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WORKPLACE INNOVATION APPLICATION

RESEARCH AND WORKPLACE INNOVATION PROGRAM

Funding occupational health research, training and education and innovative workplace solutions

CLOSING DATE

JUNE 26, 2017

PROJECT TITLE:

Administrative Requirements

Please refer to Section 4.1 to Section 4.9 of the Applicant Information Document and use this template to complete your Workplace Innovation Application

Please provide the information for questions 1 and 2 below. TION

1. Indicate if this is an initial application or re-submission of a previous application. Please mark the appropriate box with an X.

Initial Application Resubmission

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

WCB websiteWCB letterWCB emailNewspaper AdvertisementOther WCB communicationsWord of mouthRWIP brochureOther, please specify

CHECKLIST - Show an X for each completed sectionPart 1: General Information Part 3: Management of ProjectPart 2: Description of Project Part 4: Risk Assessment2.1 Project description Part 5: Project Budget2.2 Innovation Part 6: Expertise of Project Team2.3 Knowledge Transfer & Exchange

PART 1: GENERAL INFORMATION

1.1 PROJECT TITLE

1.2 PRINCIPAL APPLICANT/S

Workplace Innovation Application RWIP 2017 1

PROJECT TITLE:

NameBusiness TitleBusiness Mailing AddressTelephone NumberEmailOther Contact InformationSignatureDate

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

1.3 CO- APPLICANT/S

NameBusiness TitleBusiness Mailing AddressTelephone NumberEmailOther Contact InformationSignatureDate

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

1.4 PROJECT'S LOCATION/S

Provide the mailing addresses of sites where project activities will be undertaken

1.5 WORKPLACE SUPPORT

A. EMPLOYER'S APPROVAL

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.

* Provide the name of the business owner or designate** Applicable only if the signatory is someone designated by the business owner


PROJECT TITLE:

Name of Business Owner*Title**Business Mailing AddressTelephone NumberEmailOther Contact InformationSignatureDate

B. AGREEMENT FROM UNIONWhere Applicable

The 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.

Signed on behalf of the Union

NamePosition in UnionBusiness Mailing AddressTelephone NumberEmailOther Contact InformationSignatureDate

C. AGREEMENT FROM WORKPLACE SAFETY & HEALTH (WS&H) 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.Signed on behalf of the WS&H Committee


PROJECT TITLE:

NameWS&H ChairBusiness AddressTelephone NumberEmailOther Contact InformationSignatureDate

PART 2: DESCRIPTION OF WORKPLACE INNOVATION PROJECT

2.1 PROJECT DESCRIPTION

Please refer to Section 4.5 Part 2 (a) to (d) of the Applicant Information Document

Type here

2.2 INNOVATION Please refer to Section 4.5 Part 2 (e) of the Applicant Information Document

Type here

2.3 KNOWLEDGE TRANSFER and EXCHANGE (KTE)

Please refer to Section 4.5 Part 2 (f), Section 5 and Section 6.9 of the Applicant Information Document

Type here

PART 3: MANAGEMENT OF PROJECT

Please refer to Section 4.5 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.

Should not exceed one page

TIMETABLE OF KEY PROJECT ACTIVITIES


PROJECT TITLE:

Specify Key Project Milestones Start Date Completion Date

Estimated Cost

Add rows as needed

PART 4: RISK ASSESSMENT

Please refer to Section 4.5 Part 4 of the Applicant Information Document.

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

Should not exceed one page

RISK ASSESSMENT

Describe Potential Risk Event

Assess Risk Likelihood Estimate Impact Strategy/Plan to Mitigate

RisksUse a single row for each potential risk identified

Use specific project objectives, milestones, activities or deliverables to identify risk events.

Select one response from the list below for each risk identified:

-Very Likely-Probable-Very Unlikely

Select one response from the list below for each risk identified:

-High-Medium-Low

Describe the strategy or plan for each risk identified

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

Please refer to Section 4.5 Part 5 and Section 6 of the Applicant Information Document.

Use the Table below to assist you in completing the budget.

Year 1 Year 2 Total

Budget Item WCB $ Request

WCB $ Request

WCB $ Request

1 Salaries Insert rows as needed


PROJECT TITLE:

Year 1 Year 2 TotalBenefits costsConsultancy feesOther remuneration

Sub-Total

2Material and supplies (list each item greater than $1,000) Insert rows as needed

Subtotal

3 Equipment purchase Insert rows as neededEquipment rentalEquipment lease

Subtotal 4 KTE Planning costs Insert rows as needed

KTE Stakeholder engagementProject Advisory CommitteeKTE Meeting costsKTE Presentation costsKTE Publication costsOther KTE dissemination costs

Subtotal

5 Travel, accommodation and meals3 Itemize each expense

Subtotal

6 Other costs specify by item Insert rows as

needed

Stipends paid to participantsMeal allowances etc.

SubtotalTotal WCB Funding Request

Specific project costs met by the employer ( in-kind) Itemize

Subtotal


PROJECT TITLE:

Use 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.

1 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 description of qualifications

Other information

2 Materials and Supplies

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

List items or supplies that exceed $1,000.00

3 Equipment

Purchase, lease or rental of such as

Tools, machinery or vehicles

Software licences and licensing fees


PROJECT TITLE:

Fees to access databases or research material

Instruments for testing and for experiments

Desktop or laptop computers, tablets

Portable data collection equipment

4 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 etc.

Other resources to promote KTE

5 Travel, Accommodation and Meals

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.

6 Other Project Costs


PROJECT TITLE:

Payment of stipends

Payment of honoraria to participants

Other items not referenced in budget expenditure items 1 to 6.

6 Other Project Costs

Payment of stipends

Payment of honoraria to participants

Other items not referenced in budget expenditure items 1 to 6.

PART 6: EXPERTISE OF PROJECT TEAM

Please refer to Section 4.5 Part 6 of the Applicant Information Document.


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