Q1-FY23.24 FRHD Community Health Contract Grant

1

Organization Information* This field is required.Please provide the legal name of the organization, as it appears on your 990. If you have a different DBA or nickname please add that in the box adjacent to the legal name.

Legal Name

DBA (if Applicable)

2

Contact Information* This field is required.Please add the contact information for the person responsible for the submission and monitoring of this grant application.

Contact Name

Title

Primary Contact Phone

Email Address

3

Program Name/Title* This field is required.

4

Brief Program Description* This field is required.Please provide a short description of the program. This is the "elevator speech version", this section is designed to refresh the reader about what this program does, and how it addresses your Statement of Need.

0/100

5

Funding Amount Awarded* This field is required.Please fill in the total amount of funding FRHD awarded through this 2023.2024 CHC Grant cycle.

6

Actual number of residents that directly benefited (participant/client) from this program during this quarter.* This field is required.The number of residents that receive the service or who are enrolled in your program.

7

Target Population - AgeList the percentages of your program participants’ ages. Percentages must add up to 100%

Percent of program participants

Estimated number of participants

Children (infants to 12)

Young Adults (13-17)

Adults (18-60)

Seniors (60+)

We do not collect this data (indicate with 100%)*

Children (infants to 12)

Young Adults (13-17)

Adults (18-60)

Seniors (60+)

We do not collect this data (indicate with 100%)*

Percent of program participants

Estimated number of participants

Percent of program participants

Estimated number of participants

Percent of program participants

Estimated number of participants

Percent of program participants

Estimated number of participants

Percent of program participants

Estimated number of participants

8

Target Population not collected - AgeIf you indicated that you do not collect data on the above question, please provide a rationale as to why that information is not sought. Write NA if this question is answered in the previous section.

0/200

9

Target Population - Gender* This field is required.List the percentages of your program participants’ gender identification. Percentages must add up to 100%

Percent of program participants

Female

Male

Non-binary

Unknown*

Female

Male

Non-binary

Unknown*

Percent of program participants

10

*Target Population - GenderIf you indicated that you do not collect data on the above question, please provide a rationale as to why that information is not sought. Write NA if this question is answered in the previous section.

0/200

11

Target Population - Income Level* This field is required.List the percentages of your program participants' income limit category - 2012 HUD – AMI Income limits (4 person family). Percentages must add up to 100%

Percent of program participants

Extremely Low-Income Limits, ceiling of $32,100

Very Low (50%) Income Limits, ceiling of $53,500

Low (80%) Income Limits, ceiling of $85,600

Higher Than Listed Limits

We do not collect this data (indicate with 100%)*

Extremely Low-Income Limits, ceiling of $32,100

Very Low (50%) Income Limits, ceiling of $53,500

Low (80%) Income Limits, ceiling of $85,600

Higher Than Listed Limits

We do not collect this data (indicate with 100%)*

Percent of program participants

12

*Target Population - Income LevelIf you indicated that you do not collect data on the above question, please provide a rationale as to why that information is not sought. Write NA if this question is answered in the previous section..

0/300

13

What language(s) does this program accommodate:* This field is required.Where most or the at least half of the program can be provided in the participant's primary language.

English

Spanish

Tagalog

Chinese (Mandarin/Cantonese)

Other

14

Program/Services Description - Social Determinants of Health* This field is required.Please select that/those of the following SDOH your program directly addresses.

Economic Stability (Employment, Food Insecurity, Housing Instability, Poverty)

Education Access & Quality (Early Childhood Education and Development, Enrollment in Higher Education, High School Graduation, Language and Literacy)

Social & Community Context (Civic Participation, Discrimination, Incarceration, Social Cohesion)

Healthcare Access & Quality (Access to Health Care, Access to Primary Care, Health Literacy)

Neighborhood & Built Environment (Access to Foods that Support Healthy Eating Patterns, Crime and Violence, Environmental Conditions, Quality of Housing)

15

Program Goal & Objectives* This field is required.Please restate the program goal(s) from your original application. Please describe the objectives of how this program serve the stated goal.

0/250

16

Program Outcomes & Measurables* This field is required.Explain how your measures of success of the program’s interventions or services. for each objective. These should be aligned with those submitted within your original application.

0/300

17

Anticipated Acknowledgment* This field is required.Please select the methods by which the Organization has acknowledged the District's investment of funding.

Social Media Postings

Signage at Service Sites

Print Materials to Service Recipients

Website Display

Other

18

Acknowledgment of District Support* This field is required.Please provide an example of how the District's support for this program was acknowledged. Please upload a pdf or image file of how the acknowledgement of support was demonstrated.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

19

Impact Story* This field is required.Please provide an example of how this program or service has made an impact on a client. You may change identifying information as necessary, but try to provide factual information regarding the relevance of eth services, how change was effected, and or how the District's funding made this service possible. Please upload a pdf or image file - this photo and story may be used as part of the District's outreach efforts. Your submission implies that you have permission to share any details and photos from your program participants.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

20

Program Budget* This field is required.Please upload the originally submitted Program Budget & Narrative file. Simply fill in the amount spent by category within the current quarter. Use the District provided spreadsheet which can be found here https://www.fallbrookhealth.org/community-health-contract-grants.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

21

Terms and Conditions* This field is required.Checking this box certifies that all information presented in, or attached to this report is complete and accurate.

22

Authorized Signature* This field is required.Please sign the application