Project Proposal Screening Template
(To be completed by individual proposing project or individual responding to request for MDAFP participation in project.)
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
E-mail
example@example.com
Phone Number
-
Area Code
Phone Number
Proposed Project/Service:
Proposed by (name of individual or outside organization):
Brief Description of Project:
What exactly would MDAFP be doing if it takes on this project/service?
What is the planned duration of this project?
This project supports which of the following strategic Areas of Focus:
Promote Family Medicine Advocacy
Promote resiliency in the Family Medicine Workforce
Promote Practice Transformation and Value Based Payment Reform
Nurture and Develop Physician Leadership
Other
Explain how the project fits or does not fit the strategic plan:
What goals and annual results would this project support?
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Would the proposed project overlap or duplicate an existing MDAFP activity?
Yes
No
If "Yes," please describe:
Could the proposed project replace an existing MDAFP activity?
Yes
No
If "Yes," please describe:
How many staff hours per month will be required?
How many member (volunteer) hours per month will be required?
Can the project be executed with available staff and member time?
Yes
No
If “No,” please describe the additional people resources that will be required (such as temporary, freelance help or contract employees):
What is the total cost of this project?
How will the project be funded? The project:
Is a revenue-producing product/service and is self-funding
Is self-funded through grant money; Source:
Is a revenue-producing product/service but will require MDAFP seed money
Will not produce revenue-and will require MDAFP funding
Additional potential outside funding sources:
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Specify what quantifiable measurements will be used to evaluate the project’s effectiveness and timetable on which success will be assessed (i.e. Measure & Timeframe):
Is this the best (most cost-effective) means for accomplishing the project’s primary objectives?
What are the risks of taking on this project?
Additional Information
Should be Empty: