Name of network member institution

LIBID

Federal Tax ID Number (FEIN)

Project Manager(s)

Mailing address

Email Address

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

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

Name of Activity

Target Population Needs Assessment

Who is the target population for this activity? Provide the numbers and types of health care professionals (i.e. the target population) that you expect to reach.

What are the specific needs of this target population?

What is your rationale for selecting this target population and this conference? Why it is 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?

Provide the name and description of the primary organization sponsoring the meeting, including the mission of the organization. Provide information about the conference where your activity will occur. What are the conference objectives?

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. 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 $2500)

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