CRSN Stroke Care
New Initiative Award


Please ensure that you have read and understood the criteria and objectives of this contest,
as laid out in the CRSN Web Site Contest page before submitting this application.



Entry Evaluation

Provide brief comments on the value of the event, to help evaluate entry.
Fields marked * are mandatory.

Title or short description of Initiative*

Please supply the name of the program you attened

Fill in a short title or description to refer to your initiative

Long description of initiative*

Please enter a description of the event or program

Please enter a more complete description of the initiative. Include a web address to event web site if useful.
You may also upload electronic documents to support your application (below).

Benefits*

Please list at least one benifit

Briefly explain the benefits you are seeing or expect to see for you, your organization and/or your colleagues. Please limit your comments to a maximum of 300 words.

Best Practice Outcomes*

Please list at least one outcome

Describe how this initiative advances and supports clinicians with integrating stroke best practices. Please limit your comments to a maximum of 100 words.

Upload supporting documents if desired
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Team Details

List up to three team member names.

Organization where applicants work*

Please list the name and address of your organization

Name of organization or institution where applicants work


Team's Primary Contact full name*

Please supply the registrant's First name

Full name of person who will serve as the primary contact for the team

Primary Contact's Email Address*

Please supply your email address

The team's Primary Contact email address

Primary Contact's Work Phone*

Please fill in your work phone number, including area code.

Usual daytime phone number, including extension

Discipline of Applicant*

Please make one choice from the list provided

Position within Health Care System applicant works for. Please be sure to CLICK on your selection

2nd Team member Full Name

Please supply the registrant's Last Name

Full name of 2nd team member

3rd Team member Full Name

Please supply the registrant's Last Name

Full name of 3rd team member

2nd Team Member's Email Address

Please supply your email address

2nd Team Member email address

3rd Team Member's Email Address

Please supply your email address

3rd Team Member email address

Manager's Name*

Please add a value for First Name of Manager or Scheduler.

Applicant's Manager's full name

Manager Email*

Please supply your manager's email address

Manager's email

Manager's Phone*

Please fill in your work phone number, including area code.

Manager's usual daytime phone number, including extension if needed

Any other comments

Anything else of relevance to this application?


Submission of Request


By clicking the box to the right, I agree to supply all original and final receipts for the funding being requested.
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This statement must be agreed to prior to submitting request

By clicking the box to the right, I acknowledge that I have read, understood, and agree to the criteria and objectives of this contest, as laid out in the CRSN Web Site Contest page.

 
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In the event this application is declared the winning application, you will be contacted to supply your SIN number and other payment details.

Contact us

Champlain Regional Stroke Network The Ottawa Hospital - Civic Campus Civic Parkdale Clinic, Main North 1053 Carling Avenue Ottawa, ON K1Y 4E9

Phone: 613-798-5555 x 16153
SPC Phone: 613-798-5555 x 16156