Request Resource Form

Point of Contact First Name (Value Required)

Point of Contact Last Name (Value Required)

Rank, if any

Are you an active-duty military nurse?

Point of Contact Email (Value Required)

Military Facility/Organization to Receive Resources (Value Required)

TSNRP Award # or N/A (Value Required)

Date Resources Needed (Value Required)

Purpose of Request
What will resources be used for? What are the anticipated benefits/returns on investment? Highlight how the requested resources will support military nursing research and/or Evidence-Based Practice. (Value Required)

Other Funding?
Did you receive other funding for this work/project? (Value Required)

Please describe the other funding received. (Value Required)

IF this is a software request, did IT approve use of the software at your military treatment facility?

Name of the IT department representative at your facility

Email of the IT department representative at your facility

Requested Item 1
Describe Item 1. Include URL to purchase. (Value Required)

Justification
Justify cost of Item 1. (Value Required)

Qty Item 1 (Value Required)

Cost Per Item 1 ($) (Value Required)

Item 1 TOTAL Cost ($) (Value Required)

Requested Item 2
Describe Item 2. Include URL to purchase.

Justification
Justify cost of Item 2.

Qty Item 2

Cost Per Item 2 ($)

Item 2 TOTAL Cost ($)

Requested Item 3
Describe Item 3. Include URL to purchase.

Justification
Justify cost of Item 3.

Qty Item 3

Cost Per Item 3 ($)

Item 3 TOTAL Cost ($)