COMMUNITY GRANTS PROGRAM REQUEST FOR APPLICATIONS

Transcription

1 COMMUNITY GRANTS PROGRAM REQUEST FOR APPLICATIONS FOR BREAST CANCER PROJECTS PERFORMANCE PERIOD: APRIL 1, MARCH 31, 2019 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 Nrthern and Central Califrnia 2880 Sunrise Blvd, Suite 220. Ranch Crdva, CA P Street, Suite 315 Fresn, CA KmenNCCalifrnia.rg Page 1 f 19

2 TABLE OF CONTENTS Cntents Key Dates... 3 Abut Susan G. Kmen Nrthern and Central Califrnia... 3 Ntice f Funding Opprtunity and Statement f Need... 3 Eligibility Requirements... 4 Allwable Expenses... 6 Imprtant Granting Plicies... 7 Educatinal Materials and Messages... 7 Review Prcess... 8 Submissin Requirements... 9 Applicatin Instructins... 9 Appendix A: FY18 Reprting Metrics Appendix B: Writing SMART Objectives Page 2 f 19

3 KEY DATES Grant Writing Wrkshp December 13, 2017 at 10am PST Applicatin Deadline January 19, 2018 at Nn PST Award Ntificatin March 20, 2018 Award Perid April 1, March 31, 2019 ABOUT SUSAN G. KOMEN NORTHERN AND CENTRAL CALIFORNIA 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 Kmen was funded in 1982 by Nancy G. Brinker, wh prmised her sister, Susan G. Kmen, that she wuld end the disease that claimed Suzy s life. Kmen Nrthern and Central Califrnia is wrking t better the lives f thse facing breast cancer in the lcal cmmunity. Thrugh events like the Kmen Sacrament Valley and Central Valley Race fr the Cure, Kmen Kmen Nrthern and Central Califrnia has invested $15.8 millin in cmmunity breast health prgrams in twenty-nine cunties r gegraphic area and has helped cntribute t the mre than $920 millin invested glbally in research. Fr mre infrmatin, call r visit KmenNCCalifrnia.rg. NOTICE OF FUNDING OPPORTUNITY AND STATEMENT OF NEED Kmen Nrthern and Central Califrnia will award cmmunity grants t rganizatins that will prvide breast cancer prjects that address specific funding pririties, which were selected based n data frm the 2015 Kmen Sacrament Valley and Central Valley's Cmmunity Prfile Reprt. The 2015 Cmmunity Prfile Reprt can be fund n ur website at The funding pririty areas are listed belw based n the needs identified in the Cmmunity Prfile: NORTHERN CALIFORNIA Amadr Cunty Slan Cunty (zip cdes 94589, 94590, Yuba Cunty CENTRAL CALIFORNIA Hispanics/Latinas in MSSA 25 (Firebaugh, Mendta) Hispanics/Latinas in MSSA 26 (Cantua Creek, San Jaquin and Tranquility) All Wmen in MSSA 32 (Orange Cve/Parlier/Reedley/Squaw Valley/Tivy Valley/Wnder Valley). African-Americans in MSSA 35 (City f Fresn) Page 3 f 19

4 Reducing Barriers t Care Evidence-based prjects that reduce barriers t quality breast cancer care experienced by uninsured and underinsured individuals residing afrementined pririty cunties r cunties where 29-39% diagnsed advance stage as substantiated by Medical Study Service Area (MSSA). Underinsured is defined as having sme insurance cverage but nt enugh, r when ne is insured yet unable t affrd the ut-f-pcket respnsibilities nt cvered by his r her insurer (Patient Advcate Fundatin, MSSA inf: The Affiliate seeks t fund prgrams/prjects fr rganizatins that have the ability t serve BOTH Central and Nrthern Califrnia: Examples: Partnerships with Federally Qualified Health Centers/MediCal/EWC prviders t ffer breast health care services in a clinical setting, including but nt limited t clinical breast exams and n-site mammgraphy/mbile mammgraphy screening. Prvide ne-n-ne evidence-based breast health educatin and reminder systems t encurage screening behavir. Prjects must be designed t result in dcumented ageapprpriate, breast cancer actin. Financial assistance cmpnent fr screening/diagnstic mammgrams, ultrasunds with/withut bipsy fr uninsured r underinsured wmen wh cannt meet c-pay r thse wh d nt qualify fr MediCal r Every Wman Cunts. NOTE: Mandatry pre-qualificatin/pre-eligibilty in Every Wman Cunts, MediCal r ther assistance is required prir t mammgram. Kmen Nrthern and Central Califrnia des nt pay fr billable exams. Applicants may request funding frm $20,000 up t $50,000 (cmbined direct and indirect csts) fr ne year. ELIGIBILITY REQUIREMENTS Applicants must meet the fllwing eligibility criteria t apply. 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. Applicant rganizatins must prvide services t residents f ne r mre f the fllwing lcatins: Alpine Cunty Fresn Cunty Amadr Cunty Glenn Cunty Butte Cunty Iny Cunty Calaveras Cunty Kings Cunty Clusa Cunty Lassen Cunty El Drad Cunty Madera Cunty Page 4 f 19

5 Maripsa Cunty Merced Cunty Mn Cunty Nevada Cunty Placer Cunty Plumas Cunty Sacrament Cunty San Jaquin Cunty Sierra Cunty Slan Cunty Stanislaus Cunty Sutter Cunty Tehama Cunty Tulare Cunty Tulumne Cunty Yl Cunty Yuba Cunty 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 grants t an applicant 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. Page 5 f 19

6 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 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 Develpment f educatinal materials r resurces that either duplicate existing Kmen materials r fr which there is nt a demnstrated need 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 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 Land acquisitin Prject-related investments/lans Schlarships Thermgraphy Equipment ver $5,000 ttal Prjects r prtins f prjects nt specifically addressing breast cancer Page 6 f 19

7 IMPORTANT GRANTING POLICIES Please nte these plicies befre submitting a prpsal. These plicies are nn-negtiable. The prject must ccur between and 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 grant. N expenses may be accrued against the grant until the cntractual 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 Nrthern and Central Califrnia. Grant payments will be made in installments pending executin f grant agreement and cmpliance with terms and cnditins f 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 Nrthern and Central Califrnia, the grantee may request ne n-cst extensin f n mre than six mnths per grant. 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, and prperty damage; 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. In the event any transprtatin services are prvided in cnnectin with prject, $1,000,000 cmbined single limit f autmbile liability cverage will be required. If any medical services (ther than referrals) are prvided r facilitated, 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 Nrthern and Central Califrnia with a Certificate f Insurance with Susan G. Kmen Breast Cancer Fundatin, Inc., Susan G. Kmen Nrthern and Central Califrnia, 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, including 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, Page 7 f 19

8 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: Breast self-exam must nt be taught r endrsed Accrding t studies, teaching breast self-exam (BSE) has nt been shwn t be effective at reducing mrtality frm breast cancer. Therefre, Kmen will nt fund educatin prjects that teach r endrse mnthly breast self-exams r use breast mdels. As an evidencebased rganizatin, we d nt prmte activities that are nt supprted by scientific evidence r that pse a threat t Kmen s credibility as a reliable surce f infrmatin n the tpic f breast cancer. Creatin and Distributin f Educatinal Materials and Resurces Kmen grantees are encuraged t use Kmen-develped educatinal resurces, including messages, materials, Tlkits r ther nline cntent during their grant perid. This is t ensure that all breast cancer messaging assciated with the Kmen name r brand is current, safe, accurate, cnsistent and based n evidence. In additin, this practice will avid expenses assciated with the duplicatin f existing educatinal resurces. Grantees can view, dwnlad and print all f Kmen s educatinal materials by visiting If a grantee intends t use ther supplemental materials, they shuld be cnsistent with Kmen messages. Kmen materials shuld be used and displayed whenever pssible. If an rganizatin wants t develp educatinal resurces, they must discuss with Kmen Nrthern and Central Califrnia prir t submitting an applicatin and prvide evidence f need fr the resurce. Use f Kmen s Breast Cancer Educatin Tlkits fr Black and African-American Cmmunities and Hispanic/Latin Cmmunities and Other Resurces 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 use t meet the needs f their cmmunities. The Hispanic/Latin Tlkit is available in bth English and Spanish. T access these Tlkits, please visit Kmen has additinal educatinal resurces n kmen.rg, that may be used in cmmunity utreach and educatin prjects. Check with Kmen Nrthern and Central Califrnia fr resurces that may be used in prgramming. REVIEW PROCESS Each grant applicatin will be reviewed by at least three reviewers frm the cmmunity. Reviewers will cnsider each f the fllwing selectin criteria: Impact 20%: 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? Page 8 f 19

9 Statement f Need 20%: 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 20%: 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 20%: 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 20%: T what extent will the dcumented evaluatin plan be able t measure prgress against the stated prject gal and bjectives, and the resulting utputs and utcmes? T what extent are the applicant s mnitring and evaluatin (M&E) resurces/ expertise likely t adequately evaluate prject success? 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. Applicant Supprt: Questins shuld be directed t: Sharn Jhnsn, Directr f Missin and Grants SJhnsn@KmenNCCalifrnia.rg 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 the Affiliate s Grants webpage, r cntact /SJhnsn@KmenNCCalifrnia.rgl. When initiating an Page 9 f 19

10 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 basic rganizatin and prject infrmatin, including the title f the prject, cntact infrmatin and partner rganizatins. 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 yur rganizatin 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 pririties t be addressed and a summary f the prject (abstract). This abstract shuld include the target cmmunities t be served, the need t be addressed, a descriptin f activities, the expected number f individuals served and the expected change yur prject will likely bring in yur cmmunity. The abstract is typically used by the Affiliate in public cmmunicatins abut funded prjects. PROJECT NARRATIVE This is the main cntent sectin 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 (e.g., Black/African American, lw-incme, rural) using race, ethnicity, sciecnmic and breast cancer mrtality statistics. Describe hw this prject aligns with 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). 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 Page 10 f 19

11 crrespnd with thse prviding letters f supprt/cllabratin r MOUs n Prject Prfile page. Organizatin Capacity (limit 5,000 characters) Explain why 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) 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 ffered (see Appendix A) The Mnitring and Evaluatin (M&E) narrative must address the fllwing items: Describe hw the rganizatin(s) will measure prgress against 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. Please include any templates, lgic mdels r surveys as attachments in the Prject Wrk Plan page(s). Describe the specific utcmes that will be measured as a result f prpsed prject activities. 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 M&E during the prject perid. Specify if the expertise and resurces are requested as part f this prject, r if they are existing rganizatinal resurces. PROJECT TARGET DEMOGRAPHICS This sectin cllects infrmatin regarding the varius grups yu intend t target with yur prject. This des nt include every demgraphic grup yur prject will serve but shuld be based n the grups n which yu plan t fcus yur prject's attentin. Page 11 f 19

12 PROJECT WORK PLAN In the Prject Wrk Plan cmpnent f the applicatin n GeMS, yu will be required t submit SMART bjectives in rder t meet the universal gal: Reduce breast cancer mrtality by addressing disparities, increasing access t quality and timely care, and/r imprve utcmes thrugh patient navigatin. The prject 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 bjectives: Specific Measurable Attainable Realistic Time-bund A guide t crafting SMART bjectives is fund in Appendix B r at Yu will als be required t submit the timeline and the anticipated number f individuals t be served. Write yur Prject Wrk Plan with the understanding that each bjective must be reprted n in prgress reprts. The Prject Wrk Plan must include measureable bjectives that will be accmplished with funds requested frm Kmen Nrthern and Central Califrnia. Objectives that will be funded by ther means shuld nt be reprted here, but instead, can be included in yur verall prject descriptin. Example Wrk Plan (Fr additinal examples and a SMART bjective checklist, please refer t Appendix B). OBJECTIVE 1: By February 1, 2019, the patient navigatr will have cntacted 100 percent f all wmen with an abnrmal screening result in Green Cunty within three business days t schedule a fllw-up appintment. OBJECTIVE 2: By March 31, 2019, the prject will prvide 30 uninsured/underinsured Green Cunty wmen free/reduced cst diagnstic prcedures within 30 days f an abnrmal screening. Attachments t supprt the Prject Wrk Plan page may include, but are nt limited t: Evaluatin frms, surveys, lgic mdels, etc., that will be used t assess the prgress and/r the effectiveness f these bjectives. Page 12 f 19

13 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 that will be needed t cmplete the prject. Any individual playing a key rle in the prject shuld be included in this sectin. This sectin shuld als include infrmatin fr any emplyee's salary fr which yur prject is requesting funds, if applicable. If n funds are requested frm Kmen fr staff s salary, enter $0 in the salary request fields t prperly cmplete an applicatin. Attachments Needed fr Key Persnnel/Salaries Sectin: Resume/Jb Descriptin Fr key persnnel that are currently emplyed by the applicant rganizatin, prvide a resume r curriculum vitae that includes educatin level achieved and licenses/certificatins btained. Fr new r vacant psitins, prvide a jb descriptin (Tw-page limit per individual). CONSULTANTS/ SUB-CONTRACTS This sectin shuld be cmpleted if the applicant requires a third party t help with the prject. Cnsultants are persns r rganizatins that ffer specific expertise nt prvided by 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 ffice supplies r any ther type f supplies the applicant will need t cmplete the prject. Nte: Kmen grant funds may nt be used fr the develpment f educatinal materials r resurces that either duplicate existing Kmen materials r fr which there is nt a demnstrated need. Only Kmen-develped r Kmen-apprved educatinal resurces may be used/ distributed. 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 cmplete the prject. (This sectin is NOT fr transprtatin assistance fr patients/clients this expense shuld be recrded n the Patient Care page.) 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 mentined in the gal and bjectives sectin f the applicatin. 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. Page 13 f 19

14 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 yur federal tax-exempt status, attach yur determinatin letter frm the Internal Revenue Service. Evidence f state r lcal exemptin will nt be accepted. Please d nt attach yur Federal tax return. T request verificatin f yur rganizatin s tax-determinatin status, visit the fllwing page n the IRS Web site: Cpies-f-Exemptin-Determinatin-Letter-frm-IRS Page 14 f 19

15 APPENDIX A: FY18 REPORTING METRICS Grantees will be required t reprt n the belw metrics in FY18 Prgress/Final Reprts. All grantees will reprt n Demgraphics f thse served. 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, Unspecified Ethnicity Clmbian, Cuban, Dminican, Mexican/Mexican-American, Chican, Puert Rican, Salvadran, Other Hispanic/Latin/Spanish rigin, Nt f Hispanic/Latin/Spanish rigin 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* Diagnstic services* Cmmunity navigatin int screening* Diagnstic patient navigatin* 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 Page 15 f 19

16 Number f individuals reached by tpic area Fllw-up cmpleted Actin taken If healthcare prvider training, ttal number f prviders trained in each sessin (ne-nne, grup) and number by prvider type (Cmmunity health wrkers, lay educatrs, patient navigatrs, scial wrkers, nurses, technicians, nurse practitiners/physician assistants, dctrs) Screening Services First time t facility Number f years since last screening Screening facility accreditatin* American Cllege f Radilgy - Breast Imaging Center f Excellence (BICOE) American Cllege f Surgens - Natinal Accreditatin Prgram fr Breast Centers (NAPBC) Cunt f screening services prvided* Screening result* Referred t diagnstics* Diagnstic Services Time frm screening t diagnsis* Diagnstic facility accreditatin* American Cllege f Radilgy - Breast Imaging Center f Excellence (BICOE) American Cllege f Surgens - Natinal Accreditatin Prgram fr Breast Centers (NAPBC) Cunt f diagnstic services prvided* Referred t treatment* Treatment Services Time frm diagnsis t beginning treatment* Treatment facility accreditatin* American Cllege f Radilgy - Breast Imaging Center f Excellence (BICOE) Natinal Cancer Institute-Designated Cancer Center (NCI) American Cllege f Surgens - Cmmissin n Cancer (CC) Cunt f treatment services prvided* Cunt f patients enrlled in a clinical trial* Treatment Supprt Cunt f treatment supprt services prvided Page 16 f 19

17 Barrier Reductin Cunt f barrier reductin assistance services prvided* Transprtatin, interpretatin/translatin services, c-pay/deductible assistance, daily living expenses, childcare Cmmunity Navigatin, 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 - Breast Imaging Center f Excellence (BICOE) American Cllege f Surgens - Natinal Accreditatin Prgram fr Breast Centers (NAPBC) Time frm abnrmal screening t diagnstic reslutin* Accreditatin f diagnstic facility navigated t* American Cllege f Radilgy - Breast Imaging Center f Excellence (BICOE) American Cllege f Surgens - Natinal Accreditatin Prgram fr Breast Centers (NAPBC) Time frm diagnstic reslutin t beginning treatment * Accreditatin f treatment facility navigated t* American Cllege f Radilgy - Breast Imaging Center f Excellence (BICOE) 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 17 f 19

18 APPENDIX B: WRITING SMART OBJECTIVES Prject planning includes develping prject bjectives. Objectives are specific statements that describe what the prject is trying t achieve and hw they will be achieved. Objectives are mre immediate than the gal and represent milestnes that yur prject needs t achieve in rder t accmplish its gal by a specific time perid. Objectives are the basis fr mnitring implementatin f strategies and/r activities and prgress tward achieving the prject gal. Objectives als help set targets fr accuntability and are a surce fr prject evaluatin questins. Writing SMART Objectives T use an bjective t mnitr prgress twards a prject gal, the bjective must be SMART. A SMART bjective is: 1. 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. 2. 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. 3. Attainable: Objectives shuld be achievable within a given time frame and with available prject resurces. 4. 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. 5. 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 Page 18 f 19

19 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, 2017, 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, 2018, 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, 2018, 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. 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 19 f 19