training and education application · web viewproject title: 1 training and education application...

WORKERS COMPENSATION BOARD OF MANITOBA

TRAINING and EDUCATION APPLICATION

RESEARCH AND WORKPLACE INNOVATION PROGRAM

Funding Occupational Health Research, Training and Education and Innovative Workplace Solutions

To be submitted electronically via email to:

Bruce M. Cielen, Manager, Research and Workplace Innovation Program at Email:

[email protected]

on or before the

CLOSING DATE

June 26, 2018 by

4:00 p.m. CST

PROJECT TITLE:

Administrative RequirementsPlease refer to Section 3.1 to Section 3.8 of the Applicant Information Document and use this template to complete your Training and Education ApplicationTION

1. Indicate by highlighting "yes" or "no" if this is an initial application or re-submission of a previous application.Initial NOI

YesNo

Resubmission YesNo

2. Please let us know how you became aware of the Research and Workplace Innovation Program (RWIP) and the annual call for applications. Please mark the appropriate box with an X.

Check List of Items Check XWCB emailWCB letterWCB websiteWord of mouthOther

1. Use the Checklist below to ensure you have completed all parts of application

CHECKLIST Check XPart 1: General InformationPart 2: Description of Training and Education project2.1 Project Description2.2 Knowledge Transfer & ExchangePart 3: Management of ProjectPart 4: Risk AssessmentPart 5: Project BudgetPart 6: Project Team Information

1Training and Education Application

Project Title:

PART 1: GENERAL INFORMATION

1.1 PROJECT TITLE

Type here

1.2 PRINCIPAL APPLICANT/S

Principal Applicant Fill in belowNameTitleHost InstitutionBusiness Mailing AddressTelephone NumberEmailOther contact InformationSignatureDate

If there is more than one principal applicant provide information as above.

1.3 CO- APPLICANT/S

Co-Applicant Fill in belowNameTitleHost InstitutionBusiness Mailing AddressTelephone NumberEmailOther contact InformationSignatureDate

If there is more than one co-applicant provide information as above.

1.4 SUPPORT FOR PROJECT

A. INDUSTRY/SAFETY ASSOCIATION/INDUSTRY BASED SAFETY PROGRAMWhere Applicable

Please refer to Section 3.6 of the Applicant Information Document


Project Title:

Signatory Fill in belowNameTitleHost InstitutionBusiness Mailing AddressTelephone NumberEmailOther contact InformationSignatureDate

If there is more than one Industry Association provide information as above.

B. EMPLOYER'S APPROVALWhere Applicable

I consent to the undertaking of the project (named above) and promise to give my full cooperation to ensure its successful completion within the time period specified in the contract between the applicant and the Workers Compensation Board of Manitoba.


C. AGREEMENT FROM UNION

Where ApplicableThe undersigned on behalf of the Union named below consents to the undertaking of the project (named above) and promises to give full cooperation to ensure its successful completion within the time period specified in the contract between the applicant and the Workers Compensation Board of Manitoba.


Project Title:


D. AGREEMENT FROM WORKPLACE SAFETY AND HEALTH COMMITTEEWhere Applicable

The undersigned on behalf of the WS&H Committee named below consents to the undertaking of the project (named above) and promises to give our full cooperation to ensure its successful completion within the time period specified in the contract between the applicant and the Workers Compensation Board of Manitoba.

Principal Applicant Fill in belowNameTitleHost InstitutionBusiness Mailing AddressTelephone NumberEmailOther contact InformationSignatureDate


Project Title:

PART 2: DESCRIPTION OF TRAINING AND EDUCATION PROJECT

2.1 PROJECT DESCRIPTION

Please refer to Section 3.5 Part 2 of the Applicant Information Document

Type here

2.2 KNOWLEDGE TRANSFER AND EXCHANGE (KTE)

Please refer to Section 3.5, Section 5 and Section 6.9 of the Applicant Information Document

Type here


Project Title:

PART 3: MANAGEMENT OF PROJECT

Please refer to Section 3.5 Part 3 of the Applicant Information Document.

Please use the format below. Activities should be listed in sequence, indicating related activities and dependencies for successful completion.

TIMETABLE OF KEY PROJECT ACTIVITIES

Describe Key Milestone Start End Estimated CostActivity 1Activity 2

Should not exceed one page


Project Title:

PART 4: RISK ASSESSMENT


Use the Risk Assessment Matrix below to describe the risks and potential solutions to mitigate the risks identified.

1-Potential RiskInsert rows as needed

2-Assess Likelihood of Risk

3-Estimate Impact 4-Plan Risk Mitigation

Risk 1Risk 2Risk 3

1-Potential Risk - Describe each risk in detail

2-To assess the Likelihood of Risk-select one response from the list below for each risk identified:

Very Likely Probable Very Unlikely

3-To estimate the Impact of Risk select one response from the list below for each risk identified:

High Medium Low

4-To plan Risk Mitigation- Describe the strategy or plan for each risk identified.

Should not exceed one page


Project Title:

PART 5: PROJECT BUDGET: EXPLANATION OF BUDGET AND JUSTIFICATION OF BUDGET ITEMS

Please refer to Section 3.5 Part 5 and Section 6 of the Applicant Information Document. Use the Table below to assist you in completing the budget.

Budget Year 1 Year 2 TotalBudget Item Insert rows as needed

WCB Request $

WCB Request $ Total WCB Request $

SalariesBenefit CostsConsultancy Fees Other RemunerationSubtotalMaterials & Supplies list each item greater than $1,000SubtotalEquipment PurchaseEquipment RentalEquipment LeaseSubtotalKTE PlanningKTE Stakeholder EngagementKTE Project Advisory CommitteeKTE MeetingsKTE PresentationsKTE PublicationOther KTE DisseminationSubtotalTravel, Accommodation and MealsSubtotalOther costs-StipendsOther Costs-Meal allowancesOther Costs-ItemizeSubtotalTotal WCB Funding RequestItemize Project Costs met by Employer- In-Kind costs


Project Title:

Budget Year 1 Year 2 TotalBudget Item Insert rows as needed

WCB Request $

WCB Request $ Total WCB Request $

SubtotalUse the list below to assist you in developing your budget line items.

Justification of Budget Expenditures

You are required to provide a description of each budget expenditure item.

Salaries, Benefits and Consultancy Fees

Number of staffing positions

Brief description of the roles and responsibilities of each position

Employment status of the position e.g. whether it is full time or part time

Estimated number of working hours Pay rate e.g. whether hourly/weekly/monthly

Brief description of qualifications

Other information

Materials and Supplies

Cost office supplies, photocopying, printing, telephone, fax, conference calls, consumables, printer supplies etc.

List items or supplies that exceed $1,000.00

Equipment

Purchase, lease or rental of such as

Tools, machinery or vehicles


Project Title:

Software licences and licensing fees

Fees to access databases or research material

Instruments for testing and for experiments

Desktop or laptop computers, tablets

Portable data collection equipment

Knowledge Transfer and Exchange (KTE)

Costs of setting up a Project Advisory Committee (PAC)

Meeting costs for the PAC

Costs of other stakeholder engagement

Costs for publication in peer reviewed journals

Costs of materials for dissemination of project resources

Costs of travel, meals and accommodation for presentations in Canada

Other resources to promote KTE

Travel, Accommodation and Meals in Canada

Transportation

Accommodation

Meals

Please refer to Section 11 of the Applicant Information Document for estimating travel, accommodation and meal costs for Part 5 of the application templates.

Other Project Costs


Project Title:

Payment of stipends

Payment of honoraria to participants

Other items not referenced in budget expenditure items above.


Project Title:

PART 6: EXPERTISE OF PROJECT TEAM



training and education application · web viewproject title: 1 training and education application...

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