Mary Seacole Leadership Award

1.1 Details of Project/Activity

Title of project:*

Start date:*

End date:*

Your opinion*

Specify how the outcomes from the project/activity will contribute to improving health outcomes of people from black and minority ethnic communities

Have you applied for financial help elsewhere?*

Yes
No

If so, where?

With what results?

Is this project a component of current higher degree studies?*

Yes
No

(Please note that the award is not given for the sole purpose of funding studies and cannot be put towards educational fees)

If yes, please provide details of course and education institute

1.2 Employment Details: Current Post

Job Title:*

Name and address of your current line manager and employer:*

Start date of current role/post:

If your role includes Leadership/Managerial responsibilities in the delivery of care please outline your duties:

1.3 Do you hold current registration on the NMC register?

Yes
No

1.4 Membership Organisation Details

Are you a member of*

RCM?
RCN?
UNISON?
Unite CPHVA?

Please tick if appropriate and give your membership number:

2.1 Study Leave

Note: This section should be completed in consultation with your immediate line manager or their equivalent and their signature is required.

What actual study leave has been granted over the period of the project to carry out the work associated with completing your proposed project?*

2.2 Manager’s Supporting Reference

Please comment on:

1. The applicant’s suitability to receive funding.*

2. How do you see the award contributing to the strategic needs of the organisation?*

3. How will you support the applicant to complete the project/activity?*

(Please include any agreed study leave to be granted over the period of the project/activity and whether or not the applicant will have access to the IT needed to deliver their work)

4. In what ways can you help the sustainability of the project once completed in July 2021?*

5. Nomination of a workplace mentor for the duration of the project*

Manager’s Name and Job Title (please print):*

Note: We would urge you to discuss any project/ activity with your immediate line manager or equivalent as well as any senior staff who could act as project mentors or support your work through integrating your plans in their work or providing access to resources.

3.1 Project /activity Proposal*

Set out the title, aims and objectives, methods and outcomes, key questions, benefits of the project/activity, preparation and expected timescales, including the key role of leadership and how you intend to demonstrate and develop further your leadership qualities. (1000 words maximum excluding references) Reference: Healthcare Leadership Model

3.2 Contributing to current NHS policy and standards*

Set out how your project will contribute to addressing the key challenges for the NHS and promote equality and reduce health inequalities (500 words maximum) Suggested references: NHS England Five Year Forward View, Health Education England Strategic Framework; NHS England Equality Delivery System; NHS Workforce Race Equality Standard

3.3 Improving your organisation*

How does your project/activity link into the improvement plans of your organisation? (100 words maximum)

3.4 Ethical approval*

indicate if the project requires ethical approval and the likely timescales for this.

3.5 Draft Budget for completion of your project*

Please note that the final budget is subject to discussion with and approval by the mentors that are assigned to successful applicants. Examples of appropriate and inappropriate use of funds are given below:

Examples of appropriate use of funds

a) Venue hire costs for work undertaken externally (not employer premises)
b) Transport costs for users to attend meetings
c) Reasonable hospitality costs for focus groups
d) Conference attendance (as agreed with MSASG / mentors)
e) Vocational course attendance to develop specific skills (as agreed with MSASG / mentors)
f) Cost of producing education media / materials
g) Cost of advertising the project activities
h) Cost of printing the final report
i) Travel and accommodation costs for attending the Mary Seacole Award ceremony in London in March 2021 and March 2022.
j) Travel and accommodation costs for attending 6 learning events during the course of the award year.
k) Project related IT equipment where this is additional to equipment already supplied by the employer (up to £500)
l) The cost of a proof reader for your final report or any other material outputs

Examples of inappropriate use of funds

a) Academic course fees
b) Backfill costs for research assistants
c) Travel costs for your guests to attend the ceremony
d) Personal items
e) Cash incentives for focus group participants
f) The cost of an editor for your final report or any other material outputs

3.6 Timeline*

Set out the expected timeline for your work from March 2020 to February 2021 and indicate the stages at which you expect there to be costs to the award bursary.

3.7 Project Stakeholders*

Identify which stakeholder groups will be affected by the project, describe how you will work with them, what they will contribute and how they will benefit. Outline how you will make use of diverse media (including social media) to consult, share and inform (100 words maximum).

3.8 Outputs*

You will be expected to produce and present a report and a conference poster on your work. What other material outputs will there be? e.g. research report, articles, conferences etc (50 words maximum)

3.9 Dissemination & Sustainability*

How do you intend to disseminate and sustain the outcome/ outputs of your project, within your own organisation and further afield? (50 words maximum)

4.1 Personal Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Tel No: (work)

Tel No: (home)

Email*

Mobile No:*

NMC PIN NO:*

4.2 Application Agreement

I now enclose the following in support of my application:

Completed application form including original signed, supporting statement from my line manager

In submitting this application I confirm that I will be available to attend a virtual interview on ** January 2021 in London. Should I be offered an award, I will commit to attend an induction day on * February 2021 which will be held virtually, the ceremony in March 2021, submit quarterly progress reports and the final report within the required deadlines, and present my final project at the awards ceremony in March 2022. In addition I will attend learning events scheduled during the course of the award year.

The information contained in this application is, to the best of my knowledge, correct. As an applicant, I understand I must comply with the conditions stated and that the making of false statements may lead to the withdrawal of my application. I acknowledge that the decision of the Selection Panel is final. I agree that intellectual property rights from the outcome/outputs remain the property of the NHS.

4.3 Equality monitoring questionnaire

This information is requested to ensure that we are aware of the communities applying for this award and assist the implementation of a fair and equitable application process. Please note this information will not be passed to the selection panel.

What is your ethnic group? (please tick one category only)

White

English/Welsh/Scottish/Northern Irish/British
Irish
Gypsy or Irish Traveller
Any other mixed background Please state:

Mixed / Multiple ethnic groups

White and Black Caribbean
White and Black African
White and Asian
Any other mixed background Please state:

Any other mixed background Please state:

Asian / Asian British

Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background Please state:

Black / African/ Caribbean / Black Indian British

African
Caribbean
Any other Black / African / Caribbean background Please state:

Any other Asian background Please state:

Any other Black / African / Caribbean background Please state:

Other ethnic group

Arab
Prefer not to say
Any other ethnic group Please state:

Any other ethnic group Please state:

What is your gender*

Male
Female
Transgender/transsexual
I would rather not say

Age scale range*

Do you consider yourself to have a disability?*

The Equality Act 2010 defines a person as disabled if they have a physical or mental impairment, which has a substantial and long-term adverse effect on their ability to carry out normal day to day activities.

Yes
No

If yes, please describe what reasonable adjustment you would require to carry out your award:

What is your sexual orientation?*

Heterosexual/straight
Gay man
Gay woman/lesbian
Bisexual
Other
Prefer not to say

What is your religion?*

No religion
Christian (including Church of England, Catholic, Protestant and all other Christian denominations)
Buddhist
Hindu
Jewish
Muslim
Sikh
Any other religion (please describe)
Prefer not to say

4.4 Do you have caring responsibilities for any children or adults?

Yes, Child(ren)
Yes, Adult
No
If yes, please tick if you are a registered carer

4.5 Please help us to promote these awards effectively by indicating below how or where you heard about them:

Website
Journal
Contact
Other

Please specify*

Would you like to see them advertised anywhere else? (Please specify)*

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THE ROYAL MINT MARY SEACOLE COIN

Application leadership award