FY2024 NCR HCC Partner Project Funding Application

FY2024 NCR HCC Partner Project Funding Application

This grant application is for FY 2024 North Central Region - Hospital Preparedness Program (HPP) grant projects.
Instructions: The NCR HCC Grant Funding page is available for application guidance and resource documents.

You will have an opportunity to upload your project budget, W-9, and supplemental documents within this application.

All applications must be submitted by Friday, August 30, 2024.

Please direct any question on the application document or process to Michelle Deland at mdeland@ncrhcc.org 303-588-8488.
Project Name:*
Agency/Organization Name: *
Applicant Contact Information*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Total amount of funding requested: *
Matching Funds Information: Please identify any sources of matching funds (hard match only) that will support the goals of this project. *If you do not have matching funds, please leave blank.

Project Background
Provide a summary of the project including project objectives, outcomes, and funding requirements. Consider the question, "What are we trying to accomplish with this request?"
Provide a summary description of the current state of this project
Describe how the project will directly address mitigation, preparedness, response, and/or recovery risks or gap areas associated with the public health and medical system:
Which POETE element(s) is this project focused on (select all that apply)?

Planning (developing and/or modifying plans)Organizing (key stakeholder engagement, roles and responsibilities, etc.)Equipping (equipment, supplies, MOUs, etc.)Training (training development, implementation, etc.)Exercising and Evaluation (exercise development and/or conduct, identification of areas for improvement, etc.)
Has this project received previous HPP grant funding within the last five (5) years?

YesNoUnsure
If yes, please identify how much, what year, and what activities were supported:

Hospital Preparedness Program Capability and Objectives
Please indicate which 2024-2028 National Healthcare Preparedness and Response Capabilities this project addresses.Please include a brief explanation of how the project addresses these capabilities in the bottom box.

Capability 1: Incident Management and CoordinationCapability 2: Information ManagementCapability 3: Patient Movement and DistributionCapability 4: WorkforceCapability 5: ResourcesCapability 6: Operational ContinuityCapability 7: Specialty CareCapability 8: Community Integration
Describe how the project's outcomes mitigate and/or addresses these capabilities:

Criticality and Public Health and Healthcare Linkage
Joint Risk Assessment Alignment
Describe how the project specifically addresses a hazard, gap, and/or vulnerability area(s) identified within the 2023-2024 NCR HCC Joint Risk Assessment, including how the project improves the identified aligned JRA area(s):
2023-2024 NCR HCC Joint Risk Assessment available on NCR HCC Member Portal and/or by e-mailing cburdick@ncrhcc.org

Multi-Jurisdictional and/or Multi-Agency Collaboration
Describe how this project supports multi-jurisdictional and/or multi-agency collaboration and coordination:
Identify partner agencies, jurisdictions, partners, etc. that are actively collaborating on the development and submission of this project:

Sustainability and At-Risk Populations
Describe the sustainability plan for this project, if applicable. Please include any ongoing maintenance costs and who will cover these costs following the funding period.
Describe this project's impact on at-risk populations (e.g., children, pregnant individuals, older adults, individuals with disabilities, or others who may have access and functional needs in the event of an emergency) and/or populations disproportionately impacted by disasters:

Additional Submission Documents

Please upload the following documents:
Itemized project budget.

Please upload an itemized budget for the project. Template provided on the NCR HCC website under "Grant Funding." Budget must be converted to a PDF to be uploaded.
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W-9

Please upload a completed W-9 for the primary organization on the application (i.e., the entity that will be submitting invoiced for reimbursement).
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Supplemental Documents *if applicable

Please upload any supplemental documents related to the project (e.g., quotes for products and/or services, vendor proposals, etc.)
Cancelof
Supplemental Documents *if applicable

Please upload any supplemental documents related to the project (e.g., quotes for products and/or services, vendor proposals, etc.)
Cancelof
Supplemental Documents *if applicable

Please upload any supplemental documents related to the project (e.g., quotes for products and/or services, vendor proposals, etc.)
Cancelof

Project Verification and Submission
Completion of the information below serves as the electronic signature of the individual completing this application and attests to the accuracy of the information provided.

I, the Requester, understand that I am requesting grant funds from the North Central Region Healthcare Coalition and that such funds are restricted under the guidelines set forth by the Hospital Preparedness Program, the Governance of the North Central Region Healthcare Coalition, and Trailhead Institute (fiscal agent). I agree to provide any documentation required by the Governance Board and/or fiscal agent to authorize payment or review of appropriateness of the request.
Name*

First NameLast Name
Title*
Date*

MonthDayYear
Date
Additional Signatures *only if required by the applicant's organization
Name

First NameLast Name
Title
Date

MonthDayYear
Date
Should be Empty:

Project Background