Proposal Forms 11 29 10 FINAL

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Proposal Forms 11 29 10 FINAL Powered By Docstoc
					                               MODEL COMMUNITIES PROPOSAL
Section I: Basic Information (45 points total)
A. Contact Information
Include the contact information for the lead organization responsible for this application. You will have the opportunity to list any
partners in a subsequent section.
Street Address
City, State, Zip Code
Phone Number                                                                Website

Primary Contact                                                           Secondary Contact
Title                                                                     Title
Phone Number                                                              Phone Number
E-mail Address                                                            E-mail Address

B. About Your Proposal
        1.   The proposed project takes place and impact communities within suburban Cook County?
                Yes       No
             Note: If you answered “no,” your project is ineligible for this funding opportunity. Refer to “Eligibility Requirements” in
             the RFP (pg. 2 or pg. 16).

        2.   The proposed project will support one or more of the following efforts. Check all that apply.
                Breastfeeding promotion
                Make healthy foods more available and unhealthy foods less available
                Create more safe and convenient places for walking, biking and other physical activities
                Increase opportunities for physical activity in schools
                Support children in walking and biking to/from school
                Increase access of services for adults at-risk or with chronic conditions, including obesity

        3.   The proposed project includes the following strategies from the menu of options. Check all that apply.
                Comprehensive Plan or                                                   Chronic Disease Self-Management
                Non-Motorized Transportation Chapter                                    Program
                Complete Streets Policy                                                 Worksite Wellness
                Zoning, Development & Land Use Regulations                              Adopt a Healthy Schools Program
                Safe Park Zones                                                         School Siting Policies
                Bicycle Route Signs                                                     Land/Cash Ordinances
                Sustainable Food Systems                                                School Travel Plans
                Healthy Food & Beverage Options                                         School Transportation Department Reform
                Breastfeeding Friendly Environments                                     Joint Use Agreement
                Other, please specify:

C. Applicant: Organizational Summary & Capacity – 1 Page Maximum (15 points)
   1.   Provide a brief description of your organization, its mission, and reach.

C. Applicant: Organizational Summary & Capacity CON’T - 2 Page Maximum
   2.   Grantees must be able to quickly drive local policy, systems, or environmental changes within a 13-month period.
             Please explain how your organization will complete proposed activities, addressing staffing; fiscal management
                (e.g., processes/procedures in place to meet financial requirements); and if other resources will be leveraged
                (e.g. linking with other grants, integrating existing programs, etc.). Include an explanation if your organization
                will rely on the staff, budget, or other resources of partners.
             Please describe organizational experience with advancing PSE change, work with similar initiatives (e.g.,
                collaborations), and staff readiness. If you a school district or private school applying, please discuss your
                existing wellness policies and support for those policies.

Continuation of Question 2, Section I, part C

C. Applicant: Organizational Summary & Capacity CON’T

   3.   Funding will be allocated on a monthly reimbursement basis. PHIMC will process invoices within two weeks of receipt.
        Grantees will be reimbursed for approved expenses incurred on a monthly basis. Does your organization have the
        financial resources to pay for grant activities up front and wait for reimbursement?
            Yes      No

   4.   Does your organization need an initial advancement for working capital to ensure rapid start-up?
          Yes      No

   5.   Does your organization and/or your respective partners have the resources to commit to all required activities listed in
        the RFP Guidance (pgs. 14 - 15)? Note: Include costs of this participation in your proposed budget.
           Yes     No

D. Coalition Information – 1 Page Maximum (15 points)
Projects are to maximize their impact by working with partners.
     List confirmed partners in your collaboration or coalition. If you are a school district, please include every participating
         school in the list. Note: You will need a signed letter of support from each coalition partner, or in the case of a school
         district, from the district superintendent and principals from each participating school.
     List any additional partners required to ensure your project’s success, and briefly explain how you plan to secure their
         involvement and support.

E. Population Being Served by Project – 2 Page Maximum (15 points)
Projects are to take place and impact communities in suburban Cook County.
     Describe the geographic reach of the project, including the total number and demographics (e.g., race/ethnicity,
         gender, age, socioeconomic status, etc.) of the population you intend to impact. In the case of schools, please include
         relevant school information such as percent of students on reduced/free lunch programs.

Continuation of Question, Section I, part E

Section II: Proposed Project (45 points total)
 A. Issue Statement – 1 Page Maximum (10 points)
       Explain how obesity, related risk factors (e.g., poor nutrition, physical inactivity), or environment have an impact on
        your target population and how the menu option(s) selected address the issues. Use data-driven statements to
        support your explanation (e.g., 45% of the population of Anytown is overweight or obese; 60% of schools in the
        Anytown School District do not have bicycle facilities).

B. Proposed Outcomes & Activities – 2 Page Maximum (20 points)
Based on your proposed project, provide a narrative that:
     Identifies measurable outcomes you intend to achieve, including the PSE change(s) expected by the end of the
        project period (e.g., pass or introduce legislation; adopt a policy) as well as key processes or behaviors (e.g., 10%
        increase in bicycles at school; 80% of street engineers trained). In all cases, please indicate how you intend to
        measure the specified outcome and specify any barriers you anticipate to achieving your outcomes.
     Outlines specific activities to successfully advance your PSE change(s).

Continuation of question for Section II, part B

C. Partnerships - 1 Page Maximum (10 points)
Please provide a short description of the working relationship among your coalition partners including experience working
together in the past and how you will collaborate to successfully complete the proposed activities.

D. Sustainability – 1/2 Page Maximum (5 points)
      the lasting impact of the activities you propose beyond the completion of the grant; and
      concrete steps your organization and its partners will take to ensure continued collaboration beyond the project
Note: There is no match requirement for this program. However, leveraging other resources and related on-going efforts
to promote sustainability is encouraged.

Section III: Work Plan & Budget (10 points total)
 A.   Work Plan
 Identify below specific action steps, the responsible organization, and the expected month of completion towards successfully advance your proposed PSE change(s).

 ACTION STEPS                                                                                         RESPONSIBLE ORGANIZATION        MONTH OF COMPLETION
 Example: Hire full-time Project Coordinator.                                                         Lead Applicant                  March 2010
 Example: Coordinate and facilitate monthly meetings with partner organizations.                      Lead Applicant                  On-going

B.   Budget Form and Narrative
Using the form below, please provide a budget for your project using the provided cost categories and include a justification. If there is cost category that is not
applicable, please leave blank. Note: Federal guidelines must be followed, and budgets of all successful applicants are subject to negotiation prior to contract award.

                                                                                                                                                Amount Requested
Personnel Costs
Salaries and Wages
Position/Title (include                                                                 # of        Annual
name, if available)            Description of job responsibilities                    Positions     Salary        % Time      Months            Amount Requested

Total Salaries and Wages
Rate of Fringe Benefits       %
Total Personnel Costs
Non-Personnel Costs
Contractual Services
Contactor Name                        Period of performance              Scope of Work

                                                                                                    Total Amount for Contractual Cost

Non-Personnel Costs CON’T
Professional Services: Costs when hiring an individual to give professional advice or services (e.g., training, expert consultant) for a fee but not as an employee of
the successful applicant.
Consultant Name                      Nature of Service and Relevance to Project                    Hours/Days of Service Rate

                                                                                                   Total Amount for Professional Cost
Travel – includes travel for staff only (Current mileage reimbursement rate is $.50.). Travel for partners should be placed in the Other category.

                                                                                                            Total Amount for Travel
Materials and Supplies - include unit cost, # needed & total amount. Provide justification w/relationship to project outcomes and activities.

                                                                                        Total Amount for Materials and Supplies
Equipment - defined as $5,000 or more per unit (needs pre-approval before purchase) – see page 9 in the RFP for relevant examples under this RFP

                                                                                                        Total Amount for Equipment
Other Costs - includes facility rental, postage, telephone expense and other operational expenses.

                                                                                                         Total Amount for Other Cost
Total Non-Personnel Costs:
Indirect (@ 10%)
Total Budget Amount Requested:

Section IV: Agreements
1. We agree to provide project reports, including financials, as requested and required by the Public Health
   Institute of Metropolitan Chicago.
       Yes      No

2. We agree to participate in the Change Institute as described in the RFP (see pg. 7).
      Yes     No

3. We agree to participate in the Alliance for Healthy & Active Communities, including attendance at the
   quarterly meetings.
      Yes     No

4. We agree to participate in Model Communities and CDC evaluation activities, including participation in the
   Community Readiness Assessment.
     Yes      No

    OPTIONAL: If not selected to receive grant funds, we would still be interested in participating in the
    Community Readiness Assessment.
       Yes     No


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