COMMUNITY GRANTS PROGRAM

2017-2018 COMMUNITY GRANTS PROGRAM FOR BREAST HEALTH PROGRAMS TO BE HELD BETWEEN APRIL 1, 2017 AND MARCH 31, 2018 SUSAN G. KOMEN AFFILIATE COMMUNITY GRANTS TO SAVE LIVES BY MEETING THE MOST CRITICAL NEEDS OF OUR COMMUNITIES AND INVESTING IN BREAKTHROUGH RESEARCH TO PREVENT AND CURE BREAST CANCER. Susan G. Kmen Central Tennessee 4009 Hillsbr Pike, Suite 209 Nashville, TN 37215 www.kmencentraltennessee.rg Page 1 f 25

TABLE OF CONTENTS Cntents Key Dates... 3 Abut Susan G. Kmen Central Tennessee... 3 Ntice f Funding Opprtunity and Statement f Need... 4 Eligibility Requirements... 7 Allwable Expenses... 9 Imprtant Granting Plicies... 10 Educatinal Materials and Messages... 11 Review Prcess... 12 Submissin Requirements... 14 Applicatin Instructins... 14 Appendix A: Writing SMART Objectives... 19 Appendix B: Funding Pririty Definitins... 22 Appendix C: Data Cllectin and Reprting Requirements and Examples.25 Page 2 f 25

KEY DATES Mandatry Reginal Grant Writing Wrkshps: Chattanga Regin Nvember 10, 2016 frm 1pm t 3pm Greater Nashville Regin Nvember 1, 2016 frm 9:30am t 11:30am r Nvember 9, 2016 frm 2:30pm t 4:30pm Upper Cumberland Regin Nvember 3, 2016 frm 11am t 1pm Applicatin Deadline December 16, 2016 at nn Award Ntificatin March 2017 Award Perid April 1, 2017 - March 31, 2018 ABOUT SUSAN G. KOMEN CENTRAL TENNESSEE Susan G. Kmen is the wrld s largest breast cancer rganizatin, funding mre breast cancer research than any ther nnprfit while prviding real-time help t thse facing the disease. 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 Central Tennessee is wrking t better the lives f thse facing breast cancer in the lcal cmmunity. Thrugh events like the Race fr the Cure, Kmen Central Tennessee has invested 8.6 millin in cmmunity breast health prgrams in the 41 cunty service area and has helped cntribute t the mre than $920 millin invested glbally in research. Fr mre infrmatin, call 615-383-0017 r visit www.kmencentraltennessee.rg. Page 3 f 25

NOTICE OF FUNDING OPPORTUNITY AND STATEMENT OF NEED Kmen Central Tennessee will award cmmunity grants t rganizatins that will prvide breast health and breast cancer prjects that address funding pririties, which were selected based n data frm the 2015 Kmen Cmmunity Prfile Reprts fr Chattanga, Greater Nashville and Upper Cumberland. The 2015 Cmmunity Prfile Reprts can be fund n ur website at www.kmencentraltennessee.rg. Definitins related t funding pririties can be fund in Appendix B. Funding Pririties fr Chattanga Regin Fr this RFA, the Chattanga Regin cnsists f the fllwing cunties: Hamiltn Cunty, TN Bradley Cunty, TN Plk Cunty, TN McMinn Cunty, TN Meigs, Cunty, TN Rhea Cunty, TN Bledse Cunty, TN Sequatchie Cunty, TN Grundy Cunty, TN Marin Cunty, TN Dade Cunty, GA Walker Cunty, GA Catsa Cunty, GA Whitfield, Cunty, GA Murray Cunty, GA Fannin Cunty, GA Applicants may request funding frm $10,000 up t $25,000 (cmbined direct and indirect csts) fr ne year. While applicatins will be accepted fr prgrams prviding services within the Chattanga Regin, pririty will be given t applicants that demnstrate benefit t ne r mre f the fllwing cmmunities identified in the Cmmunity Prfile: African-Americans in Hamiltn Cunty, TN Hispanic/Latinas in Murray Cunty, GA The fllwing zip cdes in Hamiltn Cunty, TN: 30402, 37403, 37404, 37408, 37410, 37411 and lw-incme sectins f 37405, 37406 and 37415. Fannin Cunty, GA Rhea Cunty, TN The funding pririties fr the Chattanga Regin are listed belw: Pririty 1: Prgrams that increase access t apprpriate breast cancer screening and diagnstic services fr lw-incme and underinsured individuals wh are nt eligible fr ther prgrams (e.g., Gergia BCCP, Tennessee BCCP) r grant funding. The Affiliate seeks t fund prgrams that prvide n cst r lw cst breast cancer Page 4 f 25

screening and diagnstic services, financial assistance with diagnstic services cpays/deductibles and transprtatin assistance. Pririty 2: Prgrams that prvide evidence-based, culturally relevant breast cancer educatin that results in dcumented age-apprpriate breast cancer actin (e.g., talk t dctr abut breast cancer risk and/r receive a screening mammgram. One-nne and grup breast cancer educatin prgrams must include Kmen s breast selfawareness messages, dispels myths and misinfrmatin, addresses wmen s fears related t breast cancer, and prvide lcal breast cancer services. Pririty 3: Prgrams that prvide evidence-based patient navigatin that increases navigatinal services prmting seamless care alng the breast health cntinuum frm educatin thrugh diagnsis, treatment, fllw up care and survivrship. Funding Pririties fr Greater Nashville Regin: Fr this RFA, the Greater Nashville Regin cnsists f the fllwing cunties: Cheatham Cunty, TN Davidsn Cunty,TN Dicksn Cunty, TN Maury Cunty, TN Mntgmery Cunty, TN Rbertsn Cunty, TN Rutherfrd Cunty, TN Sumner Cunty, TN Trusdale Cunty, TN Williamsn Cunty, TN Wilsn Cunty, TN Applicants may request funding frm $10,000 up t $75,000 (cmbined direct and indirect csts) fr mbile mammgraphy prgrams and up t $45,000(cmbined direct and indirect csts) fr ther breast health related prgrams fr ne year. While applicatins will be accepted fr prgrams prviding services within the Greater Nashville Regin, pririty will be given t applicants that demnstrate benefit t ne r mre f the fllwing cmmunities: Maury Cunty, TN Trusdale Cunty, TN African-Americans in Davidsn Cunty, TN and/r Mntgmery Cunty, TN The funding pririties fr the Greater Nashville Regin are listed belw: Pririty 1: Increase and imprve access t breast health services including screening, diagnstics and treatment by reducing financial and gegraphical barriers. The Affiliate seeks t fund prgrams that prvide: Page 5 f 25

N cst r lw cst breast cancer services Patient navigatin Financial assistance with diagnstic and treatment c-pays/deductibles Mbile mammgraphy, especially in Maury, Mntgmery and Trusdale Cunties Transprtatin assistance in Trusdale Cunty Pririty 2: Prgrams that prvide evidence-based, culturally relevant breast cancer educatin that results in dcumented age-apprpriate breast cancer actin (e.g., talk t dctr abut breast cancer risk and/r receive a screening mammgram) fr underinsured and uninsured individuals. One-n-ne and grup breast cancer educatin prgrams must include Kmen s breast self-awareness messages and prvide lcal breast cancer services. Funding Pririties fr Upper Cumberland Regin: Fr this RFA, the Upper Cumberland Regin cnsists f the fllwing cunties: Cannn Cunty, TN Clay Cunty, TN Cumberland Cunty, TN DeKalb Cunty, TN Fentress Cunty, TN Jacksn Cunty, TN Macn Cunty, TN Overtn Cunty, TN Picket Cunty, TN Putnam Cunty, TN Smith Cunty, TN Van Buren Cunty, TN Warren Cunty, TN White Cunty, TN Applicants may request funding frm $10,000 up t $20,000 (cmbined direct and indirect csts) fr ne year. While applicatins will be accepted fr prgrams prviding services within the Upper Cumberland Regin, pririty will be given t applicants that demnstrate benefit t ne r mre f the fllwing cmmunities: Clay Cunty, TN Macn Cunty, TN Smith Cunty, TN Page 6 f 25

The funding pririties fr the Upper Cumberland Regin are listed belw: Pririty 1: Prgrams that prvide evidence-based, culturally relevant breast cancer educatin that results in dcumented age-apprpriate breast cancer actin (e.g., talk t dctr abut breast cancer risk and/r receive a screening mammgram) fr underinsured and uninsured individuals. One-n-ne and grup breast cancer educatin prgrams must include Kmen s breast self-awareness messages and prvide lcal breast cancer services. Pririty 2: Prgrams that increase access t breast cancer services fr individuals that are nt eligible fr ther breast cancer prgrams (e.g., Tennessee BCCP). The Affiliate seeks t fund n cst r lw cst screening mammgrams and transprtatin assistance. Pririty 3: Evidence-based prgrams that increase breast cancer survivrs and thse living with metastatic breast cancer quality f life. The Affiliate seeks t fund prgrams that prvide breast cancer specific supprt grups, exercise prgrams and nutritin guidance. Examples f successful prjects funded by Kmen in the past include thse that: Increased the number f wmen that utilize regular breast cancer screening; Decreased time frm referral t mammgraphy screening; Reduced the number f wmen lst t fllw up; Reduced time frm abnrmal screening t diagnstic prcedures; Reduced time frm diagnstic finding t treatment; Increased treatment cmpliance; and Increased mammgraphy capacity, thrugh develpment f prcess imprvements and relatinship building effrts. ELIGIBILITY REQUIREMENTS Applicants must cnfrm t the fllwing eligibility criteria t apply. Eligibility requirements fr the applicants must be met at the time f Applicatin submissin. Individuals are nt eligible t apply. Applicatins will nly be accepted frm a nn-prfit rganizatin with 501(c)3 status (such as an educatinal institutin, hspital r ther medical facility, r a cmmunity rganizatin) r a lcal/state gvernment lcated in r prviding services t ne r mre f the fllwing lcatins: Bledse Cunty, TN Marin Cunty, TN Sumner Cunty, TN Bradley Cunty, TN Maury Cunty, TN Trusdale Cunty, TN Cannn Cunty, TN McMinn Cunty, TN Van Buren Cunty, TN Cheatham Cunty, TN Meigs, Cunty, TN Warren Cunty, TN Page 7 f 25

Clay Cunty, TN Mntgmery Cunty, TN White Cunty, TN Cumberland Cunty, TN Overtn Cunty, TN Williamsn Cunty, TN Davidsn Cunty, TN Picket Cunty, TN Wilsn Cunty, TN DeKalb Cunty, TN Plk Cunty, TN Catsa Cunty, GA Dicksn Cunty, TN Putnam Cunty, TN Dade Cunty, GA Fentress Cunty, TN Rhea Cunty, TN Fannin Cunty, GA Grundy Cunty, TN Rbertsn Cunty, TN Murray Cunty, GA Hamiltn Cunty, TN Rutherfrd Cunty, TN Walker Cunty, GA Jacksn Cunty, TN Sequatchie Cunty, TN Whitfield, Cunty, GA Macn Cunty, TN Smith Cunty, TN Prpsed prjects must be specific t breast health and/r breast cancer and address the pririties identified in the Affiliate s 2015 Cmmunity Prfile. 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 r awards t applicant are up-t-date and in cmpliance with Kmen requirements. Applicant has dcumentatin f current tax exempt status under the Internal Revenue Service cde. 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 des nt recur. MANDATORY GRANTWRITING WORKSHOP: At least ne individual frm the applicant rganizatin wh will be invlved in the writing f the applicatin and administratin f the grant must attend ne f the Reginal Grant Writing Wrkshps. Dates, times and lcatins are listed n kmencentraltennessee.rg. Page 8 f 25

ALLOWABLE EXPENSES Funds may be used fr the fllwing types f expenses prvided they are directly attributable t the prject: Salaries and fringe benefits fr prject staff Cnsultant fees Clinical services r patient care csts (allwed up t Medicare reimbursement rates) Meeting csts Supplies Reasnable travel csts related t the executin f the prgram Other direct prgram expenses Equipment, nt t exceed $5,000 ttal, essential t the breast health related prject t be cnducted Indirect csts, nt t exceed 15 percent f direct csts 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 Educatin regarding breast self-exams/use f breast mdels Develpment f educatinal materials r resurces Educatin via mass media (e.g. televisin, radi, newspapers, billbards), health fairs and material distributin. These methds may be used t prmte prjects, but evidence-based methds such as 1-1 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 Payments/reimbursement made directly t individuals Land acquisitin Prject-related investments/lans Schlarships Thermgraphy Equipment ver $5,000 ttal Prjects r prtins f prjects nt specifically addressing breast cancer Patient treatment csts, including but nt limited t, surgery, chemtherapy, radiatin, hrmne therapy, targeted therapy and survivrship care plan Page 9 f 25

IMPORTANT GRANTING POLICIES Please nte these plicies befre submitting a prpsal. These plicies are nn-negtiable. The prject must ccur between April 1, 2017 t March 31, 2018. 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 Central Tennessee. Grant payments will be made in installments pending cmpliance with terms and cnditins f grant agreement and receipt f satisfactry prgress reprts. 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 Tennessee, 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 prgram, $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 Central Tennessee with a Certificate f Insurance with Susan G. Kmen Breast Cancer Fundatin, Inc., Susan G. Kmen Central Tennessee, 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. If the grantee is nly funding and nt directly prviding screening and diagnstic services, the umbrella cverage is nt required. Hwever, it is the grantee s respnsibility t make sure all prviders they use have the required insurance. Page 10 f 25

EDUCATIONAL MATERIALS AND MESSAGES Susan G. Kmen is a surce f infrmatin abut breast health and 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, 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: http://ww5.kmen.rg/breastcancer/breastselfawareness.html. 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 and therefre Kmen will nt fund educatin prjects that teach r endrse the use f mnthly breast self-exams r use breast mdels. As an evidence-based 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 Affiliate Grantees are encuraged t use Kmen-develped educatinal resurces, including messages, materials, tlkits r nline cntent during their grant perid. This is t ensure that all breast cancer messaging assciated with the Kmen name r brand are current, safe, accurate, cnsistent and based n evidence and t avid expense assciated with the duplicatin f existing educatinal resurces. Kmen Grantees can purchase Kmen educatinal materials at the Affiliate preferred price. If a grantee intends t use ther supplemental materials, they shuld be cnsistent with Kmen messages. Kmen grantees are eligible t receive preferred pricing fr Kmen educatinal materials. Kmen materials shuld be used and displayed whenever pssible. T view ur educatinal materials, visit www.shpkmen.cm. 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 educatrs and rganizatins t use t meet the needs f these cmmunities. The Hispanic/Latin Tlkit is available in bth English and Spanish. T access the Tlkits, please visit http://kmentlkits.rg/. Kmen has additinal educatinal resurces, including n kmen.rg, that may be used in cmmunity utreach and educatin prjects. Check with Kmen Central Tennessee fr resurces that may be used in prgramming. Page 11 f 25

REVIEW PROCESS Each grant applicatin will be reviewed by at least three independent reviewers. They will cnsider each f the fllwing selectin criteria: Impact 18%: Will the prject have a substantial psitive impact n increasing the percentage f peple wh enter, stay in, r prgress thrugh the cntinuum f care? Will the prject have a substantial impact n the need described in the funding pririty selected? Is the impact likely t be lng-term? Statement f Need 18%: Des the prject address at least ne f the funding pririties stated in the RFA and the Affiliate s 2015 Cmmunity Prfile? Des the prject prvide services t ne r mre f the target cmmunities described in the Affiliate s 2015 Cmmunity Prfile? Prject Design 18%: D the gal and bjectives described in the Prject Wrk Plan align with the prject descriptin and activities? Is it clear what, specifically, is being dne thrugh this prject? Is the prject designed t meet the needs f specific cmmunities including the cultural and scietal beliefs, values, and pririties f each cmmunity? Is the prject evidence-based? Is the budget apprpriate and realistic? Des the budget justificatin explain in detail the reasning and need fr the csts assciated with the prject? If the prpsed prject includes cllabratin with ther rganizatins, are the rles f the partners apprpriate, relevant and clearly defined? Hw likely is it that the bjectives and activities will be achieved within the scpe f the funded prject? Organizatin Capacity 18%: Des the applicant rganizatin, Prject Directr and his/her team have the expertise t effectively implement all aspects f the prject? Is there evidence f success in delivering services t the target ppulatin? Is the rganizatin fiscally capable f managing the grant prject, including having apprpriate financial cntrls in place? Des the applicant rganizatin have the equipment, resurces, tls, space, etc., t implement all aspects f the prject? Des the rganizatin r staff have apprpriate licenses, certificatins, accreditatins, etc. t deliver the prpsed services? Des the rganizatin have a plan t btain the resurces (financial, persnnel, partnerships, etc.) needed t sustain the prject beynd the grant term (if awarded)? Are cllabratins (if prpsed) likely t be sustained beynd the grant term? Mnitring and Evaluatin 18%: Is there a dcumented plan t measure prgress against the stated prject gal and bjectives, and the resulting utputs and utcmes? Is there sufficient mnitring and evaluatin (M&E) expertise fr the prject? Are there sufficient resurces in place fr M&E effrts? Plans t Acknwledge Partnership with Central Tennessee 10%: Did the rganizatin prvide details n hw its partnership with Kmen Central Tennessee will be publicized? Did the rganizatin adequately describe a plan t cllect and use patient stries t publicize the prgram? Page 12 f 25

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: Daveisha Mre, Missin/Educatin Directr 615-383-0017 dmre@kmencentraltennessee.rg Page 13 f 25

SUBMISSION REQUIREMENTS All prpsals must be submitted nline thrugh the Kmen Grants e-management System (GeMS): https://affiliategrants.kmen.rg. Applicatins must be received n r befre December 16, 2016 at nn CST. N late submissins will be accepted. APPLICATION INSTRUCTIONS The applicatin will be cmpleted and submitted via the Kmen Grants e-management System (GeMS), https://affiliategrants.kmen.rg. 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, kmencentraltennessee.rg r cntact Daveisha Mre, 615-383- 0017 r dmre@kmencentraltennessee.rg. 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 detailed infrmatin regarding yur rganizatin s histry, missin, prgrams, staff/vlunteers, budget, and scial media. PROJECT PRIORITIES AND ABSTRACT (limit 1,000 characters) This sectin cllects imprtant 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 sectin is the cre piece f the applicatin. On the Prject Narrative page f the applicatin n GeMS, please address the requests belw fr each sectin. Statement f Need (limit- 5,000 characters) Describe evidence f the risk/need within the identified ppulatin, using the RFA funding pririties and the 2015 Cmmunity Prfile as a guide. Describe the characteristics (race, ethnicity, ecnmic status, and breast cancer statistics) specific t the target ppulatin t be served with Kmen funding. Describe hw this prject aligns with Kmen Central Tennessee target cmmunities and/r RFA funding pririties. Page 14 f 25

Prject Design (limit- 5,000 characters) Explain the prpsed prject s verall gal and bjectives, as utlined in yur Prject Wrk Plan, and what specifically will be accmplished using Kmen funding. Explain hw the prpsed prject s gal and bjectives align with the stated pririties in the Affiliate s 2015 Cmmunity Prfile. Describe in detail what will be dne and hw the prject will increase the percentage f peple wh enter, stay in, r prgress thrugh the cntinuum f care. Explain hw the prject is designed t meet the needs f specific cmmunities including the cultural and scietal beliefs, values, and pririties f each cmmunity. Explain if and hw the prject is evidence-based and/r uses prmising practices (please cite references). References may be included in Prject Design text bx r separate reference page may be upladed. Describe prject cllabratin and the rles and respnsibilities f all rganizatins r entities participating in the prject, and explain hw the cllabratin strengthens the prject and why partnering rganizatins are best suited t assist in carrying ut the prject and accmplishing the gal and bjectives set frth in this applicatin. Organizatin Capacity (limit- 5,000 characters) Explain why the applicant rganizatin, Prject Directr and staff are best-suited t lead the prject and accmplish the gal and bjectives set frth in this applicatin. Please include apprpriate rganizatin r staff licenses, certificatins and/r accreditatins. Describe evidence f success in delivering breast health/cancer services t the prpsed ppulatin. If the breast health/cancer prgram is newly prpsed, describe relevant success with ther prgrams. Describe the equipment, resurces, tls, space, etc., that the applicant rganizatin pssesses r will utilize t implement all aspects f the prject. Describe fiscal capability t manage the delivery f the prpsed gal and bjectives and ensure adequate measures fr internal cntrl f grant dllars. Describe the rganizatin s current financial state. Hw has yur rganizatinal budget changed ver the last three years? Please explain increase r decrease. Describe the plan t secure and allcate resurces (financial, persnnel, partnerships, etc.) t sustain the prject at the cnclusin f the grant perid. 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: successes and accmplishments, challenges, lessns learned, prmising practice example, a cmpelling stry frm an individual that was served with Kmen funding and number f individuals served thrugh Kmen funding fr each bjective (cunty, race and ethnicity, age and ppulatin grup). Additinal data cllectin and reprting requirements and examples are in Appendix C. Applicants shuld include any templates, lgic mdels r surveys t supprt the Mnitring and Evaluatin narrative by adding attachments t the Prject Wrk Plan page. The Mnitring and Evaluatin narrative must address the fllwing items: Page 15 f 25

Describe in detail hw the rganizatin(s) will measure prgress against the stated prject gal and bjectives. Describe hw the rganizatin(s) will assess hw the prject had an effect n the selected pririty. Describe hw the rganizatin(s) will assess prject delivery. Describe the mnitring and evaluatin (M&E) expertise that will be available fr this purpse. Describe the resurces available fr M&E during the curse f the prject. Specify if these resurces are requested as part f this grant, r if they are existing rganizatinal resurces. Plans t Acknwledge Partnership with Kmen Central Tennessee (limit 5,000 characters) Describe in detail hw yur rganizatin will publicize its partnership with Kmen Central Tennessee. Describe hw yur rganizatin will patient stries and utilized them t prmte the partnership and prgram. 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. PROJECT WORK PLAN In the Prject Wrk Plan cmpnent f the applicatin n GeMS, yu will be required t submit a single gal and crrespnding bjectives: The Gal shuld be a high level statement that prvides verall cntext fr what the prject is trying t achieve. Objectives are specific statements that describe hw the prject will meet the gal. An bjective shuld be evaluated at the end f the prject t establish if it was met r nt met. The prject gal must have at least ne bjective; there is n limit t the number f bjectives. Please ensure that all bjectives are SMART bjectives: Specific Measurable Attainable Realistic Time-bund A guide t crafting SMART bjectives can be lcated in Appendix A r at the fllwing: http://ww5.kmen.rg/writingsmartobjectives.html. Yu will als be required t submit the timeline, the anticipated number f individuals t be served, and the evaluatin methd yu will utilize fr each bjective. Page 16 f 25

Write yur Prject Wrk Plan with the understanding that each item must be accunted fr during prgress reprting. The Prject Wrk Plan shuld include a single gal that will be accmplished with funds requested frm Kmen Central Tennessee. Objectives that will be funded by ther means shuld nt be reprted here, but instead, can be included in yur verall prgram descriptin. Example Wrk Plan (Fr additinal examples and a SMART bjective checklist, please refer t Appendix A.) GOAL: Prvide patient navigatin t wmen with screening abnrmalities in rder t reduce delays in and barriers t diagnstic care. OBJECTIVE 1: By February 12, 2018, the patient navigatr will have cntacted 100 percent f all wmen with an abnrmal screening result within three business days t schedule a fllw-up appintment. OBJECTIVE 2: By March 31, 2018, the prject will prvide 30 uninsured/underinsured 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: Frms, surveys, and lgic mdels that will be used t assess the prgress and/r the effectiveness f these bjectives. BUDGET SECTION Fr each line item in the budget, prvide a 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. 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 yur prject requires a third party t help with a piece f 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 yur rganizatin. Direct Patient Care services, even in subcntracted, shuld nt be included in this sectin; thse funds shuld be included in the Patient Care budget sectin. SUPPLIES Page 17 f 25

This sectin shuld include ffice supplies, educatin supplies, and any ther type f supplies yur rganizatin will need t cmplete the prject. Nte: Kmen grant funds may nt be used fr the develpment f educatinal materials r resurces. If awarded prject funds, grantees must use/distribute nly Kmen-develped r Kmen-apprved educatinal resurces. Kmen grantees are eligible t receive preferred pricing fr Kmen educatinal materials. Kmen materials shuld be used and displayed whenever pssible. T view ur educatinal materials, visit www.shpkmen.cm. TRAVEL This sectin shuld be cmpleted if yu are requesting funds fr any type f travel including cnference travel, registratin fees and mileage reimbursement by rganizatin staff r vlunteers related t prject activity. (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 a direct service fr a patient. This shuld be the cst yu will need t prvide the services mentined in the gal and bjectives f the applicatin. Navigatin r referral prgrams shuld nt include the prgram csts in this sectin. Calculatins fr prpsed services shuld be included in the budget justificatin text bx. Fr example- 50 clinical breast exams at $50 each; 100 mammgrams at $100 each; etc. OTHER This sectin shuld include any allwable expenses that d nt fit the ther budget categries. This sectin shuld nly be used if the item cannt be included n any f the ther varius budget sectins. INDIRECT This sectin cllects the allwable indirect cst which is requested as a percentage f direct csts. Include details n intended use f indirect funds. PROJECT BUDGET SUMMARY This sectin includes a summary f the ttal prject budget. Other surces f funding 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: http://www.irs.gv/charities-&-nn-prfits/eo-operatinal-requirements:-obtaining- Cpies-f-Exemptin-Determinatin-Letter-frm-IRS Page 18 f 25

APPENDIX A: WRITING SMART OBJECTIVES Prject planning includes develping prject gals and bjectives. Gals are high level statements that prvide verall cntext fr what the prject is trying t achieve. Objectives are specific statements that describe what the prject is trying t achieve and hw they will be achieved. Objectives are mre immediate than gals 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 3 f the 4 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 prjectmatic 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. Page 19 f 25

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 cnducted, wh the wmen are and by when the educatinal sessins will be cnducted. SMART bjective 1: By September 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 prjectmatic 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? Page 20 f 25

Surce: Department f Health and Human Services- Centers fr Disease Cntrl and Preventin. January 2009. Evaluatin Briefs: Writing SMART Objectives. http://www.cdc.gv/healthyyuth/evaluatin/pdf/brief3b.pdf Page 21 f 25

APPENDIX B: FUNDING PRIORITY DEFINITIONS Fr the purpse f the Reginal Funding Pririties the belw terms are defined as the fllwing: Lw incme: Incmes at r belw 300% f the Federal Pverty Level. The 2016 Federal Pverty incme numbers are belw : $11,880 fr individuals $16,020 fr a family f 2 $20,160 fr a family f 3 $24,300 fr a family f 4 $28,440 fr a family f 5 $32,580 fr a family f 6 $36,730 fr a family f 7 $40,890 fr a family f 8 Underinsured: 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 Navigatin: is a prcess by which a trained individual- patient navigatr- guides patients thrugh and arund barriers in the cmplex breast cancer care system. The primary fcus f a patient navigatr is n the individual patient, with respnsibilities centered n crdinating and imprving access t timely diagnstic and treatment services tailred t individual needs. Patient navigatrs ffer interventins that may vary frm patient t patient alng the cntinuum f care and include a cmbinatin f infrmatinal, emtinal, and practical supprt (i.e., breast cancer educatin, cunseling, care crdinatin, health system navigatin, and access t transprtatin, language services and financial resurces). Page 22 f 25

APPENDIX C: DATA COLLECTION AND REPORTING REQUIREMENTS AND EXAMPLES The fllwing data shuld be cllected during the grant perid and included with prgress and final reprts. GeMS REPORTING OUTPUTS (Required reprting fr all individuals served) Fr all individuals served thrugh screening and diagnstic services, treatment supprt services, educatin, and patient navigatin, the fllwing data shuld be cllected: Race and ethnicity Age Gender Cunty Special ppulatin grups listed in GeMS The fllwing are examples f metrics that can be gathered in additin t that included in the prgress and final reprts in GeMS: GRANTS PROVIDING SCREENING AND DIAGNOSTICS This wuld include grants that prvide funding fr the fllwing breast cancer services: Screening- including, but nt limited t, clinical breast exams and mammgrams Diagnstics- including, but nt limited t, diagnstic mammgrams, ultrasunds and bipsies Data reprted shuld include: Demgraphic data (race and ethnicity, age, gender, cunty, and ppulatin grup data) fr each patient receiving screening and/r diagnstic services Number f individuals that received a (insert service). Number/Percentage f individuals that received (insert service) within 30 days r less frm referral date. Number/Percentage f individuals that received (insert service) 31-60 days frm referral date. Number/Percentage f individuals that received (insert service) 61-90 days frm referral date. Number/Percentage f individuals that received (insert service) 91 r mre days frm referral date. Of the individuals that received a (insert service), the number f individuals that had an abnrmal result. Of thse with an abnrmal result, the number f individuals that cmpleted the referred diagnstic services. Fr Bipsy Only: Of the individuals that received a diagnstic bipsy, the number f individuals that were diagnsed with breast cancer. Page 23 f 25

Of the individuals diagnsed with breast cancer, the number f individuals referred nt treatment. Of the individuals diagnsed with breast cancer and referred fr treatment, the number that initiated treatment. GRANTS PROVIDING FINANCIAL ASSISTANCE/TREATMENT SUPPORT SERVICES A lg f all patients assisted will be kept. In additin t the reprting utputs required in GeMS (race and ethnicity, age, gender, cunty, and ppulatin grup data), grantees shall keep detailed recrds t include the fllwing: Patient name/initials Referring persn/rganizatin Treating physician Amunt f funds given Date funds given Purpse/need f funds given If a grant includes educatin and/r patient navigatin bjectives, additinal data shuld be cllected and reprted as nted belw. EDUCATION This includes ne-n-ne and grup educatinal sessins and trainings. Data shall be cllected t include the fllwing: Number f educatinal/training sessins cnducted. Number f participants that attended the educatinal/training sessins. Number and type f Kmen breast health and breast cancer educatinal materials distributed t participants. Number/Percentage f participants that demnstrated an increase in breast cancer knwledge after the educatinal/training sessins. This data wuld be gathered by the participant cmpleting a pre-test and pst-test. Average percentage increase in knwledge reprted by participants that attended the educatinal/training sessins. This data wuld be gathered by the participant cmpleting a pre-test and pst-test. Number/Percentage f participants that reprted that they intended t take apprpriate breast self-awareness actin after attending the educatinal/training sessin. This data wuld be gathered by the participant answering an intent t take breast self-awareness actin questin n a survey r pst-test. Number/Percentage f individuals that had intended t take actin that cmpleted the actin within 3, 6 and/r 9 mnths after the educatinal/training sessin. This data wuld be gathered by cntacting the participant t determine if they cmpleted their intended actin. Number/Percentage f participants that attended the educatinal/training sessin and reprted they intend t share the infrmatin with smene else in their netwrk. This data wuld be gathered by the participant answering an intent t share infrmatin questin n a survey r pst-test. Page 24 f 25

Number/Percentage f participants that intended t share the infrmatin that did share the infrmatin within 3, 6 and/r 9 mnths after the educatinal/training sessin. This data wuld be gathered by cntacting the participant t determine if they shared the infrmatin. Additinal educatinal measures culd include the number/percentage that indicated the infrmatin was new, infrmatin is pertinent t their jb, training develped a new skill and new skill practiced within 3, 6 and/r 9 mnths after training. PATIENT NAVIGATION Patient navigatin is a prcess by which an individual a patient navigatr guides patients thrugh and arund barriers in the cntinuum f care, t help ensure access t timely screening, diagnsis, treatment and survivrship services. Data cllected fr patient navigatin services shall include the fllwing: Number f individuals that were navigated t a health care prvider/facility fr a (insert service). Number f navigated individuals that received/initiated a (insert service) within 30 days. Number f navigated individuals that received/initiated a (insert service) in 31-60 days. Number f navigated individuals that received/initiated a (insert service) in 61-90 days. Number f navigated individuals that received/initiated a (insert service) in 91 days r mre. Number f navigated individuals that cmpleted a (screening/diagnstic) service and had an abnrmal result. Number f navigated individuals that had an abnrmal result that were navigated t diagnstic services. Number f navigated individuals that were diagnsed with breast cancer that were navigated t treatment services. Number f navigated individuals that were diagnsed with breast cancer that were navigated t survivrship supprt services. Page 25 f 25