Request for Support

Details of person responsible for QIP at institution (QIP Lead)

Full name

Job title

Department

Telephone number (incl. international code)

Email address

Details of institution where QIP is taking place

Full name

Address line 1

Address line 2

City

Post / zip code

Country

Details of QIP

Title

Background / Aims (please give details of area for improvement, including relevant epidemiological data)

Planned start

Planned end

Details of Mölnlycke products to be involved in QIP (please give full names of products and intended uses)

Details of plan (please include details of planned activities / tasks)

How the impact of the plan will be measured (please include details of performance indocators)

Details of how the outcome of the QIP will be communicated within the instititon

Details of how the outcome of the QIP will be communicated outside of the institution

Will the QIP include any clinical research activitities for which support from Mölnlycke is being sought? Please consult QIP / Clinical Research decision tree for guidance

No

Yes, If Yes, please submit a separate proposal at: https://www.molnlycke.com/about-us/investigator-initiated-studies-program/submit-full-proposal/ and record the date of submission and study title below

Submission date

Study title

Support being sought from Mölnlycke

Financial grant (if applicable, please give details of amount and what it would be used for)

Mölnlycke products (if applicable, please give details of product names, sizes and quantities)

Assistance with data analysis (if applicable, please give details of exactly what will be required)

Assistance with medical writing (if applicable, please give details of what you have in mind, e.g. slide decks, posters)

General support and guidance (if applicable, please give details)

Request for Support

Details of institution where QIP is taking place

Details of QIP

Support being sought from Mölnlycke

Other documentation