Name of network member institution

Network Member LIBID

FEIN (Taxpayer ID#)

Project Manager(s)

Email Address

Mailing address

Day time telephone number (e.g. 555-555-5555)

Fax Number (e.g. 555-555-5555)

Business Office/Sponsored Programs Office Contact Information

Business Office Contact Email Address

Name of activity

Target Population Needs Assessment

Who is the target population for this activity?

What are the specific needs of this target population?

What is your rationale for selecting this activity? What benefits will the target population gain from your activity? Why is this activity appropriate to the NN/LM outreach mission?

Activity Plan

Describe the activity. What are the activity objectives? What steps are involved in performing this activity?

What is your proposed timeline for the activity, including proposed start date and end date?

What is the proposed location for the activity?

Who are the personnel who will be involved in the activity? Provide a list of the key personnel for the project and describe each person's responsibilities. Submit resumes/curriculum vitae for key personnel via email, postal mail, or fax. Supporting documentation should explain how applicable personnel are qualified to provide bioinformatics instruction.

Send letters of support from partnering organizations or other related organizations via email, postal mail, or fax.

Provide an itemized budget for your activity with justifications for all costs.

Examples of allowable expenses include publicity, honoraria and travel, professional services (writing, editing), consultant costs, room rental, equipment rental, printing/reproduction/graphics, other materials/supplies (specify). Submit quotes for equipment purchase via email, postal mail, or fax.

Total amount requested (maximum $15,000)

Evaluation

How will you evaluate the success of your activity? Develop evaluation criteria to explain how your activity objectives will be achieved. In developing the evaluation component, consider what is expected to be different once your activity is complete.

to the MAR office for review