DESIGN & DIGNITY GRANTS SCHEME

APPLICATION FORM

Please submit 6 copies of the completed application form & supporting materials to Pamela Withero, The
Irish Hospice Foundation, Morrison Chambers, 32 Nassau Street, Dublin 2 by Friday 16 September 2016

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:
Type of Project:
(family room, privacy room, mortuary etc)
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:

1
 B. HOSPITAL INFORMATION
Number of inpatient hospital beds:
Hospital Model number (1,2,3 or 4):
Emergency departments: hours and days of
operation:
Number of patient deaths in 2015:
Number of patient deaths in 2014:
Number of patient deaths in 2013:
Any other information relevant to this application
(max 50 words):

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):
(max 75 words)
Describe how this project has potential to become an
exemplar project. Include details of the design
concept and design features including something
beautiful feature.
(For more info re. exemplar projects refer to the D&D
Style Book.) (Max 75 words)
Describe how the project will ensure exemplar status
is met (max 50 words)

Describe the extent to which the project has the

support of relevant hospital staff, including senior
managers and front-line staff (max 50 words)

Describe the extent to which the project has/will have

patients/families/representatives involved (max 50
words)

2
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 (max 75 words)

Describe how your proposal takes account of the

Design and Dignity Guidelines (max 50 words)

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?

3
 E. TECHNICAL INFORMATION & IMAGES
Please attach the following information to this application:
Survey drawings
Yes
(Site location plan, floor plans, sections and elevations
of the proposed area (at appropriate scales)).
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?
3D images of proposed project (if available):
Yes
No
High quality photographs of project area:
Included?
Including corridors the room opens on to and
Yes
adjoining environments (staff kitchens / changing
No
rooms)
Any additional information you wish to share- please
state:

F. PROJECT COSTS- ALL COSTS MUST BE INCLUSIVE OF VAT

Design team fees, including breakdown:
architect
mechanical and electrical engineer
structural engineer
other
Construction:
(please provide a breakdown of costs)

Local authority charges:

Loose furniture, furnishings (blinds, curtains etc) &
equipment (a minimum 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 15% of overall budget.
Other (please describe):

Total project cost:

4
 G. HOSPITAL FUNDING COMMITMENT
Please outline the funds committed to this project Funding amount % of overall project cost
from the hospital (including voluntary groups/hospital
based charities)
(hospitals are expected to contribute a minimum of
30% of the total cost including the contingency budget
for smaller projects and this may increase for larger
projects such as mortuary refurbishments)
Is your hospital willing to ensure an ongoing
maintenance fund to ensure this project retains
exemplar status in the long term?

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 Signature Date:

Project sponsor:

Project lead:

Hospital Manager:

Chair of End of Life Care Committee:

Name of local HSE/hospital estates

contact: