Educational Activity Grant Recipient Proposed Audience Budget Therapeutic Area * Opioid Use Disorder Opioid Overdose Treatment Is this an accredited activity? * Yes No Independent Medical Education (IME) grant requests for unaccredited activities currently are not being supported by Indivior. You will not be able to submit this grant request as the activity is unaccredited. Accreditation Type * CME CE CPE Other Please Specify * Are you the accrediting organization? * Yes No Please attach proof of accreditation * Upload an additional file IME grant requests for an ACCME-accredited program must be submitted by the organization accrediting the activity (the accredited provider) regardless of the dollar amount requested. Activity Type * Live National Live Regional Web Print Live + Web Live + Print Title of Activity * Description of the Activity and/or Learning Objectives * Please include your formal request on official letterhead. (attach your request in PDF or Word): * Upload an additional file Activity Start Date * Request should be submitted at least 90 days prior to the scheduled program or activity. Activity End Date * Please attach Needs Assessment * Description of Evaluation and/or Outcomes Assessment * Please attach Activity Agenda or Program. Note: For enduring media, please provide Table of Contents/Outline. * Upload an additional file Organization Name * (Legal entity name, e.g. LLC, Inc. etc.) What type of organization? * For Profit Not-For-Profit Address 1 * Address 2 City * Country * United States State * Zip Code * Website Contact First Name * Contact Last Name * Contact Phone Number * Contact Email Address * Tax ID * Will you be partnering with a joint sponsor/organization? * Yes No Partner Organization Name * Partner First Name * Partner Last Name * Partner Title * Partner Email Address * Partner Phone Number * Name(s) of Signatory Note: If partner signature required, please provide name 1st Signatory Name* Email* 2nd Signatory Name Email Target Audience * Physician NP/PA Nurse Pharmacist Other Please Specify Estimated number of participants * What method(s) do you intend to utilize to recruit participants to the activity? Live Activity Location(s) Total cost of activity (USD) * Amount requested (USD) * Are you receiving or requesting funding from any other organization? * Yes No If yes, please list: * Is any of the funding confirmed? * Yes No If yes, which one(s)? * Attach Budget * Upload an additional file Attach Form W-9 (sign and date with current year) * Upload an additional file Was an Indivior Sales or Marketing representative involved in any aspect of this grant submission other than directing the organization to the grant website? * Yes No Payment mailing address (pending grant approval) Address 1 * Address 2 City * Country * United States State * Zip Code * Previous Page Submit Next Page Any information provided in this submission will be processed in accordance with Indivior’s Privacy Policy [Indivior | Privacy Policy]. You are about to submit a grant request with the following attachments. Edit Request Submit Grant Request Any information provided in this submission will be processed in accordance with Indivior’s Privacy Policy [Indivior | Privacy Policy].
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