UK Donations Application Please be aware that you are unable to save and return to this form. If you do not receive a receipt of application via email in the next 7 working days, please contact Grantscommittee@msd.com. “*” indicates required fields About your organisationGP Practice Name* GP Practice Code* Registered AddressBuilding Number or Name Road / Street* City / Town* County Postcode* GP Clinical System*EMISSystmOneVisionName of Applicant* Job title* Date of application* DD slash MM slash YYYY Telephone*Email* Criteria for Donation*Tick to confirm, note all criteria must be selected to proceed. I can confirm; The GP practice is in England The electronic healthcare records at the GP Practice are updated with HPV vaccinations from other settings, such as school immunisation programme The GP Practice have no capability OR lack capacity to identify individuals in practice who missed out on HPV vaccination in school Select AllAcknowledgements*Tick to acknowledge, note all criteria must be selected to proceed I acknowledge that the form is completed and submitted by an individual with the authority to act on behalf of the GP Practice I acknowledge that if successful, the donation service (the tool and support) will cease on 30th June 2024 If successful, MSD will share contact details of the GP Practice with a third-party, Vision in Primary Care (ViPC) Ltd who will provide access to the tool, support and follow up If successful, the GP Practice will provide monthly metrics, aggregated and anonymised, via ViPC Ltd, specifically:- Baseline and monthly data for:- • Potentially eligible population for HPV vaccination The metrics will be used for internal MSD monitoring purposes and will not be revealed to any third parties or made public. If successful, the GP Practice will provide monthly metrics, aggregated and anonymised, via ViPC Ltd, specifically:- Baseline and monthly data for:- • Number of people identified who are potentially eligible for HPV vaccination and have not been vaccinated The metrics will be used for internal MSD monitoring purposes and will not be revealed to any third parties or made public If successful, the GP Practice will provide the required information to complete MSD’s contracting and assurance processes For providing the search tool and support for free to the GP Practice, the GP Practice agree to the transfer of the value being declared by MSD as required by the ABPI code of conduct 2021. This will be at the value of £200 I have read and understood the privacy statement – available from the ‘Privacy Policy’ link at bottom of page I acknowledge that the data on the form will be shared with the MSD UK Grants Committee Select AllCommentsThis field is for validation purposes and should be left unchanged. Δ GB-NON-08148 | Oct 2023