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COLLEGE OF EDUCATION, HEALTH, AND HUMAN SCIENCES
REQUEST OF CEHHS FUNDING FOR STUDENT DISSEMINATION OF RESEARCH
Student’s Name
Faculty Sponsor’s Name
Student’s Email
Faculty Sponsor’s Email
Student’s ID #
Student’s Major
Project Title
Project Authors (in order)
Conference/Event Name
Conference/Event Location
Received Notice of Acceptance?
Conference/Event Date(s)
YES
NO
If Not Accepted Yet, Anticipated Notification Date
Will the faculty sponsor be attending/co-presenting?
YES
NO
Will other students be attending/co-presenting?
YES
NO
Beyond the dissemination activity itself, to how many total hours of the conference/event does the requesting student commit
to engaging directly (e.g., attending presentations, workshops, & activities at the conference)?
HOURS
Brief Description of the Research:
NO
Yes
Funded
Yes
Pending
Amount
Have you applied for other funding? (i.e. Research Services, SSA, student
organizations)
$
Have you applied for dissemination funds through your major department?
$
What amount from personal funds do you expect to spend on this activity?
$
Projected Budget
(Attach Detailed Budget Form)
Amount
Requested from
CEHHS
Cost
Conference/Event Registration
$
$
Transportation (Student’s Share, if Appropriate)
$
$
Lodging (Student’s Share, if Appropriate)
$
$
Meals
$
$
Other Expenses (e.g., Printing)
$
$
$
$
TOTAL
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The limited dissemination funds are not granted as a reward; rather, funds are granted to support the pursuit of specific
learning goals associated with the dissemination activity. Clearly identify the learning goals to be supported by the requested
funds. Funded students are expected to participate fully in the conference/event beyond their project; identify all activities to
which the requesting student is committed, and make clear how the student and the institution will benefit from this
investment of funds.
QUESTIONS TO BE COMPLETED BY FACULTY SPONSOR
Was the project funded through a grant?
YES
NO
Grantor:
Are you interested in seeking grants for future projects?*
YES
NO
*contact UW-S Research Services to start receiving RFP’s
Signing below, we certify the accuracy of the information presented on this form and we indicate our understanding that the student is
responsible for filing a Goal Accomplishment Report with the CEHHS Dean’s Office within one month of the event’s conclusion. We
understand that failure to file a Goal Accomplishment Report may influence future funding decisions related to the student and others
who later work under the sponsoring faculty member.
_______________________________________________
_______________________________________________
Student Applicant Signature
Faculty Sponsor Signature
Date
Date
Submit the signed form along with attachments to Tina Bauer, CEHHS Dean’s office. Proposals may be submitted at any time, but
priority will be given to proposals received by October 1 and February 1 (Fall/Spring review dates). Funds are limited; applicants
are urged to submit high quality proposals in a timely manner.
Attach: Copy of conference/event proposal
Copy of acceptance notification
Detailed Budget Form
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The faculty sponsor will
provide the student with a
completed copy of this page
(some fields will naturally
remain blank). If needed, an
explanatory note may be
attached.
GROUND TRANSPORTATION:
Mode (choose an item):
Fleet Vehicle *must be authorized driver
http://www.uwstout.edu/safety/riskmanagement.
cfm
Personal Vehicle with non-availability or 100
miles or less (round trip)
Personal Vehicle without non-availability
Other (specified in Summary)
miles
$
cents/mile
$
miles
$
cents/mile
$
From:
To:
# of persons traveling:
Mode (choose an item):
Fleet Vehicle
Personal Vehicle with non-availability or 100
miles or less (round trip)
Personal Vehicle without non-availability
Other (specified in Summary)
From:
To:
# of persons traveling:
AIRFARE:
Round trip
One way
Date price quoted:
From:
To:
Round trip One way
Date price quoted:
From:
To:
Price: $
Price: $
Total Airfare:
LODGING:
Place:
$
nights @ $
per night
$
per night
$
Place:
nights @ $
Total Lodging:
MEALS:
Breakfast:
$8 (in-state)
$10 (out-of-state)
Lunch:
$9 (in-state)
$10 (out-of-state)
Dinner:
$17 (in-state)
$20 (out-of-state)
$
days
$
days
$
days
$
TOTAL
TRAVEL:
T:Forms/CEHHS Dissemination of Research Feb 2013
$