Title
Name
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First Name
Last Name
Organization Name
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
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Approved Uses for Funds
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Please indicate under which category of Approved Uses you plan to provide activities.
Agency Information
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Please describe your organization's Mission, staffing structure, history, and previous experience in providing services the same as, or similar to, those proposed.
1. Describe the proposed project in the text box below, identifying the ways in which it will address the opioid concerns in your community(ies) served.
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2. Clearly identify project resources and activities, and clearly state the project's anticipated goals, objectives, and outcomes.
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3. Describe the target population and service area(s) of the proposed project.
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1. Personnel
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Identify and describe the expenses related to wage and fringe for any personnel paid through this award.
2. Travel
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Identify and describe the expenses related to Travel. Please breakdown by anticipated costs for flight, lodging, per diem, transportation, if applicable.
3. Supplies
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Describe and identify costs for Supplies to support project activities. These may include office supplies, program supplies, medical supplies, etc. Note: Food expenses are not allowed.
4. Equipment
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Describe and identify costs for Equipment to support project activities. Note: Equipment costs are for items that are more than $5,000.
5. Other Costs
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Describe and identify other costs to support project activities. Examples include consultant costs, professional services, and similar items.
6. Indirect
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If you have an indirect rate, please include the percentage and total expense. Note: Contractor and equipment costs are excluded from calculation.
