Name of Network Member Institution

Federal Tax ID Number

Project Lead

Position Title

Mailing Address

Internet E-mail Address (e.g., maryc@project.org)

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

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

Proposed period of award. (Most assessment and planning awards are 3-12 months in duration.)

Title of your assessment and planning project:

What do you hope to accomplish with this assessment and planning award?

How will you accomplish your goals? Describe specific assessment and planning activities proposed. (For more information on needs assessments, see publications for the Outreach Evaluation Resource Center, in particular Getting Started with Community-based Outreach and Stage 1: Conducting a Community Assessment from Measuring the Difference.)

What is the audience or community focus of your assessment and planning project?

Do you anticipate partnering with other organizations in this assessment and planning process? If so, describe any previous work with these partners.

Award maximum is $2000. Please supply a brief budget. How will you spend the award?

Reporting Requirement (1-2 pages): At the conclusion, submit to the RML a summary of assessment process and results and a short description of next steps (if any).

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