Mini Grant Announcement Template by ftw35794

VIEWS: 9 PAGES: 5

									            Tobacco Control and Prevention Mini Grant Application



 Region
Applicant Name
Proposal Name
Mailing Address
City/State/Zip
Contact Person
Telephone
E-mail

Fiscal Agent
(If different from
Applicant)
Mailing Address
City/State/Zip
Contact Person
Telephone
E-mail


Which one of the following goals will your mini grant address?

    1. Prevent tobacco use
    2. Promote cessation
    3. Educate community about the dangers of secondhand smoke
    4. Enforce clean indoor air regulations *
* Only applies to counties with at least smoke-free restaurants and only Health Departments
can enforce CIA regulations.

Will you be working with more than one county within your region?

    Yes Specify counties
    No




Signature of
Applicant Representative ____________________________________ Date: ____________




Print Name and Title of
Applicant Representative ____________________________________________________
Describe your mini grant project.

How will funding be used?




What is the expected outcome?
Work Plan: The work plan will guide your project. Careful consideration should be given
to your goal(s), objectives, and activities. We suggest keeping the following definitions
in mind as you prepare your work plan.

Goal – a broad, long-range outcome you intend to achieve.

Objectives – the key steps needed to meet a specific goal. Each objective should
contain only one expectation that is both specific and measurable and has a clear end
date. Each goal can be supported by one or more objectives.

Activities – the key steps needed to accomplish a specific objective. Each objective can
be supported by one or more activities.


Goal:


Objective 1.


Activity to Complete Objective                                          Target Date of
                                                                         Completion




Objective 2.


Activity to Complete Objective                                          Target Date of
                                                                         Completion




Objective 3.


Activity to Complete Objective                                          Target Date of
                                                                         Completion
        Budget

                                                      Funds                       WVBPH
                   Budget Item                      Requested   In-kind   Total   use only
                                                    from DTP    Support

Personnel

                                          Percent
            Name/Position                   (%)
                                           Effort




                    SUB TOTAL
Materials/Supplies:



Consultants


Other expenses:


Total Direct Costs (Sum of Personnel,
Materials/Supplies, Consultants and Other
Expenses)
Administrative Costs (limited to 10% of direct
costs)


TOTAL
                                     Budget Justification

Personnel




Materials/Supplies




Consultants




Other expenses




Administrative costs (limited to 10% of direct costs)

								
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