Network Member Institution

LIBID

FEIN (Taxpayer ID#)

Project manager(s)

Mailing address

E-mail address

Telephone number (e.g., 555-555-5555)

Fax number (e.g., 555-555-5555)

Business Office/Sponsored Programs Office Contact Information

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?  How does this activity advance the progress of medicine and improving the public health through access to health information (the NN/LM 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?
All funded project must be complete by April 30, 2011.

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. If you are partnering with other organizations, send letters of support from those 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). Meal per diems are the only allowable food expenditure.

Total amount requested (Maximum $25,000)

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.

Click "Submit" to email your application to MAR. Any supporting documentation should be faxed to MAR at 212.263.4258