DESIGN & DIGNITY GRANTS SCHEME
APPLICATION FORM
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:
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
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B. HOSPITAL INFORMATION
Number of inpatient hospital beds:
Hospital Model number (1,2,3 or 4):
Emergency department’s: hours and days of
operation:
Number of patient deaths in 2013:
Number of patient deaths in 2012:
Number of patient deaths in 2011:
Any other information relevant to this application:
C.
PROJECT DESCRIPTION
Name of project:
Description of the project need:
Description of the project:
Description of the project benefits for patients,
families and staff (including estimated numbers of
patients/families that will be directly benefit):
Describe how this project has potential to become an
‘exemplar’ project. Include details of the design
concept and design features (for more info re.
exemplar projects refer to the D&D Style Book)
Describe how the project will ensure ‘exemplar’ status
is met
Describe the extent to which the project has the
support of relevant hospital staff, including senior
managers and front-line staff
Describe the extent to which the project has/will have
patients/families/representatives involved
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Briefly describe related major capital works projects
Briefly describe enabling works if required for this
project:
(Enabling Works: works needed to make a site ready
for construction (and costs involved) e.g. preliminary
construction work etc.)
Describe any other benefits that may arise from this
project
Describe how your proposal takes account of the
Design and Dignity Guidelines
D. PROJECT TIMELINE
How many months will your project take to complete?
Please factor in time for:
Stage 1 – initial design, staff workshop with staff,
patient/family reps
Stage 2 – planning permission application (12 weeks),
fire cert and disability cert application (8 weeks),
building regulation cert (if required)
Stage 3- detailed design and tendering (6-8 weeks)
Stage 4 – Construction work, consultation with staff &
Design & Dignity Project Team re furnishing, art work
etc.
Does the project need input from an architect/interior
designer?
Does the project need input from a mechanical &
electrical engineer?
Does the project need input from a structural
engineer?
Does the project need input from a quantity
surveyor?
Does the project require planning permission?
Does the project require a fire safety certificate,
disability access cert and building regulation
certificate?
Does the project require a disability access certificate?
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E.
TECHNICAL INFORMATION & IMAGES
Please attach the following information to this application:
Survey drawings
(Site location plan, floor plans, sections and elevations
of the proposed area (at appropriate scales)).
Yes
Basic concept drawings to explain the project:
(Drawings should indicate: the location of the
proposal and its context within the hospital and the
Yes
grounds, room layouts, fixed and loose furniture,
external and internal finishes and general
specifications. Drawings should be appropriate scales,
floor plans at 1:100 or 1:50 for smaller rooms ideally )
Included?
Yes
No
3D images of proposed project (if available):
High quality photographs of project area:
Yes
Any additional information you wish to share- please
state:
F.
Design team fees:
(architect, mechanical and
structural engineer, other)
PROJECT COSTS- ALL COSTS MUST BE INCLUSIVE OF VAT
electrical
engineer,
Construction:
(please provide a breakdown of costs)
Local authority charges:
Loose furniture, furnishings (blinds, curtains etc) &
equipment (10% of the overall project cost):
Artwork (please allow at least 1% of the overall
project cost):
Landscaping (if any):
Enabling works cost (if any):
Subtotal project cost:
Contingency fund: please allow 10-15% of overall
budget
Other (please describe):
Total project cost:
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G. HOSPITAL FUNDING COMMITMENT
Please outline the funds committed to this project Funding amount
from the hospital
% of overall project cost
Please outline any funds that will be made by Funding amount
voluntary groups/hospital based charities for this
project
% of overall project cost
Is your hospital willing to ensure an ongoing
maintenance fund to ensure this project retains
‘exemplar’ status?
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 of project sponsor:
Signature of project sponsor:
Date:
Name of project lead:
Signature of project lead:
Date:
Name of Hospital Manager:
Signature of Hospital Manager:
Date:
Name of Chair of End of Life Care
Committee:
Signature of Chair of End of Life Care
Committee:
Date:
Name of local HSE/hospital estates
contact:
Signature of local HSE Estates contact/
equivalent::
Date:
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