East Indiana Area Health Education Center (EI-AHEC)
2016-2017 Mini-Grant Application – SEI Simulation Consortium
Due by 5PM Thurs, October 27, 2016 – may be emailed or sent as hard copy.
1. Name of project:
2. Which AHEC objective does your project/proposal address:
☐ 1) High school & undergrad student health careers awareness and readiness to pursue
☐ 2) Clinical and community experiences for students in health professions college programs
☐ 3) Professional development / continuing education for current health professionals
3. Is the organization applying for this grant a 501c3 nonprofit or a government or educational entity?
☐ yes
☐ no
EI-AHEC can only issue checks to 501c3s and government or educational entities. If you answered “no” above, an
eligible organization must serve as your fiscal agent to handle granted funds. If this is the case, please verify that an
organization is willing to serve as your fiscal agent by submitting a letter of support from the fiscal agent org’s board
president. Applications from non-eligible organizations will not be considered without this letter of support.
4. List details about the organization applying (or serving as fiscal agent):
Organization Name:
Contact Person:
Mailing Address:
Phone:
Email:
Tax ID Number:
5. Please provide a brief project description including goals and expected outcomes. Describe how
your project addresses AHEC objective 1, 2, or 3 as indicated on previous page.
6. Describe your project’s target audience. Estimate the number and type of program participants.
(examples - 12 high school students, 6 nursing students, 20 health professionals, etc.)
7. Identify the location, facility, or geographic area where the project will take place.
8. If applicable, list community partner organizations and what they will provide to the project.
9. If applicable (for objective 2 or 3 programs), describe how the project will be an Interprofessional
learning opportunity involving professionals or students from more than one health care discipline.
10. What are the costs of your proposal? Complete the budget template below and provide details of
any other forms of support including cash or in-kind contributions from your organization or other
community partners.
Budget Category
EI-AHEC Grant
Funds Request
Local/Partner
In-Kind Support
Local/Partner
Cash Support
Total for Budget
Category
Contractor / Professional
Services:
Education Supplies:
Travel:
Other (briefly explain):
Column Totals:
(up to $1,500 total here)
Priority is given to expenses that fund new or innovative programs. Applicants requesting funding for ongoing
activities are encouraged to address how this funding will improve or enhance learning opportunities.
Priority is given to applications that include a level of organizational or community partner in-kind or cash support.
Priority is given to applications that include Interprofessional learning opportunities for health professions students or
health care providers.
Reimbursement for food, entertainment, promotional items, scholarships, salaries, and administrative overhead is not
allowed with these grant funds.
Applicants will be asked to provide documentation of local cash and in-kind support as part of reporting process.
Successful applicants are expected to complete three steps to fulfill grant reporting and evaluation
requirements (details available online at www.eiahec.org/minigrants) :



Submit receipts for reimbursement by May 5, 2017
Short narrative report completed via online form by May 31, 2017
Individual participants/learners complete Indiana AHEC evaluation forms by May 31, 2017
Email completed applications as attachments to [email protected] with “sim mini-grant” in subject
line or mail hard copy to East Indiana AHEC, 4 S. Park Avenue, Batesville, IN 47006, Attn: mini-grant.
For questions, please contact:
Jenny Geers, Simulation Consultant, East Indiana AHEC
812-212-7374 or [email protected]