NN/LM PNR
Community Health Outreach Award Application

Submit application via email to:

National Network of Libraries of Medicine,

Pacific Northwest Region (NN/LM PNR)

Email:

Required Submissions (forms provided):

  • Cover Sheet
  • Project Information and Plan
  • Budget (including detailed narrative budget justification)
  • Direct Beneficiaries / Populations Targeted
  • NN/LM Goals

Attach or send separately:

  • Curriculum vitae of key personnel
  • Letters of support from applicant’s institution

Word format (.doc or .docx) is preferred.

Deadlines:

Applicants should inform NN/LM PNR of their intent to apply by emailing o later thanthree weeks before submitting the application, per instructions on the funding page:

Applications will be accepted until the date specified on the funding page:

COVER SHEET

Project Title:

Date of Submission:

Organization Name and Address:

Name and Address of Organization to whom payment will be made:

Federal Tax ID Number:

Project Manager/Leader Name and Title:

Project Manager/Leader Telephone:

Project Manager/Leader E-mail Address:

Amount being requested:

Is your organization a member of the National Network of Libraries of Medicine Pacific Northwest Region?

PROJECT INFORMATION AND PLAN

  1. Project Title:
  1. Proposed start and end dates for project:
  1. Summary statement:

Provide a one paragraph summary of the proposed project to summarize the goal and objectives, the intended outcomes, and the work plan.

  1. Describe the target audiences and need for your project:

Include demographics, health information assets and needs, and how this data was gathered. Explain why there is a need for information outreach to the target audience. Include an estimate on the number of individuals you expect to reach during the project. For more information on needs assessments, see publications of the NN/LM Evaluation Office, in particularBooklet 1: Getting Started with Community-Based Outreach.

  1. Identify the goals of the proposed project:
  1. State the specific objectives to be achieved by the project:

Objectives should be stated in measurable terms. Include process objectives about what will be done (outputs) and outcomes-based objectives that specify what will happen or change as a result.Outcomes are the benefits you expect your project will have for individual participants and possibly the community, organization, or system. Use of a logic model to develop an outcomes-based project plan is strongly recommended. See Booklet 2, "Planning Outcomes-Based Outreach Projects" at.

  1. Provide a detailed work plan (max 1000 words), and indicate a rationale for the plan.

Describe how the project will be implemented, and the products, strategies or services you will produce or carry out to achieve intended outcomes. If training and/or demonstrations are included as a methodology, describe what will be taught or demonstrated, who will do it, where it will be done, length of class, type of continuing education credit, what training materials will be used, and a description of the target audience for each event. Applicants are expected to use or adapt existing training materials before developing new materials. Consult the National Training Office to identify training materials already available ().

  1. Evaluation plan.

Explain how the success of the project will be measured and the methods to measure that success. Evaluation should be tied to project goals and objectives. For assistance, consult “Step Three--Use Your Logic Model to Develop an Outcomes Assessment Plan” in Booklet 2: “Planning Outcomes-Based Outreach Projects” at . Members are strongly encouraged to consult the NN/LM PNR or the NN/LM Evaluation Office (NEO) publications and resources in developing an effective evaluation plan:

Award recipients conducting certain NN/LM activities will be asked to collect specific information and report it at the end of the project using forms provided by the NN/LM. If your project includes training, technology improvement, exhibiting/health fairs, or professional development activities, you will need to report this standard information. Please refer to the NN/LM Evaluation Office’sNN/LM Evaluation Materialsweb page for the type of information you will need to report. In your evaluation plan, explain how and when you will use the NN/LM forms to collect the information,andinclude any additional evaluation that you are planning for the project.

  1. Please provide a timeline for your project.

Provide a list of tasks in chronological order and indicate timeline for each task. The project should be completed by April 30, 2017. A no-cost extension may be requested if needed.

  1. Identify all project personnel and their role in the project.

If consultants are proposed, (note that prior approval from NLM is required) include the following information in this application:

• Name of Consultant

• Description of Work

• Hourly Rate

• Total Amount/Not to Exceed Amount

• Period of Performance

  1. List types of partner organizations you will work with to carry out the project: (check all that apply)

___ State or RegionalHealth Organization

___ State or County Health Department

___ State Library

___ Public Library

___ Health Sciences Library

___ Academic organizations (please specify):

___K-12 library

___ Community organizations (please specify):

  1. List name(s), address(es), website(s) (if any) and description(s) of partner organization(s) and key contact person.
  1. Please complete the budget form on the following page.

PROJECT INFORMATION AND PLAN

BUDGET FORM[1][2][3]

Please use the budget form provided below and provide an itemized narrative budget justification. Note instructions given in the form, and allowable expenses listed below.

Budget Item / Description / Costs for performance period
from: [day/mo/yr] to [day/mo/yr].
  1. Salaries[4]

  1. Fringe Benefits[5]

  1. Equipment

  1. Travel[6]

  1. Supplies

  1. Other Costs

Total Direct Costs
(A+B+C+D+E+F)
Modified TDC (TDC minus Equipment)
Indirect Costs[7]
(MTDC*x%)
Total Costs
(TDC+IDC)

Allowable expensesPersonnel, equipment, supplies, travel and other costs such as reproduction of materials, software, Internet service provider fees. These are examples only and are not meant to be all-inclusive. Purchase of print materials is permitted, but must not exceed 5% of the direct costs.

Expenses are also allowed to publicize a health information service, event or resource, including National Library of Medicine (NLM) or National Network of Libraries of Medicine (NN/LM) resources or services, but the allowable costs are limited to educational materials or publicity, such as posters, displays, flyers, bookmarks, or brochures. Please consult the policy at

Non-allowable expenses: Furniture is not allowed and food is not allowed unless certain circumstances apply. Please consult the policy under Meals at

Indirect Costs (IDC) or Facilities and Administrative (F&A) Costs:Indirect cost (IDC)/F&A can be included based on your institution's federally approved IDC agreement (non-research rates apply). A 10% MTDC rate may be used if no IDC agreement exists.

Additional Forms to be Included with Proposal

The following three forms must be included with your proposal. Please fill out the forms and submit them with your proposal.

  1. Direct Beneficiaries
  2. Populations Targeted
  3. Goal Identification

Direct Beneficiaries / Populations Targeted

Institution Name:______

Please check categories applicable to the target populations that will benefit from the funding.

ConsumersScientists

General Public / Biomed/Genetics/Biotech
Patients & Families / Chemistry/Toxicology/Environment

Librarians Students

Health Science / College
Hospital / Health Professionals
Public / Other / K - 12

Health Professionals

All Types (no special focus) / Pharmacists
Allied Health / Physicians
Dentists / Public Health Workforce
Health Services Researchers / Veterinarians
Mental Health / Community Health Workers
Nurses / Other ______

Other

Disaster & Emergency Professionals / Responders / Historians
Educators / Journalists
Health Administrators / Other ______
Primary Demographic of Targeted Populations (select up to 3)
African Americans / Native Hawaiians
Alaska Natives / Pacific Islanders
American Indians / Rural
Asian Americans / Seniors
Hispanics/Latinos / Women
HIV/AIDS / Youth/Teen
Displaced / Other ______
Inner City / Not Applicable
International

Please check the NN/LM goals that apply:

Goal ID / Applies / Description
1. / / Increase awareness and use of NLM information resources.
2 / / Serve as a primary source for reliable and authenticated content
3 / / Train in the use of medical information resources
4 / / Strengthen communications and connectivity for health, i.e. infrastructure.
5 / / Reduce and eliminate health disparities among minority and other underserved populations.
6 / / Support the information needs of health professionals who serve underserved and special populations.
7 / / Conduct assessments to learn what improvements in service or new support is needed and to evaluate effectiveness of current programs.
8 / / Improve understanding of research data management practices, services and tools
9 / / Establish strategic partnerships to support access to biomedical and research tools.
10 / / Support community and academic partners’ outreach to students and encouragement of careers in science, technology, engineering, and mathematics (STEM)
11 / / Upgrade, replace or adopt technologies that will increase access to health information

NN/LM PNR Community Health OutreachApplication

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[1] This form should be accompanied by a narrative justification to provide sufficient supporting detail.

[2] Whole dollar amounts are sufficient.

[3]The total allowable performance period for this award is up to 12 months.

[4]Use base salary. Specify monthly dollar amount and full time equivalent for each individual. *e,g,.025 FTE)

[5] Express as percentage(s) of salaries.

[6]Itemize mode of travel, fare, lodging and per diem expenses, and name of traveler(s) for each trip.

[7]Indirect cost (IDC; F&A) may be included if desired, based on the proposing institution's federally approved indirect cost rate agreement (the 10% Modified Total Direct Cost rate may be used if the institution has no federally approved IDC agreement).