2022 ASIRT Request For Applications: Rural Health Clinic and/or Federally Qualified Health Center
Organization Profile
Organization Information
Organization Name
*
Organization Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization Mailing Address (if different than physical address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tax ID Number
*
RHC and/or FQHC Confirmation
*
I confirm that this organization is a Rural Health Clinic and/or Federally Qualified Health Center.
Back
Next
Save
Applicant Contact Information
Applicant Name
*
First Name
Last Name
Applicant Title
*
Applicant Email
*
example@example.com
Applicant Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Save
Authorization Information
Person authorized to sign contract
Name
*
First Name
Last Name
Title
*
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Save
Project Questions
Organizational Capacity
Organization History and Mission
*
0/500
List all clinical locations and addresses
*
0/500
Select all Parishes your organization currently serves.
*
Concordia
Catahoula
East Carroll
Madison
Morehouse
Richland
St. Landry
Tangipahoa
Tensas
Select all Communities that would be impacted by your organization's project.
*
Bastrop
Delphi
Ferriday
Jonesville
Kentwood
Lake Providence
Newellton
Opelousas
St. Joseph
Tallulah
Describe the community your clinic/health center serves (Parish name, race, demographics, etc.)
*
0/500
Select the populations served by your organization.
*
African-American
Asian
Caucasian
Latino or Hispanic
Native American
Native Hawaiian or Pacific Islander
Other
List the percentage of your clients/patients that are Black or African-American? (priority populations for this grant)
*
Describe the programs and services your clinic/health center provides and specify any community health or health care programs.
*
0/500
Provide the number of community members your organization served in 2021.
*
Describe your organization's technology capacity regarding access to the internet and ability to participate in video meetings and video trainings?
*
0/500
Provide the name of your organization's Electronic Health Record system and how long you have used the systemand information and intend to stay in the system.
*
0/500
List your organization's key accomplishments
*
0/500
List at least three of your organizational goals for the next 12 to 18 months.
*
0/500
Back
Next
Save
Clinical Practice Guidelines for Tobacco Cessation
Describe the tobacco cessation services offered by health center provided to patients and community members.
*
0/500
Describe any challenges faced in delivering these services.
*
0/500
Describe your interest and past experience in participating in learning collaboratives centered on incorporating best practices for clinical quality improvement, including tobacco cessation at your organization.
*
0/500
What do you hope to enhance related to tobacco cessation within your organization's practice?
Tobacco screening protocols
Improving documentation of tobacco screening
Brief-intervention for tobacco screeningtion 3
Referral systems for tobacco cessation
Certificed Tobacco Treatment Specialist Training
Communicate and promote tobacco cessation services
Other
List the clinical providers and staff who would be available to attend learning collaborative sessions on tobacco cessation interventions.
*
0/500
Does your clinic/health center currently refer patients to 1-800-QUITNOW, the Louisiana tobacco quitline.
*
0/500
Back
Next
Save
Community Engagement and Activities
Describe if and how your clinic/health center provides outreach services to community members.
*
0/500
How would your clinic/health center incorporate this project with its other community programs and activities?
*
0/500
What are some other priority health and social issues that your community is dealing with now?
*
0/500
Describe any other community mobilization or advocacy activities your organization is currently involved in.
*
0/500
Is your organization currently involved in a Healhty Communities Coalition? (See Appendix C for contact information of LPHI staff that can provide coalition information)
*
0/500
Back
Next
Save
Financial Information and Budget
Complete and submit the program expense form for the organization’s proposed grant using the template in the RFA Appendix B. The form must be uploaded as a Word document or PDF. Note: indirect costs should be at or below 12 percent of the total direct costs.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Describe any other sources of funding for this work.
*
0/500
Back
Next
Save
Monitoring and Evaluation
Clinics/Health Centers will be required to submit quarterly reports and a final report that describes program activities and impact including a financial report.
Describe clinic/health center’s ability to submit required reports.
*
0/500
Describe clinic/health center’s current capacity for monitoring and evaluation (ex: tracking progress & measuring outcomes).
*
0/500
Please list the top three impacts that your clinic/health center would like to have on your community with this grant project.
*
0/500
Back
Next
Save
Print
Save
Submit
Clear All Questions
Should be Empty: