FY19 COMMUNITY GRANTS PROGRAM REQUEST FOR APPLICATIONS

Transcription

1 FY19 COMMUNITY GRANTS PROGRAM REQUEST FOR APPLICATIONS FOR BREAST CANCER PROJECTS in the EDUCATION AND LINKAGE TO CARE PROGRAM PERFORMANCE PERIOD: APRIL 1, MARCH 31, 2020 OUR MISSION: SAVE LIVES BY MEETING THE MOST CRITICAL NEEDS IN OUR COMMUNITIES AND INVESTING IN BREAKTHROUGH RESEARCH TO PREVENT AND CURE BREAST CANCER Susan G. Kmen Central Indiana 3500 DePauw Blvd, Suite 2070 Indianaplis, IN Page 1 f 18

2 TABLE OF CONTENTS Cntents Key Dates... 3 Abut Susan G Kmen and Kmen Central Indiana... 3 Ntice f Funding Opprtunity and Statement f Need... 3 Eligibility Requirements... 4 Allwable Expenses... 5 Imprtant Granting Plicies... 6 Educatinal Materials and Messages... 7 Review Prcess... 8 Submissin Requirements... 9 Applicatin Instructins... 9 Appendix A: FY19 Reprting Metrics Appendix B: Writing SMART Objectives Page 2 f 18

3 KEY DATES Grant Writing Wrkshp GeMS Technical Webinar Applicatin Deadline Award Ntificatin Award Perid Indianaplis: Thursday, Octber 11, :00am Terre Haute: Thursday, Octber 18, :00am Mnday, Octber 29 10:00am Friday, January 11, :00pm On r Befre March 31, 2019 April 1, March 31, 2020 ABOUT SUSAN G KOMEN AND KOMEN CENTRAL INDIANA Susan G. Kmen is the wrld s largest breast cancer rganizatin, funding mre breast cancer research than any ther nnprfit utside f the U.S. gvernment while prviding real-time help t thse facing the disease. Kmen has set a Bld Gal t reduce the current number f breast cancer deaths by 50 percent in the U.S. by Since its funding in 1982, Kmen has funded mre than $956 millin in research and prvided mre than $2.1 billin in funding t screening, educatin, treatment and psychscial supprt prgrams. Kmen has wrked in mre than 60 cuntries wrldwide. Kmen was funded by Nancy G. Brinker, wh prmised her sister, Susan G. Kmen, that she wuld end the disease that claimed Suzy s life. Kmen Central Indiana is wrking t better the lives f thse facing breast cancer in the lcal cmmunity. Thrugh events like the Kmen Central Indiana Race fr the Cure, Kmen Central Indiana has invested ver $17 millin in cmmunity breast health prgrams in 41 cunties. NOTICE OF FUNDING OPPORTUNITY AND STATEMENT OF NEED Kmen Central Indiana is ffering cmmunity grants t supprt breast cancer prjects that address specific funding pririties, which were selected based n data frm the current Kmen Central Indiana Cmmunity Prfile Reprt, fund n ur website at The funding pririty areas are listed belw in n particular rder: Breast Cancer Educatin Prjects that prvide evidence-based and culturally relevant breast cancer educatin in ne-n-ne and grup settings. Prjects must be designed t result in dcumented ageapprpriate, breast cancer actin (e.g., getting a screening mammgram, btaining recmmended fllw-up after an abnrmal mammgram). Based n findings frm the Cmmunity Prfile, these prjects shuld target un- and underinsured individuals that reside in the pririty cunties f Bne, Marin, Rush Shelby, Vermillin, Vig, and Wayne. Breast cancer educatin prjects MUST include Kmen s breast self-awareness messages, if apprpriate, based n the need, audience and purpse f the educatinal prject. Prjects must prvide evidence f linkage t lcal breast cancer services and include Page 3 f 18

4 fllw up with participants. Health fairs and mass media campaigns are nt evidencebased interventins and will nt be accepted. Pririty will be given t prjects actively utreaching t individuals living in the pririty cunties listed abve. Reducing Financial Barriers t Care Educatin prjects may use Kmen Central Indiana funds t prvide n cst r lw-cst screening and/r diagnstic services, mbile mammgraphy, diagnstic c-pay and deductible assistance, transprtatin t/frm a screening r diagnstic appintment, and interpreter services at a screening/diagnstic appintment fr individuals wh meet the fllwing criteria: Are uninsured Are underinsured, defined fr the purpses f this grant applicatin as experiencing csts assciated with screening and/r diagnstic tests greater than 5% f their annual husehld incme Have a referral frm a physician fr a screening r diagnstic test that their insurance carrier will nt cver, r D nt currently qualify fr Medicaid, HIP 2.0, BCCP, r ther public assistance funds fr their screening r diagnstic service. Applicants t this prgram must demnstrate knwledge f and wrking partnerships with payers fr screening and diagnstic services, as well as a plan t use Kmen dllars in the mst efficient way pssible by cnnecting an individual t the mst apprpriate payer fr service. Applicants may apply fr educatin dllars nly, r a cmbinatin f educatin and financial barrier reductin dllars. Applicatins fr nly financial barrier reductin prgrams, withut an educatinal cmpnent, will nt be accepted. Examples f successful prjects include thse that result in: An increase in breast cancer actin due t knwledge gained; An increase the number f never screened wmen getting breast cancer screening; A reductin in the number f wmen lst t fllw up; A reductin in time frm abnrmal screening t diagnstic prcedures; Applicants may request funding frm $10,000 and up (cmbined direct and indirect csts) fr ne year. ELIGIBILITY REQUIREMENTS The fllwing eligibility requirements must be met at the time f applicatin submissin: Individuals are nt eligible t apply. Applicatins will nly be accepted frm gvernmental rganizatins under Sectin 170(c)(1) r nnprfit rganizatins under Sectin 501(c)(3) f the Internal Revenue Service (IRS) cde. Applicants must prve tax exempt status by prviding a letter f determinatin frm the IRS. Page 4 f 18

5 Applicant rganizatins must prvide services t residents f ne r mre f the fllwing lcatins: Clark Cunty, IL Edgar Cunty, IL Barthlmew Cunty, IN Blackfrd Cunty, IN Bne Cunty, IN Brwn Cunty, IN Clay Cunty, IN Clintn Cunty, IN Decatur Cunty, IN Delaware Cunty, IN Fayette Cunty, IN Funtain Cunty, IN Franklin Cunty, IN Grant Cunty, IN Greene Cunty, IN Hamiltn Cunty, IN Hancck Cunty, IN Hendricks Cunty, IN Henry Cunty, IN Hward Cunty, IN Jay Cunty, IN Jhnsn Cunty, IN Madisn Cunty, IN Marin Cunty, IN Mnre Cunty, IN Mntgmery Cunty, IN Mrgan Cunty, IN Owen Cunty, IN Parke Cunty, IN Putnam Cunty, IN Randlph Cunty, IN Rush Cunty, IN Shelby Cunty, IN Sullivan Cunty, IN Tippecane Cunty, IN Tiptn Cunty, IN Unin Cunty, IN Vermillin Cunty, IN Vig Cunty, IN Warren Cunty, IN Wayne Cunty, IN Prpsed prjects must be specific t breast health and/r breast cancer and address the pririties identified within this RFA. If a prject includes ther health issues alng with breast cancer, such as a breast and cervical cancer prject, funding may nly be requested fr the breast cancer prtin. All past and current Kmen-funded prjects must be in cmpliance with Kmen requirements. If applicant, r any f its key emplyees, directrs, fficers r agents is cnvicted f fraud r a crime invlving any ther financial r administrative imprpriety in the 12 mnths prir t the submissin deadline fr the applicatin, then applicant is nt eligible t apply fr a grant until 12 mnths after the cnvictin. After such 12-mnth perid, applicant must demnstrate in its applicatin that apprpriate remedial measures have been taken t ensure that any criminal miscnduct will nt recur. ALLOWABLE EXPENSES Funds may be requested fr the fllwing types f expenses, prvided they are directly attributable t the prject: Key Persnnel / Salaries Cnsultants/ Sub-cntracts Supplies Page 5 f 18

6 Travel Patient care Other direct prject expenses Equipment, including sftware, nt t exceed $5,000 ttal, essential t the breast healthrelated prject t be cnducted Indirect csts, nt t exceed 10 percent f direct csts Fr mre infrmatin, please refer t the descriptins in the Budget Sectin belw. Funds may nt be used fr the fllwing purpses: Research, defined as any prject r prgram with the primary gal f gathering and analyzing data r infrmatin. Specific examples include, but are nt limited t, prjects r prgrams designed t: Understand the bilgy and/r causes f breast cancer Imprve existing r develp new screening r diagnstic methds Identify appraches t breast cancer preventin r risk reductin Imprve existing r develp new treatments fr breast cancer r t vercme treatment resistance, r t understand pst treatment effects Investigate r validate methds r tls Educatin regarding breast self-exams/use f breast mdels. Accrding t studies, teaching breast self-exam (BSE) has nt been shwn t be effective at reducing mrtality frm breast cancer. Develpment f educatinal materials r resurces that either duplicate existing Kmen materials r fr which there is nt a demnstrated need. Grantees can view, dwnlad and print all f Kmen s educatinal materials by visiting If a grantee intends t use supplemental materials, they shuld be cnsistent with Kmen messages. Educatin via mass media (e.g., televisin, radi, newspapers, billbards), health fairs and material distributin. Evidence-based methds such as ne n ne and grup sessins shuld be used t educate the cmmunity and prviders. Cnstructin r renvatin f facilities/ land acquisitin Plitical campaigns r lbbying General perating funds (in excess f allwable indirect csts) Debt reductin Fundraising (e.g., endwments, annual campaigns, capital campaigns, emplyee matching gifts, events) Event spnsrships Prjects cmpleted befre the date f grant apprval Prject-related investments/lans Schlarships Thermgraphy Equipment ver $5,000 ttal Prjects r prtins f prjects nt specifically addressing breast cancer IMPORTANT GRANTING POLICIES Please nte the fllwing nn-negtiable plicies befre submitting an applicatin: Page 6 f 18

7 The prject must ccur between April 1, 2019 and March 31, Recipients f services must reside in the Affiliate Service Area. The effective date f the grant agreement is the date n which Kmen fully executes the grant agreement and shall serve as the start date f the prject. N expenses may be accrued against the prject until the grant agreement is fully executed. The cntracting prcess can take up t six weeks frm the date f the award ntificatin letter. Any unspent funds ver $1.00 must be returned t Kmen Central Indiana. Grant payments will be made in installments pending acceptance f and cmpliance with terms and cnditins f a fully executed grant agreement. Grantee will be required t submit a minimum f ne semi-annual prgress reprt and ne final reprt that will include, amng ther things, an accunting f expenditures and a descriptin f prject achievements. Additinal reprts may be requested. At the discretin f Kmen Central Indiana, the grantee may request ne n-cst extensin f n mre than six mnths per prject. Requests must be made by grantee n later than 30 days prir t the end date f the prject. Certain insurance cverage must be demnstrated thrugh a certificate f insurance at the executin f the grant agreement, if awarded. Grantee is required at minimum t hld: Cmmercial general liability insurance with cmbined limits f nt less than $1,000,000 per ccurrence and $2,000,000 in the aggregate fr bdily injury, including death, prperty damage and advertising injury; Wrkers cmpensatin insurance in the amunt required by the law in the state(s) in which its wrkers are lcated and emplyers liability insurance with limits f nt less than $1,000,000; and Excess/umbrella insurance with a limit f nt less than $5,000,000. T the extent any transprtatin services are prvided, $1,000,000 cmbined single limit f autmbile liability cverage will be required. T the extent medical services are prvided, medical malpractice cverage with cmbined limits f nt less than $1,000,000 per ccurrence and $3,000,000 in the aggregate will be required. Grantees are als required t prvide Kmen Central Indiana with a certificate f insurance with Susan G. Kmen Breast Cancer Fundatin, Inc., Susan G. Kmen Central Indiana, its fficers, emplyees and agents named as Additinal Insured n the abve plicies slely with respect t the prject and any additinal plicies and riders entered int by grantee in cnnectin with the prject. EDUCATIONAL MATERIALS AND MESSAGES Susan G. Kmen is a surce f infrmatin abut breast cancer fr peple all ver the wrld. T reduce cnfusin and reinfrce learning, we nly fund prjects that use educatinal messages and materials that are cnsistent with Kmen messages, such as ur breast self-awareness messages - knw yur risk, get screened, knw what is nrmal fr yu and make healthy lifestyle chices. The cnsistent and repeated use f the same messages can reduce cnfusin, imprve retentin and lead t the adptin f actins we believe are imprtant fr quality breast care. Please visit the fllwing webpage befre cmpleting yur applicatin and be sure that yur rganizatin can agree t prmte these messages: Page 7 f 18

8 If an applicant wants t develp educatinal resurces, they must discuss with Kmen Central Indiana prir t applicatin submissin and prvide evidence f need fr the resurce. Kmen has develped breast cancer educatin tlkits fr Black and African-American cmmunities and Hispanic/Latin cmmunities. They are designed fr health educatrs and rganizatins t meet the needs f their cmmunities. The Hispanic/Latin tlkit is available in bth English and Spanish. T access these tlkits, please visit REVIEW PROCESS Each grant applicatin will be reviewed by at least three reviewers frm the cmmunity, wh will cnsider each f the fllwing selectin criteria: Impact 10%: Hw successful will the prject be at increasing the percentage f peple wh enter, stay in r prgress thrugh the cntinuum f care, thereby reducing breast cancer mrtality? T what extent has the applicant demnstrated that the prject will have a substantial impact n the selected funding pririty? Statement f Need 15%: Hw well has the applicant described the identified need and the ppulatin t be served, including race, ethnicity, ecnmic status and breast cancer mrtality statistics? Hw clsely des the prject align with the funding pririties and target cmmunities stated in the RFA? Prject Design 25%: Hw likely is it that prpsed activities will be achieved within the scpe f the prject? Hw well has the applicant described the prject activities t be cmpleted with Kmen funding? T what extent is the prpsed prject designed t meet the needs f specific cmmunities including the cultural and scietal beliefs, values and pririties f each cmmunity? Hw well des the applicant incrprate an evidence-based interventin and/r a prmising practice? T the extent cllabratin is prpsed, hw well des the applicant explain the rles, respnsibilities and qualificatins f prject partners? Hw well des the budget and budget justificatin explain the need assciated with the prject? Organizatin Capacity 10%: T what extent des the applicant s staff have the expertise t effectively implement all aspects f the prject and prvide fiscal versight, including the apprpriate licenses, certificatins, accreditatins, etc. t deliver the prpsed services? Hw well has the applicant demnstrated evidence f success in delivering services t the target ppulatin described? T what extent has the applicant demnstrated they have the equipment, resurces, tls, space, etc., t implement all aspects f the prject? Mnitring and Evaluatin 25%: T what extent will the dcumented evaluatin plan be able t measure prgress tward the stated prject gal and bjectives, and the resulting utputs and utcmes? T what extent des the evaluatin plan aim t cllect the relevant required metrics in Appendix A f the RFA? T what extent are the applicant s mnitring and evaluatin (M&E) resurces/ expertise likely t adequately evaluate prject success? Cmmunity Cllabratin and Outreach 15% Des the rganizatin plan t actively utreach t individuals residing in the pririty cunties f Bne, Marin, Rush, Shelby, Vermillin, Vig, and Wane? What kind f utreach is the rganizatin ding? If the applicant rganizatin is nt actively utreaching t individuals in these cunties, d subcntractrs and/r cmmunity partnerships demnstrate an active utreach t these pririty cmmunities? Page 8 f 18

9 The grant applicatin prcess is cmpetitive, regardless f whether r nt an rganizatin has received a grant in the past. Funding in subsequent years is never guaranteed. SUBMISSION REQUIREMENTS All prpsals must be submitted nline thrugh the Kmen Grants emanagement System (GeMS): All applicatins must be submitted befre the Applicatin Deadline listed in the Key Dates sectin abve. Applicants are strngly encuraged t cmplete, review and submit their applicatins with sufficient time t allw fr technical difficulties, human errr, lss f pwer/internet, sickness, travel, etc. Extensins t the submissin deadline will nt be granted, with the rare exceptin made fr severe extenuating circumstances at the sle discretin f Kmen. APPLICATION INSTRUCTIONS The applicatin must be cmpleted and submitted via the Kmen Grants emanagement System (GeMS), The required sectins/pages in GeMS are listed in ALL CAPS and described belw. Fr an applicatin instructin manual, please visit ur webpage, r cntact Stephanie Laskey, slaskey@kmencentralindiana.rg. When initiating an applicatin in GeMS, make sure it is a Cmmunity Grants applicatin, designated CG, and nt a Small Grants ( SG ) applicatin t apply t this RFA. PROJECT PROFILE This sectin cllects applicant infrmatin including prpsed partner rganizatins, and accreditatins earned (if applicable). Attachments fr the Prject Prfile page (if applicable): Letters f supprt r memranda f understanding frm prpsed cllabratrs t describe the nature f the cllabratin and the services/expertise/persnnel t be prvided thrugh the cllabratin. ORGANIZATION SUMMARY This sectin cllects infrmatin regarding the applicant s histry, missin, prgrams and accmplishments, staff/vlunteers, budget and scial media. PROJECT PRIORITIES AND ABSTRACT (limit 1,000 characters) This sectin cllects infrmatin abut the funding pririties t be addressed and the prject abstract. The abstract shuld include the target ppulatins t be served, the need t be addressed, a descriptin f key activities, the expected number f individuals t be served and the expected change the prject will likely bring t the cmmunity including hw it will be measured. The abstract is typically used by the Affiliate in public cmmunicatins abut funded prjects. Page 9 f 18

10 PROJECT NARRATIVE This is the cre piece f the applicatin divided int the fllwing subsectins: Statement f Need (limit 5,000 characters) Describe evidence f the risk/need within the identified ppulatin. Describe the target ppulatin t be served with Kmen funding using race, ethnicity, sciecnmic and breast cancer mrtality statistics. Describe hw this prject aligns with Kmen target cmmunities and/r the RFA funding pririties. Prject Design (limit 5,000 characters) Describe hw the prject will increase the percentage f peple wh enter, stay in r prgress thrugh the cntinuum f care and thereby reduce breast cancer mrtality. Explain what specifically will be accmplished using Kmen funding and hw the prject s gal and bjectives align with the selected funding pririties. Explain hw the prject is designed t meet the needs f specific cmmunities and reflects the cultural and scietal beliefs, values, and pririties f each cmmunity. Explain hw the prject incrprates an evidence-based interventin (please cite references). Due t character limits in GeMS, citatin pages may be ed t Stephanie Laskey (slaskey@kmencentralindiana.rg) Explain hw cllabratin strengthens the prject, including rles and respnsibilities f all rganizatins and why partnering rganizatins are qualified t assist in accmplishing the gal and bjectives. Organizatins mentined here shuld crrespnd with thse prviding letters f supprt/cllabratin r MOUs n Prject Prfile page. Organizatin Capacity (limit 5,000 characters) Explain hw the applicant rganizatin and assciated prject staff are suited t lead the prject and accmplish the gal and bjectives. Include apprpriate rganizatin r staff licenses, certificatins and/r accreditatins. Describe evidence f success in delivering breast cancer services t the prpsed ppulatin. If the breast cancer prject is new, describe relevant success with ther prjects. Describe the equipment, resurces, tls, space, etc., that the applicant rganizatin pssesses r will utilize t implement all aspects f the prject. Describe the rganizatin s current financial state and fiscal capability t manage all aspects f the prject t ensure adequate measures fr internal cntrl f grant dllars. If the rganizatinal budget has changed ver the last three years, explain the reasn fr the change. Mnitring and Evaluatin (limit 5,000 characters) Describe hw the rganizatin(s) will measure prgress tward the stated prject gal and bjectives, including the specific evaluatin tls that will be used t measure prgress. These tls can include client satisfactin surveys, pre- and pst-tests, client tracking frms, etc. Page 10 f 18

11 Describe the specific utcmes that will be measured as a result f prpsed prject activities, including thse metrics required in Appendix A f the RFA. Outcmes reprted can include number f days t diagnstic reslutin after an abnrmal imaging test, number f days frm diagnsis t first day f treatment, etc. Describe the resurces and expertise available fr mnitring and evaluatin during the prject perid. Specify if the expertise and resurces are requested as part f this prject, r if they are existing rganizatinal resurces. Grantees will be required t reprt n the fllwing utputs and utcmes in the prgress and final reprts: Accmplishments Challenges Upcming tasks Lessns learned A cmpelling stry frm an individual that was served with Kmen funding Demgraphics f individuals served thrugh Kmen funding (see Appendix A) Types f services prvided (see Appendix A) Cmmunity Cllabratin and Outreach (limit 5,000 characters) Describe hw the applicant rganizatin and/r its subgrantees and/r cmmunity partners will actively utreach t individuals residing in the pririty cunties f Bne, Marin, Rush, Shelby, Vermillin, Vig and Wayne. PROJECT TARGET DEMOGRAPHICS This sectin cllects infrmatin regarding the varius grups the prject will target. This des nt include every demgraphic grup the prject will serve but shuld be based n the grups that the prject will primarily fcus its attentin. PROJECT WORK PLAN In this sectin, all applicants are required t develp prject bjectives in rder t meet the universal gal t: Reduce breast cancer mrtality by addressing disparities, increasing access t quality and timely care, and/r imprve utcmes thrugh patient navigatin. All prjects must have at least ne bjective. While there is n limit t the number f bjectives allwed, the number f bjectives shuld be reasnable, with each able t be evaluated. Please ensure that all bjectives are SMART: Specific Measurable Attainable Realistic Time-bund A guide t crafting SMART bjectives is lcated in Appendix B with examples prvided. The submissin f a timeline and anticipated number f individuals t be served is als required. Page 11 f 18

12 Write the Prject Wrk Plan with the understanding that each bjective must be reprted n in prgress reprts. The Prject Wrk Plan must nly include measurable bjectives that will be accmplished with funds requested frm Kmen Central Indiana. Objectives that will be funded by ther means shuld nt be reprted here, but instead can be included in the descriptin f the verall prgram in the Prject Narrative sectin. Attachments t supprt the Prject Wrk Plan page may include, but are nt limited t: Evaluatin frms, surveys, lgic mdels that will be used t measure the bjectives. BUDGET SECTION Fr each line item in the budget, applicant must prvide an estimated expense calculatin and a brief justificatin explaining hw the funds will be used and why they are necessary t achieve prpsed bjectives. A descriptin f each budget categry fllws: KEY PERSONNEL/SALARIES This sectin cllects infrmatin regarding the persnnel needed t achieve prpsed prject bjectives. Any individual playing a key rle shuld be included with infrmatin fr emplyee's salary and benefits adjusted t reflect the percentage f effrt n the prject. If n funds are requested frm Kmen fr staff salary, enter 0 in the % f Salary n Prject request field t prperly cmplete an applicatin. Attachments Needed fr Key Persnnel/Salaries Sectin: Resume/Jb Descriptin Fr any staff member invlved in the prject, please prvide a resume. Fr thse staff wh are seeking Kmen Central Indiana funds t supplement their salaries, please prvide BOTH a resume and a jb descriptin (Tw page limit per individual per dcument.) CONSULTANTS/ SUB-CONTRACTS This sectin shuld be cmpleted if the applicant requires a third party t help achieve prpsed prject bjectives. Cnsultants are persns r rganizatins that ffer specific expertise nt prvided by prject staff and are usually paid by the hur r day. Subcntractrs have substantive invlvement with a specific prtin f the prject, ften prviding services nt prvided by the applicant. Patient Care services, even if subcntracted, shuld nt be included in this sectin; thse funds shuld be included in the Patient Care budget sectin. SUPPLIES This sectin shuld include the supplies needed t help achieve prpsed prject bjectives. TRAVEL This sectin shuld be cmpleted if travel expenses such as cnference registratin fees/travel r mileage reimbursement by rganizatin staff r vlunteers related t prject activity is necessary t achieve prpsed prject bjectives. This sectin is nt fr transprtatin assistance fr patients/clients this expense shuld be recrded n the Patient Care page. Page 12 f 18

13 PATIENT CARE This sectin shuld include all funds requested fr prviding direct services fr a patient. This shuld be the cst needed t prvide the direct services t achieve prpsed prject bjectives. Navigatin r referral prject csts shuld nt be included in this sectin but can be included in Key Persnnel/ Salaries r Cnsultants/ Sub-Cntracts sectins, as apprpriate. OTHER This sectin shuld nly be used fr items that are directly attributable t the prject but cannt be included in the existing budget sectins. INDIRECT The allwable indirect cst, which is requested as a percentage f direct csts, includes expenses supprting the prject, including, but nt limited t, allcated csts such as facilities, technlgy supprt, cmmunicatin expenses and administrative supprt. PROJECT BUDGET SUMMARY This sectin includes a summary f the ttal prject budget. Other surces f funding fr this prject must als be entered n this page. Attachments Needed fr the Prject Budget Summary Sectin: Prf f Tax-Exempt Status T dcument the applicant s federal tax-exempt status, attach a determinatin letter frm the Internal Revenue Service. Evidence f state r lcal exemptin will nt be accepted. Please d nt attach a Federal tax return. T request verificatin f the applicant rganizatin s tax-determinatin status, visit the fllwing website: Organizatinal 990 frm the last fiscal year Optinal: Organizatinal annual reprt frm the last fiscal year Applicant Supprt: Questins shuld be directed t: Stephanie Laskey slaskey@kmencentralindiana.rg Page 13 f 18

14 APPENDIX A: FY19 REPORTING METRICS Grantees will be required t reprt n the belw metrics in FY19 Prgress/Final Reprts. All grantees will reprt n services prvided, race and ethnicity, and breast cancer diagnses by cunty f residence f thse served; demgraphics f thse served; and a mre detailed accunt f breast cancer diagnses, including by race and ethnicity and services that led t a diagnsis. The remaining categries will nly need t be reprted n if a grantee ffers thse services in their Prject Wrkplan. Fr example, if a grantee has nly an educatin bjective, they will nly have the ptin t reprt metrics fr the Educatin & Training categry. * Indicates data must be prvided by race & ethnicity (nly by Hispanic/Latin and nn-hispanic/latin nt by specific Hispanic/Latin/Spanish rigin) Demgraphics State f residence Cunty f residence Age Gender: Female, Male, Transgender, Other, Unknwn Race: American Indian r Alaska Native, Asian, Black/African-American, Middle Eastern r Nrth African, Native Hawaiian r Pacific Islander, White, Unknwn r Other Ethnicity: Clmbian, Cuban, Dminican, Mexican/Mexican-American/Chican, Puert Rican, Salvadran, Other Hispanic/Latin/Spanish rigin, Nt f Hispanic/Latin/Spanish rigin, Unknwn r Other Special Ppulatins: Amish/Mennnite, Breast cancer survivrs, Healthcare prviders, Hmeless/residing in temprary husing, Immigrant/Newcmers/Refugees/Migrants, Living with metastatic breast cancer, Individuals with disabilities, Identifies as LGBTQ, Rural residents Breast Cancers Diagnsed Staging f breast cancers diagnsed resulting frm: Screening services* Nn-Bipsy diagnstic services* Bipsy-nly Cmmunity navigatin int screening* Patient navigatin int diagnstics* Educatin & Training Type f sessin: One-n-ne, Grup Tpic f sessin: Breast self-awareness, available breast health services and resurces, clinical trials, treatment, survivrship and quality f life, metastatic breast cancer Number f individuals reached by tpic area Fllw-up cmpleted Actin taken: Did nt take actin, talked t health care prvider, received a breast cancer screening, shared infrmatin with family/friends, received genetic cunseling/testing, talked t prvider abut clinical trials, enrlled in a clinical trial, adpted healthy behavir If health care prvider training, ttal number f prviders trained in each sessin (ne-n-ne, grup) and number by prvider type (Cmmunity health wrkers, lay educatrs, patient navigatrs, scial wrkers, nurses, technicians, nurse practitiners/physician assistants, dctrs) Page 14 f 18

15 Screening Services First time t facility Number f years since last screening Screening facility accreditatin* American Cllege f Radilgy Mammgraphy accreditatin (ACR) American Cllege f Radilgy - Breast Imaging Center f Excellence (BICOE) Cunt f screening services prvided* Clinical breast exam Mammgram in facility Mammgram mbile Genetic testing/cunseling Screening result* Referred t diagnstics* Diagnstic Services Time frm screening t diagnsis* Diagnstic facility accreditatin* American Cllege f Radilgy any individual ACR breast diagnstic test accreditatins (ACR) American Cllege f Radilgy - Breast Imaging Center f Excellence (BICOE) American Cllege f Radilgy Diagnstic Imaging Center f Excellence (DICOE) American Cllege f Surgens - Natinal Accreditatin Prgram fr Breast Centers (NAPBC) American Cllege f Surgens - Cmmissin n Cancer (CC) Cunt f diagnstic services prvided* Diagnstic mammgram Breast ultrasund Breast MRI Bipsy Genmic testing t guide treatment Referred t treatment* Treatment Services Time frm diagnsis t beginning treatment* Treatment facility accreditatin* American Cllege f Radilgy any individual ACR breast cancer treatment accreditatins (ACR) American Cllege f Surgens - Natinal Accreditatin Prgram fr Breast Centers (NAPBC) Natinal Cancer Institute-Designated Cancer Center (NCI) American Cllege f Surgens - Cmmissin n Cancer (CC) Cunt f treatment services prvided* Chemtherapy Radiatin therapy Surgery Hrmne therapy Targeted therapy Page 15 f 18

16 Cunt f patients enrlled in a clinical trial* Treatment Supprt Cunt f treatment supprt services prvided Barrier Reductin Cunt f barrier reductin assistance services prvided* Transprtatin, interpretatin/translatin services, c-pay/deductible assistance, daily living expenses, childcare Patient Navigatin, Care Crdinatin & Case Management Cunt f individuals receiving crdinatin f care t diagnstic services Cunt f individuals receiving crdinatin f care t treatment services Time frm referral t screening* Accreditatin f screening facility navigated t* American Cllege f Radilgy Mammgraphy accreditatin (ACR) American Cllege f Radilgy - Breast Imaging Center f Excellence (BICOE) Time frm abnrmal screening t diagnstic reslutin* Accreditatin f diagnstic facility navigated t* American Cllege f Radilgy any individual ACR breast diagnstic test accreditatins (ACR) American Cllege f Radilgy - Breast Imaging Center f Excellence (BICOE) American Cllege f Radilgy Diagnstic Imaging Center f Excellence (DICOE) American Cllege f Surgens - Natinal Accreditatin Prgram fr Breast Centers (NAPBC) American Cllege f Surgens - Cmmissin n Cancer (CC) Time frm diagnstic reslutin t beginning treatment * Accreditatin f treatment facility navigated t* American Cllege f Radilgy any individual ACR breast cancer treatment accreditatins (ACR) American Cllege f Surgens - Natinal Accreditatin Prgram fr Breast Centers (NAPBC) Natinal Cancer Institute-Designated Cancer Center (NCI) American Cllege f Surgens - Cmmissin n Cancer (CC) Patient enrlled in a clinical trial* Individual cmpleted physician recmmended treatment* Survivrship care plan prvided Breast cancer recrds prvided t primary care prvider Page 16 f 18

17 APPENDIX B: WRITING SMART OBJECTIVES A SMART bjective is: Specific: Objectives shuld prvide the wh and what f prject activities. Use nly ne actin verb since bjectives with mre than ne verb imply that mre than ne activity r behavir is being measured. Avid verbs that may have vague meanings t describe intended utput/utcmes (e.g., understand r knw ) since it may prve difficult t measure them. Instead, use verbs that dcument actin (e.g., identify three f the fur Kmen breast self awareness messages). The greater the specificity, the greater the measurability. Measurable: The fcus is n hw much change is expected. Objectives shuld quantify the amunt f change expected. The bjective prvides a reference pint frm which a change in the target ppulatin can clearly be measured. Attainable: Objectives shuld be achievable within a given time frame and with available prject resurces. Realistic: Objectives are mst useful when they accurately address the scpe f the prblem and prgrammatic steps that can be implemented within a specific time frame. Objectives that d nt directly relate t the prject gal will nt help achieve the gal. Time-bund: Objectives shuld prvide a time frame indicating when the bjective will be measured r time by which the bjective will be met. Including a time frame in the bjectives helps in planning and evaluating the prject. SMART Objective Examples Nn-SMART bjective 1: Wmen in Green Cunty will be prvided educatinal sessins. This bjective is nt SMART because it is nt specific, measurable, r time-bund. It can be made SMART by specifically indicating wh is respnsible fr prviding the educatinal sessins, hw many peple will be reached, hw many sessins will be cnducted, what type f educatinal sessins will be cnducted, wh the wmen are and by when the educatinal sessins will be cnducted. SMART bjective 1: By September 30, 2019, Pink Organizatin will cnduct 10 grup breast cancer educatin sessins reaching at least 200 Black/African American wmen in Green Cunty. Nn-SMART bjective 2: By March 30, 2020, reduce the time between abnrmal screening mammgram and diagnstic end-result fr wmen in the cunties f Jacksn, Mrse and Smith in Nrth Dakta. This bjective is nt SMART because it is nt specific r measurable. It can be made SMART by specifically indicating wh will d the activity and by hw much the time will be reduced. SMART bjective 2: By March 30, 2020, Nrthern Regin Hspital breast cancer patient navigatrs will reduce the average time frm abnrmal screening mammgram t diagnstic cnclusin frm 65 days t 30 days fr wmen in the cunties f Jacksn, Mrse and Smith in Nrth Dakta. Page 17 f 18

18 SMART Objective Checklist Criteria t assess bjectives Yes N 1. Is the bjective SMART? Specific: Wh? (target ppulatin and persns ding the activity) and What? (actin/activity) Measurable: Hw much change is expected? Achievable: Can be realistically accmplished given current resurces and cnstraints Realistic: Addresses the scpe f the prject and prpses reasnable prgrammatic steps Time-bund: Prvides a time frame indicating when the bjective will be met 2. Des it relate t a single result? 3. Is it clearly written? Surce: Department f Health and Human Services- Centers fr Disease Cntrl and Preventin. January Evaluatin Briefs: Writing SMART Objectives. Page 18 f 18