CCOT Injury Prevention Grant .pdf

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Original filename: CCOT Injury Prevention Grant.pdf
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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 University, Feinberg School of Medicine
676 N. St. Clair, Suite 650
Chicago, IL 60611
(312)695-4835
mcrandall@northwestern.edu

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:

Organization (if applicable):

Street Address:
Best Contact Telephone Number:

City, State

Zip
Fax Number:

Email:
Project Name:
Geographic Area Served:



Target Population:

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)

Name:

Relationship:

Telephone:
Address:

Email:

Name:

Relationship:

Telephone:
Address:



Email:

Academic/Professional Training (if applicable.) (Provide educational experience to
present)

High School

City/State

From

To

Diploma (y/n)

Date Rec’d

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)

Employer

City/State

Telephone

From

To

Position

_____ _____

_____ _____

_____ _____

I hereby certify that the information provided in this application and proposal is true and correct.

Signature:

Typed Name and Title:

Date:


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