Applicant's details First name Last name Email address Are you a UZ Leuven employee? Yes No Doctor/service provider involved First name Last name UZ Leuven email address Department First and last name contact at UZ Leuven UZ Leuven contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. Email address contact at UZ Leuven UZ Leuven contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. UZ Leuven 2nd contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. UZ Leuven 2nd contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. UZ Leuven 2nd contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. UZ Leuven 2nd contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. I want to add another doctor/service Second doctor/service involved First name Last name Department First and last name contact at UZ Leuven UZ Leuven contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. Email address contact at UZ Leuven UZ Leuven contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. First and last name 2nd contact in UZ Leuven UZ Leuven 2nd contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. Email address 2nd contact in UZ Leuven UZ Leuven 2nd contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. I want to add another doctor/service Third doctor/service involved First name Last name Department First and last name contact at UZ Leuven UZ Leuven contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. Email address contact at UZ Leuven UZ Leuven contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. First and last name 2nd contact in UZ Leuven UZ Leuven 2nd contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. Email address 2nd contact in UZ Leuven UZ Leuven 2nd contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. I want to add another doctor/service Fourth doctor/service involved First name Last name Department First and last name contact at UZ Leuven UZ Leuven contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. Email address contact at UZ Leuven UZ Leuven contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. First and last name 2nd contact in UZ Leuven UZ Leuven 2nd contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. Email address 2nd contact in UZ Leuven UZ Leuven 2nd contact within the medical department involved (≠ legal department) for further coordination regarding contract and signing. Contracting party Name Street and number Postal code City First and last name contact Email address contact First and last name 2nd contact E-mail 2nd contact I want to add another contracting party Second contracting party Name Street and number Postal code City First and last name contact Email address contact First and last name 2nd contact Email address 2nd contact I want to add another contracting party Third contracting party Name Street and number Postal code City First and last name contact Email address contact Voornaam en naam 2de contactpersoon E-mailadres 2de contactpersoon I want to add another contracting party Fourth contracting party Name Street and number Postal code City First and last name contact Email address contact Voornaam en naam 2de contactpersoon E-mailadres 2de contactpersoon Details contract proposal Contract language Dutch English Contract template Company agrees with a UZ Leuven template Company uses template agreed between UZ Leuven and company Draft contract (no template) To be determined Upload contract in Word Choose a file Upload data processing agreement in Word (if applicable) Choose a file Type of contract Guest 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 Sponsorship of/or educational grant for the participation of a UZ Leuven employee in an external scientific event Clinical observations, training & workshops for healthcare practitioners or with involvement of UZ Leuven patients Except for proctoring outside UZ Leuven: this is followed up by the legal department of LRD’. (scientific) grant with costs borne by UZ Leuven related to a scientific research project or a care or quality improvement project Outside the framework of a (future) clinical study at UZ Leuven. Type internal agreements Guest speaker assignment as UZ Leuven employee Sponsoring of/or educational grant for a scientific event organised by and with costs borne by UZ Leuven Sponsorship of/or educational grant for the participation of a UZ Leuven employee in an external scientific event Clinical observations, training & workshops for healthcare practitioners or with involvement of UZ Leuven patients Except for proctoring outside UZ Leuven: this is followed up by the legal department of LRD (Scientific) grant with costs borne by UZ Leuven related to a scientific research project or a care or quality improvement project Outside the framework of a (future) clinical study at UZ Leuven Confidentiality agreement if related to the cooperation with UZ Leuven Outside the context of a (future) clinical study of UZ Leuven Collaboration with other healthcare facility Extra muros assignment in another healthcare facility Deliverables by UZ Leuven on behalf of the government/NIHDI/FOD/... Guest speaker assignment as a UZ Leuven employee Name of the event Event start date 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 Will the speaker use medical images of patients or patient data for educational purposes in the presentation? Yes Please note: medical images are not considered anonymous. Read more about medical images of patients or patient data. No 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 the event is organised Live Virtual Hybrid Sponsoring amount 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 estimation of the total costs for 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. is 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. If the event concerns a emeritaat/PhD/patient or family day, please contact the legal department. Sponsor request Choose a file 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 Clinical observations, training and workshops for healthcare practitioners or with involvement of UZ Leuven patients Name of the clinical observation, training or workshop Clinical observation, training or workshop start date Clinical observation, training or workshop end date Involvement of patients Yes No Location of the clinical observation, training or workshop 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 agreement if related to the 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.bePlease use the pharma.be (pdf) template. Collaboration agreement with other healthcare facilities Start date collaboration End date collaboration 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) Deliverables by UZ Leuven on behalf of the government/NIHDI/FOD/... Start date of the deliverables End date of the deliverables Business Manager (BMer) involved Relevant information Remarks Last edit: 25 march 2024