Project Title

Provide an 150-200 character summary for the project.

Project Manager Name

Email Address

Name of network member institution

LIBID

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

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

Mailing address

Award funding is a maximum of $2,500. No indirect costs are allowed. Please supply a brief budget.

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

Award should be made payable to what institution?

Federal Tax ID Number (FEIN)

Proposed start date (e.g. December 1, 2008). 

List your project objectives

Describe target population or audience.
(e.g. specific health professionals)

Describe how you will complete the project objectives.

List project personnel, their role in this project and experience relevant to this project.
You may submit CVs via separate emails to rml@library.med.nyu.edu or fax to 212-263-4258.

List any institutional support that will be provided.

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, NY 10010
Non-profit clinic providing outpatient services to primarily Native American population. Health Professionals on staff total 10, including physicians, nurses and health educators.

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

How will you evaluate your project's effect?

to the MAR office for review