REQUEST FOR PROPOSAL (RFP)

2009 REQUEST FOR PROPOSAL (RFP) THE LEXINGTON AFFILIATE OF THE SUSAN G. KOMEN BREAST CANCER FOUNDATION Grant applications now being accepted for BREAST HEALTH AND/OR BREAST CANCER EDUCATION, TREATMENT SUPPORT, OR SCREENING PROJECTS The mission of the Susan G. Komen Breast Cancer Foundation is to eradicate breast cancer as a lifethreatening disease by advancing research, education, screening, and treatment. Affiliates of the Komen Foundation represent one of the nation’s largest private funding sources for breast health and breast cancer screening, education, and treatment support programs. The Lexington Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc is currently offering grants for innovative projects in the areas of breast health and/or breast cancer education/outreach, screening, or treatment support projects targeting services not otherwise available to the medically underserved populations of Central and Eastern Kentucky. Grants are available for up to one (1) year. STATEMENT OF NEED: A community needs assessment of Central and Eastern Kentucky has determined that there is a significant need for:     Projects focusing on breast health education among women > age 40 Projects focusing on breast screening services among disparate populations Projects focusing on providing culturally-appropriate support services to breast cancer survivors Projects focusing on medically underserved populations Funding priority will be given to those projects that specifically address these needs. Application guidelines and instructions are included in this announcement. APPLICATION DEADLINE IS NOVEMBER 15, 2008 GUIDELINES AND INSTRUCTIONS FOR APPLICANTS EMPHASIS: The purpose of this grant program is to address the breast health and/or breast cancer screening, treatment, and education needs of the Central and Eastern Kentucky. Through a community needs assessment, the Lexington Affiliate of the Susan G. Komen Breast Cancer Foundation has identified the following needs:  Projects focusing on breast health education among women > age 40  Projects focusing on breast screening services among disparate populations  Projects focusing on providing culturally-appropriate support services to breast cancer survivors  Projects focusing on medically underserved populations QUALIFICATIONS: Applications are accepted from US nonprofit institutions; US citizenship or residency is not required. Applications must be submitted in English. Applicant organizations must be located and/or providing services in Central and Eastern Kentucky. RESTRICTIONS:  Project must be specific to breast health and/or breast cancer; e.g. if a project is a combined breast and cervical cancer project, funding may only be requested for the breast cancer portion  Applicants must be a US nonprofit (federally tax-exempt) organization, e.g. nonprofit organizations, educational institutions, government agencies, and Indian tribes are eligible  Services are provided in Central and Eastern Kentucky eligible counties. (see website for listing: www.komenlexington.org)  Indirect costs, if applicable, should be no more than 5% of direct costs  Equipment costs, if applicable, may not exceed 30% of direct costs and should be used exclusively for this project  Salaries, if requested, are for personnel related to this project only  Prior grant recipients must be compliant and current with grant requirements and reporting  Multiple grant requests within a county may be asked to work collaboratively  Treatment funds will be allocated at current Medicare reimbursement rates Failure to adhere to these guidelines will result in denial of the application or delayed processing. REVIEW: Completed applications meeting compliance with these guidelines, will be submitted for grant review by a panel established through the local grants committee. CONTRACTS: A grant contract will be the legal mechanism for funding. GRANT PERIOD: Grant period begins April 1, 2009 and will conclude on March 31, 2010. PAYMENT AND REPORTING: Payment will be made no later than thirty (30) days after receipt of the fully executed contract. Grants over $10,000 will be funded in two (2) payments. The initial progress report is due on September 30, 2009. A final report is due on April 15, 2010. Reports must include documentation of expenditures, including receipts and documentation of the number of women served. LETTERS OF SUPPORT AND ADDITIONAL MATERIALS: Please do NOT send additional materials with this Application. CONFIRMATION OF RECEIPT OF APPLICATION: Confirmation of receipt of application will be electronically mailed to the project director following review for compliance to guidelines. Please do not contact the Lexington Affiliate of the Komen Foundation regarding the status of the application during the review period. ANNOUNCEMENT: Announcement of grants awarded will be made by March 15, 2009. Project directors will be notified of the outcome of the review. NUMBER OF GRANTS TO BE AWARDED: The actual number of awards will depend on the amount of funding granted per project and the success of all development/fund raising activities. APPLICATIONS SHOULD INCLUDE AND BE ORDERED AS FOLLOWS: A. Cover Page (Form attached) Note: Signature of approving institutional personnel, other than project director, required B. Project Description (This section should not exceed five typewritten pages. Font size should be no smaller than a ten-point typeface.) 1. Brief explanation of project. 2. Statement of need/problem to be addressed. 3. Description of constituency to be served, how many will be served and how they will benefit. 4. Description of program goals and measurable objectives. 5. Description of activities planned to accomplish these goals. Is this a new or ongoing activity of your hospital/organization? 6. Timetable for accomplishing goals and amount of progress anticipated by each noted reporting period. 7. Description of other organizations/entities, if any, participating in the Program. If applicable, letters of collaboration should be included from each organization. C. D. E. F. 8. Long term sources/strategies for funding of the Program after initial funding by this funding. 9. A review of comparable programs offered in this service area and an explanation of how this program works collaboratively with them or whether it is unique. 10. Definition of success for the Program and how it will be measured. 11. Use of the Program's results and how they are to be disseminated. Financial Information (Not to exceed three typewritten pages) 1. Budget for requested funds (Form attached) 2. Budget justification. 3. List of other sources of current funding for the project. Biosketch form for project director and other personnel listed in budget request. Proof of non-profit status for applicant institution. If a previous Komen Grant Recipient, attach a copy of the six month and year-end report for the most recent grant received. Reports must include documentation of expenditures, including receipts and number of women served. Applications must be submitted by the director of the project. Please keep grant requests to the page limits as stated above. Submit seven (7) typed copies of each application and one copy electronically. APPLICATIONS MUST BE RECEIVED (SEVEN (7) HARD COPIES AND ONE ELECTRONIC) BY NOVEMBER 15, 2008 AND SENT TO THE FOLLOWING ADDRESS Komen Lexington Affiliate Attn: Grants Committee P.O. Box 998 Lexington, KY 40588 Electronic copy may be sent to lexingtonkomen08@gmail.com GRANT RECIPIENTS WILL BE NOTIFIED BY MARCH 15, 2009 THE LEXINGTON AFFILIATE OF THE SUSAN G. KOMEN BREAST CANCER FOUNDATION REQUEST FOR FUNDING FOR BREAST HEALTH AND/OR BREAST CANCER PROJECT PROJECT DIRECTOR & TITLE INSTITUTION ADDRESS PHONE FAX EMAIL ( ( ) ) TITLE OF PROJECT TOTAL AMOUNT REQUESTED GRANT PERIOD $ April 1, 2009 through March 31, 2010 SIGNATURE AND TITLE OF APPROVING INSTITUTIONAL PERSONNEL DATE: NAME AND TITLE OF APPROVING INSTITUTIONAL PERSONAL (TYPED) PLEASE CHECK TYPE OF APPLICATION:  EDUCATION  SCREENING  TREATMENT APPLICATIONS MUST BE RECEIVED BY NOVEMBER 15, 2008 (Photocopies of this form are acceptable.) ABSTRACT PAGE PROJECT DIRECTOR ORGANIZATION/INSTITUTION ABSTRACT In the space below, please provide a short abstract, not to exceed 200 words, written in lay terms for release to the general public should this application be chosen for funding. Permission to publish: Permission is hereby granted to the Susan G. Komen Breast Cancer Foundation, Inc. to publish the above abstract should this application be selected for funding. Signature Date Name (typed) Phone number ( ) BIOSKETCH FORM PROJECT DIRECTOR (Last name, first, middle) BIOGRAPHICAL INFORMATION Information should be submitted for the project director and other personnel included in budget request. Please use a separate form for each person. NAME EDUCATION TITLE (Begin with baccalaureate or initial professional education, such as nursing, include postdoctoral training) INSTITUTION (Indicate location) DEGREE YEAR CONFERRED FIELD OF STUDY PROFESSIONAL EXPERIENCE: Please list, in chronological order, concluding with present position, previous employment, experience and honors. List, in chronological order, the titles, authors, and complete references to all publications during the past three years and to representative earlier publications pertinent to this application. DO NOT EXCEED TWO PAGES BUDGET FORM Lexington Affiliate of The Susan G. Komen Breast Cancer Foundation GRANT APPLICATION REQUIRED BUDGET FORM Detailed Budget for Entire Budget Period Personnel (must be specific to project) Name Role on Project Type % Effort Base Salary Appt. on (Months) Project Salary Requested From: 04/01/2009 Through: 3/31/2010 Dollar amount requested Fringe Benefit Totals Subtotals Supplies (Itemize by category) Equipment (not to exceed 30% of direct costs) Travel Patient Care Costs Inpatient Outpatient Other Expenses (Itemize by category) Subtotal - Direct Costs Indirect cost allocation (not to exceed 5%) Total Funding Request PLEASE ATTACH ADDITIONAL SHEET WITH BUDGET JUSTIFICATION INFORMATION. REPORT FORM FIRST REPORTING PERIOD (DUE SEPTEMBER 30, 2009) PLEASE SUMMARIZE YOUR ACTIVITIES, EXPENDITURES AND OUTCOMES TO-DATE PROJECT DIRECTOR: PROJECT NAME: Project Activities: Project Expenses: Explanation if Project has not met stated goals: Attach all documentation verifying project progress including copies of announcements, advertisements, and supporting information documenting number of women served. Report should contain to-date information of treatments, screening mammograms and attendees at events. Submit to Komen Lexington Affiliate, ATTN: Grants Committee, PO Box 998, Lexington, KY 40588. Incomplete or late reports may delay or result in forfeiture of any additional grant funds. Report is due September 30, 2009. GRANTEE FINAL REPORT OUTLINE Due Date: April 15, 2010 EXHIBIT C FINAL GRANT REPORT TO THE: Lexington Affiliate of the Susan G. Komen Breast Cancer Foundation Please Type PROJECT DIRECTOR: Last name First name Middle Initial AGENCY: PROJECT TITLE: RIOD START DATE: Month/Day/Yearns/Day/Year END DATE: 1. PROJECT SUMMARY I: List each objective outlined in the original grant application. 2. WHAT PERCENTAGE OF OBJECTIVES WERE MET SPECIFIC AIMS: Percent Completed: 1-25% OBJECTIVE 1 OBJECTIVE 2 OBJECTIVE 3 26-50% 51-75% 76-100% N/A 3. PROJECT SUMMARY II: In this section, please provide a short summary (200 words or less) in lay language describing the outcomes and accomplishments of this project. Include a statement of plans for the future of the program. 4. TYPES OF SERIVCES PROVIDED (CHOOSE ONLY THOSES THAT PERTAIN TO YOUR GRANT): # of People Served _____ _____ SCREENING MAMMOGRAPHY EDUCATION/COUNSELING SESSIONS CLINICAL TRIALS ENROLLMENT CLINICAL BREAST EXAMS PSYCHOSOCIAL # of People Served _____ CLINICAL TRIALS EDUCATION _____ TREATMENT ASSISTANCE ______ WRITTEN MATERIALS PROVIDED _____ _____ DIAGNOSTIC SERVICES _____ COMPLEMENTARY/ALTERNATIVE _____ _____ _____ OTHER ___________________________ 5. 6. NUMBER OF SCREENING MAMMOGRAMS PROVIDED WITH THIS GRANT (IF APPLICABLE): __________________ NUMBER OF CLIENTS REFERRED OUT FOR FURTHER DIAGNOSIS: _______________________ 7. 8. 9. NUMBER OF CLIENTS REFERRED OUT FOR MAMMOGRAMS (NOT PAID FOR BY KOMEN GRANT): _______________ NUMBER OF BREAST CANCERS DETECTED: ________________________________ OTHER SOURCES OF SUPPORT: In this section, please list any notice or receipt of other sources of support for this project received during the past six months. Organization Dollar Amount 10. PROJECT MATERIALS: In this section, please list all published or produced materials, pictures, etc. for this grant project. Include copies of materials for Affiliate files. 11. ACCOUNTING OF GRANT FUNDS: Please attach a final budget for the entire term of the grant period. (Use attached form) ____________________________________________ Signature of Project Director Date Permission is hereby granted to the Susan G. Komen Breast Cancer Foundation to publish the above information. Proper credit will be given to grantee where appropriate. BUDGET PROGRESS REPORT FORM ACCOUNTING FROM MONTH/DAY/YEAR MONTH/DAY/YEAR OF GRANT FUNDS TO ORIGINAL BUDGET PERSONNEL ACTUAL EXPENSES TO DATE SUPPLIES (ITEMIZE BY CATEGORY) EQUIPMENT (NOT TO EXCEED 30% OF DIRECT COSTS) PATIENT CARE COSTS INPATIENT OUTPATIENT SUBTOTAL (DIRECT COSTS) $ $ INDIRECT COST ALLOCATION (NOT TO EXCEED 15% $ OF DIRECT COSTS) $ Total Grant Funds Expenditures $ $ SIGNATURE: DATE REQUESTED: (TYPED) PROJECT DIRECTOR