Week 3
Application Community Health Endowment of Lincoln Nebraska
Printed On: 29 August 2017 Targeted Application (2017-2018 Fall) 1
Targeted Application (2017-2018 Fall) Community Health Endowment of Lincoln Nebraska Grant Number Grant Number Character Limit: 100
Project Name* Character Limit: 100
Project Summary* Character Limit: 350
Total Request from CHE* Character Limit: 20
Amount Requested Year 1* Character Limit: 20
Amount Requested Year 2* Character Limit: 20
Amount Requested Year 3* Character Limit: 20
Total Project Cost* Character Limit: 20
Targeted Application Stage II (2017-2018 Fall) Applications are limited to those that address one or more of the following priorities. Be sure to review more information about the funding priorities here. Select all priorities that apply to your project. Please note that you cannot uncheck boxes.
FUNDING PRIORITIES
CHE has three funding priority areas for 2017-2018. By inviting applications that address these priorities, CHE strives to tackle recognized community challenges, create lasting impact, and make Lincoln the healthiest community in the nation.
Application Community Health Endowment of Lincoln Nebraska
Printed On: 29 August 2017 Targeted Application (2017-2018 Fall) 2
Health Innovation Choices Helping adults and children stay healthy outside of a clinical setting Embracing bold ideas/solutions to enhance traditional models of health care/behavioral health
Early Childhood Trauma Choices Reducing or eliminating childhood toxic stress Reducing childhood obesity Improving maternal health and birth outcomes
Prevention Choices Fostering healthy behaviors that lead to improved health outcomes
FUNDING PREFERENCES CHE believes that grant requests in the three priority areas can have an improved chance of success when certain factors are also considered. While including these factors in a grant application does not guarantee funding from CHE, applicants are encouraged to consider the following Funding Preferences whenever possible:
Cross-Sector Collaboration Choices Creates intentional linkages between cross-sector partners
Impact of Poverty Choices Recognizes the role poverty plays in causing or addressing a community issue
Use of Local Data Choices Uses local data to inform the need, target group or geographic area to be addressed
Evidence-Based Models Choices Uses evidence-based models or proven approaches to inform program design and delivery
If you are applying for a grant for fitness or wellness activities, please review this best practices document and include information in the narrative of your application about how you will address or incorporate these practices.
Application Community Health Endowment of Lincoln Nebraska
Printed On: 29 August 2017 Targeted Application (2017-2018 Fall) 3
INSTRUCTIONS In the fields below, please provide a clear and concise summary of the proposed project using the headings provided. Answer each question or statement included in the heading. Your response is limited to the character counts listed under each heading. Please note that character limits include spaces. CHE recommends that applicants compose your application in a word processing document, then copy and paste into the online application. Character counts can vary between programs. You may need to edit after you paste the information into the online application.
Population(s) to be Served* Provide a clear description of the population(s) that will be served by your project. Why did you choose to focus on this population? What are the size, characteristics and location of the population? How many people and what percentage of the target population will be served by your project? Include Lincoln-specific data (e.g. demographics, health status, poverty rate) and, if applicable, geographic target area (e.g. census tract(s), block group(s), neighborhood) to support your focus on this target population. Maps, both static and interactive, from CHE’s Place Matters Community Mapping project are available here: http://www.chelincoln.org/placematters/. Character Limit: 4000
Project Outcomes* Describe specific and measurable outcomes you expect to achieve. Describe the indicators you will track to measure your progress toward these outcomes and how you will evaluate the project. Be ambitious, yet reasonable, in proposing outcomes. Whenever possible, set your project outcomes relative to baseline data. Character Limit: 4000
Project Overview and Activities* Describe your project and the activities you will undertake to achieve your expected outcomes. Identify any partnerships or collaborations that will be part of the project and the current status of those relationships. Character Limit: 10000
Expected Barriers/Challenges* Every project will face barriers and challenges. Describe barriers and challenges that could arise for your project and how you would address them. Character Limit: 4000
Diverse Perspectives* How do you propose to draw upon diverse perspectives in the community to strengthen the proposed project? Character Limit: 2400
Application Community Health Endowment of Lincoln Nebraska
Printed On: 29 August 2017 Targeted Application (2017-2018 Fall) 4
Applicant's Qualifications* Describe how your organization is uniquely qualified to carry out this project. If you include information about your organization’s history, mission, vision, services provided, and/or populations and geographic area served, explain how it is relevant to your ability to successfully complete this project. Character Limit: 2400
Applicant Status* Has your agency violated state or federal law in the current year or the preceding two years? Choices No Yes
Explanation If yes, please explain. Character Limit: 1000
WORK PLAN
Project Work Plan* Please complete the following steps to attach your work plan. Refer to the work plan worksheet to guidance in completing your work plan.
1. Download the work plan template. 2. Complete the work plan and save it to your computer. Be sure to fill in the " Project
Name" and "Agency" sections of the form. 3. Attach the completed work plan to this application by clicking the Upload a file button
below. File Size Limit: 1 MB
BUDGET AND JUSTIFICATION
Budget* https://chelincolnorg.presencehost.net/file_download/d143af7b-b936-4161-aad1- 8881dc1e7362A Budget is required for each year of requested funding. The Budget template available in Excel format. Two tabs are provided for each budget year in this file (one tab for support/revenue and one tab for expenses). Please complete the following steps to submit your Budget Form(s).
Application Community Health Endowment of Lincoln Nebraska
Printed On: 29 August 2017 Targeted Application (2017-2018 Fall) 5
Download a Budget template.
Complete the Budget and save it to your computer.
Attach the completed Budget to this application by clicking the Upload a file button below.
File Size Limit: 1 MB
Budget Justification Explain any discrepancy between the Revenue and Expense budgets. Explain the factors used to determine the costs of budget line items such as mileage rates, personnel benefits, etc., and any other factors affecting your budget. Character Limit: 1000
Sustainability If this project is funded, describe how/if you will continue the project when CHE funding ends. What is it about this project that is likely to attract ongoing interest and support? Character Limit: 2400
Rationale* Why is your project the best use of CHE funds? Character Limit: 1200
SUPPORTING DOCUMENTS Please upload documents in PDF format whenever possible. If the document is not available in a digital format, you can use the “Fax to File” option available in the Tools section.
Board of Directors Roster* Attach a roster of the agency’s Board of Directors or governing body including individual names, affiliations, and addresses, and an aggregate summary of the race/ethnicity and gender composition of the Board. The summary is required. File Size Limit: 1 MB
Letters of Commitment
Attach no more than three (3) letters of commitment. A letter of commitment provides evidence of sharing of actual resources. Include only letters that show a commitment of financial or human resources to the project. If you have included other sources of support in your Revenue Budget, either cash or in-kind, that support should be documented with a Letter of Commitment.
Application Community Health Endowment of Lincoln Nebraska
Printed On: 29 August 2017 Targeted Application (2017-2018 Fall) 6
Letter #1 File Size Limit: 1 MB
Letter #2 File Size Limit: 1 MB
Letter #3 File Size Limit: 1 MB
Operating Budget* The agency's operating budget for the current year. File Size Limit: 3 MB
Income/Expense Statement The agency's income/expense statement and balance sheet for the current period. Choices Not Applicable/Not Available
File Size Limit: 4 MB
Financial Statements Provide the highest level financial statement review available for the most recent complete fiscal year, unless a government agency. (If your statements are not audited or reviewed, submit a balance sheet and income/expense statement for your agency's most recently completed fiscal year.) Choices Not Applicable/Not Available
File Size Limit: 4 MB
ELECTRONIC SIGNATURES
Authorized Officer Signature* Enter your full name, business title, and the date of submission. (e.g.; Erin Smith, Executive Director, August 20, 2017) Character Limit: 100
By entering your signature and clicking "I Agree," you certify that the statements contained in this application are true and correct to the best of your knowledge and belief, and you are authorized to sign official documents on behalf of the organization.
Application Community Health Endowment of Lincoln Nebraska
Printed On: 29 August 2017 Targeted Application (2017-2018 Fall) 7
Choices I Agree
NOTE: Your submission of this application completes the application process. There is no need to provide additional hard copies of these materials to CHE.