Applicant details First name Name E-mail address Are you a UZ Leuven employee? Yes No Betrokken arts/dienstverlener Voornaam Naam Dienst Voornaam en naam contactpersoon in UZ Leuven Contactpersoon in UZ Leuven voor verdere afstemming rond contract en ondertekening. E-mailadres contactpersoon in UZ Leuven Contactpersoon in UZ Leuven voor verdere afstemming rond contract en ondertekening. Ik wil nog een betrokken arts/dienstverlener toevoegen Tweede betrokken arts/dienstverlener Voornaam Naam Dienst Voornaam en naam contactpersoon in UZ Leuven Contactpersoon in UZ Leuven voor verdere afstemming rond contract en ondertekening. E-mailadres contactpersoon in UZ Leuven Contactpersoon in UZ Leuven voor verdere afstemming rond contract en ondertekening. Ik wil nog een betrokken arts/dienstverlener toevoegen Derde betrokken arts/dienstverlener Voornaam Naam Dienst Voornaam en naam contactpersoon in UZ Leuven Contactpersoon in UZ Leuven voor verdere afstemming rond contract en ondertekening. E-mailadres contactpersoon in UZ Leuven Contactpersoon in UZ Leuven voor verdere afstemming rond contract en ondertekening. Ik wil nog een betrokken arts/dienstverlener toevoegen Vierde betrokken arts/dienstverlener Voornaam Naam Dienst Voornaam en naam contactpersoon in UZ Leuven Contactpersoon in UZ Leuven voor verdere afstemming rond contract en ondertekening. E-mailadres contactpersoon in UZ Leuven Contactpersoon in UZ Leuven voor verdere afstemming rond contract en ondertekening. Contractpartij Naam Straat en huisnummer Postcode Gemeente Voornaam en naam contactpersoon E-mailadres contactpersoon Ik wil nog een contractpartij toevoegen Tweede contractpartij Naam Straat en huisnummer Postcode Gemeente Voornaam en naam contactpersoon E-mailadres contactpersoon Ik wil nog een contractpartij toevoegen Derde contractpartij Naam Straat en huisnummer Postcode Gemeente Voornaam en naam contactpersoon E-mailadres contactpersoon Ik wil nog een contractpartij toevoegen Derde contractpartij Naam Straat en huisnummer Postcode Gemeente Voornaam en naam contactpersoon E-mailadres contactpersoon Contract proposition details Contract language Dutch English French Contract template Company agrees with a UZ Leuven template Company provides its own template To be determined Upload your template in Word Choose a file Type of contract Speaker assignment as a UZ Leuven employee Sponsoring of or educational grant for a scientific event organised by and with costs borne by UZ Leuven Sponsoring of or educational grant for the participation of a UZ Leuven employee to an external scientific event (employee sponsoring) Training & workshops for practitioners of the care profession or with the involvement of UZ Leuven patients (training) (Scientific) grant with costs at UZ Leuven related to a scientific research project or care or quality improvement project - Outside the framework of a (future) clinical study at UZ Leuven. (research grant) Confidentiality agreements if related to operation of or cooperation with UZ Leuven Outside the framework of a (future) clinical study at UZ Leuven. (Confidentiality agreement) Collaboration agreements with other healthcare facilities Extra muros assignment in another healthcare facility Performances by UZ Leuven on behalf of the government/NIHDI/FOD/… Speaker assignment as a UZ Leuven employee Name of the event Event start date event Event end date Title of the presentation Manner in which event is organised Live Virtual Hybrid Will there be pictures, audio or video recordings during the execution of the assignment? No Yes What else will the footage be used for? Target audience Healthcare practitioners Everyone Students Company employees Others Specify Sponsoring of or educational grant for a scientific event organised by and with costs borne by UZ Leuven Name of the event Event start date Event end date Manner in which event is organised Live Virtual Hybrid Amount of sponsoring in euro Detail of the quid pro quo(s) that will be granted to the sponsors E.g. presence of X number of representatives, installation of an information booth amounting to X m², mention of the company's logo on ... Programme Choose a file I confirm that The total costs consist of the organisation of the event with breakdown into venue hire, catering (if < 6 hrs scientific activity max. amount €23/hr.; if ≥ 6hrs scientific activity max. amount €135/day; max. amounts (incl. drinks) lunch € 45, dinner € 90, breaks € 23), speakers' fees, printing etc. compliant with the legislation of section 10 of the Law on Medication and the Mdeon-legislation and that the necessary supporting documents in this context will be filed by the department for a period of 10 years. Sponsoring of or educational grant for the participation of a UZ Leuven employee in an external scientific event Name of the event Event start date Event end date Training and workshops for healthcare practitioners or with the involvement of UZ Leuven patients Name of the training or workshop Training or workshop start date Training or workshop end date Involvement of patients Yes No Location of the training UZ Leuven External Target audience Healthcare practitioners Students Company employees Others Specify (Scientific) grant with costs borne by UZ Leuven related to a scientific research project or a care or quality improvement project Project description without inclusion of confidential info Such as may be added to the contract. Letter of application Choose a file Start date project or of the sub-period of the project during which the funds will be spent End date project or of the sub-period of the project during which the funds will be spent Is there a quid pro quo provided for the firm? No Yes Details of the quid pro quo(s) that may be granted E.g. reporting Confidentiality agreements if related to the operations of or cooperation with UZ Leuven Specific description of the purpose for which confidential information is exchanged Who will share confidential information? UZ Leuven External party Both parties Template pharma.be Please use the pharma.be (pdf) template. Cooperation agreements with other healthcare facilities Start date cooperation End date cooperation Business Manager (BMer) involved Relevant information Extra muros assignment in another healthcare facility Start date of the extra muros assignment End date of the extra muros assignment Business Manager (BMer) involved Content of the assignment (clinical) Performances by UZ Leuven on behalf of the government/NIHDI/FOD/... Start date of the performances End date of the performances Business Manager (BMer) involved Relevant information Remarks Last edit: 18 September 2023