IU Health Values Fund
for the Integration of
Spiritual and Religious Dimensions in Health Care
2014- 2016 PROGRAM APPLICATION
PROJECT DIRECTOR:
Name:
Department:
Mailing Address:
Phone: Fax: Email:
Which of the following apply to you? (You must fit at least one category to be eligible.)
IU Health Employee Member of IU Health Medical Staff Holds an Official IU Health Appointment
TITLE OF PROPOSAL:
LOCATION OF WORK:
Start Finish
BUDGET PERIOD: (Not to exceed 24 months) 4/1/2014 to
AMOUNT REQUESTED: (Not to exceed $50,000 per year)
First Year: Second Year:
SIGNATURE OF APPLICANT: ______
Mail to: Office of Values, Ethics, Social Responsibility & Pastoral Services
Indiana University Health.
Fairbanks Hall, Suite 6107
340 W. 10th St.
Indianapolis IN 46202
Project Title: Application Form Page 2
ABSTRACT OF VALUES PLAN
KEY PROFESSIONAL PERSONNEL ENGAGED ON PROJECT
NAME POSITION TITLE DEPARTMENT
ABSTRACT OF VALUES PLAN: State the application’s long-term objectives and specific aims, making reference to the spiritual or religious dimensions of the project, and describe the process for achieving these goals. Avoid summaries of past accomplishments and the use of the first person. The abstract is meant to serve as a succinct and accurate description of the proposed work when separate from the application.
DO NOT EXCEED THE SPACE PROVIDED.
Project Title: Application Form Page 3
LAY DESCRIPTION:
Introduction:
Plan:
Outcome Measures:
Project Title: Application Form Page 4
DETAILED BUDGET FOR GRANT PERIOD #1 FROM THROUGH
PERSONNEL TIME/EFFORT AMOUNT REQUESTED $
Name Position title % hours per SALARY FRINGE TOTALS
Week BENEFITS
Principal Project Director
Co-Director
Subtotals Year # 1.
CONSULTATION COSTS:
EDUCATIONAL MATERIALS:
SUPPLIES:
OTHER EXPENSES
ALTERNATE SOURCES OF FUNDING
TOTAL DIRECT COSTS FOR YEAR #1:
Project Title: Application Form Page 5
DETAILED BUDGET FOR GRANT PERIOD #2 FROM THROUGH
PERSONNEL TIME / EFFORT AMOUNT REQUESTED $
Name Position title % hours per SALARY FRINGE TOTALS
Week BENEFITS
Principal Project Director
Co-Director
Subtotals Year # 2.
CONSULTATION COSTS:
EDUCATIONAL MATERIALS:
SUPPLIES:
OTHER EXPENSES
ALTERNATE SOURCES OF FUNDING
TOTAL DIRECT COSTS FOR YEAR #2:
Project Title: Application Form Page 6
BUDGET JUSTIFICATION:
Project Title: Application Form Page 7
RATIONALE FOR FUNDING, SIGNIFICANCE
- What is the potential importance of the proposed program? Discuss novel ideas and/or contributions the project offers.
- Make clear the potential importance of the proposed project to further spiritual and religious dimensions of healthcare, especially at IU Health. Explain how this project supports the IU Health values and is of benefit to the IU Health system and, if applicable, how it involves the larger faith community.
Project Title: Application Form Page 8
BIOGRAPHICAL SKETCH (Note: A current Curriculum Vita may be attached instead of the following)
EDUCATION: (Begin with baccalaureate training or other initial professional education, such as nursing, and include postdoctoral training.)
INSTITUTION AND LOCATION DEGREE YEAR FIELD OF
CONFERRED STUDY
PROFESSIONAL EXPERIENCE: Concluding with present position, list, in chronological order, previous employment, experience, and honors. List, in chronological order, the titles, all authors, and complete references to all publications during the past three years and to representative earlier publications pertinent to this application.
Project Title: Application Form Page 9
OTHER SUPPORT
(Include all support, active and/or pending)
(Use continuation pages if necessary)
Active Pending _ None
a. Source and identifying no. Project Director
TITLE :
b. Your role on project % of your effort:
c. Dates and costs and entire project (For renewals, include only the most recent competitive award. List direct and indirect costs separately.
Project Title: Application Form Page 10
PLAN:
Project Title: Application Form Page 11
GRANT APPLICATION SUMMARY
(NOTE: Do not exceed one page.)
TITLE:
PROJECT DIRECTOR:
MAILING ADDRESS:
TELEPHONE NUMBER:
AUDIENCE:
FUNDING:
PROJECT SUMMARY:
VALUES:
IU Health Values Fund Grant Application – 2014 - 2016