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Express Outreach Project Award Application

1. Name of Network Member Institution:
*

2. Network Member LIBID:
*

3. Project Manager:
*

4. Position/Title of Project Manager:
*

5. Department:
*

6. Mailing Address:
Street 1:  *
Street 2: 
City:  *
State:  *
Zip Code:  (e.g., 99999 or 99999-9999) *

7. Email Address (e.g., maryc@project.org):
*

8. Telephone Number [e.g., (222) 222-2222 or 555-555-5555]:
*

9. Fax Number [e.g., (222) 222-2222 or 555-555-5555]:
*

10. Award funding is a maximum of $6,000.00 please supply a brief budget.
  • Funding will cover personnel, communication, equipment, supplies, reproduction, and travel.
  • Meal per diems are the only allowable food expenditure.
  • No indirect costs are allowed.
  •  Furniture costs are not allowed.
  • No costs for promotional items are allowed.
Expenditure Category Total Charges
Personnel
Equipment
Supplies
Travel
Communication
Reproduction
Other (specify)
Total Amount Requested ($6,000 maximum): $0

11. How will you spend the award? (Provide a cost break down and justification for each budget line.)
4,000 characters left

12. Award should be made payable to what institution (i.e., Southeastern Regional Medical Center)?
*

13. Federal Tax Id Number (FEIN):
*

*

*

16. Proposed start date for project ending April 30, 2016 (e.g. 10/19/2011):
*

17. Project Title:
*

18. List your projects objectives.
4,000 characters left

19. Describe target population or audience.
Example: Senior Citizens, Public Health Nurses, Health Educators
4,000 characters left

20. Describe how you will complete the project objectives (your project plan).
4,000 characters left

21. List project personnel, their role in this project and experience relevant to this project.
4,000 characters left

22. List any institutional support that will be provided.
4,000 characters left

23. The Network member will work with the following organization(s).
(Check all that apply)
4,000 characters left

24. Name, address, website (if any) and description of partner organization(s) involved in the follow-up activities.
Example.
Mary Jones, Nurse Supervisor
South Neighborhood Clinic
101 South Street
Anywhere, MD 21220
http://www.southclinic.go
Non-profit clinic providing outpatient services to primarily Native American population. Health Professionals on staff total 10, including physicians, nurses and health educators.

4,000 characters left

25. For training projects, how many demonstration/training session(s) will the Network member provide?
(e.g. 2) *

These demonstration/training session(s) will cover:
(check all that apply)
4,000 characters left

26. How will you promote your project to the target audience?
4,000 characters left

27. How will you evaluate your project's effect?
4,000 characters left

28. What are the plans to sustain contact with the target group?
4,000 characters left

29. Comments
4,000 characters left

 the form then submit to the SE/A office for review

Contact us at:

NN/LM SE/A Region

University of Maryland, Baltimore

Health Sciences and Human Services Library

601 W. Lombard Street

Baltimore, MD 21201-1512

Phone: 1-800-338-7657 or 410-706-2855

Last updated on Tuesday, 03 May, 2011

Funded by the National Library of Medicine under contract HHS-N-276-2011-00004-C with the Health Sciences and Human Services Library of the University of Maryland