WELLNESS@WORK GRANT PROGRAM
2019 APPLICATION FORM
CONTACT INFORMATION
Department/Group Name(s):
Campus or Work Site:
Contact Person 1
Name:
Title:
Email:
Phone Number:
Contact Person 2
Name:
Title:
Email:
Phone Number:
PROGRAM OR INITIATIVE DESCRIPTION
Title of program, idea or theme:
Please describe your proposed idea in detail. Specify the goals of the initiative.
How often and for how long will the initiative run? (ex. One class/week for 12 weeks starting in May.)
How many staff and/or faculty within your department/group will have the opportunity and are anticipated to
participate or take part in this initiative?
PROGRAM ALGINMENT
Please identify which element(s) of a healthy workplace your proposal fits within and explain how it aligns.
Healthy Lifestyle
Mental Health and Workplace Culture
Organizational Social Responsibility
In what ways does this proposal help bring to life the university’s commitment to the Okanagan Charter: An
International Charter for Health Promoting Universities and Colleges?
NEEDS ASSESSMENT
How did you determine that this is the best initiative for your staff/faculty health needs? What type of needs
assessment or consultation has been done to verify interest in this program? (ex. A survey, brainstorming session, team
meeting, etc.)
HEALTH BENEFITS
What are the anticipated health benefits of your program or idea? Why would participants in your department/group or
unit benefit from the proposed initiative?
PROGRAM EVALUATION
Please describe what outcomes you are hoping to achieve through this initiative? What will success look like?
How will you evaluate the success of your initiative?
PROGRAM SUSTAINABILITY
How might this initiative continue to be supported or implemented by the department/group in the future?
PROPOSED BUDGET
Successful applicants will have to submit their expenses including invoices and receipts, which will be used to reimburse
the department/group for the agreed upon expenses.
Item Name
Quantity
Brief Description
Estimated Cost
TOTAL AMOUNT REQUESTED
$
Please list any additional sources of funding to help make this initiative successful (department/group matching funds,
other grants, in-kind donations, etc.).
Quantity
Brief Description
Estimated Cost
TOTAL AMOUNT IN-KIND
$
DEPARTMENT/GROUP COMMITMENT
If our grant proposal is successful, I agree to complete a pre- and post-
project evaluation form, attend an orientation session, meet all project deadlines and submit a final evaluation report to
share key highlights from our initiative. These findings may be shared publicly through the Wellness@Work website and
other University of Guelph communications. The final report template will be provided and will include:
a summary of the initiative
any tools or promotional materials developed with the grant
a positive story resulting from the initiative
any evaluation feedback
supplemental materials such as photos, videos, etc.
Yes, I agree. Signature of applicant(s):
AVP OR DEAN ENDORSEMENT
Name:
Title:
Department/Group:
Campus Location:
Email:
Phone Number:
Signature of AVP or Dean:
Please email your completed PDF application form to sjoosse@uoguelph.ca or drop a printed copy off in Human
Resources with attention to Sarah Joosse. All applications are due by March 29
th
, 2019 at 5pm.
Thanks for your application! All applicants will be notified of the review committee’s decision by April 30
th
, 2019.
Successful grant recipients will also be invited to the Wellness@Work Grant Program Celebration to recognize their
accomplishments, share ideas and learn about the other wellness programs that have taken place at the University of
Guelph.
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