Support TP for Educational Activities Review Form (6.

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Company: DKSH Wicaksana, Healthcare

Internal Requester:
Unit:
DETAILS OF REQUEST FROM THIRD PARTY
Requesting Organization/Institution:

Name of Requester:

Nature and objective of the educational activity:

To update diseases and treatment management

Other_____________________

Please see details in following attachment:

Event Brochure/Agenda
Other (specify) ……………………………………..

Intended participants of the educational activity:

The HCP who would like to update new information in diseases and treatment management.
The HCP who would like to develop his/her expertise on the meeting topics.
Other (specify) _____________________

Location :

Venue: _____________________

City : _____________________

Amount requested:

REVIEW & APPROVAL Page 2 of 2

Please check:

Is the request for educational grant made in writing?

Support is for a specific bona fide educational activity for HCPs or patients
The requested amount is fair market cost for the intended activities

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 Does not support normal operating or overhead activities of HCPs
Does not benefit an individual HCP, patient group or GO
Does not support the Company’s promotional activities
Not as a vehicle to induce the use of products or as hidden discounts
The venue/location is appropriate

___________________________________
Approved by

Date: ________________

Approval:

Approved Conditional Declined

If conditional or declined, please specify rationale:

____________________________________
Name & Signature of 1st Approver (Medical Affairs)

Date: ________________

____________________________________
Name & Signature of 2nd Approver (Business Unit Head) if applicable

Date: ________________