Proposal Questionnaire for Expanded Critical Supports Application
Grant Number
*
E.g. ECS1-1
Legal Agency Name
*
City and State
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Name of Program Manager
*
First Name
Last Name
Email Address of Program Manager
*
example@example.com
Phone Number of Program Manager
*
Please enter a valid phone number.
Name of CEO
*
First Name
Last Name
Email Address of CEO
*
example@example.com
Name of Agency Board Chair
*
First Name
Last Name
Email Address of Agency Board Chair
*
example@example.com
Community Demographics and Need
1. Provide a brief description of the Holocaust survivor population in the community, including estimates of the total number of Holocaust survivors, number currently served, and unmet needs that could result in a crisis or premature institutionalization. (200 words max.)
*
0/200
2. Provide a brief description of the older adult population with a history of trauma in the community that you plan to serve through this grant and type of unmet needs that could result in a crisis or premature institutionalization. (200 words max.)
*
0/200
3. Provide a brief description of the needs of family caregivers who are caring for Holocaust survivors and/or older adults with a history of trauma in the community that you plan to serve through this grant. (200 words max.)
*
0/200
Leadership Council Strategy and Planning Process
4. How will you convene community agencies to develop strategies to provide critical supports to Holocaust survivors, older adults with a history of trauma, and their family caregivers? (500 words max.)
*
0/500
5. Please specify which agencies and individuals you plan to invite as part of your Leadership Council planning process, outreach strategies to those agencies and individuals and timelines. (500 words max.)
*
0/500
6. How will you involve Holocaust survivors in the Leadership Council planning process? (200 words max.)
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0/200
7. How will you involve older adults with a history of trauma in the Leadership Council planning process? (200 words max.)
*
0/200
8. How will you involve family caregivers of older adults with a history of trauma in the Leadership Council planning process? (200 words max.)
*
0/200
9. How will you use the Leadership Councils to determine the critical needs of Holocaust survivors that could lead to crisis or premature institutionalization? (200 words max.)
*
0/200
10. How will you use the Leadership Councils to determine the critical needs of older adults with a history of trauma that could lead to crisis or premature institutionalization? (200 words max.)
*
0/200
11. How will you use the Leadership Councils to determine the needs of family caregivers of older adults with a history of trauma? (200 words max.)
*
0/200
12. Describe the decision-making processes that you anticipate the Leadership Council will use to determine funding priorities and strategies. (500 words max.)
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0/500
13. How will you incorporate person-centered, trauma-informed (PCTI) approaches into all aspects of the Leadership Council, including training partner agencies on trauma and PCTI care? (500 words max.)
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0/500
Direct Services
14. Describe the logistical process for distributing grant funds. (200 words max.)
*
0/200
15. How will you track and monitor grant funds, both internally and to sub-subgrantees, to ensure compliance with all requirements? (200 words max.)
*
0/200
16. What percent breakdown do you anticipate serving among Holocaust survivors, older adults with a history of trauma, and their family caregivers through direct service?
*
17. How many individuals do you anticipate serving in Year 1 and Year 2?
*
Year 1
Year 2
Holocaust Survivors
0
1-15
16-25
26-35
36-50
51+
0
1-15
16-25
26-35
36-50
51+
Older Adults with a History of Trauma
0
1-15
16-25
26-35
36-50
51+
0
1-15
16-25
26-35
36-50
51+
Family Caregivers
0
1-15
16-25
26-35
36-50
51+
0
1-15
16-25
26-35
36-50
51+
Program Management
18. How often will you communicate with sub-subgrantees and what mode of communication will you use? How will you periodically collect the information required for JFNA’s reporting? (200 words max.)
*
0/200
19. How do you intend to staff the program? (200 words max.)
*
0/200
20. How will you sustain the Leadership Council at the end of the grant period to coordinate care for Holocaust survivors, older adults with a history of trauma, and their family caregivers? (200 words max.)
*
0/200
21. Describe the challenges you anticipate while planning and implementing this program and how you may overcome them. (500 words max.)
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0/500
Evaluation
22. Thinking about the activities proposed by your project, what outcomes would you like your project to achieve? (500 words max.)
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0/500
23. What are indicators by which you will measure the outcomes of your project? (500 words max.)
*
0/500
24. What data collection tools will you use to measure the outcomes of your project? (500 words max.)
*
0/500
25. Please describe your organizational capacity to measure the outcomes of your project. This may include a description of staff assignments, evaluation resources, or other aspects. (500 words max.)
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0/500
Budget
26. Provide a brief description of plans to meet the match requirement. (200 words max.)
*
0/200
27. Explain the rationale of your proposed budget, including program revenue sources and program expenses. Please explain the numbers and decisions behind the proposed budget. Include an explanation of program expenses, including personnel, program activities, and overhead. Explain in-kind funds, including how you will assess monetary value for donated goods and services (e.g. personnel, space, etc.). Include whether the matching funds have been secured or are anticipated. (500 words max.)
*
0/500
28. The program budget should be submitted using the template provided. Please upload your completed budget here:
*
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Work Plan
The work plan should be completed using the template provided. It provides a schematic overview of the narrative, including anticipated timelines, objectives, and activities associated with the proposal. See directions in work plan template.
29. Please upload your completed 2-year work plan here:
*
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