HIV RFP Application Worksheet

This form is optional. You may use this document to prepare your answers for the online application. You may complete the sections in the worksheet to check your word count and proof the proposal. The sections can be cut and paste from this document onto the online version. The online form has word limitations and will truncate any answers that exceed the limits. Check your word counts carefully prior to cutting and pasting.

If you have any questions, you may contact Nancy Rogan, Manager of Grants and Initiatives at 954-761-9503 or .

Section A: Grant Information

Project Name
Limit to 10 words/50 Characters
Project Summary
Please provide a compelling one to two sentence statement that conveys what the project will achieve, who it will target, how many, using what strategies, and what will be the measurable outcomes for the target population. Limit, 60 words.

Numbers to be served
Total Unduplicated / Males served
Unduplicated / Females served
Unduplicated
Total Project Budget / Amount Requested
Dates Project Begins / Dates Project Ends

Section B: Organization Information

In this section of the online form you will need to provide the basic information on your organization, including ED/CEO/President in addition to what is below.

Organization Mission
State your organization's mission in one or two sentences.
Organization History
Provide a brief history of your organization. Include major accomplishments, premiere projects, and number of clients served in previous 12 months. Limit 200 words.
Description of Board Involvement
Please describe how your Board is actively involved in building the capacity of your organization. Provide information on activities your Board engages in to support your organization, such as meeting schedule/frequency and financial and/or in-kind support. Do not list the names of your board members. Limit 200 words.
Annual Budget

Section C: Project Details

Application Contact: Please list the person who will be the primary contact for this proposal.
Name of Contact
Title
Phone / Email
Project Stage
New Project Existing Project Project Expansion
Project Category: Choose one
Animal Welfare Arts & Culture Civic/Community Engagement Education
Environment Health/Medical Human Service
Project’s Secondary Category. Choose the secondary category of your project. Choose only one.
Animal Welfare/Protection/Animal Related
Basic Needs Assistance Cancer
Boards In Action
Civic Engagement/Human Rights
Early Childhood Development
Emergency Relief/Crisis Intervention
Employment Services/Voc/Job Skills
Extra Curricular/Out of School/Tutoring
Family Support/Parenting
Foster Care - Transitional (18+ yrs) / Foster Care (0-17 yrs)
GLBT
Health & Wellness/Nutrition/Physical Fit
HIV/AIDS
Housing/Shelters
Instruction/Education/Training
Legal Services
Literacy
Medical Research/Medical Treatment
Mental Health/Therapy/Substance Abuse / Mentoring
Natural Resource
Neighborhood Improvement/
Parks & Playgrounds
Patient Care/Hospice/Home Health Care
Performing/Visual Arts
Pollution Abatement & Control/Recycling
Technology
Transportation

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Target Population

Proposed program/project must include one or more of the Primary Target Populations listed below.
Please check all that apply
White (Non-Hispanic) MSM
Black (Non-Hispanic) MSM
Hispanic MSM
Black (Non-Hispanic) Heterosexual Women & Men
White (Non-Hispanic) Heterosexual Women & Men / Hispanic Heterosexual Women and Men
White (Non-Hispanic) Injecting Drug Users Black (Non-Hispanic) Injecting Drug Users Hispanic Injecting Drug Users
Proposed program/project must include one or more of the Significant Populations listed below.
Please check all that apply
African American, Haitian & Latino Communities
Alcohol and/or Club Drug users
Homeless
Incarcerated Persons/Commercial Sex Workers
Mentally ill
People with Disabilities / Seniors
Transgender
Victims of Domestic Violence
Women
Young People
Other
If you chose other, please list the population below and provide justification for providing services. 150 word limit.
Please describe your organization’s track record in working with the identified population.

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Project Demographics

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Population Served:
Elderly Disabled GLBT Homeless General Public
Sex
Male Female Transgender All
Ethnicity:
Asian African American Caribbean Hispanic/Latino
Native American White/Non Hispanic All Other:
Region Project Covers
North Broward South Broward Central Broward West Broward East Broward All
Age Group
Children (0-12) Teens (13-17) Adults (18+) All

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Intervention Levels

Proposed program/project must utilize one or more of the following Prevention Intervention Levels and Types as defined below:
Individual Level (ILI): Health education and risk-reduction counseling provided for one individual at a time. ILI's help clients make plans for behavior change and ongoing appraisals of their own behavior and include skills-building activities. These interventions also facilitate linkages to services in both clinic and community settings (for example, substance abuse treatment settings) in support of behaviors and practices that prevent transmission of HIV, and help clients make plans to obtain these services.
Group Level (GLI): Health education and risk-reduction counseling that shifts the delivery of service from the individual to groups of varying sizes. GLI's use peer and non-peer models involving a range of skills, information, education, and support.
Community Level (CLI): An intervention that seeks to improve the risk conditions and behaviors in a community through a focus on the community as a whole, rather than by intervening only with individuals or small groups. This is often done by attempting to alter social norms, policies, or characteristics of the environment. Examples of CLI include community mobilizations, social marketing campaigns, community-wide events, policy interventions, and structural interventions.
Please choose all that apply
Individual Level Group Level Community Level
Choose Prevention Intervention Type(s) utilized.
Peer Education Prevention Case Management Risk Reduction Counseling
Skills Building Sessions Social Support Street Outreach
Why have you chosen the specific population(s), level(s), and intervention(s)?
Limit 300 words

Project Outcomes

What are the measurable results this project will accomplish in order to achieve the outcomes.
Minimum two. For each Outcome:
  • Describe the strategy you will use to achieve the Outcome
  • Describe how you will evaluate each Outcome.
Limit for each field below 60 words.
Outcome #1
Strategy
Evaluation
Outcome #2
Strategy
Evaluation
Outcome #3
Strategy
Evaluation
Outcome #4
Strategy
Evaluation

Project Description

Provide a clear narrative describing how your project will be delivered (do not use bullets), and paints a well-defined picture as to how this project will achieve the outcomes listed previously by clearly outlining:
What are the exact services provided, how they will be implemented, when & where they occur (days/time/location/duration), who will implement them, how target population will access your project. Limit 400 words.

Intervention Category

Proposed programs must fall into one or more of the following categories.
  • Evidence-based HIV prevention interventions (EBIs) are either based on scientifically proven models, or are intentionally designed based on behavioral or social research and include at least basic process and outcomes evaluation to help improve the intervention and determine effectiveness.
  • Community Innovations are creative efforts that have theoretical basis for effectiveness, incorporate new or evolved strategies to address HIV/AIDS.
  • Structural interventions prevent HIV/AIDS and/or improve health and quality of life by changing community norms or community structures (social networks, service delivery systems, public policy, etc.) rather than changing individual behavior one person at a time.
  • New Interventions provide interventions that have not yet been proven effective and will measure the impact of the project in the field. These programs will have strong processes in place to collect evidence that can demonstrate the potential to be replicated and the promise of new models for future prevention work.

Evidence-Based Prevention Intervention Community Innovation
Structural Intervention New Intervention
Please describe how your program fits into the category chosen above. Limit 300 words.

CDC Tier of Evidence

Please identify into which Tier of Evidence the above program fits.
Please review the Tier of Evidence Framework from the CDC website at http://www.cdc.gov/hiv/topics/research/prs/tiers-of-evidence_tierI-II.htm.
You may cut and paste this link into a new browser to access the page.
Tier I: Best-Evidence Behavioral Intervention
Tier II: Promising-Evidence Behavioral Interventions
Tier III: Theory-Based Interventions with Positive Outcome Monitoring
Tier IV: Theory-based interventions with No Outcome Monitoring (based on theory, evaluation conducted)

Section D: Project Planning Limit 100 words for each answer below.

Describe how you will engage/select participants for your project?
How was community input and/or target population input included in the project planning?
Why is this project a good fit for your organization and the community?
Staff
List key staff and volunteers involved in implementing this project. Identify their roles and qualifications.
Collaborations
Describe who you will collaborate with on your projects and the specific role of each partner and/or the type of support to be provided. If receiving funding, please include a clearly outlined MOA. If there are not any collaborations, please describe why.
Sustainability
Please outline what other funding sources you have sourced/will source to ensure the sustainability or this project?

To complete each online application, you will need to upload the following information at the end of the application:

  1. A Budget Bundle with all three tabs completed
  2. Project Budget tab
  3. Project Narrative tab
  4. Organization Line Item Budget tab
  5. A copy of your IRS Designation letter
  6. A list of your Board Members with contact information and affiliations (this information will not be shared with other parties)
  7. Most recent Audited Financial Statement.
  8. MOA and/or Letters of support from collaborating partners

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