The Dr. Mark A. Keroack Health Equity Grant Request For Proposal (RFP) Form
Due Date: August 28, 2024, 11:59 PM ET
Lead Organization
Organization Name
*
Website
*
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Fiscal Agent
(If Applicable)
Contact Name
(of person submitting grant application)
Name
*
First Name
Last Name
Title/Position
*
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Executive Officer of Organization
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Program Information
Program Name
*
Program Dates
Program needs to start in 2024
Brief program overview, including whether it is an existing or new program.
*
0/500
Program Website
*
(Please include website for existing programs if available and different from organization's)
Budget
Total Program Budget
*
Any in-kind/matching funding? If yes, please describe
*
0/200
Organizations annual operating budget
*
Community Investment Tax Credit (CITC) Eligible.
*
Yes, CITC eligible
No
Populations to be Served
Identify proposed program targeted population.
*
Please include but not limited too: age, ethnicity, gender, and race.
0/250
Geographic Area Served
*
Franklin
Hampden
Hampshire
Estimated Reach / Anticipated Number of Lives Program will Touch
*
0/100
All grants must focus on one of the prioritized Social Determinants of Health (SDOH) identified in the HNE CHNA (Check all that apply. Must select at least one).
*
Built Environment (includes Access to food & transportation)
Education
Employment
Housing
Social Environment (institutional racism and social isolation)
Violence and Trauma
1.) Describe your organization
*
0/500
2.) Describe the need for your program in the population you will be serving. Specifically, describe the problem(s) and/or gaps you will address, which should be clearly aligned with health outcomes, and any health inequities you will focus on. Use data (e.g, HNE Community Health Needs Assessment, County Health Rankings, other hospital health needs assessments, local report(s)) to describe the need.
*
0/1000
3.) Describe the proposed program you are planning to implement, enhance or expand. Please explain how it will advance health equity in the community your organization serves. Please include the issue(s) the project will address and how it will impact health. (Work/Evaluation Plan should reflect program activities and intended outcomes).
*
0/2000
4.) Describe your current capacity to implement your program. Include past experience, current experience and expertise of organization and key staff, and any relevant partner expertise/experience. Describe your plans for staffing and managing project.
*
0/1000
5.) List and describe organization (include all sectors, including community-based, healthcare, municipal) that would be partnering with you on this program and whether a structure already exists for this partnership. If structure exists, please provide examples of other initiatives in which you have collaborated. If a structure does not exist, how will you establish and formalize one. Community partners should be incorporated into your programs work plan.
*
0/1000
6.) Describe plans to sustain, continue or work towards institutionalizing the program once grant funding ends.
*
0/1000
W-9 or proof of tax-exempt status for a fiscal agent. Fiscal sponsorship agreement letter is required to be submitted if utilizing a fiscal sponsor.
*
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Budget worksheet and narrative.
*
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Request template by emailing CommunityGiving@hne.com
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of
Work/Evaluation Plan
*
Browse Files
Request template by emailing CommunityGiving@hne.com
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of
Signed Letters of Support for all projects collaborators necessary for the implementation of the project.
*
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Letters should clearly state collaborators' roles. All applicants are required to submit at least one letter of support. If no collaborators are included in proposed project, letter of reference from an organization familiar with applicant's work should be included.
Cancel
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List of members of your organization's Board of Directors
*
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Please include names and affiliations (i.e. profession/organization, community represented)
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Submit
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