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

Describe your institution and your community (the target population)?

What are the specific emergency preparedness needs of your institution and community.

How would the “train-the-trainer” Emergency Preparedness Workshop at NYU on April 12-13, 2010 benefit you and your institution? How would a follow-up workshop benefit your community? Why is this activity appropriate to the NN/LM outreach mission?)

Activity Plan For Your Local Emergency Preparedness Workshop

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 emergency preparedness workshops conducted in your community following the April 12-13, 2010 “train-the-trainer” must be completed by April 30, 2010.

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). Submit quotes for equipment purchase via email, postal mail, or fax.

Total amount requested (Maximum $1,000)

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