and activities should be specific, measurable, attainable, relevant, and time-bound. Desired outcomes should be clearly articulated and provide a meaningful benefit for the participant.

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* Evaluation Tools to be Utilized to Determine Success: (300 words or less)
Describe evaluation tools used to measure success. Evaluation tools should correspond to the goals, objectives, activities, and outcomes described above.

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* Estimated Timeline for the Project:

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* Estimated Costs of the Project:
Please note total amount of funding requested followed by the specific line-item costs that justify the request.

Total Amount Requested: (cannot exceed $2,500)

Line Item Cost 1

Line Item Cost 2

Line Item Cost 3

Line Item Cost 4

Line Item Cost 5

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* Additional Comments/Resources that Support Project:

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* Contact Information:

First

Last

Suffix (MD/DO/FAAFP)

Practice/Institution Name

City

Email Address

Cell Number

VAFP Family Medicine Practice Transformation Grant Initiative Application

Question Title

* Please Check the Practice Transformation Function(s) this Project Supports:

Question Title

* Title of the Project:

Question Title

* Description of the Project: (300 words or less)

Question Title

* Target Population:

Question Title

* Problem/Need Statement:(300 words or less): Please include data and supporting information.

Question Title

Question Title

* Evaluation Tools to be Utilized to Determine Success: (300 words or less)Describe evaluation tools used to measure success. Evaluation tools should correspond to the goals, objectives, activities, and outcomes described above.

Question Title

* Estimated Timeline for the Project:

Question Title

* Estimated Costs of the Project:Please note total amount of funding requested followed by the specific line-item costs that justify the request.

Question Title

* Additional Comments/Resources that Support Project:

Question Title

* Contact Information:

* Problem/Need Statement:(300 words or less):
Please include data and supporting information.

* Evaluation Tools to be Utilized to Determine Success: (300 words or less)
Describe evaluation tools used to measure success. Evaluation tools should correspond to the goals, objectives, activities, and outcomes described above.

* Estimated Costs of the Project:
Please note total amount of funding requested followed by the specific line-item costs that justify the request.