Name of Activity

Brief Abstract (200 words or less; include objectives, methods and anticipated outcomes)

Name of network member institution

LIBID

FEIN (Taxpayer ID#).
Award check will be payable to this Taxpayer ID#

Project Manager(s)

Mailing address

Email Address

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

Target Population

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

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? The scope of the activity needs to be such that it can feasibly be completed by April 30, with a funded start date in mid- to late October 2010 (within approximately 6 months)

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 total 10, including physicians, nurses and health educators.

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.

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