HRSA Grant Budget Request Form HRSA Grant Budget Request Form Date - must be mm/dd/yyyy format(Required) MM slash DD slash YYYY Recipient's Name(Required) First Last Recipient's Email(Required) Amount Requested from HRSA Budget(Required)Select the HRSA Grant these funds are being requested from::(Required)Please select one of the following:HRSA POSME (Byers)HRSA MSE (Westfall/Turnage)HRSA PCTE ( Attwood)Which grant objective is satisfied by your request?(Required)Please select one of the following:Objective 1: Enhance pre-medical pipeline recruitment and retention strategies to increase the number of students from Arkansas’ rural and/or MUCs enrolling in the UAMS College of Medicine (COM), and who ultimately return to practice in rural and/or MUC primary care settings in Arkansas.Objective 2: Increase community-based field placement and experiential training opportunities in rural and/or MUC primary care clinical training sites by expanding strategic partnerships across the state.Objective 3: Expand UAMS COM pre-clinical experiences, clinical rotations, service projects, and other opportunities to increase medical student knowledge, skills, and abilities related to HRSA Core Topics and service in rural and/or MUC settings.Objective 4: Develop and implement an interprofessional Faculty/Staff Development series designed specifically for new FQHC and CAH teaching clinicians.Objective 5: Improve all communications, incentives, and recruitment approaches to attract more students to new and existing rural/underserved/primary care experiences and initiatives.Objective 6: Improve standardization and evaluation processes to effectively document, track, measure and disseminate findings and outcomes for this project and all community—based primary care initiatives.Is this request supported within the narrative of the budget?(Required) Yes No If yes, please select a justification category for your request.(Required)Please select one of the following:Office Supplies/Educational Supplies/Promotional ItemsMembership DuesLunch and Learn EventFaculty/Staff Travel (in-state/local)Faculty/Staff Travel (out-of-state/long distance)MD2BStudent TravelStudent recruitment eventStudent Project Stipend (student)AHEC Scholars Award (student)Family Medicine Preceptorship Stipend (student)Elective Rotation Meal Stipend (student)Rural Student Ambassador Program Stipend (student)Summer STEM AcademyHonoraria for SpeakerRegional Programs/DFPM Annual UpdateHBCU Medicine Mentorship MixerASU MCAT Student StipendPMSS MCAT Student StipendSalaryMedical EquipmentMedical Spanish Interpreter ProgramContinuity ClinicHonors Program StipendIf requesting an AHEC Scholars Award (Student), select assisting recruiter/advisor:(Required)Select from the following:Yalanda MerrellJanet LigonDestiny CarterAna SanchezStephen AtteberyJesse CargillUrsula RedmondDanielle HarrisOtherIf 'Other', please provide the name of the recruiter/advisor assisting with this submission:(Required) Recruiter/Advisor's Email(Required) Processor's Name(Required) First Last If the person submitting this form is different from the fund recipient.Processor's Email(Required) If the person submitting this form is different from the fund recipient.Purpose of RequestPlease attach vendor number and any other supporting documentation needed for this fund request. *Please do not attach W9 or Vendor forms, or any documents that list protected information. For AHEC Scholars awards, W9 forms are to be emailed directly to Sheila Williams. Vendor Setup is now a Workday Process. Drop files here or Select files Max. file size: 15 MB. Additional Information (Optional)
