COVER PAGE FOR GRANT PROPOSAL - PAGE 1

Transcription

1 COVER PAGE FOR GRANT PROPOSAL - PAGE 1 PROJECT DIRECTOR & TITLE INSTITUTION ADDRESS PHONE FAX TITLE OF PROJECT TOTAL AMOUNT REQUESTED INDIVIDUAL WHO IS AUTHORIZED TO CONTRACTUALLY BIND THE ORGANIZATION PRINT NAME AND TITLE GRANT PERIOD 04/01/2012 to 03/31/2013 SIGNATURE AND DATE PLEASE CHECK TYPE OF APPLICATION: (More than one box can be checked) EDUCATION SCREENING TREATMENT NEW KOMEN GRANT REQUEST Returning Komen Grant Request APPLICATIONS MUST BE RECEIVED IN AFFILIATE OFFICE BY 5:00 P.M. ON THURSDAY, JANUARY 19, 2012

2 COVER PAGE FOR GRANT PROPOSAL PAGE 2 Project Title: Counties where clients reside: Mark as many as applicable with an X before the specific county Adams County OH Warren County OH Brown County OH Butler County OH Boone County KY Clermont County OH Campbell County KY Clinton County OH Gallatin County KY Darke County OH Grant County KY Greene County OH Kenton County KY Hamilton County OH Highland County OH Dearborn County IN Miami County OH Ohio County IN Montgomery County OH Switzerland County IN Preble County OH Population Served: Total Clients Served: Cost per client/participant: (Please use figure c. from Budget page 5) Target population: Please numerically rank the top three primary groups that will benefit from this grant. Choose only three out of all the options: Ethnic/Racial Groups: Patients: Medically Underserved: African American Breast Cancer Patients Homeless Native Indian Breast Cancer Survivors Immigrants Asian Lymphedema Patients In a Shelter East Indian Recently Diagnosed Patients Migrant Workers Hispanic/Latino Refugees Middle Eastern Rural Pacific Islander White/Caucasian Health Professionals: Other Groups: Health Educators Co-survivors Healthcare Providers College Students Scientists Elderly (>65) High School Students Incarcerated Lesbian/Gay/Bisexual/Transgender Low-Literacy Men Persons with Disabilities Collaborating Agency List (If this is a collaboration project): PROJECT DIRECTOR ORGANIZATION/INSTITUTION BCCP provider? Yes No (Breast and Cervical Cancer Program)

3 ABSTRACT PAGE PAGE 3 ABSTRACT ***In the space below, please provide a brief description of the proposal, including the following; 1) the purpose of the program; 2) a description of key activities; 3) a summary of evaluation methods; and 4) concluding remarks regarding the likely impact of the program. Abstract is not to exceed 1200 characters including spaces, written in lay terms for release to the general public should this application be chosen for funding. Permission to publish: Permission is hereby granted to Susan G. Komen for the Cure to publish the above abstract should this application be selected for funding. Signature Date Name (typed) Phone number

4 PROPOSAL NARRATIVE PAGE 4 Consult RFA Guidelines and Instructions on page 3-4 for specific order of material (questions 1-11) to include in the narrative. Do not exceed 4 pages, 12 point font.

5 GRANT APPLICATION REQUIRED BUDGET FORM PAGE 5 Detailed Budget for Entire Budget Period Personnel (must be specific to project) 04/01/12 through 03/31/13 Amount Requested from Komen: $ Weekly Hours Spent on project (not to exceed.5 FTE from Komen funding) Name Role on Project Annual salary Total Komen Funding Request Project Budget Other Funding Sources Total Budget For Project Supplies (Itemized by category)* Subtotals Equipment [not to exceed 30% of direct costs(a)] (Please contact Peggy Isenogle before submitting Equipment requests) Travel Patient Care Costs (See Attachment A) Inpatient Outpatient Other Expenses (Itemized by category) SUBTOTAL OF DIRECT COSTS Indirect Cost Allocation: not funded, do not include. TOTAL FUNDING REQUEST (a)* Number of Clients Served (b)* Cost per client (c)* *Total Komen Funding Request (a) *Number of Clients Served (b) = *Cost per client (c)

6 BUDGET NARRATIVE PAGE 6 PLEASE ATTACH BUDGET JUSTIFICATION FOR EACH CATEGORY: PERSONNEL SUPPLIES EQUIPMENT TRAVEL PATIENT COSTS INPATIENT OUTPATIENT OTHER EXPENSES OTHER SOURCES OF FUNDING FOR THIS PROJECT AND AMOUNT RECEIVED OR REQUESTED, IF PENDING. PLEASE INDICATE % OF BUDGET SPENT ON FOLLOWING 3 AREAS: EDUCATION SCREENING TREATMENT

7 BIOSKETCH FORM PAGE 7 PROJECT DIRECTOR (Last name, first, middle) BIOGRAPHICAL INFORMATION Information should be submitted for the project director and other personnel included in budget request. Please use a separate form for each person. NAME TITLE EDUCATION (Begin with baccalaureate or initial professional education, such as nursing, include postdoctoral training) INSTITUTION (Indicate location) DEGREE YEAR CONFERRED FIELD OF STUDY PROFESSIONAL EXPERIENCE: Please list, in chronological order, concluding with present position, previous employment, experience and honors. List, in chronological order, the titles, authors, and complete references to all publications during the past three years and to representative earlier publications pertinent to this application. DO NOT EXCEED TWO PAGES

8 ATTACHMENT A Ohio Reimbursement Rates (based on Medicare B): Screening Mammogram- Bilateral (CPT Code 77057) $79.42 Diagnostic Mammogram Unilateral (77055) $84.65 Diagnostic Mammogram Bilateral (77056) $ Digital, Screening Mammogram- Bilateral (G0202) $ Digital, Diagnostic Mammogram- Unilateral (G0206) $ Digital, Diagnostic Mammogram- Bilateral (G0204) $ Breast Ultrasounds, additional diagnostic services (76645) $87.05 * Please note: these rates to be used for all mammography reimbursements of the Greater Cincinnati Affiliate of Susan G. Komen for the Cure in the fiscal year of 4/1/2012 3/31/2013. Additional Komen funding rates: Transportation rates mileage reimbursement not to exceed $0.50 per mile for a personal car. Transportation rates public transportation rates to be reimbursed as appropriate for your service area.

9 CONFIRMATION LIST PAGE 8 CONFIRM ALL COMPONENTS OF PROPOSAL Cover Pages Form supplied on application page 1 and 2, signature required. Abstract Form supplied on application page 3, signature required. Project Narrative; no form. See outline on page 3-4 of RFA Guidelines and Instructions. Narrative is not to exceed 4 typewritten pages with 12 point font and pages numbered consecutively. Budget Form supplied on application page 5. Budget Justification (narrative) Page supplied on page 6 of the application. Biographical information Biosketch Form supplied on page 7 of the Application. Attachments: One copy of each included with the original application Proof of nonprofit status W-9 Completed and signed: Collaborations letters for each agency (only if it is a collaboration project) Deadline: Received in Affiliate Office by 5:00 p.m. on Thursday, January 19, signed original copy with all attachments* 1 electronic copy (NOT.pdf) to mission@komencincinnati.org Fifteen (15) Hard Copies of grant application (RFA) *No faxed copies will be accepted