2022 ASIRT Request for Applications: Community Based Organizations
Organization Profile
Organization Name
*
Organization Physical Address
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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/FQHC Confirmation
*
I confirm that this organization is a 501c3 Registered Public Charity.
Upload the organization’s latest IRS letter showing 501c3 tax exempt status
*
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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.
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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.
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Population Served
Select all parishes your organization currently serves.
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Concordia
Catahoula
East Carroll
Madison
Morehouse
Richland
St. Landry
Tangipahoa
Tensas
Select all communities that would be impacted by your organization's project.
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Bastrop
Delphi
Ferriday
Jonesville
Kentwood
Lake Providence
Newellton
Opelousas
St. Joseph
Tallulah
Select the populations served by your organization.
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African-American
Asian
Caucasian
Latino or Hispanic
Native American
Native Hawaiian or Pacific Islander
Other
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Project Questions
Organizational Capacity
History and mission of the organization.
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0/500
Organization’s programs and services provided. Also, specify any community health/health care programs
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0/500
Number of community members served in 2021
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What percentage of your clients/customers identify as Black or African-American (priority population for this grant)?
*
What is the organization’s technology capacity regarding access to the internet and ability to participate in virtual meetings and virtual trainings (via Zoom and/or Microsoft Teams platform)?
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0/500
List key accomplishments of the organization.
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0/500
List at least three of your organization's goals for the next 12 to 18 months.
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0/500
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Community Engagement and Activities
What are some priority social issues that your community is dealing with now?
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0/500
Describe your interest in this project.
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0/500
How would your organization incorporate this project with its other community programs and activities?
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0/500
Describe any other community mobilization or advocacy efforts that your organization is currently involved in.
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0/500
Are you currently involved in a local or statewide coalition? (See Appendix B for contact information of LPHI staff that can provide coalition information.)
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0/500
Capacity Building
What skills do you hope to enhance related to grassroots advocacy, Tobacco Control and Healthy Communities within your organization?
Understanding systemic inequities
Engaging and mobilizing communities to create policy change
Understanding equity and social determinants of health
Increasing the use of traditional and non-traditional tobacco cessation programs for tobacco users who want to quit smoking
Supporting local smoke-free policy
Designing and promoting prevention strategies to build Healthy Communities
Other
What skills or topics are you “considered an expert” in and can provide trainings to others? (For example: communicating to elected officials, project development, meeting facilitation, developing presentations)
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0/500
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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.
*
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Describe any other sources of funding for this work.
*
0/500
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Monitoring and Evaluation
Organizations will be required to submit monthly reports and a final report that describes program activities and impact including a financial report.
Describe your organization’s ability to submit required reports.
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0/500
Describe your organization’s current capacity for project monitoring and evaluation (ex: tracking progress & measuring outcomes)
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0/500
Please list the top three impacts that your organization would like to have on your community with this grant project.
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0/500
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