HEALTH MATTERS

OFFICE OF HUMAN RESOURCES

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CAMPUS INCENTIVE FUND PROPOSAL 2009 - 2010

Submissions will be accepted until May 29, 2009

Instructions: You can request a form by e-mailing Cassandra Kitko or you may print out this page by using the print button at the bottom of the form.

Form A -- Title Page

Campus Contact:

Campus:

Campus Address:

Telephone Number:

Contact Email Address:

User ID of person completing this proposal:

Name of Administrator:

User ID of Administrator:

Title of Administrator:

This project/program must be approved by the Administrator listed above.
Checking this box verifies that the Administrator has approved this project/program.

Program/Project Title:

Projected Number of Participants:

Abstract of Proposal (limit to 750 characters):

Form B -- Project Summary

Please limit all answers on this form to 750 characters each. A character is a letter, space, or punctuation.

1. Rationale: Briefly describe why you want to offer this program.

2. Objectives of the Program: The program will enable participants to:

3. Program Delivery: How do you plan to deliver this program?

4. Program Timetable: Timetable for program implementation:

5. Evaluation Plans: All proposals should have an evaluation piece. It is required for the follow-up report. Briefly describe the evaluation piece you plan to use.

Form C -- Budget Proposal

Itemized Expenses (limit to 750 characters): Please show a list of your expenses.

Total Cost of Program: $

From the above total cost of the program, how much money from the Campus Incentive Fund is your campus requesting? $

From the above total cost of the program, how much support money is the campus providing for the program offering? $

From the above total cost of the program, how much is the campus recommending the participants contribute to the screening
(cost for each participant)? $