Health Improvement Innovation Application
2023-2024
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)
*
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.
*
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.
*
Need (10 Points): Describe the need to implement strategy(s) and provide a detailed explanation about how this effort will impact the population(s) experiencing health disparities. Include supporting state or local data to justify the need.
*
Partners/Organizations (5 Points): List all partners/organizations that will be involved in the strategy(s).
*
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.
*
Evaluation (10 Points): Provide a workable evaluation plan that can describe the strategy(s) and its impact. Include evaluation questions to measure impact.
*
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:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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
*
Application Contact Name
*
First Name
Last Name
Preferred E-mail
*
example@example.com
Organization Name
*
Organization Address
*
Street Address
Street Address Line 2
City
State
Zip Code+ 4
Phone Number
*
Please enter a valid phone number.
Unique Entity Identifier Number/Tax Identification Number
*
Organization's Fiscal Year
*
Fiscal Agent Name
*
Name of the individual authorized to sign on behalf of the fiscal agent
*
Email address of the individual authorized to sign on behalf of the fiscal agent
*
Proof of Organization (5 Points)
Please upload W-9 and Proof of Insurance.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Save
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform