INDIANA BREAST CANCER AWARENESS TRUST, INC.

Screening Mammography LargeGrant Program

The mission of the Indiana Breast Cancer Awareness Trust, Inc. (IBCAT) is to increase awareness and improve access to breast cancer screening and diagnosis throughout Indiana. IBCAT receives funds through sales of breast cancer awareness specialty license plate. Indiana Breast Cancer Awareness Trust plate sales began in January of 2002.

Through these sales, monies are available for grants deemed to best address the unmet screening needs of the people of Indiana. Each Indiana Breast Cancer Awareness plate sold generates a $25.00 donation. The Indiana Breast Cancer Awareness Trust is a 501(C) 3 Not for Profit organization incorporated in the State of Indiana.

Large Grant Guidelines

  • Project must be specific to providing Screening Mammogramsto low income, medically underserved women.
  • Large Grant Requests are limited to a maximum of $15,000.00 per request.
  • Organizations may only apply for either one (1) Mini-Grant OR one (1) Large Grant, annually.
  • Screen Mammography reimbursement rates are based on the current Medicare rates. For 2012 grants, this amount is $80.00 per film screening mammogram and $135.00 per digital screening mammogram and includes both the technical and professional component.
  • Funding will be limited to expenses as stated on the Budget Form page. No indirect expenses will be covered by the Large Grant program and should not be included in your application.
  • If your organization is not the direct provider for mammography services, a Letter of Agreement must be included from the service provider.
  • American Cancer Society (ACS) guidelines for screening mammography should be followed.
  • Mammography service providers must be AmericanCollege of Radiology (ACR) certified.
  • Applicants must be a U.S. nonprofit (federally tax-exempt) organization.
  • Services are to bewithin the State of Indiana.
  • A grant contract will be the legal mechanism for funding of grant.
  • Grantees will submit a six-month progress report as well as a final grant report to IBCAT.
  • Announcement of awards will be made no later than December 15, 2011.
  • Grant funding for this project will begin January 1, 2012 and end December 31, 2012.
  • Grant Applications must be postmarked no later than Friday, September 30, 2011.
  • Application must be submitted as stated on the following page. Applications not submitted in the proper order and/or not including all required information may be rejected.
  • Please use United States Postal regular or priority mail service. No certified mail or other forms that require a signature for pick-up. No faxed applications will be accepted.
  • Submit one original, plus eight (8) additional copies. All copies should be stapled. No binders, folders or paperclips.

APPLICATION ORDER

Applications MUST be ordered as follows. Applications should usethe headings listed below with one (1) inch page margins, font style Times New Roman or Arial and no smaller than twelve (12) point typeface. Failure to follow the criteria as outlined may result in rejection of the application.

  1. Cover page (Form on Page 3) - Must include signature of approving institutional personnel, other than project director.
  2. Project/Organization Information Page (Form on Page 4)
  3. Project Description (Do not exceed two (2) pages.)

a)Brief explanation of proposed project.

b)Statement of need supported by local or regional data/community assessment

c)Describe your primary goals and your plan to achieve those goals.

d)Are there comparable programs offered in your service area? How is this project unique?

  1. Resources (Do not exceed one (1) page)

a)List resources your organization has for this project. Please refer to facilities, equipment and community partnerships.

b)How will you recruit participants for your project?

c)What potential challenges do you foresee and how will you overcome them?

  1. Timeline (Do not exceed ½ page)

a) Provide a realistic timeline for implementing your proposed project.

  1. Evaluation Methods (Do not exceed ½ page)

a)What is your plan for collecting data in order to define success?

  1. Financial Information (Form on Page 5, plus one (1) typewritten page.)

a)Budget for requested funds.

b)Budget Justification

  • Personnel will only be funded if a clear demonstration of need is expressed.
  • No Indirect Expenses will be funded

c)List other sources of current funding for this project.

  1. Biographical Information(Form on Page 6)

a)Please complete form or include resume for each budgeted personnel. If not requesting funding for personnel, no biographical information is needed.

  1. Letter(s) of Agreement –

a)Those organizations who are not the direct provider of mammography services must include a Letter of Agreementfrom the provider withthe application. This letter must state acceptance of defined IBCAT &/or Medicare reimbursement rates.

  1. Proof of Not for Profit status for applying organization.

Applications must be postmarked by Friday, September 30, 2011.

Send to: Indiana Breast Cancer Awareness Trust

P.O. Box 8212

Evansville, IN 47716

Please submit one original, plus eight (8) additional copies.

Questions should be directed to - or call (866) 724-2228.

Indiana Breast Cancer Awareness Trust

Request for Large Grant funding: Cover Page

Project Director & Title
Organization Name
Address
Email
Phone / ( )Fax ( )
Federal Tax ID #
Grant Contact (if different from Project Director)
Phone / ( )
Email
Patients in Need of Assistance should contact: / Name:
Phone: ( )
Title of Project
Total Amount Requested
(Maximum of $15,000.00)
Grant Period / 01/01/2012 to 12/31/2012
Name & Title of Approving
Organization Personnel (Typed) / Date
Signature & Title of
Approving Personnel (Other
Than Project Director)

By signing this document permission is hereby granted to the Indiana Breast Cancer Awareness Trust to publish this award should your application be selected for funding.

Application Must Be Postmarked by Friday, September 30, 2011.

See mailing instructions listed on previous page.

Questions may be directed to IBCAT at 866.724.2228 or .

Project/Organization Information

Project Name: ______

Organization:______

Target Population: CaucasianAfrican American Hispanic Other*

(Check top three) RuralElderly Under/Uninsured

*List Other: ______

All programs should be limited to low-income patients. This proposed program guidelines will be restricted to those falling into which poverty level?

200% 225% 250%

County/ies to be served:______

______

Does your organization have experience developing and implementing programs for the specified target population(s)? Yes No If yes, briefly outline below.

Are you a BCCP Provider? YesNo

Are you a current grant recipient of (please check applicable programs)–

Susan G. Komen for the Cure IBCAT Avon Other*

*Specify Other: ______

Request for Funding: Budget Form

Detailed Budget for Entire Budget Period
From January 1, 2012 Through December 31, 2012
Personnel
(must be specific to project)
Personnel Expense Not To Exceed
10% of Total Funds Requested* / Type
Contract
Hourly
Salaried / % Effort
on Project / Base
Salary / Grant Amount Requested
Name / Role
on Project / Salary
Requested / Fringe
Benefit / Totals
Subtotals
Supplies (itemize by category)
Travel(Reimbursable at IRS rate in effect on September 15, 2011.)
Patient Care Costs: Maximum Reimbursement of:
$80.00 Per Film Screening Mammogram
$135.00 Per Digital Screening Mammogram
Other Expenses (itemize by category. Do not include Indirect Expenses.)
Total Funding Request (Maximum $15,000.00)

Please attach anarrative explanation justifying the proposed budget. Do not exceed one typed page. *Please note – If requesting monies for personnel, please provide a clear demonstration of need for these salary dollars.

Biographical Information

Provide the following information for budgetedpersonnel ONLYin project request. You may attach resume(s). Please use a separate sheet for each staff member. If you are not requesting funding for personnel, you do not need to provide this information.

Name ______Title______

Role in project: ______

Education and Background including:

Institution DegreeDateField of study

Professional Experience, in chronological order from current to prior employment, experience, honors. Do not exceed two typed pages.

IBCAT Grant Application07/11