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2011 Lynne Doll Grant for Dissemination of Findings

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Congratulations on completing your study, funded by a J. Patrick Barnes Grant of The DAISY Foundation. If you are applying to present your findings at a professional conference, we will be happy to help you with your expenses, up to $2,000. We will help you fund travel expenses, poster production, etc.

Please provide the following information:

Your JPB Grant Number (if you need to be provided with this number, please email bonniebarnes@DAISYfoundation.org): *

Title of Your Study: *

Institution at which study was conducted: *

Principal investigator's first name: *

Principal investigator's last name *

Principal investigator's email: *

Principal investigator's phone number (555 555 5555): *

Principal Investigator's Title: *

Principal Investigator's Credentials: *

Date of Study Completion: *

Amount of grant you are applying for (not to exceed $2,000): *

Has Your Final Report Been Submitted To The DAISY Foundation? *

If your final report has not been submitted, when do you anticipate it will be sent to The DAISY Foundation?

Tell us about the conference at which you plan to present. (If you have more than one, please submit separate applications. Keep in mind that we will fund only up to $2,000 per study funded by DAISY.)

Name of organization whose conference you are applying to: *

Name of conference: *

Conference location (city and state): *

Conference dates: (mm/dd/yyyy - mm/dd/yyyy) *

Has your abstract or submission been approved for presentation yet? *

If your abstract has not yet been approved, when do you anticipate hearing from the conference organization?

If your abstract has been approved, please upload the approval letter from the organization.

Who will be presenting your study at the conference? *

Please upload your abstract as submitted to this organization *

Funding Requested

What specific expenses are you applying to have paid for by your grant? Please indicate the item and the amount. Be as specific as possible. (E.g. Poster production - $100, airfare to conference from San Francisco - $550, etc.) *

Mailing Address for Payment

To whom will the check be written if you are approved? (an institution or a fund at your institution, only. Not to an individual.) *

Department/Mailstop/P.O. Box, etc.

Street: *

City: *

State: *

Zip Code: *

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