Professional Documents
Culture Documents
APPLICATION FORM
Please submit 6 copies of the completed application form & supporting materials to Pamela Withero, The
Irish Hospice Foundation, Morrison Chambers, 32 Nassau Street, Dublin 2 by Friday 16 September 2016
Prior to completing this form, please familiarise yourself with the Design & dignity Guidelines and
Design & Dignity Style Book which can be downloaded from: www.designanddignity.ie.
A guidance document was also circulated with this document which should also be read in advance.
A. CONTACT INFORMATION
Name of Hospital:
Type of Project:
(family room, privacy room, mortuary etc)
Project sponsor:
(ideally a member of the senior management
team)
Project lead:
Job title:
Office telephone number:
Mobile phone number:
Email address(s):
Project team members:
HSE estates team member / equivalent
Clinical staff member:
End-of-Life Care Coordinator:
Others:
1
B. HOSPITAL INFORMATION
Number of inpatient hospital beds:
Hospital Model number (1,2,3 or 4):
Emergency departments: hours and days of
operation:
Number of patient deaths in 2015:
Number of patient deaths in 2014:
Number of patient deaths in 2013:
Any other information relevant to this application
(max 50 words):
C. PROJECT DESCRIPTION
Name of project:
2
Briefly describe related major capital works projects
D. PROJECT TIMELINE
How many months will your project take to complete?
3
E. TECHNICAL INFORMATION & IMAGES
Please attach the following information to this application:
Survey drawings
Yes
(Site location plan, floor plans, sections and elevations
of the proposed area (at appropriate scales)).
Basic concept drawings to explain the project:
4
G. HOSPITAL FUNDING COMMITMENT
Please outline the funds committed to this project Funding amount % of overall project cost
from the hospital (including voluntary groups/hospital
based charities)
(hospitals are expected to contribute a minimum of
30% of the total cost including the contingency budget
for smaller projects and this may increase for larger
projects such as mortuary refurbishments)
Is your hospital willing to ensure an ongoing
maintenance fund to ensure this project retains
exemplar status in the long term?
H. DOCUMENTARY
Would your hospital like to be considered for a
TV/radio documentary?
Has the project team contacted a local third level
institute to seek support in documenting the project?
Is your hospital happy for before photographs to be
used publically when promoting D&D projects?
I. SIGNATURES
Name Signature Date:
Project sponsor:
Project lead:
Hospital Manager: