2017-19 RPE RFA Forms Included in this file are:
§ Prevention Program Application Face Sheet (Pgs. 32-22 in the RFA)
§ Prevention Program Application Checklist (Pg. 31 in the RFA)
§ Prevention Program Training Form (Appendix 4) (Pg. 39 in the RFA)
2017-2019 Rape Prevention and Education Program
Prevention Program Application Face Sheet
A copy of this form is available for download & completion on the AGSATF website by accessing: http://oregonsatf.org, then clicking on “Programs,” “Prevention Program,” and then “Rape Prevention and Education”
1. Legal Name of Agency (Please also include the name under which the organization is conducting business if different from the organization’s legal name):2. Name of Individual with Signature Authority:
3. Mailing Address:
4. Address to which check should be mailed (if different than mailing address):
5. Street Address (if different than mailing address):
6. Agency/Organization Website:
7. Contact Person for this Grant Application:
· Name:
· Title/Position:
· Telephone Number:
· Fax Number:
· Email:
8. Agency Status (check all that apply):
o Public o Private o Local Health Department
9. Agency Federal Tax ID Number:
10. Agency’s Financial Reporting Year:
11. Current Service Delivery Area (counties and communities):
12. Proposed Area(s) To Be Served with RPE Funding (counties and communities):
13. Type of Project & Grant Term o Prevention Program (8/17 – 7/19)
14. Project Focus:
o Engaging Men o Engaging Youth o Engaging Community
(Community Mobilization)
15. Project Title:
16. Project Description (no more than 300 words that will be posted on the SATF’s website if the project is funded):
17. Amount of Funding Requested:
Certification: The undersigned is authorized to submit this application on behalf of the applicant organization. The information contained herein is, to the best of my knowledge and belief, complete and accurate. I have read and agree to the guidelines and regulations dictated in the grant application packet and recognize that failure to comply with these guidelines may result in the loss of RPE funding from the Oregon Attorney General’s Sexual Assault Task Force or another contracting agency.
18. Name of Authorized Representative:
19. Signature of Authorized Representative:
20. Date:
Prevention Program Application Checklist
(Put this form at the beginning of the Application Form)
All applicants must submit a Letter of intent by January 25, 2017.
Please be sure that all of the following items are included in your application. Assemble the application in the following order. Number each page consecutively and label each Attachment (e.g., “Attachment A: Letters of Commitment and/or Statements of Support”). Applications must be typed in at least an 11-point font, double-spaced with 1-inch margins, and single-sided.
___ Cover Letter: The application must include a cover letter, on agency letterhead (if available), signed and dated by an individual authorized to legally bind the Applicant. If said individual is not the corporate/Board president, submit evidence showing the individuals’ authority to bind the Applicant. (See Attachment E: Letter from Board President/Chairperson Identifying Individual(s) Authorized to Sign Contracts.)
___ Application Face Sheet (see next pages) followed by a completed application.
___ Completed Application Form (not to exceed 23 pages, not including required attachments)
___ Attachment A: Documentation of Board Support (not required) and Letters of Commitment for Match (match is NOT required and these are optional)
___ Attachment B: Project Budget & Narrative – include a budget and accompanying budget narrative on the forms and in the format provided.
___ Attachment C: Current Agency or Program Division Budget
___ Attachment D: 501 (c) (3) Letter (Private Non-Profit Agencies) – Public organizations shall submit a document verifying their legal name and tax identification number.
___ Attachment E: Letter from Board President/Chairperson Identifying Individual(s) Authorized to Sign Contracts. Local government agencies should obtain the signature of town manager, chair of county commissioners, etc.
___ Attachment F: Letter from Board President/Chairperson Identifying Individual(s) Authorized to Sign Expenditure Reports. Local government agencies should obtain the signature of town manager, chair of county commissioners, etc.
___ Attachment G: Job Descriptions for Prevention Coordinator and Supervisor. Resumes for Prevention Coordinator (if available) and Supervisor.
___ Attachment H: Other Information (e.g., Organizational Chart, Training Lists, Letters of Support, Media Articles, Documents Detailing General Community Support
Topic
/Hours
/Date of Completion by Prevention Coordinator
/Organization Providing Training & Title of Training (e.g., SATF Advocate Training)
/SA Dynamics
/2
/ /Victim Impact (the effect of trauma)
/1
/ /Effective Advocacy
/2
/ /How to Support Survivors
/2
/ /Interrupting Victim Blaming
/1
/ /Medical Response & Advocacy
/1
/ /Documentation & Confidentiality
/1
/ /Legal Advocacy & Civil Legal Remedies
/1
/ /Victim’s Rights
/1
/ /Criminal Justice System
/1
/ /Collaboration & Systems Advocacy
/1
/ /Oppression and the Root Causes of Violence
/1
/ /Cultural Sensitivity and Considerations of Working with Specific Populations
/1
/ /Adolescent Sexual Assault[1]
/1
/ /LGBTQ Survivors of Sexual Assault1
/1
/ /Native American Victims of Sexual Assault1
/1
/ /People with Disabilities1
/1
/ /Topic
/Hours
/Date
/Organization Providing Training & Title of Training (e.g., SATF Advocate Training)
[1] These specific populations are suggested, but can be replaced by other populations, as appropriate