EDUCATION TECHNOLOGY GRANT

Instructions

All fields with an asterisk (*) at the top left corner are required fields. This form must be completed in full prior to submission. You will not be allowed to return. Suggestion is to create a Word document then cut & paste to form.

First Name: *

Last Name: *

Credentials (MD, PhD, etc): *

Position Title: *

Email: *

Phone: *

Department or Program: *

Education Development
Please provide a description of the means by which acquisition of this material will enhance your educational development.

*

University Teaching Mission
Please provide a description of the means by which acquisition of this material will further the teaching mission of the University.

*

Education Technology Grant Proposal

Title *

Project Description (2500 words or less) * 🛈

Please upload vendor quote here *

Please upload additional supporting document here (if appropriate)

Budget for Expenses

Budget for Expenses * 🛈

	Amount
Education Technology Material	Amount
Additional resource 1	Amount
Additional resource 2	Amount
Additional resource 3	Amount
Total Amount Requested from the Academy	Amount

Sources of additional funding (if appropriate)

Additional Requirements After Funding

If your grant proposal is successful and funded, we will require a progress report on the use of the education technology funds and how it enhanced the educational mission to be completed by January 1, 2017. We will ask about possible publications, abstracts, or presentations resulting from this funding one year after the funding of the grant. *

Yes, I accept the additional requirements

No, I decline the additional requirements