CCOT Injury Prevention Grant
Content
Chicago Committee on Trauma of the American College of Surgeons Injury Prevention Community Grants The Chicago Committee on Trauma (CCOT) of the American College of Surgeons will be funding three to five grants to support injury prevention programs in Chicago communities. Each award will total $15003000, depending on the scope and project. Eligible applicants: individuals, schools, and community groups currently providing injury prevention services or interested in beginning promising new projects are invited to apply. Applications will be evaluated on criteria including evidence of community focus, previous successes in the field of injury prevention, and clarity of vision. We are specifically interested in funding projects that provide novel or alternative pathways to decrease violence and injury in disadvantaged communities.
Please forward this application, including the 1-page (or less) Project Summary, and 1-page (or less) Proposed Budget to: Marie Crandall, MD, MPH, FACS Associate Professor of Surgery Northwestern Feinberg School of Medicine 676 N. St. Clair, Suite 650 Chicago, IL 60611 In addition to the grant application, you may provide a letter of endorsement for your project. This letter does not have to be from someone directly involved in your project, but it cannot be from the persons acting as your personal references. Important Dates: Submission Deadline: March 14, 2014 Announcement of Awards: June 3, 2014 Funding Awarded: September 3, 2014
GRANT APPLICATION
Date: Name: Street Address: Best Contact Telephone Number: Email: Project Name: Geographic Area Served: Target Population: Organization (if applicable): City, State Fax Number: Zip
Proposed Project (Describe the Proposed Project and include why you are requesting the grant and what you hope to achieve.) Limit to no more than one page: Title: Summary of Project:
Budget Summary: (may use template below or may submit separate attachment- funding request should not exceed $3000) Personnel (e.g.,stipends) Printing/materials (specify) Space Rental Advertising/publication Other (specify) Total _________ _________ _________ _________ _________ _________
Current or Previous Injury Prevention Project Experience- Provide dates and brief summary of work
Formal Recognition/Awards Related to Research or Activities Cited in this Application (if applicable.)
Two Personal References from those who directly observed the applicant’s research or outreach/ educational activity. (Please do not list persons who have provided letters of recommendation) Relationship:
Name: Telephone: Address:
Email:
Name: Telephone: Address:
Relationship:
Email:
Academic/Professional Training (if applicable.) (Provide educational experience to present)
City/State From To Diploma (y/n) Date Rec’d
High School
College(s)
City/State
From
To
Degrees/Diploma
Date Rec’d
Graduate School(s)
City/State
From
To
Degrees/Diploma
Date Rec’d
Professional School(s)
City/State
From
To
Degrees/Diploma
Date Rec’d
Employment History (if applicable.) (Provide work/other experience to present)
City/State Telephone From To Position
Employer
_____ _____
_____ _____
_____ _____
I hereby certify that the information provided in this application and proposal is true and correct.
Signature:
Date:
Typed Name and Title:
Please forward this application, including the 1-page (or less) Project Summary, and 1-page (or less) Proposed Budget to: Marie Crandall, MD, MPH, FACS Associate Professor of Surgery Northwestern Feinberg School of Medicine 676 N. St. Clair, Suite 650 Chicago, IL 60611 In addition to the grant application, you may provide a letter of endorsement for your project. This letter does not have to be from someone directly involved in your project, but it cannot be from the persons acting as your personal references. Important Dates: Submission Deadline: March 14, 2014 Announcement of Awards: June 3, 2014 Funding Awarded: September 3, 2014
GRANT APPLICATION
Date: Name: Street Address: Best Contact Telephone Number: Email: Project Name: Geographic Area Served: Target Population: Organization (if applicable): City, State Fax Number: Zip
Proposed Project (Describe the Proposed Project and include why you are requesting the grant and what you hope to achieve.) Limit to no more than one page: Title: Summary of Project:
Budget Summary: (may use template below or may submit separate attachment- funding request should not exceed $3000) Personnel (e.g.,stipends) Printing/materials (specify) Space Rental Advertising/publication Other (specify) Total _________ _________ _________ _________ _________ _________
Current or Previous Injury Prevention Project Experience- Provide dates and brief summary of work
Formal Recognition/Awards Related to Research or Activities Cited in this Application (if applicable.)
Two Personal References from those who directly observed the applicant’s research or outreach/ educational activity. (Please do not list persons who have provided letters of recommendation) Relationship:
Name: Telephone: Address:
Email:
Name: Telephone: Address:
Relationship:
Email:
Academic/Professional Training (if applicable.) (Provide educational experience to present)
City/State From To Diploma (y/n) Date Rec’d
High School
College(s)
City/State
From
To
Degrees/Diploma
Date Rec’d
Graduate School(s)
City/State
From
To
Degrees/Diploma
Date Rec’d
Professional School(s)
City/State
From
To
Degrees/Diploma
Date Rec’d
Employment History (if applicable.) (Provide work/other experience to present)
City/State Telephone From To Position
Employer
_____ _____
_____ _____
_____ _____
I hereby certify that the information provided in this application and proposal is true and correct.
Signature:
Date:
Typed Name and Title:
