APPLICATION

2016 NYSGE Florence Lefcourt Award

$10,000

NAME: ______

INSTITUTION/PRACTICE: ______

Address: ______

phone: ______

EMAIL: ______

Public education Project description

Please address:

  • Major components of your proposed public education outreach plan
  • What needs it meets in your community/region
  • Goals you hope to accomplish

______

Description of past public education efforts

Please address:

  • Project components and results
  • If you led the outreach or if you were part of a broader campaign

______

Proposed budget

Please address:

  • Each component of plan and its individual cost up to $10,000**

**The budget request should be detailed and all items should be clearly related to the public outreach proposal. Budgets will be carefully scrutinized by the ASGE Public & Member Outreach Committee and will be considered in the scoring of the grant. Inappropriate or poorly justified budgets will jeopardize the likelihood of the application receiving an award.

1)Funding requests may include:

a)Personnel (assistant and/or faculty salary support--percentage of time for the outreach should be specified and appropriately justified).

b)Supplies essential for outreach

2)Funding will not be provided for:

a)Salary support for trainees

b)Computer purchases

c)Standard equipment and supplies needed for appropriate patient care

d)Travel to meetings

e)Indirect costs

______

***NYSGE letter of support***

Please sign below to request your letter of support from NYSGE.

I understand that a letter of support from NYSGE is a requirement for the Florence Lefcourt Award. This serves as a request for a letter of support from NYSGE to be provided to the ASGE Public and Member Outreach Committee along with my application.

Signature Print name

Deadline

Applications must be received no later than Monday, February 9, 2016. Late submissions will not be considered. The award will be announced and funds distributed in lateFebruary 2016.

Note: The ASGE Public & Member Outreach Committee reviews applications and makes an award recommendation to the ASGE Foundation Board of Trustees. The selection of the ASGE Foundation Board is then approved by the ASGE Governing Board.

Submit to:

Applications may be mailed or emailed. Applications must be submitted to ASGE andNYSGE at the same time.

Send one copy to:

ASGE

Attn: Gina Steiner

American Society for Gastrointestinal Endoscopy

3300 Woodcreek Drive

Downers Grove, IL 60515

(630) 573-0691 (fax)

For further details, please call (630) 573-0600

Send a second copy to:

NYSGE

Attn: Karen Cervenka

New York Society for Gastrointestinal Endoscopy
1461 First Avenue, Suite 324
New York, NY 10075-2201
Email:
Phone:646-218-0650
Fax: 866-381-7288

CHECKLIST

2016 NYSGE Florence Lefcourt Award

$10,000

□NAME

□INSTITUTION/PRACTICE

□Address

□phone

□EMAIL

□Public education Project description

□Description of past public education efforts

□Proposed budget

□***NYSGE letter of support***(sign this area of the application)

□Deadline: Must be received no later than Mon., February 9, 2016

□Submit to: Submit two copies—one to aSGE, one to NYSGE

Applications may be mailed or e-mailed:

ASGE

Attn: Gina Steiner

American Society for Gastrointestinal Endoscopy

3300 Woodcreek Drive

Downers Grove, IL 60515

For further details, please call (630) 573-0600

NYSGE

Attn: Karen Cervenka

New York Society for Gastrointestinal Endoscopy
1461 First Avenue, Suite 324
New York, NY 10075-2201
Email:
Phone:646-218-0650
Fax: 866-381-7288