BASL

If you are a BASL member and want to save an incomplete application form, or would like to be able to save a form before submitting it, please log in as a member first before clicking on the appropriate application form link. To access a saved application form log in and click on the application form link again, complete the missing information and submit.

Required fields are in red

Lead Applicant

Title

First Name

Surname

Profession/Discipline

Institution

Region

Local Mentor

Address for correspondence

Email for correspondence

Telephone no for correspondence

BASL membership number

BASL affiliation

Lead Applicant Declaration

I understand it is important that BASL understands its membership to ensure it can fulfil its aims in supporting excellence in liver healthcare information and education.

I have completed the equality and diversity questionnaire field in my membership profile and understand this information will be used anonymously to provide EDI reports for BASL in line with its policy to ensure equal opportunities for all members in its services and benefits (see EDI policy and strategy here).

I have ensured that other BASL (or affiliated group) members within this application have completed the equality and diversity questionnaire field in their membership profile and that they understand this information will be used anonymously to provide EDI reports for BASL in line with its policy to ensure equal opportunities for all members in its services and benefits (see EDI policy and strategy here).

I understand that this is a requirement to be eligible for this award

Other Team Members

Please list up to 5 other applicants

Team Member 1

Title

First Name

Surname

Profession/Discipline

Institution (if different to lead applicant)

Region (if different to lead applicant)

Email for correspondence

BASL membership number

BASL affiliation

Please check the Declaration box

Team Member 2

Title

First Name

Surname

Profession/Discipline

Institution (if different to lead applicant)

Region (if different to lead applicant)

Email for correspondence

BASL membership number

BASL affiliation

Please check the Declaration box

Team Member 3

Title

First Name

Surname

Profession/Discipline

Institution (if different to lead applicant)

Region (if different to lead applicant)

Email for correspondence

BASL membership number

BASL affiliation

Please check the Declaration box

Team Member 4

Title

First Name

Surname

Profession/Discipline

Institution (if different to lead applicant)

Region (if different to lead applicant)

Email for correspondence

BASL membership number

BASL affiliation

Please check the Declaration box

Team Member 5

Title

First Name

Surname

Profession/Discipline

Institution (if different to lead applicant)

Region (if different to lead applicant)

Email for correspondence

BASL membership number

BASL affiliation

Please check the Declaration box

Institution Service Manager (or equivalent)

Title

First Name

Surname

Position

Institution

Region

Email for correspondence

Address for correspondence

Telephone no for correspondence

I agree that the institution will ensure the award money is used for the purpose intended as outlined in this application form.

Project details

Project start date

Project end date

Title of project (Max 125 characters)

0 / 125

Aims of project (Max 750 characters)

e.g. what issue you want/wanted to address

0 / 750

Describe the potential impact/ impact of the project on the quality or development of your service (Max 1000 characters).

Why is it/was it needed; will it address unmet need; will it improve access; is it a novel idea

0 / 1000

Describe how you will achieve this/ have achieved this (as applicable) (Max 1000 characters).

What will you/did you do? Explain the roles of the team members in your application.

0 / 1000

Describe how your project will benefit/ has benefitted people (patients) (Max 1000 characters).

Describe how you assess this; what methods you use; is there a wider benefit to other people; what does the success of your project look like to patients

0 / 1000

Describe how your project will benefit/ has benefitted your service (Max 1000 characters).

Describe how you assess this; what methods you use; is there a wider benefit to other services; what does the success of your project look like to your service

0 / 1000

Outline how your project might be applicable to other services (Max 500 characters).

e.g. scaled up, replicated, transferred etc.

0 / 500

Outline how your work relates to any of the BASL priority areas (Max 750 characters).

These are:

Inclusiveness and Diversity (see BASL's ED&I strategy)
Reducing health inequalities or variation (aligned with patient services and COVID-19 recovery of liver services)
Sustainable healthcare delivery in liver services (see BASL's environmental sustainability policy and strategic framework)
Or state not applicable

0 / 750

Outline how you intend to use the award to support or develop the work (Max 500 characters).

e.g. audit support, costs to disseminate knowledge, travel costs, incentives for patients etc.

0 / 500

Who will mentor the lead applicant/team?

SUPPORTING DOCUMENTS

You may include up to 3 figures to support your application. Please provide clear titles for the figures but no other text. Text referencing the figures should be included in the narratives above. (Applicants not following this instruction may be disqualified).

Only .pdf, .ppt, .pptx, .doc, .docx, .xls, .xlsx, .png, .jpg, .jpeg will be accepted.

Figure 1

Figure 2

Figure 3

I confirm the applicants and institution agree to the below statements

Announcements, publicity and dissemination - Standard Release Agreements

The applicants and institution agree that summary information including the lead applicant's name and institution, summary of the project and value of award might be published on the BASL / Dr Falk and/or British Liver Trust websites and social media channels as soon as the awards are announced.
Dr Falk liaise with the successful applicants to publicise the award and the project. The applicants and institution agree to this.

Declaration

The applicants and institution agree that summary information including the lead applicant's name and institution, summary of the project and value of award might be published on the BASL / Dr Falk and/or British Liver Trust websites and social media channels as soon as the awards are announced. Dr Falk liaise with the successful applicants to publicise the award and the project. The applicants and institution agree to this.

Data protection

All applicants and institution representatives understand the data protection information below:

Out with the Standard Release Agreements above, BASL / BLT and / or Dr Falk Pharma may contact applicants and their institutions by email, telephone or post about their applications or other pertinent issues. Personal information and other data on the applications will be stored by BASL to aid processing of applications, auditing, reviewing and evaluation of the awards. Information will not be shared with any other third party except those aiding these purposes (e.g. data sharing of grant and awards with Association of medical Research Charities).

All personal information will be stored and processed in accordance with the Data Protection Act 1998 (and any subsequent legislation and guidance relating to data protection, in particular the General Data Protection Regulation 2016 and the Data Protection Act 2018). Processing of personal data is necessary for the legitimate interests pursued by BASL and with other third parties as set out above, and will be limited to that which is proportionate to those interests. Further information as to how BASL use and protect your data is available in BASL Privacy Policy.

Support the British Liver Trust

The British Liver Trust is the UK's leading liver health charity and provides high quality patient information and patient support through its helpline for those affected by liver disease and campaigns and promotes liver health for all. To find out how you can help support the work of the Trust see here https://britishlivertrust.org.uk/how-you-can-help/

Dr Falk / BASL Innovation Award

Lead Applicant

Other Team Members

Team Member 1

Team Member 2

Team Member 3

Team Member 4

Team Member 5

Institution Service Manager (or equivalent)

Project details

SUPPORTING DOCUMENTS

Announcements, publicity and dissemination - Standard Release Agreements

Declaration

Data protection

Support the British Liver Trust

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ABOUT BASL

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ABOUT BASL