The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

FKE2aEypRho7FsNK3JA4ibkXsx3pp5tnGI6vdmZMqbdV28QPnDc5FZtXMDct

Application for External Consultation Support for Health Disparities Research

Returning?

A A A

Please provide the information below. You may leave the application and return at a later time.

Your name

Position

Your position

Department

E-mail

Phone Number

I. Reseach

Title of proposed research

Technical assistance requested:

Travel for consultant

Honorarium for consultant

Other

Describe other technical assistance requested.

Describe specific expertise requested.

If a specific expert is requested, please give their name.

II. Proposal

In the space below provide project overview and purpose of request for consultation. Describe your goals for the long term project and the relevance of the project to the NM CARES objectives.

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II. Proposal the proposal will:
(Please check all that apply.)

Develop/implement a specific health disparity intervention research

Promote interdisciplinary or trans-disciplinary research

Establish/build and develop trusting partnerships between community and academia

Create community research partnership(s) / Increase community research capacity

Increase critical mass of Native American or Hispanic health disparities researchers

Increase funding opportunities (NIH or other)

Positive recognition of NM CARES in the HSC and in the state of NM

III. BUDGET FOR RESOURCES NEEDED EXTERNAL TO THE CENTER

Itemize budget. External consultations typically range from $2,000 to $5,000 and may include items such as consultant fee, honorarium, and travel.

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III. Budget: Justification of budget items.

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IV. OTHER

1-2 page abbreviated curriculum vitae, resume, or biosketch.

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