Applying for:

Katrina Relief Award

Delta Information Access Project Award

1. Organization Name:

2. Organization LIBID:

3. Project Manager:

4. Position/Title:

5. Mailing Address:

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

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

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

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

Total Amount Requested:

Personnel or indirect costs are not allowed under this award.

10. 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, 2007):

14. Project Title:

15.Target Population: Describe the specific target group (health care professionals, librarians, consumers) and estimate how many of these you expect to reach with this project.

16.  Identification of Need:  Explain why there is a need for improvement in access to Internet-based health information.

17.  Project Objectives:  List the specific objectives you expect to achieve with the project.

18.  Methodology:  Describe the project.

19.  List any partners on this project.

20.  Evaluation:  Explain your evaluation methods and how you will know that you achieved each objective.  Please see Measuring the Difference: Guide to Planning and Evaluating Health Information Outreach or call the SE/A office (1-800-338-7657, choice #1 on menu) for assistance.

For information contact J. Dale Prince or Janice Kelly at the SE/A office.

to the SE/A office for review