NIRS Project Form – FY08
*ResponseRequired
*Program Type (Check all that apply):
LEND UCEDD
*Fiscal Year: 2008
*Title of the Project: ______
No Title
Project Abbreviation: ______*Project Code: ______
(If applicable) No Project Code
Contact Name & Address Information for Project
*First Name: ______Middle Name: ______*Last Name: ______
Title: ______Highest Degree: ______
*Work Address:______
(Required, if
applicable)______
WorkCity: ______State: ______Zip Code: ______
*Home Address:______
(Required, if
applicable)______
HomeCity: ______State: ______Zip Code: ______
Email: ______Website: ______
Phone: ______Fax: ______
(Use the format 999-999-9999) (Use the format 999-999-9999)
Funding Start: ____/____/______Funding End: ____/____/______
mm dd yyyy mm dd yyyy
Total Funding(Pertains to the entire life of the Project; Omit punctuation) $______
Funding Type(Check all that apply):
___ Grant ___ Contract
___ Co-operative Agreement ___University Support
___ Fees/Per Capita Reimbursements ___ In-Kind Contributions
___ Other, Please Specify ______
Current FY Funding Amount(s) & Source(s)
(Report Current FY Amounts Only; Select all that apply; Omit punctuation)
Federal Funding Sources– Catalog of Federal Domestic Assistance Number (CFDA#) ______
HHS
ACF
ADD $______
Head Start $______
Other ACF, Please Specify ______$______
HRSA
MCHB Core Funding $______
Other MCHB
SPRANS $______
CISS $______
SSDI $______
Abstinence Education $______
Healthy Start $______
EMSC $______
Traumatic Brain Injury $______
Other HRSA Funds
Bioterrorism $______
HIV/AIDS $______
Primary Care $______
Health Professions $______
Other HRSA, Please Specify ______$______
NIH
NICHD $______
NIMH $______
NINDS $______
NIDCD $______
Other NIH Institute, Please Specify ______$______
CMS (Formerly HCFA) $______
CDC $______
AHRQ $______
AOA $______
SAMHSA $______
IHS $______
Other HHS, Please Specify ______$______
ED
OSERS
OSEP $______
NIDRR $______
RSA $______
Other ED, Please Specify ______$______
DOJ $______
DOL $______
SSA (SSI) $______
NSF $______
HUD $______
USDA$______
Other Federal, Please Specify ______$______
State Funding Sources
Department of Social Services$______
Department of Education $______
Department of Health (including Title V)$______
Department of Mental Health$______
Department of Mental Retardation/Developmental Disabilities$______
DD Council$______
Vocational Rehabilitation$______
Medicaid/Medicare$______
Other State and Local, Please Specify ______$______
Local Funding Sources
Health$______
School District$______
Social Services$______
Other Local, Please Specify ______$______
Other Sources
Foundation$______
Service Organization$______
Fee for Services$______
University$______
AUCD$______
Donations$______
Other, Please Specify ______$______
Current FY Funding(Total from all sources)$______
* Type of Activity(Check all that apply)
___ Advocacy ___ CapacityBuilding ___ Systemic Change
* Core Function (Check all that apply):
___ Training Trainees
___ Performing Technical Assistance and/or Training
___ Performing Director and/or Demonstration Services
___ Performing Research or Evaluation
___ Developing & Disseminating Information
* Areas of Emphasis(Check all that apply):
___ Quality Assurance ___ Education & Early Intervention
___ Child Care-Related Activities___ Health-Related Activities
___ Employment-Related Activities ___ Housing-Related Activities
___ Transportation-Related Activities___ Recreation-Related Activities
___ Quality of Life ___Other-Assistive Technology
___ Other-Cultural Diversity ___ Other-Leadership
___ Other, Please Specify: ______
*Target Audience (Check all that apply):
___ Students/Trainees (long or intermediated trainees)
___ Community Trainees/Short Term Trainees
___ Professionals and Para-Professionals
___ Family Members/Caregivers
___ Adults with Disabilities
___ Children/Adolescentswith Disabilities/SHCN
___ Legislators/Policy Makers
___ General Public
___ Not Applicable
*Unserved or Under-Served Populations (Check all that apply):
___ Racial or Ethnic Minorities
___ Individuals from Disadvantaged Circumstances
___ Individuals with Limited English Proficiency
___ Individuals from Underserved Geographic Areas
__ Empowerment Zone __ Renewal Community
__ Reservation __ Rural/Remote
__ Urban __ Territory
__ Other, Please Specify: ______
___ Specific Groups within the Population of Individuals with Developmental Disabilities
Please Specify: ______
___ Other, Please Specify: ______
___ Project Does Not Serve an Unserved/Underserved Population
*Agencies Collaborating on the Work of the Project (Name of Agency may be
(Must check all that apply) supplied in space provided)
___ State Title V Agency ______
___ Other MCHB Funded Program ______
___ Developmental Disabilities Council ______
___ Protection & Advocacy Agency (P&A) ______
___ UCEDD ______
___ Child Care/Early Childhood/Part C Infants & Toddlers ______
___Head Start/Early Head Start ______
___ State/Local Special Education (3-21) ______
___ State/Local General Education ______
___ Post Secondary Education (CommunityCollegeUniversity)______
___ Aging Organization ______
___ State/Local Social Services ______
___ Health Agency- Public/Private ______
___ Mental Health/Substance Abuse Agency ______
___ Employment/Voc Rehab ______
___ State/Local MR/DD Agency or Provider ______
___ Housing Agency/Provider ______
___ Recreation Agency ______
___ Transportation Agency ______
___ Consumer/Advocacy Organization ______
___ State/Local Coalition ______
___ Legislative Body ______
___ Justice/Legal Organization ______
___ Community or Faith-Based Organization ______
___ Health Insurance/Manage Core Organization______
___ Provider Organization______
___ National Association ______
___ Foundation______
___ Other ______
___ No Collaborating Agency
*Consumer Participation Role(Check all that apply):
___ Paid Staff ___ Consultant
___ Advisory Committee/Council ___ Task Force
___ Volunteer ___ None
*Geographic Scope(Check all that apply; May specify location in space provided)
___ Single County/Local ______
___Multi-County ______
___State ______
___ Multi-State/Regional ______
___ Another State______
___ National ______
___ International ______
___ Not Applicable
Key Words (List three to five key words or phrases):
______
Project Description
Using approximately 500 words, provide an overall project description or abstract that includes the following information:
1. Need
2. Overall goals and objectives
3. Unusual features
4. Expected benefits
______
FY08 NIRS Project Paper Form, Page 1 of 5