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Community Health Grants Program - Susan G. Komen of the NC


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									                       Request for Applications (RFA)
             Community Health Grants Program
                    for Awards beginning April 1, 2013
           Promoting breast health and breast cancer education, screening,
             treatment support and post-diagnosis services for uninsured,
                     underinsured, and underserved women in the
Susan G. Komen for the Cure®, North Carolina Triangle to the Coast Affiliate service area.

     Susan G. Komen for the Cure®, North Carolina Triangle to the Coast Affiliate
                133 Fayetteville Street, Suite 300 | Raleigh, NC 27601
            919.493.2873 | grants@komennctc.org or www.komennctc.org

        LETTER OF INTENT DUE: Friday, October 5, 2012- 5pm
       APPLICATION DUE DATE: Friday, November 16, 2012- 5pm
                        Susan G. Komen for the Cure®,
                  North Carolina Triangle to the Coast Affiliate
                Community Health Grants Program

                                      Table of Contents
    I.          Program Purpose……………………………………………….... 2
    II.         Background……………………………………………………….. 2
    III.        Funding Availability and Terms……………………..………....        2
    IV.         Statement of Need: Funding Priorities………………………..        3
    V.          Application Components and Evaluation Criteria…………..   6
    VI.         Ten Tips for Successful Grant Writing………………………..       16
    VII.        The Review Process……………………………………………..                  17
    VIII. After Awards Are Made…………………………………………. 18
           I. RFA Glossary…………………………………………………… 24
           II. NC BCCCP Federal Poverty Guidelines……………………… 27
           III. Project Intervention List……………………………………… 28
           IV. Attachments…………………………………………………….. 29
    Online Resources: www.komennctc.org/grants
           A.    Request for Applications (RFA: this document)
           B.    Susan G. Komen for the Cure, NC Triangle Affiliate
                   2011 Community Profile
           C.    Application Forms:
                   Grants eManagement System (GeMS):
           D.    Grant-Making Resource Directories

                                                                            Page 1 of 39 

Susan G. Komen for the Cure®, North Carolina Triangle to the Coast is currently accepting applications
for evidenced-based programs that support and promote access to and utilization of breast health
services across the continuum of care (education > regular screening > diagnosis > treatment > post-
diagnosis & support services). Susan G. Komen for the Cure® North Carolina Triangle to the Coast
Affiliate will only consider applications that appropriately respond to the guidelines outlined in this

Since its inception, Susan G. Komen for the Cure® has been committed to saving lives and bringing an
end to breast cancer forever by empowering people, ensuring quality care for all, and energizing science
to find a cure. Komen has a unique funding model that supports cutting-edge research at the
international level while allowing 125 affiliates to fund community health grants for direct services,
particularly to under-served populations.

Since its founding in 1997, Komen NC Triangle Affiliate (after an expansion in 2012 officially changed
their name to Susan G. for the Cure® North Carolina Triangle to the Coast) has raised more than $13
million dollars through events like the Komen NC Triangle Race for the Cure®, individual donations and
corporate philanthropy. Komen North Carolina Triangle to the Coast Affiliate is committed to
addressing our mission by being a catalyst for change within our 29-county service area. In addition to
offering grants to local non-profits and healthcare organizations, we offer opportunities for program
development and capacity building within these organizations so that, together, we can realize our vision
of a world without breast cancer.

The Komen NC Triangle 2011 Community Profile is a comprehensive assessment of the 20 counties in
the Affiliate service area. Data for the new 9 counties (Bladen, Brunswick, Columbus, Duplin, New
Hanover, Onslow, Pender, Sampson, and Wilson) added in 2012 is not included in this profile. The
Community Profile examines programs and services, access and barriers to breast health and cancer
care, socio-demographic data and the breast cancer epidemiologic characteristics of the communities.
Relying on data from sources such as the Cancer Registry and the Behavioral Risk Factor Surveillance
Survey, in addition to information derived from survivors, providers, and lay persons in many
communities, this data highlight important gaps in the continuum of care in terms of direct services and
outreach, the quality of services, the cultural and systemic factors associated with limited access and
utilization of services, and disparities based on race/ethnicity, socio-economic status and geographic
location. Data and recommendations from the Community Profile shape the Board-directed Statement of
Need (Section IV) and provide an essential resource for applicants as you develop your programs. The
Affiliate strongly advises all applicants to examine the 2009 and 2011 Community Profiles and
descriptions of previous grantee programs thoroughly: www.komennctc.org/grants.

                                                                                              Page 2 of 39 

Eligibility: To qualify for funding, applicants must meet all of the following criteria:
         Provide breast health/cancer services or financial support within the continuum of care
            including recovery (i.e., education, screening, diagnosis, treatment, post-
         Provide current, U.S non-profit status (i.e., 501(c) 3) certification for the applying
            organization (includes health departments, government and educational institutions, faith-
            based organizations, Native American tribes, etc.);
         Reside and serve patients in the 29-county Affiliate service area of Bladen, Brunswick,
            Caswell, Chatham, Columbus, Duplin, Durham, Edgecombe, Franklin, Granville, Halifax,
            Harnett, Johnston, Lee, Moore, Nash, New Hanover, Northampton, Onslow, Orange, Pender,
            Person, Pitt, Sampson, Scotland, Vance, Wake, Warren, and Wilson counties.
         Applicants must ensure that all past and current Komen-funded grants or awards are
            up to date and in compliance with Komen requirements.

Restrictions: Funds may not be used for the following:
            Medical or scientific research (costs for program evaluation are allowed)
            Scholarships or fellowships
            Construction or renovation of facilities
            Political campaigns or lobbying
            Equipment not necessary to success the of the program & not exclusively used for the
               proposed project

Grant Cycle: The cycle for these one-year grants runs from April 1 through March 31 each year.
During the month of September the affiliate will offer 4 grant writing workshops. It is mandatory that
organizations/institutions applying for a grant attend one workshop. All workshops will cover the
same topics (see page 21 for all key dates). If you have an issue concerning attendance please contact

Funding Limits: Your institution may submit an application with the primary focus addressing
any of the following categories: Education, Screening/Diagnosis, Treatment, and Survivorship
Support. Your institution may not submit two applications with the same primary focus. If your
institution chooses to apply for funding in more than one primary focus area a separate
application must be submitted. Komen North Carolina Triangle to the Coast Affiliate offers funding
on the following levels.
         Education/Social Support: programs that provide education and/or social support including
            survivorship and angel funds, but NOT direct screening or treatment services may be funded
            up to $30,000.
         Direct Care: programs that provide direct patient care costs/services such as screening and
            treatment may be funded up to $65,000.

                                                                                             Page 3 of 39 


Komen North Carolina Triangle to the Coast Affiliate funds programs that provide essential direct
patient care services for breast cancer screening and treatment. It is also our aim to encourage creativity,
innovation, ingenuity and collaboration among existing and potential new service providers. We look for
successful outcomes that address both the longevity of life after diagnosis and the quality of care. We
emphasize life-long education and services that address the entire continuum of care including recovery.
In considering the balance of funds awarded, we strive to minimize duplication of services within
existing programs yet maximize the use of existing structures by encouraging partnerships and
collaborations within communities. Each proposal received is evaluated with respect to available
dollars and response to the required and priority elements outlined on the next page.

                       Required & Priority Elements: What Do We Mean? 
 REQUIRED ELEMENTS:  Your program MUST include all of these elements to be considered for funding; failure to 
 address even one of these elements will result in disqualification. 
 PRIORITY FUNDING AREAS:  Based on the community needs assessments and the 2011 Community Profile the 
 Komen North Carolina Triangle to the Coast Affiliate has identified the following priority areas  
      Use partnerships and collaborations to engage communities in culturally appropriate 
         education/outreach breast health activities throughout our service area, with emphasis on uninsured 
         and under‐insured women in the rural and minority communities. 
      Increase and improve access to screening, diagnostic, and treatment services offered to women, 
         particularly women at high risk in the affiliate service area, with emphasis on uninsured and under‐
         insured women in tier 1 & 2 counties (see Appendix 1: RFA Glossary), rural communities, and 
      Reduce and remove barriers to provide timely follow up for individuals needing diagnosis after 
         screening and/or individuals undergoing treatment 
      Increase post‐diagnosis support and assistance to survivors/co‐survivors. 

I. Required Elements

The following six elements are required. Failure to clearly address the following will result in
disqualification prior to the review (see Section VII).

                                                                                                    Page 4 of 39 

A. Address at least one of the following: education, screening, diagnosis, treatment, post-diagnosis
services/issues AND include appropriate referral plans to ensure a seamless continuum of care.
  Our top priority is to fund programs that identify and serve people who are not getting access to
    education, screening, diagnosis, treatment, and post-diagnosis (both social/psychological and
    physical) services.
  In cases where the proposal focuses on one element of the continuum of care, we expect programs
    to articulate a clear and measurable continuum-of-care referral and follow-up process (example:
    patient education must lead to appropriate screening).
  Recognizing that breast health is an ongoing process for any individual, we seek programs that are
    sustainable and may have a long term impact on any individual.

B. Fill gaps and address disparities in your community.
  Programs should address gaps in the continuum of care within a particular community. Promising
    programs will offer innovative approaches that supplement or support existing education, screening,
    diagnosis, treatment and post-diagnosis options in a community.
  We encourage programs to address demographic, social or geographic disparities that impact the
    breast cancer incidence and mortality rates in a given community.
  We encourage programs to address informational gaps in regards to knowledge of resources
    available in the continuum of care and implement culturally-appropriate health communication
    mechanisms as a component of the program.

C. Utilize documented strategies and contains a strong evaluation component.
    Your program must be grounded in documented best-practices and/or evidence-based strategies
        ( See the RFA, Section V)
    All proposals must include a well-developed evaluation plan with clearly defined and S.M.A.R.T
        (Specific, Measurable, Achievable, Realistic, and Time sensitive) objectives.

D. Include uninsured and under-insured populations in your program’s target audience.
  Our service area is demographically and geographically diverse (2011 Community Profile). Higher
    disparities in breast cancer mortality, access and quality of care are especially evident in rural
    communities, among minorities, people living at or below federal poverty guidelines and those
    without health insurance. As such, these are our highest priorities and your program must include
    one or more of these populations.

E. Reduce or remove cultural and linguistic barriers to breast health services.
  In being culturally responsive, programs should demonstrate appropriate protocols for providing
    effective communication and services to diverse populations. Strategies might include offering
    multi-lingual, low-literacy and/or culturally relevant outreach and services.

F. Serve individuals within our 29-County Service area.
  Komen North Carolina Triangle to the Coast Affiliate serves the counties of Bladen, Brunswick,
    Caswell, Chatham, Columbus, Duplin, Durham, Edgecombe, Franklin, Granville, Halifax, Harnett,
    Johnston, Lee, Moore, Nash, New Hanover, Northampton, Onslow, Orange, Pender, Person, Pitt,
    Sampson, Scotland, Vance, Wake, Warren, and Wilson. Grant funds can only be used in these
  Patients, clients, and/or co-survivors must be served in one of these 29 counties.
                                                                                            Page 5 of 39 

II. Summary of Funding Priority Areas

Based on the community needs assessments and the 2011 Community Profile the Affiliate has identified
the following priority areas.

   A. Engage communities by providing culturally appropriate education/outreach breast health
      activities to women in our service area, with emphasis on uninsured and under-insured
      minorities and individuals living in rural communities.
    Program should increase breast self awareness and screening mammography knowledge ( for
      example: Train and utilize Lay Health Advisors and/or Promotoras
    For successful outcomes we look for measurable objectives that will not only educate the target
      community but connect them with some type of screening (clinical breast exam, mammogram,
    In addition to increasing education/ awareness about breast health, proposals may include
      education pertaining to regular screening, receiving a timely diagnosis and follow-up care, as it
      relates to early detection.
    We highly encourage a partnership with your local BCCCP and encourage you to provide
      education about the BCCCP program to individuals in the community in addition to appropriate
      health care providers.
    Where appropriate, programs should provide cultural, economic and privacy sensitivity training
      to breast health providers who serve target populations

   B. Increase and improve access to screening, diagnostic, and treatment services offered to
      women, particularly women at high risk within our affiliate service area, with emphasis on
      uninsured and under-insured women in tier 1 & 2 counties, rural communities, and
    We encourage clinics, hospitals, oncology facilities and health departments to document in your
      proposal that you offer low-cost or subsidized services for high-need patients. These costs should
      reflect the current Medicaid rate wherever possible.
    Programs should aim to find breast cancer in its earliest stages. We are interested in programs
      that decrease barriers while promoting screening & diagnostic methods that complete the breast
      health screening cycle, including clinical breast exams and/or mammograms.
    In order to remove barriers to care for the uninsured and under-insured, we encourage programs
      to creatively address issues that may include: transportation, language, financial burdens, family
      responsibilities, disabilities, scheduling issues and/or availability of services.
    Programs should promote proactive and ongoing behaviors related to breast health, including
      consecutive annual screening procedures and appropriate follow-up and/or treatment.
    We do fund programs that address the needs of persons who are undocumented.

   C. Reduce and remove barriers to provide timely follow-up care for individuals needing
      diagnosis after screening and/or individuals undergoing treatment.
    In order to remove barriers to care for the uninsured and under-insured, we encourage programs
      to creatively address issues that will allow breast cancer patients to effectively participate in all

                                                                                                 Page 6 of 39 

       parts of their treatment plan. This may include: transportation, language, financial burdens,
       family responsibilities, disabilities, scheduling issues and/or availability of services.
      We are looking for proposals dealing with any aspect of breast cancer treatment, including but
       not limited to diagnostics and staging, chemotherapy, radiation, other alternative therapies and
       other follow-up care in a medical setting.

   D. Increase post-diagnosis support and assistance to survivors/co-survivors.
    We are interested in proposals that address quality of life issues and/or support after a breast
      cancer diagnosis for breast cancer patients and/or their families. Some examples include, support
      groups, counseling, complimentary therapies, and side- effects management (i.e. wigs,
      prosthesis, lymphedema sleeves), angel care funds, and continued screening after treatment ends.

III. Summary of Suggested Elements

Addressing the following funding priorities may increase the likelihood of grant funding

   A. Forge meaningful organizational partnerships to maximize resources and impact.
    To support our goal of catalyzing creativity and ingenuity, we give priority to programs that are
      collaborative, integrative and coordinated with other service providers, not necessarily limited to
      health care providers.
    Examples of innovative partnerships include, but are not limited to: transportation services, NC-
      BCCCP providers, public housing developments, faith-based organizations, local worksites,
      multi-cultural and community organizations, senior centers, local hospitals/clinics and
      university-based health care systems.

   B. Extend targeted outreach activities beyond your existing institutional community.
    We strongly encourage programs that innovatively and strategically bring services (including
      education) to where the target community resides or works. This may include reaching out to
      neighboring counties, regions and/or communities.
    Some programs limit outreach and marketing to “easy-to-reach” individuals, specifically those in
      the institution’s database/mailing list or who live or work nearby. We encourage programs to
      reach deeper into the community by developing innovative communication and outreach
      strategies to engage hard-to-reach populations.

The Komen North Carolina Triangle to the Coast community health grant application must be completed
and submitted through Komen’s new online Grant eManagement System (GeMS). Registration is required
to access this system, you must submit a letter of intent by October 5, 2012 to
wwiggins@komennctc.org so you may receive information regarding access to the system and an
application instruction manual.

Application Deadline: Friday, November 16, 2012 -5pm

                                                                                               Page 7 of 39 

The following pages provide you with comprehensive information about each form’s contents and format.
Additionally, we provide succinct information on how your responses on each form will relate to the criteria
that will be used by our independent review panel in rating and ranking proposals.

Recognizing that we have a new application system this year we are requiring all applicants, even
previous grantees, to attend one of the Grant Writing Workshops we offer in September 2012 (see
Timeline, Section VIII).

                       Section, Format & Content                                               Evaluation Criteria 
Forms: Your application consists of a series of forms.  You will be        Forms are required to ensure parity in the 
required to complete, upload, and submit several attachments with           review process.  
your application (see Appendix 4). We recommend that you download 
all of the forms from GeMS and review the content requirements 
                                                                           Please review the Ten Tips for Successful 
                                                                            Grant Writing section below and note tips 
described in this table. 
                                                                            identified at select passages. 
Content: You may want to organize your content prior to completing         
the forms, but you can certainly update and save the forms at any time.  
To ensure no data/information is lost you may find it helpful to 
complete the required information in a Word Document and copy and 
paste to the online system.  You must complete all required (*) items 
on each page, before you can save that page.   
Formatting: Forms will have “forced” formatting that will ensure the 
      Each section has a word limit that is noted on the form. 
      You must complete all required fields before saving each page. 
                       Section, Format & Content                                             Evaluation Criteria 
   Project Profile                                                               Because it is essential that we be able to 
Includes contact information for directors and point of contact as well as           report this information, failure to complete 
type of program to be funded.  You will not be able to save this page                this information is considered non‐
without first completing all required (*) information.                               compliance and will result in removal from 
      Project Director and Title: This is the person with the overall fiscal        the review process. 
       and programmatic responsibility.                                           
     Point of Contact: This is the individual who acts as the day‐to‐day 
      contact on logistical matters between the institution and the 
      Affiliate and may be the same as the Project Director. (See Budget: 
      Personnel below for details.) 
     Mailing Address: This field will automatically populate with the 
      information provided when your organization was registered.                     
      Because we often use overnight mail to ensure delivery, we ask 
      that you list a physical address and not a P.O. Box. 
     Title of Project: This should be no more than 100 characters.  
      Remember that your title will be published in various places and 
      should represent your program from a PR perspective. 

                                                                                                                      Page 8 of 39 

     BCCCP Affiliation: Please indicate whether your organization is 
      involved with BCCCP.  If so please choose how your organization 
      receives BCCCP funds (ex: as a provider, contractor, etc.) 
     Partners: List any partnering organizations and briefly describe the 
      services they will provide.  Provide a Letter of Support or 
      Memorandum of Understanding reflecting the mutual partnership. 
      Please note that letters of collaboration reflect an appropriate 
      relationship that is germane to your program. Do not provide 
      general letters of support.  
     Institutional Director: This should be an individual with the 
      authority to commit your institution to a contractual / fiscal 
     Signature of Approving Institutional Director: Once the project 
      director has completed and submitted the application in GeMS, 
      this individual will have a separate log‐in to electronically sign off 
      on the application 

                      Section, Format & Content                                                Evaluation Criteria 
   Organization Summary                                                        Reviewers will be asking questions like these: 
This section collects detailed information regarding your organization.          Is the organization respected and valued by 
Please provide in‐depth information regarding your organization                     the target population? 
background and structure.                                                        Has your plan addressed potential barriers to 
      Organization’s History:                                                      care, including literacy, language, physical 
       Character Limit: 750 (including spaces)                                      access? 
       Briefly describe your organizations history.                              Does your proposal illustrate that you have 
     Mission Statement:                                                            considered social & cultural issues that 
      Character Limit: 500 (including spaces)                                       might impact all of your target audiences? 
      Briefly state the mission of the organization.  If you are partnering 
                                                                                 Does the design of your program have any 
      with another organization for your project please provide the 
                                                                                    inherent biases that might discourage your 
      mission of both organizations.  
                                                                                    target audiences from participating? 
     Current Programs and Accomplishments: 
                                                                             Have you considered the needs and 
      Character Limit: 750 (including spaces) 
                                                                              potential service challenges for populations 
      In this field include information about any current programs or past 
                                                                              that might be unnoticed or undocumented? 
      accomplishments your organization has related to this project or 
      breast health.  
     Cultural Responsiveness:  
      Character Limit: 750 (including spaces) 
      All proposals must provide their communities with services that are 
      culturally responsive to their target audience(s). Culturally 
      responsive programs include, but are not limited to ensuring 
      language barriers are addressed, being attuned to literacy levels, 
      mental and physical abilities, responding to the social cultural 
      barriers that influence access and utilization of services such as 
      fear, religion, and cultural beliefs.  

                                                                                                                       Page 9 of 39 

                         Section, Format & Content                                                     Evaluation Criteria 
   Project Abstract                                                                   Reviewers will be asking questions like these: 
       Project Category: Provide at least one main focus of your program.    In addition to using the abstract for external 
         *  Education                         * Treatment Support                                publication, it is part of the package that is 
         *  Screening                         * Survivorship                                     reviewed by our independent panel.  
         * Diagnosis                           * Health Care Delivery/ System change       
         * Treatment                                                                         While the abstract is not scored by our 
                                                                                                 panel, it is your chance to make a strong first 
       Funding Priority: Refer to the statement of need and identify                            impression. 
        which funding priority your program will address. 
       Abstract Narrative:  
        Character Limit: 1500 (including spaces)                                               TIP: Write your abstract last, after your entire 
        Outline goals, objectives, and rationale for program                                proposal is completed. Keep it at a high level and 
        implementation.  In addition to methods for evaluation and the                      avoid using data and jargon. This should read like 
        impact your program will have on breast health. For grants                          an item in a magazine or newspaper. 
        awarded, this abstract will be used for external publications and 
        should be written as such.   
                         Section, Format & Content                                                      Evaluation Criteria 
  A. Organization Capacity                                                            Reviewers will be asking questions like these: 
Describe the physical facilities as well as the organizational capacity                 Does the institution have the facilities and 
that will guarantee success of your program.                                                physical infrastructure to support this 
Character Limit: 3500 (including spaces)                                                    program? 
      Describe the physical infrastructure that will support the program:              Is the program too dependent on one or two 
       office / clinical space, equipment, etc.                                             specific individuals? 

       Explain why your organization is best‐suited to lead the project and   Are there appropriate individuals, 
        accomplish the goals and objectives set forth for this program.         organizations and/or departments in place to 
                                                                                effectively implement all aspects, support, 
       Describe the organizational capacity for providing administrative       advise and evaluate the program? 
        support and for recovering from a potential loss of key personnel. 
       Describe evidence of success in delivering breast health/cancer 
        services to the proposed population. 
    Cover any other relevant aspects of the organization that will illustrate 
    stability and organizational capacity. 
  B. Statement of Need                                                                Reviewers will be asking questions like these: 
Character Limit: 3500 (including spaces)                                                 Is data presented that supports the need for 
     Describe the population to be served                                                  a program like this in the target community? 
       Provide data to illustrate the risk/ need within your target area               Is the target population appropriate (does 
       Illustrate that you have identified your target audience and are                    data demonstrate they are underserved)? 
        aware of the most appropriate way to establish and maintain                     
        contact with them. 

                                                                                                                                 Page 10 of 39 

                                                                                  Does outreach target individuals who are not 
                                                                                     already connected with or aware of your 
     Describe how and why you believe participants will be engaged in 
      the program. 
  TIP: The Komen NC Triangle Community Profiles are a rich source of 
                                                                                  Have you addressed possible obstacles, 
                                                                                     including language and literacy issues and 
  data. Make sure your proposal illustrates your grasp of the community 
                                                                                     lack of access to internet/mass media? 
  needs and the programs and services available in your area.   
  C. Project Description                                                        Reviewers will ask questions like these: 
This is the core of your proposal that outlines your program, rationale           Does the proposal illustrate that the authors 
and plan for delivery of services.                                                   studied the Komen NC Triangle Community 
Character Limit: 3500 (including spaces)                                             Profile? 
                                                                                  Is data presented in the Statement of Need 
      Describe your program and how it will improve access and                      (previous section) supporting the need for a 
        utilization of breast health services in the continuum of care               program like this in the target community? 
     Programs should include innovative approaches that increase the             Does this program compliment other similar 
      likelihood of access and utilization to breast health services by              programs OR is it the only program of its type 
      reducing barriers for under‐served populations.                                in the target community? 
     Programs that organize the community around breast health care 
                                                                                  If your program offers similar services to 
      as a part of their existing programs are encouraged.  
                                                                                     another program, how will you avoid 
     Explain your innovative outreach methods that span beyond the                  duplication of services to the same 
      existing patients in your organization to hard‐to‐reach,                       participants?  
      underserved populations in the community.  
                                                                                  Does your program plan clearly define how 
     If your program addresses one or more Priority Areas (Section IV)              clients/patients will be referred to the next 
         that should be stated clearly in your Program Description and               step in the continuum of care (education > 
         explain how your projects goals and objectives will address these.          regular screening > diagnosis > treatment > 
     There are several required elements of any program that is to be 
      considered for funding. Please review the “Required Elements”               Have your plans addressed payment 
      listed in the Statement of Need and be sure that you have clearly              restrictions for the under‐insured and, if 
      addressed each of these.                                                       appropriate, BCCCP payment parameters? 
      TIP: The Komen NC Triangle Community Profiles are a rich source 
         of data. Make sure your proposal illustrates your grasp of the 
         community needs and the programs and services available in your 

  D. Collaboration                                                              Reviewers will be asking questions like these: 
We strongly encourage meaningful and innovative partnerships that                 Have you identified meaningful collaborators 
clearly help to meet the goals articulated in our Statement of Need                  and partners that enhance the potential to 
(Section IV) and significantly enhance the success of the program.                   meet the goals and objectives proposed in 
Character Limit: 3500 (including spaces)                                             the application? 
                                                                                  If “for‐profit” partners (i.e., they don’t have a 
      Illustrate roles and responsibilities of all organizations or entities        non‐profit designation) are identified, is the 
        participating in the project                                                 relationship appropriate and is the extent of 
      Describe how the collaboration strengthens the project and why                their organizational and fiscal involvement 
      these organizations are best suited to carry out the project and               transparent? 
      accomplish the goals and objectives set forth in this application.          Have you reached outside of the standard 
     Partnerships and collaborations should reflect a seamless                      protocol to seek creative and appropriate 
      continuum of care through a clearly identified referral process,               solutions to the problems you seek to 
      especially if you do not provide comprehensive care.                           address? 

                                                                                                                      Page 11 of 39 

     Collaborating with organizations that allow for increased 
      opportunities to reach target populations and provide much 
      needed services across the continuum of care are strongly 
     We encourage innovative partnerships with non‐health entities to 
      better reach target audiences. 
     Letters of collaboration should clearly reflect the roles and 
        responsibilities of partners as they correspond with the goals and 
        objectives of the proposal 

  E. Sustainability                                                             Reviewers will be asking questions like these: 
Please describe additional current and future sources of financial and            Do you have partners and supporters outside 
institutional support that will support the ongoing success of your                  of Komen who will help to ensure the long‐
program.                                                                             term survival and health of your program? 
Character Limit: 3500 (including spaces)                                          Are documents included that support the 
      What resources (financial, personnel, partnerships, etc.) will be             involvement of partners and supporters? 
       needed to sustain the effort over time? How will those resources 
       be secured by the end of the funded project?                               Do other sources of funding compliment 
                                                                                     potential Komen funds, thus creating a high 
     What are your organization’s plans to support the project director             likelihood of success?  
      to implement, manage, and oversee all aspects of the proposed 
      project?                                                                    Do you clearly articulate what aspects of your 
                                                                                     program are being supported by other funds 
     Proposals should include a succinct sustainability plan. This 
                                                                                     and what aspects are included in your 
      includes reporting additional funders and identifying potential                proposal to Komen? 
      opportunities for additional funds, partnerships and institutional 
      support.                                                                    Is your program sustainable even without 
                                                                                     Komen funding?  

 F. Evaluation                                                                  Reviewers will be asking questions like these: 
A well thought out evaluation plan including both quantitative and                Is the scale of your evaluation strategy 
qualitative analysis of the program is required for your proposal to be              appropriate for your program? 
included in the review process.  In this section, describe your overall plan.     Is there a plan for evaluating the impact of 
Character Limit: 3500 (including spaces)                                             your program on individuals and on your 
      Identify and describe the tools and methods that will be used to              community? 
       measure the effectiveness of the program.   
                                                                                  Have you identified appropriate methods to 
     For previous grantees, use prior grant‐funded evaluations to                   effectively measure the outcomes you 
        document the impact of previous programs. For existing programs              propose?  
        that have not been previously funded by Komen, document the 
        impact of your program. For new programs, identify the potential          Have you illustrated the impact of your 
        impact of this program as part of the proposed evaluation plan.              program in the past, if appropriate? 
     Indicate what process and impact information will be collected to           Are you using proven evaluation techniques? 
      measure and demonstrate success.  Please explain how you will                   
      address the following:   
                                                                                  TIP: Attend the Grant Writing Workshop to 
           Collecting data, including the data that we have requested in            receive a list of primary sources and resources 
            this application;                                                        to assist you in developing your program. 
           Measuring changes in knowledge or attitudes of individuals or            Technical Assistance is also offered by the UNC 
            behavior of individuals or organizations;                                CPCRN/4CNC Program, Alexis Moore: 919‐843‐
                                                                                     7027 or Jennifer Leeman: 919‐966‐3648. 
           Assessing the delivery of your program (how and where it was 
            implemented) and gaps between design and delivery 

                                                                                                                      Page 12 of 39 

           Assessing constituent satisfaction with your program; 
           Assessing the impact on your community, what worked and 
            what didn’t work and why? 

 G. Evidence Based‐ Programming                                              The Affiliate is committed to fund breast health 
Evidence‐based programs and/or strategies are approaches that have            programs that are effective and it is a requirement 
been proven to be effective based on rigorous research or evaluation.         for programs to implement evidence‐ based 
You may adopt specific evidence‐based program plans or you may use            programs or emerging best practices. 
proven strategies and adapt them appropriately to your target audience.        
Character Limit: 3500 (including spaces)                                      Reviewers will be asking questions like these:  
     Provide references and a brief description of the original evidence‐     How clearly have you identified and 
      based program or strategy that you are replicating.                          documented the evidence‐based program/ 
                                                                                   strategy that you are employing?  
     Describe why and how you are adapting it to serve your target 
      population. Programs that organize the community around breast           How appropriate is the program/ strategy for 
      health care as a part of their existing programs are encouraged.              the target audience you have identified? 
     We encourage adapting evidenced‐based strategies to make them            How strong are your plans for adapting the 
      more culturally responsive to specific populations and/or utilizing           program/ strategy for the target audience?   
      marketing and promotion tools to reach the community.  

   TIP: Attend the Grant Writing Workshop to receive a list of primary 
sources and resources to assist you in developing your program. Technical 
Assistance is also offered by the UNC CPCRN/4CNC Program, Alexis 
Moore: 919‐843‐7027 or Jennifer Leeman: 919‐966‐3648. 
                      Section, Format & Content                                            Evaluation Criteria 
 A. Project Target Demographics                                               The Affiliate is committed to reaching 
This section captures information regarding the various demographic                 populations that are traditionally 
groups you intend to target with your program.                                      underserved in breast health services across 
You can select between 1 and 4 target populations                                   the continuum of care. Programs that 
                                                                                    innovatively reach low‐income, uninsured, 
      Simply check the boxes for the populations that your program will            underinsured persons will be looked upon 
        specifically aim to have the largest impact on, not all the                 favorably. 
        populations your program will serve.                                     
         Race Ethnicity 
        General Population (Age) 
        Named Groups (Other) 

B. Target Locations 
     Select the counties within our service area your project will 
      target.  Please check all that apply. 
                                                                                                                    Page 13 of 39 

                       Section, Format & Content                                             Evaluation Criteria 
  A. Bio‐ sketch forms                                                        Reviewers will be asking questions like these: 
     .                                                                         
                                                                                Does staff working directly with the program 
     Forms must be submitted for the following:                                   have the appropriate experience, education 
       Project director                                                           and/or expertise relevant to the program 
       All attendant personnel listed in budget request                           objectives to which they are responsible? 
     Operationally, the Project Director is responsible for: 
       implementation of the program in the broadest sense, 
          including ethical conduct, cultural responsibility and logistical 
       appropriate use of funds; 
       grant administration; 
       presence  at all site visits; 
       ensuring that all expectations are met or exceeded based on 
          the Affiliate’s guidelines. 
       fulfillment of the contractual obligation to the Affiliate. 
     The designated point of contact may or may not be the Project 
      Director. Responsibilities include: 
       ongoing communication with the Affiliate; 
       completion and submittal of all required forms;  
       ensuring the organization is represented at Komen events; 
          proper representation of Komen mission, materials, and 

                       Section, Format & Content                                             Evaluation Criteria 
   Goals are broad statements that capture the general impact an              Reviewers will be asking questions like these: 
organization will have on the community as a result of their program.           Are the goals and objectives directly linked to 
Goals are not always measurable. Be sure to click the save button before           the outcomes proposed? 
adding a new goal.                                                               TIP: Make sure that the information here is 
      Goal Name: Please use either numerical or alphabetical (Ex:              consistent with the Program Narrative 
         Goal 1 or Goal A)                                                      (Document 4). 
     Goal Description: Character Limit 300.  Briefly state and describe            
        your goal 
                       Section, Format & Content                                             Evaluation Criteria 
  Objectives support goals and meet the SMART criteria. These                 Reviewers will be asking questions like these:
           describe what the project will achieve and evaluate before the       Are the objectives directly linked to the goals 
           end of the funding cycle.                                               proposed? 
           S: Specific‐ does your objective specify what it intends to          Do your objectives meet the SMART criteria? 
                                                                                Does your objectives point to specific things 
           M: Measureable –can you measure whether or not you are                  you expect your target population to learn, 
           meeting your objective?                                                 achieve, receive, and apply based on your 

                                                                                                                    Page 14 of 39 

          A: Achievable‐ are your objectives achievable and attainable            program? 
          through your program?  
                                                                                TIP: Make sure that the information here is 
          R: Realistic – are your objectives realistic given the resources     consistent with the Project Narrative (Document  
          that are available?                                                      
          T: Time sensitive – have you set a clear and realistic 
          timeframe to complete the objectives within the project’s 
          funding cycle? 
     Objective Name and Description: Please numerically or 
      alphabetically name the objectives, then describe in the objective 
      in section below. Character Limit 300 
     Timeframe refers to the allotted time you believe it will take to 
      accomplish the activities. 
     Interventions are the specific things that you do to accomplish 
      your objectives. You can choose from interventions or activities 
      under the following main topics: Education, Screening, Diagnosis, 
      Treatment, Treatment Support, Survivorship, and Health Care 
      Delivery/System Change. (Refer to Appendix 3 )  
         If you do not see an appropriate intervention you may choose 
     Methods and tools describe how you will evaluate and measure 
      the number of people served and to what extent participants 
      achieve the outcomes proposed in the application. Character Limit 
     Attachments:  
     Attach the Goals, Objectives, and Outcome sheet in Appendix 4 . 
     Attach any evaluation documents you will use (i.e. Survey, Pre‐post 
        Test, participant/patient satisfaction, etc.) 
                      Section, Format & Content                                               Evaluation Criteria 
  A. Budget: Personnel/Salary                                                Reviewers will be asking questions like these: 
Document personnel and their corresponding salary proposed.                    
                                                                               Does staff working directly with the program 
     Requested salaries can be for services related to the proposed              have the appropriate experience, education 
      project only, not the general work of the applicant and MUST be             and/or expertise relevant to the program 
      explained fully in the budget justification.                                objectives to which they are responsible? 
     Do not include individuals who contribute to the overall                 Are staff expenses and responsibilities 
      administration of your organization (bookkeeper, receptionist,              inflated relative to the rest of the program 
      etc.). These expenses should be covered by your Indirect Costs.             plan? 
     Some fields auto‐calculate, but please double‐check the math. 
     Budget justification must correspond appropriately with the goals 
      and objectives of the proposal and the overall plan.  
      Character Limit: 1000 

                                                                                                                   Page 15 of 39 

  B. Budget: Supplies                                                           Reviewers will be asking questions like these: 
Itemize supplies, including educational materials and general office              Are you using education materials provided 
supplies, to be used for the proposed program only.                                  by Komen for the Cure? 
                                                                                  Are non‐Komen materials justified and 
     A variety of education materials are available from Komen for the              appropriate? 
      Cure at a discount to grantees.  We expect that our materials be 
      used in the project whenever possible.                                      Are other supplies essential to the success of 
                                                                                     your program? 
     Budget justification must correspond appropriately with the goals 
      and objectives of the proposal and the overall plan.  
      Character Limit: 1000 

  C. Budget: Travel & Transportation                                            Reviewers will be asking questions like these: 
Itemize proposed travel expenses. COST TO CONFERENCES/TRAININGS   Is the travel appropriate and essential to the 
OUTSIDE OF THOSE PROVIDED BY KOMEN NORTH CAROLINA                                    success of the program? 
TRIANGLE TO THE COAST WILL NOT BE COVERED.                                        If you propose transportation to assist in 
     Proposed travel must be necessary for the success of the program.              getting clients to your services, are the terms 
     Travel Costs must be reasonable. Mileage and per diem should be                of your plan well‐articulated and justified? 
      based on federal guidelines.                                               Note that transportation as an “access to care” 
     Budget justification must correspond appropriately with the goals          solution is a Priority Element and, as such, is 
      and objectives of the proposal and the overall plan.                       strongly encouraged. 
      Character Limit: 1000 

  D. Budget: Patient Care Costs                                                 Reviewers will be asking questions like these: 
Please use this section to detail direct patient care costs such as               Are your quoted prices aligned with the 
mammograms, MRIs, clinical breast exams, diagnostic screenings, and                  current “market value” for the services? 
treatment.                                                                        Do you explain precisely what is included in 
     Direct patient care costs can vary from institution to institution.            those costs (see left)? 
       Please negotiate the lowest costs possible with your provider.  
                                                                                  If you contract with another entity to provide 
     If you are proposing transportation costs for clients, please list             clinical services, have you attached a letter of 
      them here. Be sure to reference your transportation provider and               collaboration detailing your agreement? 
      the details of your agreement in your justification. 
     Budget justification must correspond appropriately with the goals 
      and objectives of the proposal and the overall plan.  
      Character Limit: 1000 
In your budget, it is essential to describe precisely what is included in the 
costs you quote. For example, does the cost for a mammogram include 
fees to clinical staff to read the mammogram? 
  E. Budget: Other Expenses                                                Reviewers will be asking questions like these: 
Use this section to detail expenses that do not fit in other categories.     Are the expenses clearly listed and briefly 
     Please do not include items that should be included in your indirect      described on the Budget Form?  
       costs below.                                                          Are the expenses justified and are they 
     Budget justification must correspond appropriately with the goals              essential to the success of your program? 
      and objectives of the proposal and the overall plan.  
      Character Limit: 1000 
This section can include food for workshops, program incentives, and 
other expenses that will directly impact the success of your program. 
Please list these items. Justify them in the Budget Justification document. 

                                                                                                                      Page 16 of 39 

  F. Budget: Indirect Costs                                                  Reviewers will be asking questions like these: 
It is intended to cover costs that cannot be directly assigned to a                Have you included expenses that should 
program or activity.                                                                 be considered “overhead” in any line 
       This line item should be considered “overhead.” Indirect costs                item other than this one? 
            cannot exceed 10% of the total budget. 
        Budget justification must correspond appropriately with the goals 
           and objectives of the proposal and the overall plan.  
           Character Limit: 1000 

                      Section, Format & Content                                              Evaluation Criteria 
  A. Other Funding Sources                                                    Is the program AND organization supported 
     If you are receiving cash or in‐kind donations to subsidize your            by other funding programs?   
      program include this information on this page                            Is your program sustainable even without 
     Budget justification must correspond appropriately with the goals           Komen funding?  
      and objectives of the proposal and the overall plan.                     Do current program reports reflect good 
      Character Limit: 1000                                                       stewardship based on successful 
                                                                                  implementation and outcomes?   

  B. Allocation of Funds                                                      This information will be used when 
     Indicate the percentage of total funds among the following                determining duplication of services 
      categories: Education, Screening, Diagnosis, Treatment, Treatment 
      Support, Survivorship, Healthcare Deliver/System Changes 

  Attachments                                                                 These reports, accompanied by comments 
Please include, in PDF format, the following documents from most                  from staff at the Affiliate, will help to inform 
recent Komen funding year, if applicable:                                         reviewers as they consider the likelihood of 
        Six month report                                                         your program’s success. 
        Final report                                                          Does your previous Komen‐funded program 
                                                                                  illustrate:  poor performance, non‐
    Previous performance on Komen‐funded grants has a clear impact               compliance, inappropriate or ineffective use 
         on future funding.                                                       of funds? 
The following attachments are required, please upload in PDF format on         Were requested funds used? 
         the last page of the application (Budget Summary): 
                                                                               Does past performance illustrate the ability 
     Proof of Insurance if you are a new applicant                               to adapt and evolve your program to 
     Previous Komen funding (See Appendix 4)                                     maximize your impact on the community? 

     Previous Non Komen funding ( See Appendix 4)                                                       

     Program Demographics ( See Appendix 4) 
     Outreach Activities (See Appendix 4) 
     Goals, Objectives, and Outcomes‐ Upload on your objectives 
        page (See Appendix 4) 
Please use the following attachment only if you need more space: 
      Program Description (See Appendix 4) 
                                                                                                                    Page 17 of 39 

                                                   Section, Format & Content 
  Completing Forms 
      Applications must be completed in GeMS (Grants eManagement System). These forms can be updated and saved 
       throughout the process of compiling your proposal. 
      Once completed, we recommend that you review the contents carefully before final submission. 
      Paper copies should be printed on plain white paper, 8 ½ x 11 paper.  
      To conserve resources, proposals may be copied double‐sided. 
      Please bind your copies with paper clips or binder clips. Do not bind applications by spiral binding, vellum binding, 
       stapling or placing in a folder.   

  Electronic Submission 
      Upon completion of your proposal submit application in GeMS.  The authorized signer must then review, sign, and 
       submit the application in GeMS.  This must all be completed prior to submission deadline November 16, 2012. 
      Please download and/save application in a word document or pdf to submit to the affiliate 
      Email all documents and attachments by the deadline to: grants@komennctc.org 
      You will receive an email receipt no later than 5pm on Monday, November 19, 2012.  

  Hard Copy Submission 
      You are required to submit (1) original with signatures (please print 1‐sided). 
      Mail or hand‐deliver signed application and all attachments to the Komen NC Triangle to the Coast Affiliate.  If mailing 
       the package must be postmarked no later than Friday November 16, 2012. If mailed, please request a delivery 
       confirmation from the post office.   
      FAX copies are not acceptable. 
      Paper copies should be printed on plain white paper, 8 ½ x 11 paper. 
      Please bind your copies with clips. Do not use spiral binding, vellum binding, stapling or place in folders.   

  Electronic Deadline: 5 PM, Friday, November 16th, 2012         NO EXCEPTIONS   
         Susan G. Komen for the Cure 
         North Carolina Triangle to the Coast 
         Attn: Grants Committee 
         133 Fayetteville Street, Suite 300 
         Raleigh, NC 27601  
CONFIRMATION OF RECEIPT OF APPLICATION:  All organizations submitting applications will receive confirmation of application receipt.  
Confirmation will be e‐mailed to the project director upon initial receipt of the application.  
If an email address is provided, confirmation will be emailed to the project director.   
    Please do not contact the Affiliate regarding the status of the application during the review period. 

                                                                                                                         Page 18 of 39 

   1.      Read this document and the 2011 Community Profile thoroughly and early. Be sure that you
           comply with all requirements listed in the statement of need (Section IV).
   2.      Start your application early. After reading the request for applications, begin mapping out
           your program design based on the priorities in Section IV.
   3.      Contact the Affiliate as early as possible with questions and/or ideas regarding your program.
           Early feedback will allow you to make adjustments and present a strong proposal.
   4.      Identify and document the research that supports your program design. Be familiar with
           evidence-based approaches and strong evaluation methods relevant to your program.
   5.      Develop partnerships and request letters of collaboration early in the process.
   6.      Effectively connect each component of your application to the Statement of Need (Section
           IV) and the mission of the Affiliate.
   7.      Be concise and clear. Make sure your application clearly articulates the need being
           addressed, the objectives to be met, and the feasibility and potential impact of your program.
   8.      Use active rather than passive voice, and use correct grammar and spelling.
   9.      If you are a previous grantee, show that your project has evolved. Do not submit previously
           funded applications with minor changes.
   10.     Complete all forms. Double check your work and include all attachments.

Susan G. Komen for the Cure is committed to a transparent and unbiased grant review process. It is
essential for applicants and Komen supporters to understand that the process of disseminating funds to
support our mission complies with the highest ethical and fiscal standards. The following summarizes
the process which is managed by the Affiliate’s Grants Committee and staff under the oversight of the
Affiliate’s Board of Directors.

Compliance Review
All applications submitted by the deadline are catalogued and assigned a grant number. The Affiliate’s
Grants Committee examines applications for general compliance and appropriate response to this RFA.
This examination includes the proposed program only insofar as it does or does not comply with the
requirements detailed in this RFA. Applications that do not address the Required Elements of this
RFA (Section IV) are removed from the process at this stage and applicants are notified.

Independent External Review Panel
Applications that have met the general compliance criteria are approved for full review by an
independent review panel comprised of a diverse group of researchers, community leaders, survivors,
medical providers, caregivers and other prominent leaders in the community who are committed to
addressing breast health in our service area.

                                                                                              Page 19 of 39 

Reviewers may not serve in any other capacity within the Affiliate’s network, including as a volunteer,
staff member or advisor. Current grantees and applicants are prohibited from serving as reviewers. All
reviewers sign conflict of interest statements and must disclose any potential connection to prospective
applicants. During the process, these reviewers are excused from discussing applications for which they
have any real or potential conflict of interest.

Reviewers have copies of all grants prior to meeting in person. Each reviewer reads all grants but is
responsible for scoring approximately half of the proposals and for presenting one or two proposals at
the in-person meeting. They are also provided with a copy of this RFA so that they are fully apprised of
the parameters within which you prepared your application.

Reviewers will be given the following Criterion (included are examples of some of the questions
reviewers ask while scoring your application):

      Impact: Will the project have substantial positive impact on increasing the percentage of people
       who enter, stay in, or progress through the continuum of care? Will the project have a substantial
       impact on the priority selected? How closely does the project align with the funding priorities
       stated in the RFA? Does the program describe a need in the targeted community based on the
       Community Profile and the Statement of Need? Are innovative approaches included to increase
       the likelihood of the program’s success by reducing barriers, increasing the client base, and/or
       mobilizing a broader community? Is there use of outreach methods to reach members in the
       community who are NOT currently engaged in the healthcare system? Is data provided to
       demonstrate the target population is underserved? Does the project have a sufficient documented
       plan to evaluate its impact? Does the plan describe specific topics the applicant expects the
       participants to learn, achieve, receive, and apply based on the program? Is there a clear plan for
       follow-up once patients/clients are connected with the program and have possible obstacles been
      Feasibility: How likely is it that the objectives and activities will be achieved within the scope of
       the funded project? Are outreach plans appropriate? Is the project well planned? Are methods to
       collect data consistent with and appropriate for the outcomes to be measured? Is the budget
       appropriate and realistic? Does the budget justification explain in detail the reasoning and need
       for the costs associated with the project?
      Capacity: Does the organization, Project Director and his/her team have the expertise to
       effectively implement all aspects of the project? Is the organization respected and valued by the
       target population? Has the plan addressed potential barriers to care, including literacy, language
       (translation and/or transcription), and physical access? Is it culturally competent and responsive?
       Does the plan consider the needs and potential service challenges for populations that may be
      Collaboration: Have meaningful collaborators and partners been identified who enhance the
       potential to meet the goals and objectives proposed in the application? Has the applicant
       partnered with nontraditional entities in a meaningful way that will increase access and
       utilization of breast health/cancer services? Does the program innovatively connect with
       community agencies to expand their reach to underserved communities? Are the roles of the
       partners appropriate and relevant? Is the extent of the partners’ organizational and fiscal
       involvement transparent?

                                                                                                Page 20 of 39 

      Sustainability: Is the project likely to be sustained? Is the impact likely to be long term? Does
       the applicant have support beyond Komen? Does the applicant adequately document who will
       ensure the long-term survival and health of the program? Does the applicant articulate what
       aspects of the program and/or organization are or could be supported by other funds? Are
       partnerships likely to be sustained past project period?
      Evidence Based Strategies: Has the applicant identified and documented the evidence based
       initiatives to be employed? Is there a strong understanding of the Evidence-based initiative to be
       implemented and its relevance to the need in the community? How appropriate is the evidence
       based initiative for the target population? Are plans to adapt and implement evidence-based
       initiatives well thought out?

They are charged with evaluating each criterion using a 7-point scale where one (1) represents “poor”
and seven (7) is “excellent.” Reviewers are also asked to record questions, concerns and constructive
comments that we offer back to all applicants, regardless of whether or not your proposal is funded.

The review panel meets in person for a full day. While staff and the Grants Committee are present, their
role is to inform the process and not to influence it. The review panel is charged with:
          Discussing the proposals as a group. This includes assessing one another’s scores and
             comments and, if appropriate, adjusting their individual scores based on the discussion.
          Raising and recording concerns and/or kudos about any or all criteria. This may include
             recommendations about the appropriateness of specific line items in the requested budget.
          Agreeing to final scores for each proposal and to comments that will be passed along to (1)
             the Komen Grants Committee regarding budget and program issues that need clarification (2)
             the Komen Board of Directors regarding the fundability of these programs, and (3) the
             grantees / applicants regarding strengths and weaknesses of their proposals.
          Reviewing and recommending the final slate of proposals to the Komen NC Triangle Board
             of Directors. This slate includes a list of proposals in ranked order, along with averaged
             scores and comments. It also includes an indication of “Do Not Fund” for any programs that
             are deemed to be inappropriate or generally below the standards described in this Request for

Post-Review Adjustments
Immediately following the review, the Affiliate’s staff and Grants Committee work with applicants to
address any issues that the review panel identified as needing clarification prior to a final vote by the
Board of Directors.

Board of Directors Vote
The Treasurer and Finance Committee of the Affiliate make a recommendation to the Board of Directors
for a maximum amount of funding for the coming grants cycle. The Board of Directors votes on this
funding limit, without seeing the grants slate or grant applications.

Separately, the Board of Directors is presented with the grants slate, in ranked order, as approved by the
independent review panel. The slate includes a cumulative amount of funding requested. If there is more
money requested than the Board approved, the funding cut-off is clearly delineated.
                                                                                                Page 21 of 39 

The Board of Directors may review the proposals that appear on the slate but may not adjust the ranking.
If they have exceptions, they must refer the entire slate back to the review panel. The Board of Directors
votes on the slate and, within a few days, all applicants are notified as to their status.

Immediately following the Board vote, applicants are notified. For applications that are not funded, the
Associate Director of Community Programs at the Affiliate will set up a meeting to discuss your
proposed program and possible improvements for future applications.

For applications that are funded, there may be adjustments required before a contract is signed. Once
those adjustments are made to your application, a contract is prepared and must be signed and returned
before you are considered a “Komen grantee.”

Grantee Requirements
Because our grantees represent Susan G. Komen for the Cure to the community, it is essential that
grantees have a strong understanding of our organization and our mission. Hence, we have several
requirements of our grantees and offer opportunities for capacity building and program development.

Required activities:
       Participate in the 2013 Komen NC Triangle to the Coast Race for the Cure in these ways:
          have a display in the Grantee Tent, bring a team of participants from your institution and/or
       Prepare for at least one to two site visits during the one-year grant-cycle.
       Utilize Komen education and breast health materials whenever possible.
       Make publicly available the results of the work supported by the program.
       Prepare and submit a Six-Month and a Final Report, including a listing of the ways you have
          engaged with the Affiliate during the grant period.
       Ensure that support from the Affiliate is identified on your website and on all materials
          (flyers, pamphlets, posters, displays, etc.) developed with funding from the Komen North
          Carolina Triangle to the Coast Affiliate.

       To support the development of excellent grantee programs, the Affiliate offers several
          training opportunities throughout the year. These include workshops on grant-writing and
          evaluation. We strongly encourage you to attend these events.
       Both locally and nationally, Susan G. Komen for the Cure has programs that allow
          organizations to raise funds to support our community health programs and national research.
          We encourage our grantees to support Komen by organizing small fundraising activities in
          your community or participating in national fundraising campaigns. This is not required for
          funding, nor does this have any impact on the review process.

                                                                                              Page 22 of 39 

                                     New Komen Funding Opportunity
   SMALL GRANTS:  We are now pleased to offer opportunities for organizations and/or communities to receive 
   small grants to support capacity building, infrastructure development and community mobilizing, especially 
   focusing on creation of new models, programs and partnerships. These small grants are by invitation only and 
   are available year‐round. Please contact the Komen NC Triangle to the Coast mission staff for details.

Grantee Timeline

2012: Regional Grant-Writing Workshops in 4 Locations
September 5………………Harnett County & Surrounding
September 12……………. Wilson County & Surrounding
September 19……………..Pender County & Surrounding
September 26……………..Durham County & Surrounding

October 5, 2012 at 5pm………….Letter of Intent Due (send to grants@komennctc.org )

November 16, 2012 at 5pm …….Electronic Applications Due in GeMS
November 16, 2012……………..Hardcopy must be Postmarked

2013: Awards
March………………………Awards Announced
Late March……………...........Signed Contracts Due
        Last week of March………………Award Event
        April 1………………………Grant Cycle Begins
        April/May…………………First Site Visit
        September/October…………….Second Site Visit | September/October…6-Month Report (2nd check)

        March 31………………Grant Cycle Ends
        May 31……………Final Report & Evaluation Due

                   Thank you for your interest and good luck with your application!

                                                                                                  Page 23 of 39 

                                       Appendix 1: Glossary

 Continuum of Care: Framework referring to the range of services throughout the health care
  sector. It addresses services and access to breast health education, screening, diagnosis,
  treatment, and follow -up care/survivorship.

 Cultural Competency: Cultural competence is a set of similar behaviors, attitudes, and policies
  that come together in a system, agency, or amongst professionals that enables the system,
  agency, or those professionals to work effectively in cross-cultural situations. The word culture
  refers to the integrated pattern of human behavior that includes thoughts, communications,
  actions, customs, beliefs, values, and institutions of a racial, ethnic, or religious group. The word
  competence refers to the capacity to function effectively. A culturally competent system of care
  acknowledges and incorporates—at all levels—the importance of culture, the assessment of
  cross-cultural relations, and vigilance towards the dynamics that result from cultural difference,
  the expansion of cultural knowledge, and the adaptation of services to meet culturally-unique
  needs. (Definition adapted from Toward a Culturally Competent System of Care: Vol.1, Terry
  Cross, et al. (1989).)

 Education: Defined for the purposes of this RFA as evidence-based activities targeted at
  improving overall understanding about breast health/breast cancer, promoting action toward
  early detection, increasing awareness about sources of care, how to initiate the screening process,
  and awareness/information about follow-up procedures and resources in the case of an abnormal

 Emerging Best Practices: Innovative approaches that are likely to be effective but have not yet
  been fully evaluated.

 Evidence Based Practices: Programs or strategies that have been tested, evaluated, and found
  to be effective in improving access, promoting behavioral change and/or empowering individuals
  to make good breast health decisions. Evidence Based Practices can be designed to change
  patients’, healthcare providers’, or other involved caregivers’ beliefs, knowledge, skills, and
  behaviors. They can also be designed to change organizational policies or environments and to
  overcome other barriers to accessing care. You may refer to this link to see suggested evidence
  based practices for breast cancer.

                                                                                            Page 24 of 39 

 Evaluation Plan

         Impact Evaluation: Assesses the changes that can be attributed to a particular
           intervention, such as a project, program or policy. Impact Evaluation helps us to answer
           key questions such as, what works, what doesn’t, where, why and for how much.

         Process Evaluation: Assesses the delivery of programs. Process evaluation verifies what
          the program is and whether it is being implemented as designed. It answers the questions
          of what is delivered in reality and where gaps exist between program design and

 GeMS: Susan G. Komen for the Cure® Grants eManagement System

 Lay Health Advisor/Community Health Worker/Promotora: Individuals from the
  community that may perform one or more of the following roles: bridging cultural mediation
  between communities and the health care system; providing culturally appropriate and accessible
  health education and information, often by using popular education methods; Assuring that
  people get the services they need; Providing informal counseling and social support; advocating
  for individuals and communities within the health and social service systems; Building
  individual and community capacity

 Letters of Collaboration/support: Documentation of a stated relationship between
  collaborating agencies. Example: Agency A states it will actively work with Agency B to
  complement each other’s programs and ensure non-duplicative services. Agency A should
  therefore secure a letter of support from Agency B confirming the collaboration.

 Letter of Intent: demonstrates to the funder an understanding of the grant you intend to apply
  for. It includes information about your organization and why you are positioned to apply for this
  grant, an overview of what your organization proposes to do and how it relates to the affiliates
  priorities, and information stating the area and target population your program will address.

 Medically underserved: A term that refers to individuals who lack access to primary and
  specialty care either because they are socioeconomically disadvantaged and may live in areas
  with high poverty rates or because they reside in rural areas. The term also refers to individuals
  who reside in geographic areas where there are too few primary care providers, high infant
  mortality, high poverty and/or elderly population. For more information go to:

 NC BCCCP: The North Carolina Breast and Cervical Cancer Control Program provides free or
  low cost breast and cervical cancer screenings and follow-up to eligible women in North
  Carolina. Counties in our service area with BCCCP providers are: Brunswick, Chatham,
  Columbus, Duplin, Durham, Edgecombe, Granville, Halifax, Johnston, Lee, Moore, Nash, New
                                                                                          Page 25 of 39 

                Hanover, Northampton, Pender, Person, Pitt, Sampson, Vance, Wake, Warren, and Wilson
                counties. For more information go to: http://bcccp.ncdhhs.gov/index.htm

             Outreach: For the purpose of this RFA, outreach is defined as reaching out to various
              communities to find individuals, emphasis on women, who do not use or who underuse medical
              services. Outreach is making meaningful contacts with women on their terms in their natural
              settings within well-defined communities, while also providing any service that facilitates entry
              into the screening cycle.

             Patient Navigation: For breast health, patient navigation refers to guidance provided to persons
              needing access to screening, re-screening, and in the case of abnormal findings accessing the
              cancer care system and overcoming barriers to quality, standard care. Patient Navigation may
              also be considered education, outreach, or both.

             Qualitative Analysis: Collection and analysis of data/information that can’t easily be measured
              by or translated easily into numbers (i.e feelings )

             Quantitative Analysis: Collection and analysis of data that includes numbers or numerical
              values (i.e, the number of mammograms, the number of attendees at a support group)

             RFA: Request For Applications

             Screening and Diagnosis: For the purposes of this RFA, defined as a complete breast health
              screening cycle that includes a Clinical Breast Exam (CBE), Mammography, MRI, Ultrasound,
              and/or Genetic Testing.

             Tier 1 Counties: The government ranks NC counties based on economic well-being, the most
              distressed being Tier 1 and least distressed being Tier 3. Tier 1 counties in the North Carolina
              Triangle to the Coast Affiliate include Bladen*, Caswell, Columbus*, Edgecombe, Halifax,
              Northampton, Scotland, and Warren. For more information visit http://www.ncruralcenter.org

             Tier 2 Counties: The government ranks NC counties based on economic well-being, the most
              distressed being Tier 1 and least distressed being Tier 3. Tier 2 Counties in the North Carolina
              Triangle to the Coast Affiliate include Duplin*, Franklin, Granville, Harnett, Lee, Nash,
              Onslow*, Person, Pitt, Sampson*, and Wilson*. For more information visit

             Tier 3 Counties: The government ranks NC counties based on economic well-being, the most
              distressed being Tier 1 and least distressed being Tier 3. Tier 3 Counties in the North Carolina
              Triangle to the Coast Brunswick*, Chatham, Durham, Johnston, Moore, New Hanover*, Orange,
              Pender*, and Wake. For more information visit http://www.ncruralcenter.org

             Underinsured: An individual who has some form of health insurance, but lack the financial
              protection needed to cover out of the pocket medical care expenses.

*indicates counties added in 2012 (Bladen, Brunswick, Columbus, Duplin, New Hanover, Onslow, Pender, Sampson, Wilson)
                                                                                                                Page 26 of 39 

                              Appendix 2:
                  Current NC BCCCP Income Guidelines
                    250% Below Federal Poverty Level

Household Size                     Gross Yearly Income 

1                                  $27,925 

2                                  $37,825 

3                                  $47,725 

4                                  $57,625 

5                                  $67,525 

6                                  $77,425 

7                                  $87,325 

8                                  $97,225 

                                                          Page 27 of 39 

                                                              Appendix 3:
                                                            Intervention List
Education Interventions:
 Public education (e.g. radio, television, newspaper, e-communications, social networking)
     Group education (e.g. lectures, workshops, seminars, webinars)
 One-on-one education
 Material development and dissemination (multi-cultural, and in accessible and alternative formats)
 Events (e.g. health fairs) in accessible venues
 Health care professional training and provider education
Screening Interventions:
 Reminder systems directed at patients (e.g. letters, phone calls)
 Reminder systems directed at health care providers (e.g. chart reminders)
 Outreach programs (that result in new appointments, new patients, etc.)
 In-reach programs (result in getting existing patients to get a mammogram)
 Reduce costs to patient for mammography (e.g. free or low-cost mammography)
 Expand hours for breast health services to evenings and weekends.
 Provide free or low-cost screenings (clinical breast exams and/or screening mammograms)
 Reduce other barriers to mammography (e.g. transportation, childcare)
 Provide translation/interpretation services to include sign language interpreters
 Genetic testing
 Patient navigation
     Accessible facilities for screening (education, awareness)
Diagnosis Interventions:
 Provide translation/interpretation services
 Reduce costs to patient for diagnostic services (e.g. ultrasound, biopsies)
 Patient navigation
 Reduce other barriers to diagnostic services (e.g. transportation, childcare)
Treatment Interventions:
 Reduce out-of-pocket costs for treatment (e.g. co-pay or prescription drug assistance)
     Reduce costs for treatment services (e.g. free chemotherapy, radiation, surgery)
 Clinical trials
 Patient navigation
Treatment Support Interventions:
 Provide financial assistance for day-to-day costs during treatment (e.g. housing, utilities)
 Reduce other barriers to treatment (e.g. transportation, childcare)
 Support groups
 Individual counseling/psychotherapy
 Side-effect management (e.g. prosthesis, wigs, lymphedema therapy)
 Nutrition services (e.g. meal delivery)
 Complementary therapies (e.g. meditation, yoga, acupuncture, art therapy)
 End of life care (e.g. hospice/palliative care)
 Legal services
 Caregiver support (e.g. respite programs, training for caregivers)
Survivorship Interventions:
 Support groups
 Individual counseling/psychotherapy
 Exercise/Nutrition programs
 Complementary therapies (e.g. meditation, yoga, acupuncture, art therapy)
 Side-effect management (e.g. prosthesis, wigs, lymphedema therapy)

Health Care Delivery/Systems Change Interventions:
 Interventions to increase the quality of health care delivery
 Process improvement strategies
                                                                                                       Page 28 of 39 

                                             Appendix 4:

       Program Description (see page 30) 
       Program Demographics* (see page 31) 
       Outreach Activities* (see page 34) 
       Evaluation Goals, Objectives, and Outcomes* (see page 35) 
       Program Support* (see page 37) 

*Required attachments 


















                                                                     Page 29 of 39 

Applicant Organization Name:                         Project Director:  
                                              Section A: Program Description  
    Describe your program and how it will improve access and utilization of breast health services in the continuum of care. 
                Provide data to illustrate the need in your target area as it corresponds with your program design.   
                                   Character Limit: 6000 characters.  Use 12 point font.   



                                                                                                               Page 30 of 39 

Applicant Organization Name:                          Project Director:  
                            Program Demographics: Check all that apply 
BCCCP Provider?       Yes       No 
Age                   Women under 40      Women 41‐50 

                         Women 51 – 64          Women over 65 
Ethnic/Race                African American/Black 
                           Native American/Alaskan Native 
                           Asian 
                           East Indian 
                           Hispanic/Latino 
                           Middle Eastern  
                           Pacific Islander 
                           White/Caucasian  
                           Other  
Participants               Breast Cancer Patients 
                           Breast Cancer Survivors 
                           Lymphedema Patients 
                           Recently Diagnosed Patients 
                           Other: _____________________________________ 
Medically                  Homeless 
Underserved                Immigrants 
                           Shelter Residents 
                           Migrant Workers 
                           Refugees 
                           Rural 
Health  and                Health Educators 
Community                  Health Care Providers 
Professionals              Scientists 
(personnel only) 
                           Community Outreach Worker 
 Other Groups              Co‐survivors 
                           College Students 
                           Elderly (>65) 
                           High School Students 
                           Incarcerated 
                           Lesbian/Gay/Bisexual/Transgender 
                           Low‐literacy 
                           Men 
                           Persons with disabilities 

                                                                            Page 31 of 39 


Enter specific 
details for this 
target population 
(300 character 
limit in 12 point 

                     Page 32 of 41 

Projected                  Bladen                    Estimated Number to be served:______ 
Counties to be 
                           Brunswick                 Estimated Number to be served:______ 
                           Caswell                   Estimated Number to be served:______ 
Check all that             Chatham                   Estimated Number to be served:______ 
apply and give 
your best                  Columbus                  Estimated Number to be served:______ 
estimate.                  Duplin                    Estimated Number to be served:______ 
                           Durham                    Estimated Number to be served:______ 
                           Edgecombe                 Estimated Number to be served:______  
                           Franklin                  Estimated Number to be served:______ 
                           Granville                 Estimated Number to be served:______ 
                           Halifax                   Estimated Number to be served:______ 
                           Harnett                   Estimated Number to be served:______ 
                           Johnston                  Estimated Number to be served:______ 
                           Lee                       Estimated Number to be served:______ 
                           Moore                     Estimated Number to be served:______ 
                           Nash                      Estimated Number to be served:______ 
                           New Hanover               Estimated Number to be served:______ 
                           Northampton               Estimated Number to be served:______ 
                           Onslow                    Estimated Number to be served:______ 
                           Orange                    Estimated Number to be served:______ 
                           Pender                    Estimated Number to be served:______ 
                           Person                    Estimated Number to be served:______ 
                           Pitt                      Estimated Number to be served:______ 
                           Sampson                   Estimated Number to be served:______ 
                           Scotland                  Estimated Number to be served:______ 
                           Vance                     Estimated Number to be served:______ 
                           Wake                      Estimated Number to be served:______  
                           Warren                    Estimated Number to be served:______ 
                           Wilson                    Estimated Number to be served:______ 
Total Estimated    Please note:   Actual numbers served will be required in the final report.  
to be served by 
this grant                                                                                                 0
                                                                                             Sum of above: ______ 


                                                                                                                     Page 33 of 41 

                                           Section  D: Outreach Activities 
     Describe the innovative components to your program and how they will engage and enhance program participation for 
                                                 hard‐to‐reach populations. 
                                           Character Limit: 2000 in 12 point font 


                                                                                                           Page 34 of 39 

                                        Section B: Goals and Objectives 

     On each of this page specifically identify your program’s first goal and respective objectives.  List 
    your corresponding evaluation methods, tools, and your expected outcomes. Refer to the 2012 RFA 
                                            for more instructions.  

                                               Use 12 point font. 
Goal 1:  


Objectives                      Specific Activities      Time        Evaluation Method    Outcomes 
                                                         Frame       and Tools 
Objective  1.1                  1.1A                                                       
















                                                                                                Page 35 of 39 

Objective  1.2    1.2 A             


                  1.2 B 


                  1.2 C 








Objective 1.3     1.3 A             


                  1.3 B 


                  1.3 C 







                                       Page 36 of 39 

Applicant Organization Name:                 Project Director:  
                                          A. Current Funding 

                         Identify program AND Organization sources of funding.   

                  If you are a current grantee, do NOT include Komen NCT funding.  
Granting Organization            Funding Purpose             Amount        Grant          Pending? If 
                                                                          Duration        so, date of 
















                                                                                           Page 37 of 39 

                                         PREVIOUS KOMEN FUNDING 

  List ALL prior funding your organization has received from the Komen NC Triangle Affiliate for the past four 
  Year       Grant Amount         Unexpended              Title of Grant       Status of Grant including 
                                 funds returned                                   unexpended funds* 
















                                                                                             Page 38 of 39 

                                     PREVIOUS NONKOMEN FUNDING 

  List ALL Non‐Komen funding your organization has received for the past four years in any amount or grant 
     Year         Amount                    Title of Grant                         Status of Grant 
















                                                                                          Page 39 of 39 


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