You can always press Enter⏎ to continue
Q3-FY23.24 FRHD Community Health Contract Grant - Impact Report
For Fiscal Year 2023-2024
START
Language
English (US)
Spanish (Latin America)
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)
Previous
Next
Submit
Press
Enter
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
Previous
Next
Submit
Press
Enter
3
Program Name/Title
*
This field is required.
Previous
Next
Submit
Press
Enter
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
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
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.
Previous
Next
Submit
Press
Enter
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.
Previous
Next
Submit
Press
Enter
7
Target Population - Age
List 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)
Row 0, Column 0
Row 0, Column 1
Young Adults (13-17)
Row 1, Column 0
Row 1, Column 1
Adults (18-60)
Row 2, Column 0
Row 2, Column 1
Seniors (60+)
Row 3, Column 0
Row 3, Column 1
We do not collect this data (indicate with 100%)*
Row 4, Column 0
Row 4, Column 1
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
Row 0, Column 0
Estimated number of participants
Row 0, Column 1
Percent of program participants
Row 1, Column 0
Estimated number of participants
Row 1, Column 1
Percent of program participants
Row 2, Column 0
Estimated number of participants
Row 2, Column 1
Percent of program participants
Row 3, Column 0
Estimated number of participants
Row 3, Column 1
Percent of program participants
Row 4, Column 0
Estimated number of participants
Row 4, Column 1
1
of 5
Previous
Next
Submit
Press
Enter
8
Target Population not collected - Age
If 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
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
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
Row 0, Column 0
Male
Row 1, Column 0
Non-binary
Row 2, Column 0
Unknown*
Row 3, Column 0
Female
Male
Non-binary
Unknown*
Percent of program participants
Row 0, Column 0
Percent of program participants
Row 1, Column 0
Percent of program participants
Row 2, Column 0
Percent of program participants
Row 3, Column 0
1
of 4
Previous
Next
Submit
Press
Enter
10
*Target Population - Gender
If 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
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
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
Row 0, Column 0
Very Low (50%) Income Limits, ceiling of $53,500
Row 1, Column 0
Low (80%) Income Limits, ceiling of $85,600
Row 2, Column 0
Higher Than Listed Limits
Row 3, Column 0
We do not collect this data (indicate with 100%)*
Row 4, Column 0
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
Row 0, Column 0
Percent of program participants
Row 1, Column 0
Percent of program participants
Row 2, Column 0
Percent of program participants
Row 3, Column 0
Percent of program participants
Row 4, Column 0
1
of 5
Previous
Next
Submit
Press
Enter
12
*Target Population - Income Level
If 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
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
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
Previous
Next
Submit
Press
Enter
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)
Previous
Next
Submit
Press
Enter
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
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
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
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
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
Previous
Next
Submit
Press
Enter
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
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
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
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
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
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
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.
Previous
Next
Submit
Press
Enter
22
Authorized Signature
*
This field is required.
Please sign the application
Clear
Previous
Next
Submit
Press
Enter
Should be Empty:
Q3-FY23.24 FRHD Community Health Contract Grant - Impact Report
[Edit]
Question Label
1
of
22
See All
Go Back
Submit