GSK IMPACT Awards for the Greater Philadelphia Region
Application 2017
Registration Deadline:
Friday, April 7, 2017
Application Deadline:
Friday, May 5, 2017
Application Form
· Before completing this form, please review the GSK IMPACT Award 2017 Registration and Application Instructions (Greater Philadelphia) document in full to ensure that your organization is eligible and competitive for a GSK IMPACT Award.
· To complete the application, download a copy of this form to your own computer, and click in the gray box to begin typing – boxes will expand automatically.
· The application has five sections – 1) Organizational Information, 2) Financial Information, 3) Client Information, 4) Application Questions, and 5) Detail on Program(s). All sections of the application must be completed.
· The application must be signed and dated (final page) prior to submission – unsigned applications will not be accepted.
Part 1: Organizational InformationOrganization Name:
(Legal IRS Name)
Organization AKA Name:
(if applicable)
Is organization a 501(c)3? / YES NO (If no, then not eligible)
Year organization received 501(c)(3) status: / (Ruling date): EIN#: State:
(Must be a 501(c)3 nonprofit organization)
Organization Overview/Mission: / Brief overview of organization (no more than three sentences)
Organization Category: / Please check the category(ies) for your organization (as many as apply):
Diet & Exercise
Education
Housing & Transit
Employment
Community Safety
Family & Social Support
Street address:
(street, city, state, zip)
County(ies) served: /
(Must include at least one of the following counties to be eligible: Bucks, Chester, Delaware, Montgomery, and/or Philadelphia Counties in PA)
Executive Director:
(Name, title, office/cell phone, and email)
Additional contact:
(Name, title, office/cell phone, and email)
Organization Phone:
Organization Website:
Organization Social Media:
(List account handles or URL for all that are applicable) / Twitter
Other
Staff size: / Full-time
Part-time
Volunteer
Board of Directors – Check categories that apply and indicate percentage where applicable
Women: % / Immigrants: % / Differently Abled: %
Caucasian: % / Black/African American: % / Latino or Hispanic: %
Native American: % / Asian/Asian American: % / Native Hawaiian/
Other Pacific Isl: %
Other: %
Senior management – Check categories that apply and indicate percentage where applicable
Women: % / Immigrants: % / Differently Abled: %
Caucasian: % / Black/African American: % / Latino or Hispanic: %
Native American: % / Asian/Asian American: % / Native Hawaiian/
Other Pacific Isl: %
Other: %
Does your organization, as suggested by the IRS in Part VI, Section B of the Form 990, have:
1) conflict of interest policies; 2) whistleblower policy; 3) independent process with comparability data for determining compensation; and does your organization 4) provide a copy of the 990 to board members prior to filing?
YES NO; If no, then please explain:
Is organization a past GSK IMPACT Award Winner? / YES NO If yes, then list year:
(If 2015 or 2016 Winner, then not eligible)
Is organization a current GSK grantee? / YES NO
(If 2017 calendar year GSK charitable grantee, then not eligible)
Part 2: Financial Information
Organizational gross revenue: / Current fiscal year: $; Previous fiscal year: $
Notes:
· Does not include in-kind donations
· Current year figures are based on board-approved budget forecasts; previous year figures are based on the organization’s audited statement of activities or completed 990.
· If gross revenue in current or previous fiscal year is less than $160,000 or more than $5 million, then not eligible
Last Fiscal Year Support:
(actual or estimated) / Amount / % of Budget
Government / $ / %
Fees/earned income / $ / %
Individual donors / $ / %
Foundations & Corporations / $ / %
Other (specify) / $ / %
Totals / $ / 100%
List of top funders:
Complete the following chart with the financial information for the organization covering the current and previous three years. Current year figures should be based on board-approved budget forecasts; three previous years should be based on the audited statement of activities or completed 990. Most competitive applications will demonstrate evidence of sound financial condition for three years or more.
Operating Budget / Results / Revenue / Expense / Surplus/(Deficit)
Current Year (Budget)
FY end date:
(ex: June 30, 2017)
Previous Year (Actual)
FY end date:
2 Years Prior (Actual)
FY end date:
3 Years Prior (Actual)
FY end date:
If your organization has incurred any deficits in the past three years, then please explain and also verify whether or not the deficit exceeded 10% of operating budget:
Part 3: Client Information
Number served annually:
(Total population served) /
Client location(s):
(county, city, neighbourhood, etc.)
Gender of those served: / % female / % male / % non-binary
Age: / % pre-kindergarten / % elementary age / % middle school age
% high school age / % adults / % seniors/elders
Ethnicity: / % Caucasian / % Black or
African American / % Latino or
Hispanic
% Asian or Asian American / % Native American / % Native Hawaiian/ Other Pacific Islander
% Other
Other: / % Veteran / % Physically Challenged / % Mentally Challenged
% Immigrants / % Incarcerated / % Substance Abuse
% Orphaned Children (have lost one or more parents) / % History of Domestic Violence / % Other;
please specify:
% Percentage of population served that is below federal poverty guidelines
Part 4: Application Questions
Summarize what your organization does and why it is worthy of a GSK IMPACT Award:
(250 words)
What is the community need(s) that your organization addresses and how does it affect health outcomes?
The GSK IMPACT Awards recognize local nonprofit organizations that are making communities healthier places to live, learn, work and play, based on a model of population health called the County Health Rankings & Roadmap. While many of these factors (1- Diet & Exercise, 2- Education, 3- Housing & Transit, 4- Employment, 5- Community Safety or 6- Family & Social Support) are not traditionally thought of as health factors, competitive applications will clearly articulate the connection between the community need(s) that your organization addresses and health outcomes.
(150 words)
How does your organization address these community needs and why have you selected that approach?
(150 words)
How do you include, respond, and adapt to the community that your organization works with?
(150 words)
Please describe how your organization uses quantitative and qualitative data to inform the design, implementation, evaluation, and continuous improvement of your program(s):
(150 words)
Please list up to five organizations that you partner with and describe how these meaningful partnerships have contributed to better outcomes than if your organization were working alone:
(This question is intended to identify partners who have an active role in service provision, program implementation, or broader community change. Please do not list funders unless they partner with your organization beyond funding. You may list less than five.)
1.
2.
3.
4.
5.
Please describe how your organization demonstrates operational excellence:
(e.g. employee and Board development; sound governance; strategic planning; financial stability; volunteer support; diverse and effective leadership; etc.)
(150 words)
Please describe how your organization’s work is part of a larger movement to improve the health of the community – this could include influencing systemic reform, engaging with regional or local planning efforts, and/or your programs being replicated in other communities or scaled in your community:
(150 words)
Please share a lesson you have learned that you are using to improve the effectiveness of your organization:
(150 words)
Please share a success story that demonstrates how your work improves health outcomes an individual or individuals in the community:
(250 words)
Part 5: Detail on Program(s)
Please list and describe up to three programs that your organization administers that you would like considered in your application for a GSK IMPACT Award. List the programs in order of priority.
In this section, please describe the social impact your programs have had on the community with a particular focus on improving health outcomes. We are not only interested in understanding the numbers of individuals reached or programming delivered, but also what impact you know (or believe) these interventions are having in the lives of individual beneficiaries and/or the community at large.
For each measure, we will ask you to describe how you are capturing this data – this includes tracking (e.g. surveys or other measurement tools), estimation (e.g. informed guesses by staff or inferred measures from other reports or studies), or speculation (e.g. anecdotal evidence).
Notes:
· Please describe up to three relevant programs in the application – we expect the program descriptions to represent a majority (or close to a majority) of the organization’s overall budget. For example, if you list only one program and it represents just 10% of the overall budget, your application may not be competitive.
· If your organization runs only one program, then simply list the name of the organization as Program #1. You do not need to complete Program #2 and #3.
· This section should describe current or past programs, not those that you plan to implement in the future.
Program #1 Title:
Addresses the following Health Category:
Percent of overall organization budget: %
Program description:
(Suggested format – “We help [who] achieve [what successful outcome] through [summary of your services].”)
Describe intervention(s):
(In a single sentence per entry (up to four); identify each of the core services or activities your program uses to achieve its goal.)
Note: This should be a high-level summary of your program’s intervention, not a detailed itemization of implementation tasks.
1.
2.
3.
4.
Describe program reach and social impact:
(Please respond to questions 1 – 4 below)
1. How many people are served by this program?
(This response should be a number)
2. How are you measuring the number of people served by this program?
(This response should describe your means of measurement – examples include attendance logs, surveys, public data, etc.)
3. Describe the social impact you aim to achieve in relation to this program – what is the state of improved well-being that the people you work with achieve?
(Examples include: number of people who are no longer overweight, reduced rates of violence, improved safety or injury rates, increased social networks and supports, number of people housed, improved commute times, etc.)
4. How are you measuring the social impact? In other words, how do know that your interventions are having the desired effect?
(This response should describe your means of measurement – examples include surveys, pre- and post-tests, focus groups, public data, etc. as well as the rationale for why this measurement points to your intended social impact.)
Program #2 Title:
Addresses the following Health Category:
Percent of overall organization budget: %
Program description:
(Suggested format – “We help [who] achieve [what successful outcome] through [summary of your services].”)
Describe intervention(s):
(In a single sentence per entry (up to four); identify each of the core services or activities your program uses to achieve its goal.)
Note: This should be a high-level summary of your program’s intervention, not a detailed itemization of implementation tasks.
1.
2.
3.
4.
Describe program reach and social impact:
(Please respond to questions 1 – 4 below)
1. How many people are served by this program?
(This response should be a number)
2. How are you measuring the number of people served by this program?
(This response should describe your means of measurement – examples include attendance logs, surveys, public data, etc.)
3. Describe the social impact you aim to achieve in relation to this program – what is the state of improved well-being that the people you work with achieve?
(Examples include: number of people who are no longer overweight, reduced rates of violence, improved safety or injury rates, increased social networks and supports, number of people housed, improved commute times, etc.)
4. How are you measuring the social impact? In other words, how do know that your interventions are having the desired effect?
(This response should describe your means of measurement – examples include surveys, pre- and post-tests, focus groups, public data, etc. as well as the rationale for why this measurement points to your intended social impact.)
Program #3 Title:
Addresses the following Health Category:
Percent of overall organization budget: %
Program description:
(Suggested format – “We help [who] achieve [what successful outcome] through [summary of your services].”)
Describe intervention(s):
(In a single sentence per entry (up to four); identify each of the core services or activities your program uses to achieve its goal.)
Note: This should be a high-level summary of your program’s intervention, not a detailed itemization of implementation tasks.
1.
2.
3.
4.
Describe program reach and social impact:
(Please respond to questions 1 – 4 below)
1. How many people are served by this program?
(This response should be a number)
2. How are you measuring the number of people served by this program?
(This response should describe your means of measurement – examples include attendance logs, surveys, public data, etc.)
3. Describe the social impact you aim to achieve in relation to this program – what is the state of improved well-being that the people you work with achieve?
(Examples include: number of people who are no longer overweight, reduced rates of violence, improved safety or injury rates, increased social networks and supports, number of people housed, improved commute times, etc.)
4. How are you measuring the social impact? In other words, how do know that your interventions are having the desired effect?
(This response should describe your means of measurement – examples include surveys, pre- and post-tests, focus groups, public data, etc. as well as the rationale for why this measurement points to your intended social impact.)
For Past GSK IMPACT Award Winners Only
Please describe the substantial, positive change and/or significant development that has occurred in the program(s) since you received your GSK IMPACT Award:
(150 words)
Rules for GSK IMPACT Awards