UPMC Central PA Grant Funding Request Form

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The UPMC Pinnacle Foundation is pleased to review your request for funding. Funding requests received by the 15^th of the month will be considered at the Board meeting scheduled for the following month. Please complete the following information so we can better understand the need(s) you plan to address:

Project Name:

Contact Name and Department:

Contact Email:

Amount Requested:

Direct Supervisor Name:

Impact Guidelines (Please select the guideline(s) that you plan to address) 1. Social Determinants of Health 2. Health and Wellness 3. Workforce Development

Target Population (Please describe the target population for this project)

Project Description (Please provide a detailed description of your proposed project, including how this will impact the ability to provide high quality care for our patients.)

Project Goals (Please provide 1-3 goals for this project)

Budget Request (Please provide a detailed breakout of proposed expenses for your proposed project)