REQUEST FOR PROPOSAL (RFP)
Grant Applications Now Being Accepted for
Breast Health and/or Breast Cancer
Screening and Diagnostic Services
At Susan G. Komen for the Cure®, we know that ending breast cancer is about more than
curing a medical condition - it's about overcoming the cultural, social and financial conditions
that prevent women from receiving life-saving breast health care and treatment.
To save lives and end breast cancer forever by empowering people,
ensuring quality care for all and energizing science to find the cures.
To enable women to detect and survive breast cancer.
The Greater Atlanta Affiliate of Susan G. Komen for the Cure (Komen Atlanta) is currently
offering grants of up to $150,000 for innovative, non-duplicative projects in the areas of breast
health and breast cancer screening and diagnostic services. Projects should target services,
not otherwise available, to the medically underserved populations1 of Cherokee, Clayton, Cobb,
DeKalb, Fayette, Forsyth, Fulton, Gwinnett, Henry and/or Rockdale counties. Grants are
available for up to one year.
Komen Atlanta will host two grant-writing workshops. All applicants that are not current
Komen Atlanta grantees MUST attend a workshop. Current Komen grantees are
STRONGLY recommended to attend. The dates, times and locations of the workshops will be
posted at: http://www.komenatlanta.org/grants/rfp.html.
The application deadline is November 4, 2011.
Applications must be received by 5 p.m. on this date to be accepted.
STATEMENT OF NEED
The areas highlighted below are Komen Atlanta’s funding priorities for the 2012-2013 grant
Programs that increase access to and improve affordability of screening and diagnostic
procedures for medically underserved populations.
Programs that incorporate evidence-based breast cancer strategies2 within their
standards of practice.
Programs that are both culturally competent3 and aim to eliminate cultural barriers that
preclude women from receiving information and from accessing breast health services.
Programs that ensure the availability of breast health services in the 10-county service
area, with a priority in counties with highest mortality (Rockdale, Fulton and DeKalb
WHAT WE FUND
Applications will be accepted for any breast health project in the 10-county service area.
Projects that specifically address the areas outlined in the “Statement of Need” will be given
Komen Atlanta has two requests for proposal (RFPs) posted for the 2012-2013 grant year: one
for Screening and Diagnostic Services and one for Education, Navigation and Support. Priority
between the two RFPs will be given to Screening and Diagnostic Services grant requests. A
grant application is classified according to the particulars of its budget. In particular, an
application is considered to be for Screening and Diagnostic Services if 75% or more of the
total budget is focused on screening or diagnostic direct-care services (i.e., delivery of hands-
on care, including making provision for and/or performing clinical breast exams or other
screening and diagnostic services).
If an organization is requesting funding for screening services, it must have a current FDA
certification prior to submission of its application, and an official copy of the FDA certification
must be submitted with the application.
Komen Atlanta will only fund education projects that are found to be effective in promoting
behavioral change or empowering individuals to make good breast health decisions. Mass
distribution of breast health materials or mass media will not be funded.
All requests for science research funding should be directed to the National Komen Award and
Research Grant Program. More information on research funding is available at
TYPES OF COMMUNITY GRANTS
Education, Navigation and Support Grants Screening and Diagnostic Services Grants
Limit: $50,000 Limit: $150,000 (see exceptions below)
Mixed grants, which are those with less Limit of $75,000 for genetic counseling
than 75% of the total budget used for and testing applicants
screening and diagnostic direct-care Limit of $75,000 for first time
services applicants (never funded by Komen
Support grants include, but are not limited Atlanta)
to exercise, diet, nutrition, complementary 75% or more of the total budget is focused
and alternative medicines, support on screening or diagnostic direct-care
groups, lymphedema management and services
care, transportation and non-medical in- Designed to ensure a continuum of care
home care for a patient from screening to diagnosis
Navigation programs as defined by the Diagnostic services include, but are not
National Cancer Institute.4 limited to: screening and diagnostic
mammograms, MRI, ultrasound and
GENERAL GUIDELINES FOR COMMUNITY GRANT
Project must be specific to breast health and/or breast cancer; for example, if a project is a
combined breast and cervical cancer project, funding may be requested for only the breast
Applications are accepted from U.S. nonprofit institutions that are tax-exempt under Section
501(c)(3) of the Internal Revenue Code; US citizenship or residency is not required.
Applications must be submitted in English.
Services must be provided in Cherokee, Clayton, Cobb, DeKalb, Fayette, Forsyth, Fulton,
Gwinnett, Henry and/or Rockdale counties.
Funds from Komen Atlanta should be used to provide services to individuals who do not
qualify for other forms of aid, such as Medicare, Medicaid or other insurance payments
for such services.
Indirect costs, if applicable, should be no more than 7.5% of direct costs.
Equipment costs, if applicable, may not exceed $2,000. Equipment costs must be directly
necessary for the implementation of this project, reasonable, and used exclusively on
Salaries, if requested, must be for personnel directly associated with the project for which a
grant is sought (i.e., not for personnel who perform general work of the organization) and
must be reasonable and consistent with salaries generally paid by non-profit
organizations for similar work. The reasonableness of salaries will be evaluated based
on the type of work provided, and not based on the qualifications of persons providing
the services. (Example – A physician is the project director of an education program.
The salary requested should be that of a health educator and not that of a physician.)
Travel, if requested, must be for travel expenses related only to the project and for travel
inside the service area - not for the general travel of the project director, others related to
the project or travel outside the service area.
Although most approved grants are fully funded in accordance with the submitted
budget, the Grants Committee may opt to recommend funding of an application only
after receiving requested budget modifications or to fund only a portion of the
An organization may submit multiple applications. Projects must have independent
program goals and measurable objectives.
A variety of education materials are available from Susan G. Komen for the Cure. Some
items are targeted to specific populations. While not required, we recommend that Komen
materials be used in the project whenever possible. See http://www.shopkomen.com.
INSTRUCTIONS FOR COMMUNITY GRANT APPLICATIONS
APPLICATIONS SHOULD INCLUDE AND BE ORDERED AS FOLLOWS
A. Cover Page
B. Project Description (This section should not exceed five typewritten pages. Font size
should be no smaller than a 12-point typeface with 1 inch margins.)
1. Background/Organization Information: Explanation of project, including brief
summary of organization’s history, description of current programs, activities and
accomplishments as relevant to the project.
2. Problem to be Addressed: Description of constituency to be served (indicate
estimated number and demographics of people to be served), organization’s
experience serving the target population, how they will benefit from services and how it
will be determined that they are medically underserved. Also, please indicate how the
project addresses Komen Atlanta’s funding priorities.
3. Goals and Objectives: Description of program goals and specific, measurable,
achievable, realistic and time-bound (“SMART”) objectives.
4. Activities and Timeline: Description of activities planned to accomplish these goals. Is
this a new or ongoing activity? Provide a detailed timeline for implementing the
5. Collaboration: Description of other organizations or entities, if any, participating in the
program. Do not attach letters of support.
6. Evaluation: Description of how the organization will measure completion of the
objectives and ultimately the success of the program.
7. Sustainability: Description of long-term strategies for funding of the program after
initial funding, if applicable.
C. Financial Information (This section should not exceed four typewritten pages.)
1. Budget for requested funds.
2. Budget justification.
3. List of other sources of current or pending funding for the project, including amounts.
D. Personnel - Please insert employment history on the Biosketch form provided or attach
curriculum vitae or resume for project director and personnel listed in budget request (no
more than two pages per person).
E. Proof of the Applicant Organization’s Tax-Exempt Status Under Section 501(c)(3) of
the Internal Revenue Code (A copy of the organization’s Internal Revenue Service
determination letter is preferred.)
F. Official Copy of Current FDA Certification (for Screening and Diagnostic Services
Please note that letters of support and additional materials are not required and will not be
reviewed (e.g., reprints, curriculum vitae in excess of two pages, or letters of support).
Compliance Review: All applications are pre-screened by the Grants Manager to ensure the
required components have been submitted. Complete applications will be submitted for full review
by a Community Review Panel established through Komen Atlanta’s Grants Committee.
Community Review Panel: An independent group of community members are invited by Komen
Atlanta to review and score all incoming grant applications. Members are selected from diverse
backgrounds and include healthcare professionals, community advocates, breast cancer survivors,
non-profit representatives and other professionals. Due to the volume of applications received, the
Community Review Panel is divided into two groups: Screening and Diagnostic Services grant
reviewers and Education, Navigation and Support grant reviewers. After the review period, Panel
members meet to discuss scores and create a recommended slate for the Grants Committee.
Each Community Review Panel member is required to sign a confidentiality agreement and to
disclose all potential conflicts of interest. Any Community Review Panel member who reports a
conflict of interest will not be involved in reviewing, discussing, or voting on approval of any
application from an organization with which a conflict exists.
Grants Committee: The Grants Committee is composed of the Executive Director, the Grants
Manager, and members of the Board of Directors of Komen Atlanta. The Grants Committee
accepts the Community Review Panel’s scoring and makes the final decision on funding
recommendations to Komen Atlanta’s Board of Directors for final approval.
Members of the Grants Committee also sign confidentiality agreements and conflict of interest
Komen Atlanta’s Board of Directors: After receiving the recommendation of the Grants
Committee, Komen Atlanta’s Board of Directors approves or rejects the entire slate of grants.
Approved Grants versus Funded Grants: “Approved” grants are those the Community
Review Panel has voted to recommend for funding, but does NOT guarantee that the grant will
be funded. “Funded” grants have been both “approved” by the Community Review Panel and
favorably voted on for funding by the Komen Atlanta’s Board of Directors. Please note some
approved applications are not funded due to limited funding.
Announcement of Grants Awarded: Project directors will be notified of the outcome of the
review in writing by March 5, 2012.
PREPARING YOUR APPLICATION
Key Points for Preparing a Strong Application
Submit a clear, concise, and realistic application.
Submit a complete application and follow the grant guidelines closely.
Assume that Komen Atlanta is not familiar with your organization or your project (paint a full
picture in the grant application).
When preparing the application, use the application for the correct type of grant.
Download the required cover sheet and abstract page from Komen Atlanta’s website
Review the information about Komen Atlanta’s grantmaking process prior to preparing an
Review all of the information in these guidelines and on our website. Please do this prior to
calling or emailing Komen Atlanta’s office.
The first step in preparing the grant application is to develop a concept for your project. While
many applicants have existing breast health and/or breast cancer projects, new and emerging
projects will be considered for funding.
Here are some important questions to ask when developing the concept:
How does this project fit with the mission and funding priorities of Komen Atlanta?
What does the organization want to accomplish through this project? Is this in line with the
community’s needs? Is it in line with the applicant organization’s mission? Does the plan
address how the organization will accomplish the goals and address the community in a
culturally and linguistically appropriate manner?
Does your organization have the capacity to implement and manage the project?
Is the project unique or does it duplicate other efforts? If the project is not unique, please
explain why this project is needed within the community.
Should the project include partners?
PROPOSAL COVER PAGE
Please use the form provided (download from www.komenatlanta.org).
The project title will appear on all of our public materials advertising the projects we fund.
Therefore, please choose a project title that is descriptive yet concise.
The cover sheet must be signed by someone within your organization who has the legal
authority to enter into contracts and bind the organization (often the executive director or the
ABSTRACT SHEET – THE FIRST IMPRESSION
A good abstract will state the problem or need the project will address and then will discuss how
the organization plans to address the problem or need. It is essential to develop a succinct
abstract to communicate the essence of the project to Komen National, individuals looking for
breast health and breast cancer services, and healthcare providers within Komen Atlanta’s
service area. The abstract should include a short description of the project, the service(s) the
organization plans to provide (including numbers, if applicable), the target population, the
geographic focus and any other relevant information. The abstract should not exceed 200
words and should be written in lay terms.
Women living in rural communities outside the Metro Atlanta area lack access to breast health
education and screening services. Sigma Community Hospital, a leader in improving access to
health care in rural Atlanta, will provide breast cancer education and screening services to
medically underserved women ages forty and older living in rural areas outside the Metro
Atlanta area. Sigma Community Hospital’s program will target women over the age of forty
whose income is below 250% of poverty and who are uninsured, underinsured, or at-risk; and
are living in Clayton, Henry or Rockdale Counties. Sigma Community Hospital will provide free
screening mammograms and related follow-up services (including case management) to 150
women using Sigma Community Hospital’s mobile mammography van. It also will provide one-
on-one education to 400 medically underserved women on the importance of early detection,
breast self exam techniques, and general breast health and breast cancer information. Bilingual
staff members will be available to assist clients throughout the screening process.
NOTE: THIS IS JUST A SAMPLE – PLEASE DO NOT DUPLICATE. DEVELOP AN
ABSTRACT THAT IS APPROPRIATE FOR YOUR PROJECT.
For funded projects, the abstracts are used for the following purposes:
Susan G. Komen for the Cure® includes the abstract in a book summarizing all projects
funded through Komen Affiliates and posts the abstract on its website.
Susan G. Komen for the Cure® reviews the abstracts to determine which projects will be
invited to present at the annual Komen Mission Conference.
Komen Atlanta posts the abstracts on its website and publishes it in a variety of materials,
all of which are available to the community.
The narrative section of the grant application is the place where your organization can share the
essence of the project. There are a few important points to keep in mind for all projects:
During the training process, the Community Review Panel and the Grants Committee will be
given current breast cancer statistics (both national and local). Therefore, it is not necessary
to state general breast cancer statistics. However, the use of local statistics or statistics
gathered by your organization can help substantiate the need for your organization’s project
and are important to include when relevant.
When appropriate, consider using research to bolster your approach to addressing the
problem identified in the application, especially when basing the approach on emerging,
promising, or best practices within the field. When using outside sources or internal
research, be sure to include appropriate citations. Claims and quotes without citations can
reduce the appearance of credibility for your organization.
Keep the narrative clear, concise, and consistent.
When preparing the narrative, help the grant reviewers understand where this project fits
within your organization and within the organization’s larger community.
ADDITIONAL TIPS ON COMPLETING THE NARRATIVE
Discussing Need(s) the Project Will Address
When answering the question about needs or problems the project will address, demonstrate
that the organization has a broad understanding of the situation, and present specific evidence
to support the organization’s view of the need or problem and how it will be addressed. This
section is a good place to use local statistics or those gathered by the organization to
substantiate the need for the project.
Defining the Project’s Target Population
All projects funded by Komen Atlanta must target the medically underserved. In a general
sense, medically underserved refers to people who are uninsured, underinsured, lack access to
medical care, or are at-risk. However, Komen Atlanta has chosen to leave the term “medically
underserved” undefined because different communities will need to define the term in different
ways, according to the needs within a specific community. When preparing the application, be
sure to specifically define the project’s target population and include relevant numbers and
statistics when appropriate to bolster the organization’s application.
Developing the Goals and Objectives
Because Komen Atlanta is committed to measuring the impact of its funding and wants your
organization to be able to measure its success, we place emphasis on a project’s goals and
objectives during the grant review process. Therefore, we encourage all grant applicants to
spend time developing solid goals and objectives for their projects. Goals should communicate
the changes the organization will produce through the project. Objectives should define the
goals in measurable and specific terms.
Here are some additional tips for preparing solid goals and objectives:
Goals and objectives should be clear and concise.
Objectives should be specific, measurable, achievable, realistic and time bound (SMART).
Goals and objectives should be feasible for the grant period.
Choose a few key goals and objectives - this approach will help the reviewers understand
A sample goal with objectives for Sigma Community Hospital:
Goal 1: Increase access to breast cancer screenings for women living in the rural parts of
Komen Atlanta’s service area and ensure continuity of care for women in need of
Objective 1: During the grant period, provide screening mammograms to 150 medically
underserved rural women, ages 40 and older, living in Komen Atlanta’s service
area using Sigma Community Hospital’s mobile mammography van.
Objective 2: For women in need of follow-up services, case managers will refer women to
Sigma Community Hospital’s radiology department for diagnostic services. We
estimate that approximately 15 women will need follow-up services during the
Continuum of Care
Komen Atlanta strives to ensure that all women have access to each component of the breast
cancer Continuum of Care.5 Although the project proposal may focus on one aspect of the
Continuum, please address how clients will be navigated through the next phase of the
Continuum. (For example, if the organization provides screening and diagnostic services, how
will a client be channeled into the treatment component of the Continuum of Care, if
When preparing the timetable for the application, include important milestones for the project.
Consider the Community Review Panel’s perspective when deciding which items to include in
the timetable. Ask, “Will including this item in the timetable help in evaluating this grant
application?” Also, be sure that the timetable is realistic and coordinates with the project’s goals
Evaluating the Project
In a general sense, Komen Atlanta evaluates its grantees’ success in the following ways:
Did the grantee achieve its goals and objectives?
Did the grantee spend the funding in accordance with the approved grant proposal during
the grant period?
Did the grantee achieve success according to the terms described in the approved grant
Grantees are required to report this information to Komen Atlanta as part of the reporting
process. In many cases, going beyond these basic measures of evaluation is important. The
application should include other information about evaluation techniques the organization will
use to determine the project’s success and effectiveness (for example, including feedback
from those receiving services through the project). It is important to develop evaluation
measures that are appropriate, realistic and will provide valuable information about the success
and effectiveness of the project.
PREPARING THE BUDGET
The budget is a key piece of the grant application. When preparing the budget, it is important
that the line items be very clearly explained, both in the budget and within the budget
justification. Also, budget line items must clearly align with the goals and objectives outlined in
Grant applicants are required to use the budget cover page and budget justification included in
the grant application form.
Komen Atlanta will permit up to 7.5% of a grant applicant’s budget to be used for indirect costs.
This funding is intended to cover the “overhead” costs associated with running an organization.
Indirect costs may include rent, utilities, technology infrastructure and support, accounting,
general marketing, legal affairs and fundraising costs.
Typically, the following expenses are considered indirect costs:
Accounting or bookkeeping services
Telephone and internet access charges, including cell phones and long distance charges,
DSL, cable, or dial-up internet access
Rent, utilities and facility maintenance
Marketing expenses (unless the marketing expense is directly related to the project that
Komen Atlanta would be funding)
Salary for an executive director or program director unless he or she directly and regularly
participates in the project in more than a general oversight function
General purpose office supplies, computer equipment and software (unless directly related
to the project)
If you have questions about indirect costs and your grant request, please contact the Grants
Manager prior to submitting the grant application.
The Budget Justification
Including a well written budget justification will help minimize questions about your
organization’s budget request and, therefore, may result in a higher score. A well constructed
budget justification will include two key aspects:
A clear and concise explanation of budget line-items, including information about how a line-
item was derived or calculated; and
A clear explanation of how a line-item correlates to the goals and objectives described in the
narrative portion of the application.
Please note that the budget cover page includes an overview of all costs. The budget
justification includes a detailed listing of each line item, including the quantity as well as the
price per item or procedure.
FREQUENTLY ASKED QUESTIONS
What is medically underserved?
“Medically underserved” refers to individuals of any background who are poor, lack health
insurance or otherwise have inadequate access to high-quality cancer care. Examples of
medically underserved may, depending on the circumstances, be racial or ethnic minorities,
people of lower socio-economic status, residents of a rural area, or the underinsured or
uninsured. Please detail how the population served by the grant project is medically
What are evidence-based breast cancer strategies?
The Guide to Community Preventative Services uses a scientific systematic review process to
identify evidenced-based strategies for breast cancer prevention and control. To learn more
about evidenced based breast cancer strategies visit
http://www.thecommunityguide.org/cancer/index.html and refer to the handout provided during
the Grant-Writing Workshop.
What is meant by “culturally competent?”
“Cultural competence” refers to an ability to interact effectively with people of different cultures.
What is patient navigation?
Patient navigation is defined in many different ways. Komen Atlanta uses the definition
provided by the National Cancer Institute:
“Patient Navigation is an intervention that addresses barriers to quality standard care by
providing individualized assistance to patients, survivors, and families…. The expected
outcomes of patient navigation through the cancer care system include:
Timely, definitive diagnosis following an abnormal test.
Timely treatment following positive diagnosis.
Patient satisfaction with the diagnostic and care system experience.
Patient Navigators are trained, culturally sensitive health care workers who provide support and
guidance throughout the cancer care continuum. They help people ‘navigate’ through the maze
of doctors' offices, clinics, hospitals, outpatient centers, insurance and payment systems,
patient-support organizations, and other components of the health care system. Services are
designed to support timely delivery of quality standard cancer care and ensure that patients,
survivors, and families are satisfied with their encounters with the cancer care system. Patient
Navigator activities designed to achieve these outcomes include:
Coordinating appointments with providers to ensure timely delivery of diagnostic and
Maintaining communication with patients, survivors, families, and the health care
providers to monitor patient satisfaction with the cancer care experience.
Ensuring that appropriate medical records are available at scheduled appointments.
Arranging language translation or interpretation services.
Facilitating financial support and helping with paperwork.
Arranging transportation and/or child/elder care.
Facilitating linkages to follow-up services.”
- NCI, July 2009
What is the breast cancer continuum of care?
The breast cancer continuum of care (CoC) represents the process by which a woman should
move through the health care system, from breast cancer screening through follow-up care.
There are four stages within the continuum: Screening, Diagnosis, Treatment and Follow-up
What is underinsured?
“Uninsured” refers to individuals who do not have health insurance. “Underinsured” refers to
individuals who have insurance, but that insurance does not include breast cancer screening,
diagnosis or treatment services or requires co-payments that are prohibitively expensive.
What are equipment costs?
Equipment costs cover items such as technical machines, desks, laptops and computer
software. These items should be included in the budget only if they will be used exclusively on
What are support services?
Support services can be spiritual, emotional or physical services provided to newly diagnosed
breast cancer patients, breast cancer survivors or women living with breast cancer. Support
projects can include, but are not limited to, nutrition and diet counseling, support groups,
complementary and alternative therapies, spiritual and religious support, palliative care and
Does Komen Atlanta provide ongoing funding for its grantees?
No, all grantees must reapply for funding each year. Funding from Komen Atlanta is never
guaranteed and should not be expected by any prior or future applicant. Although many of our
grantees have received a grant award for more than one grant cycle, these organizations are
never guaranteed continued funding.
How does Komen Atlanta make its funding decisions?
Komen Atlanta’s grantmaking process is independent, rigorous, and competitive. An
independent Community Review Panel evaluates all applicants, and grant awards are made in
accordance with a pre-determined process that takes many factors into consideration. Board
members then vote only on grants as a slate, never individually.
Can our organization appeal a grant decision?
No. All grantmaking decisions are final. After being denied, all applicants are welcome to
reapply for a grant during the following year’s grantmaking cycle.
Our organization is paying a consultant $1,500 to write our grant application. Can this
cost be included in the budget?
No. Komen Atlanta will consider only costs related to the execution of a breast health and/or
breast cancer project.
Do we really need to follow the page limits for the application?
Absolutely. Please follow all directions.
What happens if we are late in reporting?
Failure to submit satisfactory reports by the deadline will affect the organization’s future funding.
AFTER RECEIVING THE GRANT
Contract and Grant Period: If your organization is selected to receive a grant from Komen
Atlanta, you will be required to comply with Komen Atlanta’s Grant Contract and Management
Policies. The grant contract will be the legal mechanism for funding and outlines the terms and
conditions of the award. The grant cycle begins April 1, 2012 and will conclude on March 31, 2013.
Payment and Reporting: The first payment will be made no later than 30 days after receipt of
the fully executed contract. The first progress report is due at the end of the first three months
(July 15, 2012) for new grantees, including former grantees with a new Project Director, and the
end of the first six months (October 14, 2012) for all grantees. The second half of funding will
be mailed upon satisfactory review of the six-month progress report. A final report is due within
45 days of completion of the grant period. Final reports must be received by May 15, 2013 at
Site Visits: A Komen Atlanta Board Member, staff member and/or other representative will
conduct a site visit during the grant cycle. Substantial prior notice will be given.
CHECKLIST FOR ALL APPLICATIONS
BEFORE SUBMITTING YOUR GRANT APPLICATION:
Make sure that everyone involved in the project has a chance to review the grant application
before it is submitted.
Have a good editor review the grant application to check for grammar, budget and syntax
mistakes, as well as clarity, consistency, and flow.
Be sure that all forms are completely filled out and all questions are answered.
Allow adequate time for signatures, copying, and delivery. Remember: applications must
be received by November 4, 2011, at 5:00 p.m. with no exceptions.
AFTER SUBMITTING YOUR GRANT APPLICATION:
Please do not call the Komen Atlanta office to check on the status of your application.
After the application is reviewed for compliance with our guidelines, Komen Atlanta will
notify your organization and request additional copies as needed. Compliant applications
will be forwarded to the Community Review Panel for review.
Organizations will be notified of funding decisions by March 2012.
□ COVER PAGE (1 PAGE)
□ ABSTRACT (200 W ORDS OR LESS)
□ PROJECT NARRATIVE (5 PAGES)
□ BUDGET AND BUDGET JUSTIFICATION (4 PAGES)
□ BIOSKETCH FORM(S) (2 PAGES EACH)
□ PROOF OF SECTION 501(C)(3) TAX-EXEMPT STATUS
□ OFFICIAL COPY OF CURRENT FDA CERTIFICATION
Applications must be submitted by the director of the project. Please keep grant requests
to the page limits, as stated above. Excess pages will be removed prior to review. Submit
one original copy. After the compliance review, additional hardcopies and an electronic
copy will be requested. Applications should be bound by staples or clips only; please, no
spiral bound materials. Faxed copies will not be accepted.
Susan G. Komen for the Cure Greater Atlanta Affiliate
Attn: Grants Chair
4840 Roswell Road, Bldg. D, Suite 100
Atlanta, GA 30342
All applications should be addressed as above and may be mailed, couriered or hand delivered.
Please do not contact the Komen Atlanta office during the grant review process.
COVER PAGE FOR GRANT PROPOSAL
Request for Funding for
Breast Health and/or Breast Cancer
Screening and Diagnostic Services
PROJECT DIRECTOR & TITLE
PRIMARY CONTACT & TITLE
CITY & ZIP CODE
PHONE ( )
FAX ( )
TITLE OF PROJECT
TOTAL AMOUNT REQUESTED
GRANT PERIOD 04/01/2012 to 03/31/2013
APPROVING PERSONNEL (OTHER THAN
PROGRAM DIRECTOR) DATE
NAME & TITLE OF APPROVING
ORGANIZATION PERSONNEL (TYPED)
PLEASE CHECK TYPE OF APPLICATION: Screening
Applications must be RECEIVED by 5:00 pm on November 4, 2011
* $75,000 Limit for Genetic Testing and First-Time Applicants (Never Funded)
STATE OF GEORGIA CANCER
(BREASTEST AND MORE) PROVIDER? YES NO
In the space below, please provide a short abstract, not to exceed 200 words, written in lay
terms. Komen Atlanta posts the abstract on its website and publishes it in a variety of materials,
all of which are available to the community.
Permission to publish:
Permission is hereby granted to Susan G. Komen for the Cure to publish the above abstract
should this application be selected for funding.
PROJECT DIRECTOR (Last Name, First)
Information should be submitted for the project director and other personnel included in
budget request. Please use the form below or attach curriculum vitae or resume for each
person. Please limit curriculum vitae or resume to TWO pages.
Information should be submitted for the project director and other personnel included in
budget request. Please use a separate form for each person.
(Begin with baccalaureate or initial professional education, such as nursing, include postdoctoral training)
INSTITUTION DEGREE YEAR FIELD OF
(Indicate Location) CONFERRED STUDY
PROFESSIONAL EXPERIENCE: Please list, in chronological order concluding with present
position, previous employment, experience, publications and honors.
DO NOT EXCEED TWO PAGES.
Detailed Budget for Entire Requested
04/01/2012 – 03/31/2013
Personnel (provide detail in Budget Justification form on next page)
Supplies (itemize by category)
Equipment (not to exceed $2,000)
Patient Care Costs Inpatient
Other Expenses (itemize by category)
Subtotal - Direct Costs
Indirect cost allocation (not to exceed 7.5% of direct costs)
Total Funding Request from Komen Atlanta
BUDGET JUSTIFICATION FORM
ALL ITEMS AND/OR PROCEDURES MUST BE ITEMIZED, INCLUDING QUANTITY AND PER ITEM OR
PROCEDURE PRICE. SEE CHART FOR MAXIMUM ALLOTTED SCREENING AND DIAGNOSTIC RATES.
Name Role on Effort on Base Salary Fringe TOTAL (Total
Project Project Salary Requested Benefit must be
(% of FTE (Annual for Project calculated and
or hours salary or included)
spent hourly rate)
Supply Explanation Amount
Equipment Explanation Amount
Travel Explanation Amount
PATIENT CARE COSTS – See Page 19
Outpatient Care Explanation Amount
PATIENT CARE COSTS – See Page 19
Inpatient Care Explanation Amount
Other Expenses Explanation Amount
* ADDITIONAL ROWS CAN BE ADDED TO ACCOMMODATE ADDITIONAL LISTINGS
Additional Budget Justification Comments:
List Additional Current and Pending Sources of Funding for Project, Including Amounts:
FUNDING SOURCE AMOUNT STATUS (PENDING OR
Please indicate which screening and diagnostic services will be provided onsite (at your
physical address) by the organization requesting funds:
□ CLINICAL BREAST EXAM
□ SCREENING MAMMOGRAM
□ DIAGNOSTIC MAMMOGRAM
□ RADIOLOGIST READINGS
□ OTHER (LIST) ________________________________________________
SCREENING AND DIAGNOSTIC SERVICE REIMBURSEMENT RATES
(DO NOT INCLUDE THIS FORM IN YOUR RETURNED APPLICATION – THIS IS FOR YOUR USE ONLY)
Below are the most common procedures found in grant applications, including price based on
Medicare 2011 rates. While Komen Atlanta realizes that some providers may have negotiated
rates that are higher or lower than listed below, we expect applicants to seek competitive rates.
We have provided this chart as a reference for the average costs of the procedures, as well as
the maximum amount that Komen Atlanta will pay for each procedure. If the budget reflects a
price higher than the provided rate, the cost will not be accepted.
SERVICE TOTAL FEE
Clinical Breast Exam $ 50.00
Screening Mammogram $140.00 (digital)
Diagnostic Mammogram $133.00 (bilateral)
MRI (w/or without contrast) $437.00
Ultrasound Biopsy $745.00
$90.00 tissue marker
Stereotactic Biopsy $709.00
$90.00 tissue marker
Cyst Aspiration $118.00
Fine Needle Aspiration (w or w/out $155.00
Core Biopsy (no imaging) $232.00
Excisional Biopsy $1512.00
*Should only account for 2% of all
requested biopsy funding
Pathology Fee $116.00
Only , Level IV
Surgical Consultation $300.00
Office Visit $150.00