Health Improvement Innovation Application
2022-2023
Workplan(50 Points Total)
Workplan (50 Points Total)
Activities must fall within at least one of the three broad categories of Determinants of Health: Economic Opportunity, Physical Environment, Social Factors.
Determinants of Health: (Choose as least one of the three areas)
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Economic opportunity
Physical environment
Social factors
Strategy(s) Narrative (20 Points): Describe in detail the proposed strategy(s), how you plan to accomplish the strategy(s), and identify a lead person responsible for each strategy(s). Evidence-based practices are preferred, but innovative, promising practices are also eligible with justification.
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Population Served: Please describe which population will be served by these activities and which barriers you plan to impact. Please include an anticipated total number served.
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Need (10 Points): Describe the need for the implementation of the strategy(s) in the selected sector and the health disparities experienced. Include supporting state or local data.
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Partners/Organizations (5 Points): List all partners/organizations that will be involved in the strategy(s).
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Timeline (5 Points): Provide a detailed timeline for the strategy(s) within the funding period. If overall goals are anticipated to take longer than the funding period, provide an additional long-term timeline with broad goals and objectives.
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Evaluation (10 Points): Provide a workable evaluation plan that can describe the strategy(s) and its impact. Include evaluation questions to measure impact.
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Budget (40 Points Total)
Using the excel template provided, formulate your budget request. Applicants must provide sufficient budget narrative to justify costs to achieve selected strategies:
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Supporting Information (10 Points Total)
Organization Information (5 points)
This information will be used for follow-up communications and to develop contracts for successful applicants.
Full Organization Name
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Lead application contract
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First Name
Last Name
Preferred e-mail
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example@example.com
Organization name
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Organization Address
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Street Address
Street Address Line 2
City
State
Zip Code+ 4
Phone Number
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Please enter a valid phone number.
Organization DUNS/unique entity identifier number
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Organization's fiscal year
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Fiscal agent
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Proof of Organization (5 Points)
Please attach a W9 and proof of insurance.
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