March of Dimes, California Chapter

march of Dimes Nevada community grant

PROPOSALPROJECT OVERVIEW

(2 pages maximum; single spaced)

Name of Organization:
Proposed Project Title:
Organization Type:
Clinic Community-based OrganizationEducational Institution
Health Department (State/Local) Hospital Professional Association
Other For-Profit Organization (please state):
Other Non-Profit Organization (please state):
County or counties where services will be provided:
Primary Contact (Name and Title): / Secondary Contact (Name and Title):
Address:
Telephone:
Email: / Address:
Telephone:
Email:
Please provide a brief synopsis of your project (3-5 sentences highlighting goals, activities and expected impact of the project):
Previous March of Dimes funding recipient? (Yes/No)
If yes, state grant type and year: / Amount Requested
Number of unduplicated individuals to be served: / Cost per individual served:
$
Is your agency willing to accept partial funding? (Yes/No)
Does this project target adolescents (17 and under)? / YesNo
Does this project aim to reduce disparities? / YesNo
Race/ethnicity of majority of individuals served:
(Enter ONE race/ethnicity in this field, then list the percentage breakdown of all individuals served in box at right) / Approximate percentage breakdown of race/ethnicity of all individuals served: (Percentages should add up to 100)
Please indicate which of the outcomes listed below will be measured and reported on throughout your grant project.
Change in knowledge Change in behaviorChange in birth outcomes
Change in health indicatorsOther (please state):
Does the budget include funds for a consultant or other subcontract? (Yes/No) / Does the budget include funds to conduct an evaluation? (Yes/No)
Will your agency or an evaluator be collecting Personal Health Information (PHI) from any individuals? (Yes/No)
Will your agency or an evaluator be seeking the following? (If you will seek full or expedited review, provide brief details of your expected timeline)
Full review by an Institutional Review Board (IRB)
What is the expected timeline for review?
Expedited review by an Institutional Review Board (IRB)
What is the expected timeline for review?
No review by an Institutional Review Board (IRB)
Does this project involve development of health education materials? (Yes/No)
If yes, provide a brief description.
Please detail any potential conflicts of interest that your organization may have with members of the March of Dimes State MCH Committee orMarket Board:
Signatures are ONLY required on the hard copy (mail) application.
Signatures on the hard copy must be original.
Executive Director/Manager Signature:
Sign in space above, then enter date below.
Date: / Primary Contact Signature:
Sign in space above, then enter date below.
Date:

Proposal Narrative Template (6-7pages maximum)

Problem statement: What is the problem that your organization plans to address? Provide relevant data (as local as possible) to describe the needs and issues.

Target population: What is the target population? What needs of the target population are you addressing with this project? How will the project have an impact on these needs?

Project goal: What is the goal of the project? What factors or health indicators does your project aim to improve?

Project objectives: What are the specific, measurable objective(s) the proposed project aims to achieve? Please limit your proposal to no more than 3 objectives. At least two outcome objectives must seeks to change knowledge, behavior or birth outcomes. One objective may be related to a process measure. Additional information about objectives and outcomes can be found in Appendix A of the RFP guidelines.

Project activities: What activities will you undertake to achieve each stated objective? Provide the timeline on which project activities are expected to occur. Explain the roles of any collaborative partners, if applicable.

Expected outcomes: What impact and changes will this project have on the stated problem? Include baseline data.

Evaluation plan: describe what you will measure and how you will measure it, to demonstrate progress and success in reaching your objectives. Evaluation tools can include, but are not limited: pre-test/post-test, interviews, surveys, focus groups, medical records review, client records review, patient/provider self-report. What data or information will be needed to measure outcomes?

Organizational capacity and staffing: Description of the organization’s capacity to carry out the project. Include agency’s mission, key staff, clientele, and experience working with the target population group. What will be the responsibilities of the staff members listed in the proposal?

Collaborating organizations: How will your proposed project coordinate or collaborate with existing services and partners? If applicable, list names and roles of collaborating organizations.

Sustainability: Describe the plan for sustainability beyond the funding period through alternate sources of funding or a change in organizational systems or procedures that will sustain the project's impact.

Sharing results and outcomes: In addition to the March of Dimes, with whom and how will project impact be shared?

Visibility: Describe the ways in which March of Dimes will be visible throughout the project period.

Project Objectives/Activities/Evaluation Methods/Outcomes Template:Please limit your proposal to up to 3 objectives. Include at least two objectives that seek to change knowledge, behavior or birth outcomes. Limit to 1 page per objective. Add or delete activity rows as needed. Additional information can be found in Appendix A of the RFP guidelines.

Objectives & Activities to Achieve Objectives / Person/ Agency Responsible / Start/End Dates / Baseline Data / Description of ExpectedOutcomes/Results and number of Individuals Expected to be Served/ Reached
OBJECTIVE # 1 / MM/DD/YY MM/DD/YY

Activity:

Activity:

Activity:

Evaluation methods (include source of baseline and outcome data):
Objectives & Activities to Achieve Objectives / Person/ Agency Responsible / Start/End Dates / Baseline Data / Description of ExpectedOutcomes/Results and number of Individuals Expected to be Served/ Reached
OBJECTIVE # 2 / MM/DD/YY MM/DD/YY

Activity:

Activity:

Activity:

Activity:

Activity:

Activity:

Evaluation methods (include source of baseline and outcome data):

BUdget FORM

Complete the budget form and provide a 1-page written budget justification to detail the items on the budget form. Please include the calculation(s) used to estimate costs. The attached budget form is not acceptable without a written budget justification. Allowable and non-allowable costs are described in Appendix Bof the RFP guidelines.

Organization Name
Project Title
Overall Annual Agency Budget / $
COMPLETE ALL 3 COLUMNS
Include the calculation(s) used to estimate costs. For example: Program coordinator - .5FTE, $35/hr x 30 weeks = $21,000 / Total Proposed Project Budget / Other Support
(In-kind or other funds) / March of Dimes
Grant Request
I. PERSONNEL (Include position titles and FTE)
Benefits @ ___%
Subtotal - Personnel
II. OPERATING EXPENSES
(materials, supplies, incentives, etc)
Subtotal – Operating Expenses
III. Indirect Costs
(Not to exceed 10% of entire requested grant. Only include if your requested grant amount is over $25,000 per project year)
_____% of direct costs
VI. Total Program Costs

Signature – Executive Director/ManagerDate

Budget Justification Narrative (Maximum 1 page; provide justification/detail for each line item on the budget form, taking into account allowable and non-allowable costs outlined in Appendix B)

Optional Supplemental Information. No total page limit. Please submit additional information that supports your proposal. Additional items may include the following:

•References/citations (limit to 1 page)

•Letters of Support from collaborating organizations (limit to 1 page per letter)

•Evidence of Institutional Review Board (IRB) submission as deemed appropriate.

•Other supporting materials relevant to the proposed project.