Organizations submitting proposals in response to the Solicitation for the National Institute of Mental Health Outreach Partnership Program must complete this Organization and Contacts Form. Please include the completed form as an attachment in your proposal.

Organization Information

Organization Name 
Street Address 
City 
State 
Zip Code 
Phone 
Fax 
Web Site URL 
Email Address 
Tax Identification Number 

Primary Contact Person

Enter contact information about the person that will be responsible for the management of the organization’s work for the Program and serve as the primary point of contact for NIMH staff. Please also include a resume for this person as an attachment to the proposal.

Prefix 
First Name 
Last Name 
Degree 
Title 
Street Address 
City 
State 
Zip Code 
Phone 
Fax 
Email Address 

Backup Contact Person

Enter contact information about the person that will serve as the backup contact for your organization’s work for the Program. Please also include a resume for this person as an attachment to the proposal.

Prefix 
First Name 
Last Name 
Degree 
Title 
Street Address 
City 
State 
Zip Code 
Phone 
Fax 
Email Address 

Executive Director

Enter contact information about the organization’s Executive Director or equivalent.

Prefix 
First Name 
Last Name 
Degree 
Title 
Street Address 
City 
State 
Zip Code 
Phone 
Fax 
Email Address 

Scientific Advisor

Enter contact information about the person who will serve as your organization’s Scientific Advisor for the Program. Please also include an abridged CV for this person along with a signed letter of commitment as an attachment to the proposal.

Prefix 
First Name 
Last Name 
Degree 
Title 
Organization 
Street Address 
City 
State 
Zip Code 
Phone 
Fax 
Email Address 

To receive this document in PDF, please email partnerssfpnimh@mail.nih.gov.

NIMH Outreach Partnership Program