Health New England Where Health Matters RFP Form
Due Date, May 17, 2023, 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 Period
*
12 Months
2 Years
3 Years
Brief program overview, including whether it is an existing or new program.
*
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
Annual Operating Budget
*
Community Investment Tax Credit (CITC) Eligible.
*
Yes, CITC eligible
No
Populations to be Served
Identify program targeted population (please include WHMG priority populations).
*
Please include but not limited too: age, ethnicity, gender, and race.
Geographic Area Served
*
Berkshire
Franklin
Hampden
Hampshire
Worcester
Statewide
Other
Estimated Reach / Anticipated Number of Lives Program will Touch
*
0/100
Health New England Focus Area
*
Build Environment (food insecurity, housing needs, safe places to play, transportation)
Maternal and Infant Health
Mental Health and Substance Use
All grants must focus on one of the prioritized Social Determinants of Health (SDOH) identified in the HNE CHNA. If the applicant selects an HNE Focus Area that is a SDOH, then the applicant will identify that area and any other applicable areas from the list below 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
*
0/250
2.) Please describe how diversity, equity, inclusion and belonging is embedded into your organization.
*
0/250
3.) 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 linked to the HNE focus areas, aligned with health outcomes, and any health inequities you will focus on. Please specify why your program is addressing the HNE focus area health outcomes. Use data (i.e. HNE Community Health Needs Assessment, County Health Rankings, other hospital health needs assessments, local report(s) to describe the need.
*
0/300
4.) Describe the program you are planning to implement, enhance or expand, who will be served, and what you are intending to achieve, and how it will tie to both HNE focus area and health improvement. Please describe any evidence of effectiveness or promise/potential of effectiveness of the program. Describe roles and responsibilities of all partner organizations required for success of program implementation. (Logic Model & Work Plan should reflect program activities and intended outcomes)
*
0/400
5.) Please describe how your program addresses social determinants of health and health equity. Describe policies, scalable approaches and interventions that will best meet the health and nonmedical needs of the target population you seek to serve.
*
Addressing the social determinants of health (SDOH) is one of the most effective ways to improve health and reduce health disparities as SDOH contribute to wide health disparities and inequities. Therefore, an understanding of the intersection between the social determinants, health disparities and health outcomes is fundamental to advancing health equity.
0/300
6.) If you have applied for 2-year or 3-year funding, describe why it is important for your program to be funded for three consecutive years. Provide specific plans for year one of your program, and a high level narrative of the goals and anticipated accomplishments for years 2 and 3 of the program. Your work plan, evaluation plan and budget proposal should reflect and incorporate the same structure as listed above.
*
(Please put N/A if not applying for multi-year funding)
0/300
7.) Describe your current capacity to implement your program. Include past experience, current experience, and expertise or organization and key staff, and any relevant partner expertise/experience. Describe your plans for staffing and managing project.
*
8.) Evaluation plan narrative. Provide a brief description of your plans to conduct your evaluation as detailed in the evaluation plan template. Please include long term outcomes for multi-year requests. Indicate who will be responsible and the infrastructure you will have to support your evaluation, including staffing and data management software. Describe your capacity for data collection (qualitative and quantitative) and your ability to measure and report on outcomes.
*
0/300
9.) 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.
*
10.) Describe plans to sustain, continue or work towards institutionalizing the program once grant funding ends.
*
0/250
11.) Has your program previously received community benefits or sponsorship funding from HNE or Baystate Health? If yes, please specify from which organization, the purpose of the funding, and the amount of funding.
*
0/100
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.
*
Browse Files
Cancel
of
Logic Model
*
Browse Files
Request template by emailing CommunityGiving@hne.com
Cancel
of
Work Plan
*
Browse Files
Request template by emailing CommunityGiving@hne.com
Cancel
of
Evaluation Plan
*
Browse Files
Request template by emailing CommunityGiving@hne.com
Cancel
of
Budget
*
Browse Files
Request template by emailing CommunityGiving@hne.com
Cancel
of
Program Staff
*
Browse Files
Please include names, titles, qualifications, and resume of key staff
Cancel
of
Signed Letters of Support for all projects collaborators necessary for the implementation of the project.
*
Browse Files
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
of
List of members of your organization's Board of Directors
*
Browse Files
Please include names and affiliations (i.e. profession/organization, community represented)
Cancel
of
Submit
Should be Empty: