For Reviewers Only

FOR REVIEWERS ONLY

Date Application Received:

Received by Early Deadline?

Is this the Final Submission?

Application Advisor (if applicable):

Key Topic Search Words:

International Community Access to Child Health (ICATCH)

2016 APPLICATION

(Grant Cycle July 1, 2017 – June 30, 2020)

Please read the ICATCH Application Instruction Booklet carefully for each question while you are completing your application. Following these instructions is one of the best ways to improve your application. The instruction booklet can be found on the ICATCH website: www.aap.org/icatch

Kindly type your answers in non-bold font.

I. GENERAL INFORMATION

Please place an “X” in the correct box:

This is a new application.
This application is a resubmission from a past year. Year previously submitted:

Please place an “X” in the correct box:

This is the preliminary submission for the early deadline.
This is the final submission for the final deadline.

Name of Proposed ICATCH Project:

Country:

Is this an existing program?

Yes, our proposal expands or improves an existing program
No, this proposal is for a new program that does not exist currently

How did you first hear about ICATCH? (Please be as specific as possible: email from? listserv? colleague? conference?)

Project Director Information
FIRST (given) NAME:
SECOND (family) NAME:
Title after name (if applicable):
(e.g., MD, RN, MBBS, PhD, MPH, CHW...)
How should we address you?
(examples: Dr. Smith, Mrs. Johnson, Dr. Mike…)
STREET ADDRESS:
CITY/PROVINCE/POSTAL CODE:
COUNTRY:
PHONE/MOBILE:
FAX (if applicable):
EMAIL:
Project Directors must be one of the following. Please “X” appropriate box:
1. American Academy of Pediatrics Member and Member of the Section on International Child Health (SOICH)
2. Affiliate Member of the Section on International Child Health
3. In process of applying for SOICH membership or affiliate membership
If 1 or 2 above, please provide your AAP ID #:
Project Co-Director Information
FIRST (given) NAME:
SECOND (family) NAME:
Title after name (if applicable):
(e.g., MD, RN, PhD, MPH, MBBS, CHW...)
How should we address you?
(examples: Dr. Smith, Mrs. Johnson, Dr. Mike…)
STREET ADDRESS:
CITY/PROVINCE/POSTAL CODE:
COUNTRY:
PHONE/MOBILE:
FAX (if applicable):
EMAIL:
For Project Co-Director: Please “X” any that apply (no membership requirement):
Member of the Academy of Pediatrics
Member of the Section on International Child Health
Affiliate Member of the Section on International Child Health
In process of applying for section membership or affiliate membership
None of the above
If applicable, please provide your AAP ID #:

1.  Please provide an abstract or summary of your project in 300 words or less:

2. Please briefly describe the role of the Project Director in the community (as it relates to this project) and his/her responsibilities in carrying out your ICATCH program.

3. Please provide a brief description of how the Project Co-Director will be involved with the project; what will be his/her responsibilities?

4. Person primarily responsible for writing/submitting this application:

II. PROGRAM DETAILS

1. Please describe the community in which your project will be carried out:

2. What are some of the barriers to care in this community and how does your project help families overcome them?

3. What is the overall goal of your ICATCH program or project?

4. Describe your ICATCH project activities, demonstrating how these activities help you to meet this overall goal:

5. How and when will you evaluate your program? What will you measure or monitor to assess your progress and determine what you need to adjust or change?

6. Describe any project-related and/or planning activities completed to date:

7. Identify any present community collaborative partners and how they are helping:

8. Identify any future partners in your community that you would like to collaborate with and why:

9. Please identify past or present sources of funding for your project:

10. Describe any plans for sustainability beyond the grant period:

11. Why should the ICATCH Program fund your project?

III. BUDGET

Three-Year Budget

1. GRAND TOTAL Amount Requested ($6000 max): $

2. Submit a detailed budget in US dollars for each year:

YEAR 1
Item/Service/Activity / Why Needed/How Will Be Used / $ Amount
Year 1 Total:
YEAR 2
Item/Service/Activity / Why Needed/How Will Be Used / $ Amount
Year 2 Total:
YEAR 3
Item/Service/Activity / Why Needed/How Will Be Used / $ Amount
Year 3 Total:
GRAND TOTAL ALL 3 YEARS

3. If you will have additional funding or in-kind support for your project from other sources, please describe approximately how much, and what it will be used for:

IV. BANK INFORMATION

The AAP prefers to wire transfer the funds. If your project is selected for funding, we will need specific information at that time (not now), including the details below. We generally wire the funds to a local account in the country of the funded project, or to an affiliated non-profit organization here in the US.

1. / Name of the Bank
2. / Address of the Bank
3. / Phone number for the Bank
4. / ABA/Routing number of the Bank
5. / SWIFT Code
6. / Account number
7. / Name on Account
8. / Any other information needed to wire transfer funds (please check with your bank)

V. BIOGRAPHICAL INFORMATION

1. For the Project Director: Please include below a short description of the education, training, work experience and interests of the person as related to this project:

2. For the Co-Director: Please include below a short description of the education, training, work experience and interests of the person as related to this project:

VI. SIGNATURES

By signing below, I acknowledge that I understand a brief annual report must be submitted at the end of each funding year in order to receive funds for the following year.

Project Director signature:
Printed name: / Date:
Project Co-Director signature:
Printed name: / Date:

VII. APPLICATION SUBMISSION AND DEADLINES

Please submit your application as a Word or PDF attachment to

If we receive it by the early deadline, a reviewer will provide brief feedback to you via email on improving your application and/or proposal. Early submission is entirely optional. All applications (with revisions or as first submissions) must be received by the final deadline.

IMPORTANT: You should receive an email from ICATCH upon receipt of your application. If you do not receive an email confirming receipt of your application within 2 business days after submission, please contact Ms. Coura Badiane right away at

EARLY DEADLINE (optional): December 12, 2016 (feedback provided by January 9, 2017)

FINAL DEADLINE: February 10, 2017

AWARDS ANNOUNCED: ~May 12, 2017

FUNDS TRANSFERRED: June, 2017

YEAR 1 OF GRANT CYCLE: July 1, 2017 – June 30, 2018

QUESTIONS?

·  See ICATCH website: www.aap.org/icatch

Please refer in particular to the ICATCH Application Instruction Booklet.

·  Email or phone the ICATCH Manager at the AAP:

Ms. Coura Badiane

Section on International Child Health (SOICH)

American Academy of Pediatrics

141 Northwest Point Blvd.

Elk Grove Village, IL 60007-1098 USA

Phone: 847-434-4298

Thank you for your application to ICATCH!

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