Funding occupational health research, training and education and innovative workplace solutions
CLOSING DATE
JUNE 22, 2016
WORKPLACE INNOVATION APPLICATION
RESEARCH AND WORKPLACE INNOVATION PROGRAM 2016
Administrative Requirements
Please 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 Re-submission
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 emailOther WCB communicationsWord of mouthRWIP brochureOther, please specify
It is very important to take note of the following:
This application must be submitted electronically via email to:
Bruce M. Cielen, Manager, Research and Workplace Innovation Program at email: [email protected] by June 22, 2016, 4:00 p.m. CST.
Applications must be in Word format.
There are six (6) parts to this application. Please ensure that you have provided all the information required in each part before you submit your application. A checklist to assist you is below.
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
WORKPLACE INNOVATION APPLICATION - RWIP 2016 1
PART 1: GENERAL INFORMATION
1.1 PROJECT TITLE
1.2 PRINCIPAL APPLICANT/S
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.
WORKPLACE INNOVATION APPLICATION - RWIP 2016 2
PROJECT TITLE:
* Provide the name of the business owner or designate ** Applicable only if the signatory is someone designated by the business owner
Name of Business Owner*Title**Business Mailing AddressTelephone NumberEmailOther Contact InformationSignatureDate
Where Applicable
B. AGREEMENT FROM UNION
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 InformationSignature Date
Where Applicable
C. AGREEMENT FROM WORKPLACE SAFETY & HEALTH (WS&H) COMMITTEEThe 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
WORKPLACE INNOVATION APPLICATION - RWIP 2016 3
PROJECT TITLE:
cooperation to ensure its successful completion within the time period specified in the contract between the applicant and the Workers Compensation Board of Manitoba.
WORKPLACE INNOVATION APPLICATION - RWIP 2016 4
PROJECT TITLE:
Signed on behalf of the WS&H Committee
NameWS&H ChairBusiness AddressTelephone NumberEmailOther Contact InformationSignatureDate
NameWS&H Co-ChairBusiness AddressTelephone NumberEmailOther Contact InformationSignatureDate
PART 2: DESCRIPTION OF WORKPLACE INNOVATION PROJECT
2.1 PROJECT DESCRIPTION
The application at a minimum must: provide a comprehensive description of the project, the workplace safety and health issues to be addressed the objectives, goals, and target group/s for the project expected project results and outcomes
There are no restrictions to the number of pages.
2.2 INNOVATION
Describe the innovation that the project will undertake or implement to change and improve occupational health and safety of a specific workplace/s, and/or foster rehabilitation and return-to-work of injured workers. The innovation proposed in the project should include one or more of the following:
WORKPLACE INNOVATION APPLICATION - RWIP 2016 5
PROJECT TITLE:
Practical application of new knowledge, processes, technology, products and/or services that addresses occupational health and safety in the workplace/s, and/or fosters rehabilitation and return-to-work of injured workers;
Application of existing knowledge in new ways that addresses occupational health and safety in the workplace/s, and/or fosters rehabilitation and return-to-work of injured workers.
Practical, shop-floor solutions to improve workplace health and safety practices/behaviour that addresses occupational health and safety in the workplace/s, and/or fosters rehabilitation and return-to-work of injured workers.
See Section 3 of the Applicant Information document.
2.3 KNOWLEDGE TRANSFER and EXCHANGE (KTE)
An on-going objective of the RWIP is to ensure the resources developed and learning gained from RWIP projects are broadly shared and used by WCB leadership and staff, Manitoba employers, workers and policy makers. The KTE plan should apply the integrated KTE process to engage stakeholders and decision-makers during the life of a project. The KTE plan should also include activities to promote successful project outcomes and best practices into practical applications that can be used to prevent occupational injury, illness and disease and to foster successful rehabilitation and productive return-to-work of injured or ill workers.
Section 5.2 and Section 5.3 of the Applicant Information document has more information on the KTE of RWIP projects.
The estimated cost for KTE should be included in the project's budget. See Section 7.6 of the Applicant Information document for more information on the budget requirements.
PART 3: MANAGEMENT OF PROJECT
Please provide a timetable and work plan that will:
Identify and describe project activities; Specify key milestones; Identify start and finish dates; and Relate costs to project activities.
WORKPLACE INNOVATION APPLICATION - RWIP 2016 6
PROJECT TITLE:
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
Specify Key Project Milestones Start Date Completion Date
Estimated Cost
Add rows as needed
PART 4: RISK ASSESSMENT
Identify the potential risks to successful completion of the project, e.g. cooperation from workplace parties, participation of subjects, resource availability etc.Use the Risk Assessment Matrix below to describe the risks and potential solutions to mitigate the risks identified.
Innovation in the workplace carries some risk as the innovative actions usually introduce new or different methods, practices, procedures or techniques in managing and delivering workplace safety and health products and services. There may be resistance to the activities associated with the innovation. Take these factors into consideration when developing the risk profile for this project.
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
WORKPLACE INNOVATION APPLICATION - RWIP 2016 7
PROJECT TITLE:
PART 5: PROJECT BUDGET
5.1 EXPLANATION OF BUDGET AND JUSTIFICATION OF BUDGET ITEMS
Use the format below to assist you in completing the budget.
The WCB will provide support for the direct costs of the project [including project assistance, support for technical, professional and secretarial services, equipment (purchase or rental), project-related travel and supplies].
Project costs may include reasonable administrative costs, but should not include costs of salary replacement for staff involved in project, buy-outs of teaching time or other responsibilities of the applicant/s, co-applicant/s or the study's partners.
Applicants must also demonstrate that the WCB grant and/or any financing from other sources will provide adequate financial support to achieve the objectives of the proposal.
Please take note that the WCB is GST exempt.
BUDGET ITEMS AND JUSTIFICATION1
Year 1 Year 2 Total
Budget Item WCB $ Request
WCB $ Request
WCB $ Request Justification of Funds
1 Salaries, Benefits/Consultancy fees2. (Specify for each of project team)Sub-Total
2 Material and supplies -(list each item greater than $1,000)Subtotal
3 Equipment (purchase, rental, lease)Subtotal
4 Knowledge TransferSubtotal
5 Travel, accommodation and
WORKPLACE INNOVATION APPLICATION - RWIP 2016 8
PROJECT TITLE:
meals3
Subtotal6 Other costs (specify
by item; for example stipends paid to individuals in sampleSubtotalTotal WCB Funding Request (sum of items 1 to 6)Specific project costs met by the employer ( in-kind)Subtotal
Include all items essential for the conduct of the project. Provide a brief, clear justification for each budget item and relate it to the objectives and requirements of the proposed research. The budget quantifies the timetable and work plan in terms of personnel, materials, supplies, and other requirements. Accordingly, it is essential that the link between the research proposal and the budget be clear.2 Applies for new staff or consultants hired to work on the project. It should not include salaries or benefits of current employees participating or involved in the project.3 Any cost of transportation, accommodation and meals paid according to WCB Manitoba rates. Estimate the number of days, transportation, accommodation and meal costs by number of persons and number of days. See Section 12 of the Applicant Information document for WCB Manitoba rates for travel, accommodation and meals.
PART 6: EXPERTISE OF PROJECT TEAM
Provide resumes for the Principal Applicant and each Co-applicant. The resumes must be included with the electronic application form, may not be longer than 5 pages each, and should include the following elements:
Name Title/Designation Employer/or sponsor Educational background (institution, degree/diploma, certificate/qualification
conferred, year conferred, and field of study), Professional experience and expertise to undertake this project
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