1. Organization Name:

2. Network Member?

Yes, Network Member LIBID

No, but membership application submitted

3. Project Manager:

4. Position/Title of Project Manager:

5. Department:

6. Mailing Address:

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

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

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

10. Award funding is a maximum of $5,000.00 Please supply a brief budget.

Meal per diems are the only allowable food expenditure. No indirect costs are allowed.

How will you spend the award? (Provide a cost breakdown with a justification for each budget line.)

11. Award should be made payable to what institution (i.e., Southeastern Regional Medical Center)?

12. Federal Tax Id Number (FEIN):

13. Proposed start date for 12 month project (e.g. July 1, 2006):

14. Project Title:

15. List your project objectives.

16. Describe target population or audience.
Example: Senior Citizens, Public Health Nurses, Health Educators

17. Describe how you will complete the project objectives.

18. List project personnel, their role in this project and experience relevant to this project.

19. List any institutional support that will be provided.

20. The Network member will work with the following organization(s):
(Check all that apply)

Community or Faith Organization

Local Department of Health

Public Library

Health Professional Group

Other Organizations, please specify below

21. 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, MD 21220
http://www.southclinic.go

Non-profit clinic providing outpatient services to primarily Native American population. Health Professionals on staff total 10, including physicians, nurses and health educators.

22. What are the expected outcomes or next steps of this project?

23. How will you evaluate your project's effect?

to the SE/A office for review