PREPAREDNESS PROGRAM

SUPPORTING BUDGET FORM

Region: Date submitted:

Name of submitter:

Description of requested item:

Anticipated purchase date:
Number of items to be purchased:
Training Development - Course title and description: (include learning objectives)

Anticipated training date(s) and number of sessions:

Projected participant numbers per session:
Anticipated outcome: (what capability-based gap will be addressed)

Align to 1 (one) specific domain, capability, function, or performance measure:

Is the expense 25% of the total budget? (If over 25% of the budget a revised budget will need to be submitted)

Projected expense:

Is there anything on your work plan that will not be completed as a result of this new activity?

KDHE use below

Reviewed by: Approval date: Received sign-in sheet: ☐
Received finalized expenditure report:☐

“This publication was supported by the Grant or Cooperative Agreement Number, NU90TP921936, funded by the Centers for Disease Control
and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for
Disease Control and Prevention or the Department of Health and Human Services.”