Sanofi Pasteur

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The vaccines division of sanofi-aventis Group
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General Educational Request

bullet Areas of Interest
bullet Applicant Information
bullet Institution/CE Provider/Medical Education Company Information
bullet Program Information
bullet Target Audience
bullet Program/Publication Budget
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General Educational Request
IMPORTANT NOTES:  
  1. The system will “time out” after 2 hours of inactivity resulting in a loss of your information.
  2. Copy down the Application ID Number that is given when the request is submitted.
  3. All correspondence will be by e-mail to the address supplied in the “Applicant Information” section of the grant application. Please ensure that if you are processing this request that you have access to that e-mail account.

The following information is required unless otherwise noted:

Program Type: Select the program type which best describes your educational event from the following:
  • Live
  • Enduring
  • Live and Enduring
Program Duration and Dates:  
  1. Number of Live programs supported by this grant. (Whole numbers only)
  2. First program will start on:  (Format: mm/dd/yyyy)
  3. Last program will end on:  (Format: mm/dd/yyyy)
  4. Duration of each Live program. (Whole numbers only)
  5. Number of Enduring programs supported by this grant. (Whole numbers only)
  6. Production Start Date:  (Format: mm/dd/yyyy)
  7. Initial Distribution Date:  (Format: mm/dd/yyyy)
  8. Program Expiration Date:  (Format: mm/dd/yyyy)
Disease Area: I confirm that neither the applicant, CME Provider, nor the Medical Education Partner has an existing contract, ongoing discussions, or known potential relationship regarding a marketing or promotional activity in this disease area.

Areas of Interest: Click
here for a list of areas of interest which can be supported.

Applicant Information: (Communications from Sanofi Pasteur will be directed to the person or via the e-mail listed below)
  1. First Name
  2. Last Name
  3. Title
  4. E-mail Address (Note: All correspondence from Sanofi Pasteur, including revision requests and the grant agreement itself, will be sent to this email address.)
  5. Phone Number (Format: 999-999-9999)
  6. Fax Number (Format: 999-999-9999)
Institution / CE Provider / Medical Education Company Information:
(Note: If this grant request is for Continuing Education, the "Institution/CE Provider" information must be that of the CE provider.)
  1. Legal Name of Institution, Company, or Organization
  2. Tax ID Number (Format: 99-9999999)
  3. Tax Status - (For Profit or Not for Profit)
  4. First Name
  5. Last Name
  6. Title
  7. E-mail Address
  8. Phone Number (Format: 999-999-9999)
  9. Fax Number (Format: 999-999-9999)
  10. Mailing Address - Line 1
  11. Mailing Address - Line 2 (Optional)
  12. Mailing Address - Line 3 (Optional)
  13. Overnight Delivery Address - Line 1 (Optional)
  14. Overnight Delivery Address - Line 2 (Optional)
  15. Overnight Delivery Address - Line 3 (Optional)
  16. City
  17. State
  18. Zip Code (5 digit or 9 digit)
  19. Will you be utilizing a Medical Education Partner?
  20. (If a Medical Education Partner is used) Is Payment (partial/complete) to be made directly to the Medical Education Partner / Company?
Program Information:  
  1. Title of the Program
  2. Description of Program

  3.      A one paragraph overview of the program, e.g. A symposium on the importance of diabetes management.
  4. Educational Needs Assessment
  5. Learning Objectives (participants who complete this program will be able to:)
  6. Instructional Method(s)
  7. Evaluation and/or Outcomes Assessment
  8. Program Agenda

  9.      For enduring media, please provide Table of Contents/Outline.
  10. Other information necessary for the complete review of the grant request. (Optional)
  11. Is this an Accredited CE Program? - Yes / No
  12. Accreditation Type, # Hours (both Live and Enduring, as applicable)
  13. Number of Speakers
  14. Up to 10 key speakers with name(s), academic affiliation(s) and area(s) of expertise. If speakers are not known, describe the speakers' qualifications, expertise, and academic affiliations.
  15. Are any Program speakers full time staff of the Accrediting Institution / Organization / Company?
  16. If yes, will they receive a stipend in addition to their salary?
Enduring Materials  
  1. Type(s) of Enduring Materials for this Program
Live Program Location(s)  
  1. City/State
Target Audience
  1. Target Audience: Select one (or more) audience(s) from the list.
  2. Is this Program open to the audience beyond the Institution's employees?
  3. If yes, please describe.
  4. The estimated total Program participation across all Programs(Live and Enduring, as applicable). (Whole numbers only)
  5. Select the method(s) you intend to utilize to recruit participants to the Program.
  6. The Medical Education Mission Statement for the CE Provider.
Program / Publication Budget:
  1. A fully itemized budget including units and rates per unit, which totals the full amount of your Program.
  2. The total cost of the Program.
  3. The total amount requested from Sanofi Pasteur.
  4. The total number of sponsors.
  5. Payment distribution, if applicable.
  6. Will you be seeking funding from other Sanofi Pasteur disease area(s)?
  7. If yes, select disease areas from the list.
  8. Other than receiving a grant card and/or being directed to the grant website, I confirm that no Sanofi Pasteur Marketing and Sales personnel were involved in any aspect of this grant submission. - Yes

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This page last updated: 07/23/2017