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? Why is this activity appropriate to the NN/LM outreach mission? Special consideration will be given to applications for exhibits that address the outreach priorities of the NN/LM MAR Strategic Program Plan for Member Participation.

Activity Plan

If you created a logic model to illustrate the intended outcomes of the conference, please include the logic model as an attachment.

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.

Who are your partners for this activity? Check all applicable boxes.
Community or Faith Organization
Local Department of Health
Public Library
Health Professional Group
Other Organizations, please specify below.

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, NY 10010
Non-profit clinic providing outpatient services to primarily Native American population. Health Professionals on staff

Send letters of support from partnering 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 $7,500)

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. You may attach a logic model  to illustrate the intended outcomes of this project.

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