FY22 MAP Application - Follow Up Visit Request Form

OMB Control # 3137-0101
Expiration Date X/XX/XXXX

Museum Assessment Program (MAP)
Follow-Up Visit Request Form

PART ONE

1. Name of museum

2. TIN or EIN number

3. Name of museum representative

4. Title of museum representative

5. Email of museum representative

6. Name of Peer Reviewer (Please note that only one Peer Reviewer conducts the visit.)

7. Original MAP Assessment Type

8. Dates of original site visit

9. Has your museum participated in a previous MAP Follow-Up Visit? YES/NO

If YES, when?

10. Annual operating expenses for your most recently completed fiscal year (Include all expenses, regardless of funding source.)

FY	Operating Expenses

PART TWO

11. List your goals and objectives for the follow-up visit and explain how they relate to the recommendations made in the Final MAP Report. (Limit your answer to 150 words.)

12. List your preferred dates for the Follow-Up Visit. (The visit must be 1-1.5 days in length.)

Please note:

• If applying for the [insert date] deadline, the site visit cannot occur earlier than [insert date] and must be completed by [insert date].

• If applying for the [insert date] deadline, the site visit cannot occur earlier than [insert date] and must be completed by [insert date].

13. Draft agenda for the Follow-Up Visit

Provide an outline for the visit that includes the basics of who/what/when/where. Include a list of proposed meetings, interviews, and tours.

PART THREE

14. Describe the actions your museum has already taken in response to the recommendations and findings of the Final MAP Report, and if applicable, from prior Follow-Up Visits. (Limit your answer to 250 words; you do not need to itemize every recommendation in the report.)

PART FOUR

We the undersigned have agreed upon the goals, activities, and agenda listed above and find them acceptable and realistic for the MAP Follow-Up Visit.

We have read and agree to the MAP Museum Participation Fee Schedule.

_______________________________________________ __________________

Peer Reviewer Name Date

_______________________________________________

Peer Reviewer Signature

_______________________________________________ __________________

Museum Representative Name Date

_______________________________________________

Museum Representative Signature

_______________________________________________ __________________

Head of Governing Body Name Date

_______________________________________________

Head of Governing Body Signature