1. Name of Network Member Institution:

2. Network Member LIBID:

3. Project Manager:

4. Position/Title:

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.

• Funding will cover communication, equipment, supplies, reproduction, and travel.
• No additional food costs are allowed.
• No more than 10% of direct costs can be spent on print or audiovisual resources.
• Personnel and Indirect Costs are not allowed.
• Furniture costs are not 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. September 1, 2006);

14. Describe the project you lead or in which you participated and the need for the current award.

15. List of objectives for the follow-up project award.

16. Describe how you will complete the project objectives (your project plan).

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

18. List any institutional support that will be provided.

19. 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.

20. What are the expected outcomes of your follow-up activities?

21. From the expected outcomes, what are the anticipated next steps?

to the SE/A office for review