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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.,

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
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.)
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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.
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19. Describe target population or audience.
Example: Senior Citizens, Public Health Nurses, Health Educators
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20. Describe how you will complete the project objectives (your project plan).
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21. List project personnel, their role in this project and experience relevant to this project.
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22. List any institutional support that will be provided.
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23. The Network member will work with the following organization(s).
(Check all that apply)
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24. Name, address, website (if any) and description of partner organization(s) involved in the follow-up activities.
Mary Jones, Nurse Supervisor
South Neighborhood Clinic
101 South Street
Anywhere, MD 21220
Non-profit clinic providing outpatient services to primarily Native American population. Health Professionals on staff total 10, including physicians, nurses and health educators.

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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)
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26. How will you promote your project to the target audience?
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27. How will you evaluate your project's effect?
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28. What are the plans to sustain contact with the target group?
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 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