Express Planning and Assessment Award Application
1. Name of Network Member Institution:
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2. Network Member LIBID:
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3. Project Manager:
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4. Position/Title of Project Manager:
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5. Department:
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6. Mailing Address:
Street 1:
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Street 2:
City:
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State:
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Zip Code:
(e.g., 99999 or 99999-9999)
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7. Email Address (e.g., maryc@project.org):
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8. Telephone Number [e.g., (222) 222-2222 or 555-555-5555]:
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9. Fax Number [e.g., (222) 222-2222 or 555-555-5555]:
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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.
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)?
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13. Federal Tax Id Number (FEIN):
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*
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16. Proposed start date for project ending April 30, 2014 (e.g. 10/19/2011):
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17. Project Title:
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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.
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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.
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.
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25. What are the expected outcomes or next steps of this project?
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26. How will you evaluate your project's effect?
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27. Comments
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