Donations and GRants REQUEST FORM

THIS FORM IS TO REQUEST A DONATION OR GRANT.
PLEASE COMPLETE ALL SECTIONS AND SUBMIT WITH A LETTER OF REQUEST ON INSTITUTION LETTERHEADED PAPER.

Chiesi Limited is proud to support activities which enhance patient care. The merit of your request will be given due and full consideration against our internal Donations and Grants Policy.

In assessing your request, specific consideration will be given to the following criteria:

There must be a clear, direct benefit to patients, i.e. future management and treatment of patients is enhanced beyond routine expectations, or a benefit to the NHS is clear whilst maintaining patient care.
The requested grant and/or donation must not be linked to the use of any Chiesi product, and the application must be independently completed without the input or influence of a Chiesi employee.
Sponsorship to a Healthcare Professional to support their attendance at a Scientific congress may be considered where clear rationale is provided for how patients will benefit from their attendance, however only registration will be supported.

Items/activities which are not eligible to be funded by a donation or grant include:

Routine capital equipment or building funds, such as capital or operating expenses
An activity that the NHS would routinely consider funding, i.e. health and safety training or external training to enable or initiate delivery of standard services expected from a surgery, health centre or hospital.
Any activity or professional development that would be expected to be carried to maintain registration to a professional body and/or for appraisal and revalidation
An activity which results in an individual gaining personal benefit, i.e., funding a diploma or degree course, or similar.
Social events (such as charity balls, student graduation celebrations)
Externally sponsored scientific research

In order to give your application the best chance of success, applicants should consider the following guidance:

Applications must be submitted at least eight weeks before the proposed activity/event is due to take place.
Consideration will only be given to a funding request where all fields have been completed fully and accurately, with a full breakdown of funding.
Consideration will only be given to the provision of funding on the basis of the information stated in this Form. You may not amend the information once submitted and if there are any changes to the basis of an application this must form the subject of a fresh application.
A submitted request does not constitute a guarantee that the application will be approved, and is done so at your own risk. Any detriment (financial, time or other) incurred during the application process is at the risk of the requester and will not be reimbursed by Chiesi Limited if the application is declined.
An application is only confirmed as approved once a formal confirmation letter is received by the requester.
Chiesi Limited will disclose any payments made in cash or benefit in kind to a Healthcare Organisation and Patient Organisation/Charity on a per activity basis.
Chiesi Limited will disclose any payments made for sponsorship to Healthcare Professionals to attend Scientific Congresses, either against the individual or as an aggregate (dependent on consent provided).
The decision made by Chiesi Limited is final, and will not be subject to further review.
All funding approval is at the discretion of Chiesi UK Limited and is not guaranteed even if all criteria is met.

SECTION 1. Applicant Information

Title

{field:title_1614335081399}

Surname

{field:surname_1614335042218}

First Name

{field:firstname_1614335104701}

Job Title

{field:job_title_1614694437959}

Principal place of work and address:

(please include ward/ dept. if applicable)

{field:principal_place_of_work_1614693641293}

Post Code

{field:postcode_1614335409270}

Email

{field:email_1614335271778}

Phone

{field:phone_1614769595227}

SECTION 2. DETAILS OF INSTITUTION, patient organisation or charity RECEIVING THE goods/service/ funding

Department

{field:department_1614335383579}

Principal place of work and address:

(please include ward/ dept. if applicable)

{field:principal_place_of_work_and_address_1614335403907}

Post Code

{field:postcode_1614335409270}

VAT Number

(if applicable)

{field:vat_number_1614335429363}

Company Registration Number

(if applicable)

{field:company_registration_number_1614336671608}

Annual Turnover in previous financial year

{field:annual_turnover_in_previous_financial_year_1615814339832}

SECTION 3. details of your Request (Continue on a separate sheet if necessary)

What is the value of the donation or grant requested?

Please provide as much detail as possible, as any changes to the requested value will require a new request to be submitted

{field:what_is_the_value_of_the_donation_or_grant_requested_1614335669740}

Please provide the objective and details of the request

{field:please_provide_the_objective_and_details_of_the_request_1614335695175}

Please detail how the donation or grant requested will enhance patient care, or benefit the NHS and maintain patient care

{field:please_detail_how_the_donation_or_grant_requested_will_enhance_patient_care_or_benefit_the_nhs_and_maintain_patient_care_1614335711544}

Have you received a donation or grant from Chiesi in the last 3 years

If yes, please provide details of the activity and relevant support provided.

YES/NO {field:have_you_received_a_donation_or_grant_from_chiesi_in_the_last_3_years_1614335756249}

{field:if_yes_please_provide_details_of_the_activity_and_relevant_support_provided_1614335797824}

Please confirm whether any requests for similar/the same support has been made to other organisations (including other pharmaceutical companies).

If yes, please provide details, including amount requested and whether the request (in full or in part) was approved by that organisation

{field:please_confirm_whether_any_requests_for_similar_the_same_support_has_been_made_to_other_organisations_including_other_pharmaceutical_companies_1614335826197}

Will accurate statements of Chiesi Limited’s support be included on all on materials including all printed materials associated with this request?

Please provide a copy of relevant materials containing the declaration for our records

YES/NO {field:will_accurate_statements_of_chiesi_limited_s_support_be_included_on_all_on_materials_including_all_printed_materials_associated_with_this_request_1614335841506}

SECTION 5: DATA PROTECTION AND transfers of value

Chiesi Limited (“Company”) is required, by the ABPI Code of Practice for the Pharmaceutical Industry (“the ABPI Code”), to document and publically disclose certain transfers of value made to health professionals and healthcare organisations, and these include information about the payments or other transfers of value provided to you under this agreement (the “Agreement”). By signing this Form, you consent to:

the Company and/or its affiliates:
1. storing and using such information relating to you and arising out of the Agreement for the purposes of meeting its obligations under the ABPI Code, (including, without limitation, your name and the amount and/or value of the transfer made to you under the Agreement);
2. making public disclosures of such information consistent with the ABPI Code and with applicable laws, from time to time in force; such disclosure may be made using any media, including printed reports, electronic communication, the web-site of the Company or its affiliates or other platforms
3. disclosing such information to the ABPI, its contractors and sub-contractors as may be required in furtherance of the objectives of the ABPI Code which include monitoring the activities of member companies and those agreeing to abide by the ABPI Code to ensure compliance with the terms and spirit of the ABPI Code, particularly in relation to the prohibition of inducements to supply or prescribe particular products;
4. for the purpose of enabling the Company to meet it obligations under the ABPI Code, transferring such information to other affiliates and/or to any third party providing services to the Company, who may be established in jurisdictions outside the European Economic Area, for the purpose of storage, use and public disclosure of such information and/or to comply with codes of practice and laws applicable in other jurisdictions to the Company and / or its affiliates concerning transfers of value made to health professionals and healthcare organisations; such jurisdictions outside the EEA may not provide the same or adequate protection for such personal data; and
the Association of the British Pharmaceutical Industry (“ABPI”):
1. making public disclosures of such information consistent with the ABPI Code and with applicable laws, from time to time in force; such disclosures will be made on the Disclosure UK database hosted on the web-site of the ABPI, and will identify you by name as having received payments or other transfers of value from the Company and details of those payments or other transfers of value;
2. or its contractors or sub-contractors, contacting you to verify the accuracy of the data transferred to the ABPI by or on behalf of the Company;
3. or its contractors or sub-contractors, performing statistical analysis on the information provided to the ABPI by the Company; and
4. using the information to inform the ABPI’s engagement with the media around the transparency provisions of the ABPI Code.

Further information on how your information may be used and your rights are set out below:

Chiesi Limited will be the “controller” of the information you provide to it and that remains in its control.

Chiesi’s Data Protection Officer is Matt Wiggetts, Legal & Compliance Director who is contactable at ukdpo@chiesi.com.

The ABPI’s address is 7^th Floor, Southside, 105 Victoria Street SW1E 6QT, and is subject to English law. The ABPI shall use your information as explain in this Form. The ABPI will be the “controller” of the information provided to it and that remains in its control.

How long will your information be kept?

Your information will be kept for no longer than is necessary. It will be kept for the Term of this Agreement and for no longer than 7 years thereafter.

Your rights

You have the following rights regarding your information that may apply depending on the circumstances:

Right	What does this mean?
The right of access	You have the right to obtain access to your information (if the organisation is processing it), and certain other information (similar to that provided in this Form).
The right to rectification	You are entitled to have your information corrected if it is inaccurate or incomplete.
The right to erasure	This is also known as ‘the right to be forgotten’ and, in simple terms, enables you to request the deletion or removal of your information where there is no compelling reason for an organisation to keep using it. This is not a general right to erasure; there are exceptions.
The right to restrict processing	You have rights to ‘block’ or suppress further use of your information in certain circumstances. When processing is restricted, the relevant organisation can still store your information, but may not use it further.
The right to data portability	You have rights to obtain and reuse your personal data in a structured, commonly used and machine readable format in certain circumstances.
The right to object	You have the right to object to certain types of processing, in certain circumstances.

For more information on your rights, please see Chiesi’s privacy notice which can be found at chiesi.uk.com or contact Chiesi at ukdpo@chiesi.com or you can contact the ABPI at 7th floor, Southside, 105 Victoria Street, London SW1E 6QT.

If you would like to exercise any of your rights, please contact Chiesi’s DPO at ukdpo@chiesi.com.

Making a complaint

If you are unhappy with how your information has been handled, please contact Chiesi’s DPO at ukdpo@chiesi.com.

If you are not satisfied with the response to your complaint or believe the processing of your information does not comply with data protection law, you can make a complaint to the Information Commissioner’s Office (ICO).

You are not required to consent to the processing of your information and the arrangements pursuant to the Agreement continue to be valid, even if you do not consent to the processing of your data, but if you consent to the processing of your information as set out in this Form, please sign below.

SECTION 5: declaration

I understand and accept that all requests approved for donations or grants are subject to Chiesi Limited’s Terms and Conditions (which can be found overleaf). I understand and accept that any detriment (financial, time or other) incurred is at my own risk and will not be reimbursed by Chiesi Limited if the application is declined for support.

(IMPORTANT - please tick only one of the relevant boxes below to confirm your understanding and acceptance of the above statement and sections)

□ I have understood and hereby consent to Chiesi Limited and/or its affiliates using or otherwise processing my information as outlined in this form and in Clauses 4 and 5 of the Terms and Conditions.

□ I hereby DO NOT consent to Chiesi Limited and/or its affiliates using or otherwise processing my information as outlined in this form and in Clauses 4 and 5 of the Terms and Conditions.

{field:declaration_1614336133062}

Note: If you do not provide your consent in respect of this funding, unfortunately we will be unable to process your request.

Signature

{field:signature_1614336209272}

Date

{field:date_1614336222107}

Submit fully completed applications to mdg.uk@chiesi.com

For Internal Use Only

Date Received	Therapy Area	Vendor Number
Date of MDG Meeting	Amount Agreed	MDG Committee Member Signature
IO Code	Material Group	PO Number
Bank account verification Signature		Date
Due diligence performed

Terms & Conditions of Engagement (T&C)

Definitions and Interpretation
1. In these T&C, the following words shall have the following meanings:

ABPI - the Association of the British Pharmaceutical Industry;

ABPI Code of Practice - the ABPI’s Code of Practice for the Pharmaceutical Industry. The Code sets standards for the promotion of medicines to health professionals and other relevant decision makers in the UK. It includes requirements for the provision of information to patients and the public and relationships with patient groups. The Code also applies to a number of areas that are non-promotional. ;

Agreement - the MDG Form and these T&C which together form a legally binding contract between us and you;

Confidential Information - any and all know-how, documentation and information, whether commercial, financial, technical, operational or otherwise, relating to (without limitation) the business, finances, affairs, products, services, formulations, formulae, techniques, specifications, reports, test results, statistics, product development, research, plans, personnel, customers, suppliers or methods of one party which is disclosed to or otherwise obtained by the other party in connection with the agreement;

IPR - trade marks, patents, design rights, copyright, database rights, know-how and all other intellectual property rights in any part of the world, whether or not registered or capable of registration, and including (without limit) all goodwill and other associated rights;

MDG Form - the form which sets out the terms of the Donation or Grant;

Donation or Grant - the amount paid by us to you for the Objective as set out in the MDG Form;

Objective - as defined in the MDG Form;

We, us or our - Chiesi Limited (with registered company number 2140985) of 333 Styal Road, Manchester, M22 5LG;

You or your - the healthcare professional or other person performing the Engagement whose details appear in the Engagement Letter.

In these T&C, unless the context requires otherwise: (a) any reference to a person will be construed as a reference to an individual, firm, company or other person (natural or legal); (b) any reference to any legislation, or legislative provision, will be construed as a reference to that legislation or provision as amended, re-enacted or extended at the relevant time; (c) a reference to the agreement shall include the MDG Form and these T&C; and (d) the expressions including, include, in particular, for example and any similar expression shall not limit the preceding words.

Conditions of the Donation or Grant
1. You warrant that any information that you provide to us is accurate and complete (for example, information about yourself, the Objective for which you require the Donation or Grant, and any costs or expenses that you will incur or have incurred in connection with this Agreement).
2. You must use the Donation or Grant solely and exclusively for the Objective. You must not use the Donation or Grant for any other purpose without our prior written consent.
3. You must not do or omit to do (or permit the doing or omission of) anything which may cause damage to our reputation or cause us to lose any licence, authority, consent or permission upon which we rely for the purpose of conducting our business.
4. We and you each acknowledge and agree that nothing in this Agreement (including the provision of any funding) constitutes or is intended to be provided for the promotion of medicines or as an inducement to prescribe, supply, administer, recommend, buy or sell any medicine.
5. You will: (a) cooperate with us in all matters relating to this agreement and comply with our reasonable instructions; (b) comply with all applicable laws, rules, regulations and codes of practice including the ABPI Code of Practice; (c) not do or omit to do anything which may cause damage to our reputation or cause us to lose any licence, authority, consent or permission upon which we rely for the purpose of conducting our business.

Refund / Return of the Donation or Grant
1. You must notify us in writing immediately if any of the following occurs and shall give us full details of the relevant circumstances:
  1. you no longer require the Donation or Grant;
  2. the Objective for which we provided the Donation or Grant changes. For example, if the event or programme which the Objective relates to has been cancelled or the topic has been varied;
  3. the amount that we have sent to you is greater than the costs that you would incur for the Objective;
  4. you do not spend all of the Donation or Grant on the Objective.
2. In addition to providing notice to us under clause 3.1, unless we have agreed in writing that you may use the amount provided for another purpose, you must promptly return the Donation or Grant to us. Where you have already spent part of the Donation or Grant on the Objective, you shall return such proportion of the Donation or Grant that has not been spent. You can return the Donation or Grant to us by cheque payable to Chiesi Limited to the address set out in clause 1.1 or by direct payment to our bank account, the details of which we will provide to you upon request.
3. We may carry out such checks and/or request such evidence from you or a third party as we believe necessary to verify that you have spent any funding provided solely on the Objective. You will provide us with such information and cooperation as we may request for this purpose. If: (a) we find that you have spent the Donation or Grant (or any part of it) on any purpose for which you have not obtained our written consent; or (b) that you have not spent the Donation or Grant and the Objective for which you requested it has elapsed or no longer exists then, on request, you will promptly refund to us such proportion of the Donation or Grant as has been either spent without our consent or has not been spent on the Objective (as applicable). If you fail to cooperate with us or provide the information that we require to verify your compliance under this clause, then we may request a refund of the full amount of the Donation or Grant. You shall pay any such refunds to us in accordance with clause 3.2.

Confidentiality
1. A party will: (a) only use the other party’s Confidential Information for the purpose of the proper performance of its obligations or exercise of its rights under the Agreement; (b) take reasonable precautions to ensure that the other party’s Confidential Information is treated as confidential and is not disclosed or used other than for the express purpose of the agreement; and (c) protect the other party’s Confidential Information using at least the same standard of care as that party employs in protecting its own Confidential Information.
2. The obligations set out in clause 4.1 above will not apply to information which is: (a) or becomes public knowledge other than through breach of the agreement; (b) received from a third party who lawfully acquired the same and, as far as the recipient is aware, is under no obligation restricting its disclosure; (c) independently developed by the other party without access to the Confidential Information; (d) required to be disclosed under applicable law or by order of any court or governmental authority of competent jurisdiction (but only then to the extent so required); (e) permitted to be disclosed under clause 6.
3. Notwithstanding anything to the contrary in the Agreement and without prejudice to clause 6 below, we shall be entitled to disclose the details of this Agreement to a third party (including your name and position, the Donation or Grant and Objective) where required to do so to comply with all applicable laws, rules, regulations and codes of practice, including the ABPI Code of Practice.
4. Each party acknowledges that if it breaches its obligations of confidence under this clause 4, the other party will be entitled to seek equitable relief in addition to any other right available under the Agreement and/or at law.

Data Protection
1. In addition to the purposes set out in clause 6 below, we will use your personal information set out in the table below for the purposes contained therein and in reliance on the lawful basis for processing stated:

Purpose of processing your data

Data

Lawful basis for processing including basis of legitimate interest (if applicable)

Managing our relationship with you, including:

Notifying you of changes to our privacy policy.

Storing your contact details so that we can contact you.

Replying to any questions, suggestions, issues or complaints you have contacted us about

Keeping a record of your consent; and

Helping us to maintain administrative and regulatory records about our business and its activities (including those set out under clause 6 below)

Related Personal Data

Necessary for our legitimate interests (to maintain a record of your contact details in case we need to contact you regarding, e.g. regarding the Engagement; to keep our records updated).

Fulfilling our payment obligations under this Agreement

Bank/payment details

Performance of Contract

Your personal information may be disclosed: to companies within our group; third party companies who host our CRM database; marketing agencies that we engage to market or obtain feedback on our goods and services on our behalf; our contractors and sub-contractors as may be required in furtherance of the objectives of the ABPI Code of Practice; our professional consultants including lawyers and technology consultants when they need to give us their professional advice; and where we are required to do so by law or to comply with regulatory requirements or codes of practice (subject to your right to object to us disclosing details of Transfers of Value we have made to you in accordance with clause 6 below).
We will handle your personal information in accordance with the ABPI Code of Practice for the Pharmaceutical Industry, the Data Protection Act 2018 and Chiesi’s Privacy Policy, which can be found at chiesi.uk.com or can be provided upon request.

Disclosures of transfers of value
1. You acknowledge that we are required, by the ABPI Code of Practice, to document and publicly disclose certain transfers of value made to health professionals, other relevant decision makers and healthcare organisations, and these include information about any funding, any expenses and other transfers of value provided to you under this Agreement (Transfers of Value). Accordingly, if you are a healthcare professional or other relevant decision maker and tick the box to provide your consent on the MDG Form, you consent to us and/or our group companies using your personal information to publicly disclose any Transfers of Value made to you in accordance with the ABPI Code of Practice.
2. You may refuse to provide your consent to us using your personal information as set out in clause 6.1 at any time. If you do so, your refusal with then apply for the whole of the relevant calendar year and we will not disclose any other Transfers of Value made to you within that year. If you do not provide your consent, you acknowledge that we are still permitted to disclose the Transfers of Value as required by the ABPI Code of Practice but will do so on an anonymised, aggregated basis.

Termination
1. We may terminate the Agreement immediately upon written notice if you commit a material breach of the Agreement which is either irremediable or (if remediable) is not remedied within 14 days of a written request to do so. If we terminate under this clause 7.1 then you shall refund to us any funding provided.
2. On termination of the Agreement for any reason: (a) each party shall promptly return or destroy, at the other’s request, all Confidential Information belonging to the other party in its possession or control; (b) the accrued rights and remedies of the parties as at termination shall not be affected; and (c) clauses which expressly or by implication have effect after termination shall continue in full force and effect including the following clauses: 2.5, 4, 5, 6, 7, 11 and 12.

Anti-bribery
1. You shall: (a) comply with all applicable laws, regulations, codes and sanctions relating to anti-bribery and anti-corruption including but not limited to the Bribery Act 2010; (b) comply with our Code of Ethics and anti-bribery and anti-corruption policies in each case as we may update them from time to time; (c) not provide any financial advantage to any person in return for the improper performance of their or another person’s duties; and (d) where permitted by law, notify us of any request for any undue financial or other improper advantage that you receive.

Conflict of Interest
1. In providing the Services in accordance with this Agreement, you shall ensure that no conflict of interest arises which will or may be likely to prejudice your independence and objectivity or otherwise detrimentally affect your ability to perform your obligations under the Agreement or cause embarrassment to Chiesi Limited and/or its affiliates.
2. Upon becoming aware of any such conflict of interest during the performance of its obligations under the Agreement (whether the conflict existed before the commencement date or during the term) you shall immediately notify us in writing of the same, giving particulars of its nature and the circumstances in which it exists or arises and shall furnish such further information as we may require.
3. Where, in our sole opinion, a conflict of interest notified under clause 9.2 is capable of being ameliorated by you, we may require you to take such reasonable steps as will, in our opinion, avoid or remove the conflict.
4. Without prejudice to our rights or remedies at law or under Clause 7, we may terminate this Agreement immediately by notice in writing to you and recover from you the amount of any losses incurred by us arising from such termination if:
  1. you fail to comply with the requirements notified to you by us in accordance with clause 9.3; or
  2. in our opinion, it is not possible to avoid or remove the conflict of interest; or
  3. in our opinion, a conflict of interest existed at the commencement date and you should reasonably have discovered it with the application of due diligence and ought to have disclosed it to us at that time.

Warranties
1. By signing this Agreement, you warrant, represent and undertake on an ongoing basis that:
  1. you have and shall continue to have full capacity and authority to enter into and properly perform your obligations under this Agreement;
  2. there are no actions, proceedings or regulatory investigations commenced, pending or, to the best of your knowledge, threatened against or affecting you and which might affect your ability to properly perform your obligations under this Agreement;
  3. you are not a party to any contracts or arrangements with third parties which would prevent or hinder the performance of your obligations under this Agreement; and
  4. you have and shall continue to hold all necessary approvals from each and any authority which are necessary in connection with the proper performance of your obligations under this Agreement.

Audit
1. You agree to provide, to us or to our representatives, access on reasonable notice, to any and all data, records, documents and other materials in any media or format within your possession or control which relate to this Agreement and/or your obligations under the Agreement.

General
1. Neither party shall be liable to the other for any delay or failure in performing its obligations under the Agreement to the extent that such delay or failure is caused by an event or circumstance that is beyond the reasonable control of that party (a Force Majeure Event).
2. You will promptly at our request, do (or procure to be done) all such further acts and things and the execution of all such other documents as we may from time to time require for the purpose of securing for us the full benefit of the Agreement.
3. No variation to the Agreement will be valid unless in writing signed by both parties.
4. You may not assign, transfer or subcontract your rights or obligations under the Agreement without our prior written consent.
5. No person other than a party to the Agreement shall have any rights to rely upon or enforce any term of the Agreement.
6. If a court or other regulatory body finds that any part of the Agreement is invalid or unenforceable, the remainder of the Agreement shall not be affected and shall be construed as if such invalid or unenforceable part did not exist.
7. A waiver of any right or remedy under the Agreement is only effective if given in writing and shall not be deemed a waiver of any subsequent breach or default. No failure or delay by a party to exercise any right or remedy provided under the Agreement or by law shall constitute a waiver of that or any other right or remedy, nor shall it preclude or restrict the further exercise of that or any other right or remedy.
8. The Agreement constitutes the entire agreement between the parties relating to its subject matter and supersedes and extinguishes all previous drafts, agreements, arrangements and understanding between them whether written or oral relating to its subject matter. Each party acknowledges that in entering into the Agreement it has not relied upon any matter not set out within it. Nothing in this clause will operate to exclude or limit any liability for fraud or fraudulent misrepresentation.
9. The Agreement and any disputes in connection with it (contractual or otherwise) are subject to the laws of England and Wales and the parties submit to the exclusive jurisdiction of the courts of England and Wales.

MDG Form_Version 4 CONFIDENTIAL UKMN-SOP-MED-0002-ATT-01 FEBRUARY 2021

Donations & Grants Request

If you have any questions please contact your medical team