Opioid Abatement Grant Project Proposal Application

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* 1. Organization Name

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* 2. Name of Organizational Contact

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* 3. Phone Number

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* 4. Email Address

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* 5. Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 6. Project Title:

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* 7. Total Project Cost:

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* 8. OAA Funding Requested:

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* 9. Is this project:

A new project

A supplement or enhancement to an existing project

A combination of enhancing an existing project with new components

Other (please specify)

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* 10. Is this project:

Evidence-based

Evidence-informed

Neither

Both

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* 11. Has this project been certified or credentialed by a state/federal government agency or other organization/non-profit?

Yes

No

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* 12. Has this project received any awards or recognition?

Yes

No

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* 13. Does this project have components other than opioid-related treatment as defined by the OAA?

No, it is 100% related to opioid treatment

Yes, there are other substances involved