ASHA Reimbursement Issues Grants: Proposal and Resource Allocation Form

Application Instructions

Each Grant Application requires two forms:

Please answer briefly each question. You may put N/A if not applicable. The deadline for submissions is February 10, 2014. Late applications will not be considered. See the ASHA Reimbursement Issues Grants Procedures and Guidelines for details.

Note: You must complete this application in one sitting. Therefore, please allow sufficient time as you cannot save your information. You may wish to print this form to refer to when determining the answers beforehand. You can cut text from other applications (e.g., Word) and paste into this form.

*indicates required field.

Type of Application

Applicant Information

Project Title:*

President's First Name:*

President's Last Name:*

State Association:*

Mailing Address:*



Zip Code:*

Phone Number:*


Project Manager:*

Project Manager First Name:

Project Manager Last Name:

Mailing Address:



Zip Code:

Phone Number:


Acknowledgement of Grant Procedures and Guidelines

By checking this box, I affirm that I have fully reviewed and understand the Grant Procedures and Guidelines.

Issue Description

Describe the issue.*

Provide data or examples related to the issue.*

Solution Description and Implementation

Describe your solution and why you think this solution will work.*

Describe the project components to achieve your solution. Include any data/statistics needed and any barriers to the project's success.*

Describe the three main activities necessary to complete the project.*


List the top three project outcomes targeted, including a projected completion date for each outcome.*

What criteria will you use to measure project effectiveness?*

How do you plan to sustain the project once the grant funds are expended?*

What is the anticipated short-term effect of the project?*

What is the anticipated long-term effect of the project?*

Resource Allocation

What resources are needed for the project?

Equipment (e.g., computer, telephone):*

Supplies (e.g., note cards, envelopes, printing paper):*

Volunteers/Staff (how many, brief description of what they will do):*

Consultants (how many, brief description of what they will do):*

Other (please specify):*

President's Affirmation

The insertion of my name below is proof that I am the president of this association and can attest to the validity of the information contained in this Reimbursement Project Proposal and Resource Allocation Form.

President/Executive Officer's Name:*

Today's Date (MM/DD/YYYY):*

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