2017 Request for Applications (RFA) KOMEN FUND FOR …komenoc.org/wp-content/uploads/2012/08/2017-KF-RFA-FINAL_Orange-… · The Affiliate’s goal is also in accordance with Komen’s

Komen Fund for Breast Health Care / 2017 RFA | DUE August 19, 2016 by 5 p.m. Pacific Time via GeMS Page 1 of 21

2017 Request for Applications (RFA) KOMEN FUND FOR BREAST HEALTH

CARE – 2017

The promise of Susan G. Komen® is to save lives and end breast cancer forever by empowering people, ensuring quality care for all and energizing science to find the cures. The Affiliates of Susan G. Komen represent the nation’s largest

private funding source for research and community breast health programs.

Application Deadline: Friday, August 19, 2016, 5:00 P.M. Pacific Time

Go to affiliategrants.komen.org to complete and submit an application. NO paper copies of the application will be accepted by Komen Orange County.

Inquiries should be directed to Jennifer Nguyen at [email protected] or by calling (714) 957-9157 ext. 41.

Please allow adequate time before the application deadline for

responses to grant-related questions.


Request for Applications

Komen Fund for Breast Health Care – 2017

Susan G. Komen® Orange County —along with those who generously support us with their talent, time and resources—is working to better the lives of those facing breast cancer in our community. We join hundreds of thousands breast cancer survivors and activists around the globe as part of the world’s largest and most progressive grassroots network fighting breast cancer. Through events like the Komen Orange County Race for the Cure®, we have invested $35 million in local breast health and breast cancer awareness programs in Orange County. Up to 75 percent of net proceeds generated by Komen® Orange County stay in Orange County. The remaining income goes to the Susan G. Komen Research Program, which supports grants and scientific partnerships to find the cures. About Susan G. Komen® Susan G. Komen is the world’s largest breast cancer organization, funding more breast cancer research than any other nonprofit while providing real-time help to those facing the disease. Since its founding in 1982, Komen has funded more than $889 million in research and provided $1.95 billion in funding to screening, education, treatment and psychosocial support programs serving millions of people in more than 30 countries worldwide. Komen was founded by Nancy G. Brinker, who promised her sister, Susan G. Komen, that she would end the disease that claimed Suzy’s life. Visit komen.org or call 1-877 GO KOMEN. Connect with us on social at ww5.komen.org/social. Notice of Funding Opportunity and Statement of Need Komen Orange County established the Komen Fund for Breast Health Care (KFBHC) Grant Program as a safety net of funding-of-last-resort so that uninsured and underinsured Orange County women and men, with abnormal or suspicious breast health issues, who do not qualify for government assistance, can gain timely access to diagnostic procedures to determine breast cancer and subsequently gain access to appropriate cancer care. As found in the 2015 Komen Orange County Community Profile Report, Orange County does not have a county hospital or any other medical facility required to provide indigent care and/or free mammography. The area residents rely on the collaboration of community clinics, hospitals, and the Komen Orange County Affiliate to provide breast health care for uninsured and underinsured low income women and men. The goal of this grant program is to ensure the breast cancer continuum of care is inclusive of Orange County residents who are medically underserved, underinsured, or uninsured to access breast cancer diagnostic services without the burden of significant


financial costs associated with health/cancer care. The Affiliate’s goal is also in accordance with Komen’s Mission statement and the laws, which are governed by the State of California. Komen Orange County will award the Komen Fund for Breast Health Care to local non-profit clinics, hospitals, and cancer centers that will provide breast health services between January 1, 2017 to December 31, 2017. Applicants may request funding for up to $60,000.00 for one year. With the increased health care coverage following the Affordable Care Act, applicants are strongly encouraged to be conservative and realistic in the grant amount requested. Any organization that is NEW to Komen Orange County’s grant process or has never been awarded the Komen Fund for Breast Health Care may only submit an application up to $20,000.00. Komen Orange County has identified the following funding priority areas. Funding priorities were selected based on data from the 2015 Komen Orange County Community Profile Report. The 2015 Community Profile can be found on our website at http://komenoc.org/our-community-need/. Priority will be given to applicants that demonstrate benefit to one or more of the following 2015 Community Profile target populations: Priority Populations: (in alpha order)

・ African-American/Black Women

・ Asian and Pacific Islander Women

o Specifically Chinese, Filipino, Japanese, Korean, South Asian and Vietnamese

・ Hispanic/Latina Women

・ Women 65 years and older

Important Dates Application System Open On or around Friday, July 15, 2016 Grant Writing Workshop Tuesday, July 26, 2016 from 2-4 p.m. PT Application Deadline Friday, August 19, 2016 by 5 p.m. PT Award Notification On or before Tuesday, November 1, 2016 Award Period January 1, 2017 – December 31, 2017 Award Recognition Event Friday, December 2, 2016

Eligibility Individuals are not eligible for funding. Grants will be awarded only to eligible organizations. Applicants must meet the following eligibility criteria to be considered for funding:


Program must be specific to breast health and/or breast cancer. If a program includes other health issues along with breast cancer, such as a breast and cervical cancer program, funding may only be requested for the breast cancer portion.

All past and current Komen-funded grants or awards to Applicant are up-to-date and in compliance with Komen requirements.

Applicant has documentation of current tax exempt status under the Internal Revenue Service code.

Applicant must be a non-profit organization located in or providing services to one or more of the following locations:

o Orange County, CA

If applicant, or any of its key employees, directors, officers or agents is convicted of fraud or a crime involving any other financial or administrative impropriety in the 12 months prior to the submission deadline for the application, then applicant is not eligible to apply for a grant until 12 months after the conviction. After such 12 month period, applicant must demonstrate in its application that appropriate remedial measures have been taken to ensure that any criminal misconduct does not recur.

Applications will only be accepted from U.S. non-profit clinics and hospitals, including cancer centers.

Applicants MUST be a California Cancer Detection Program provider and/or Family Pact provider.

Applicants MUST be able to enroll patients into the Breast and Cervical Cancer Treatment Program (BCCTP).

Healthcare facilities MUST provide board certified care for breast cancer diagnosis by a qualified healthcare team.

Healthcare facilities MUST not discriminate based upon age, gender, race, disability, religion, national origin, sexual orientation and an individual’s ability to pay.

Allowable Expenses Funds may be used for the following types of expenses provided they are directly attributable to the program:

Diagnostic Breast Health Services Procedures such as: o Diagnostic Mammograms


o Breast Biopsies o Breast Ultrasounds o Breast MRI o Surgical Consultation o Surgical Follow Up Visits o Patient’s share of cost up to the allowable cost of the procedure1

Funds may not be used for the following purposes:

Research, defined as any project or program with the primary goal of gathering and analyzing data or information.

o Specific examples include, but are not limited to, projects or programs designed to: Understand the biology and/or causes of breast cancer Improve existing or develop new screening or diagnostic methods Identify approaches to breast cancer prevention or risk reduction Improve existing or develop new treatments for breast cancer or to

overcome treatment resistance, or to understand post‐treatment effects

Investigate or validate methods Education regarding breast self-exams/use of breast models Education via mass media (e.g. television, radio, newspapers, billboards), health

fairs and material distribution. These methods may be used to promote projects, but evidence-based methods such as 1-1 and group sessions should be used to educate the community and providers.

Development of educational materials or resources Construction or renovation of facilities Political campaigns or lobbying General operating funds (in excess of allowable indirect costs) Debt reduction Fundraising (e.g. endowments, annual campaigns, capital campaigns, employee

matching gifts, events) Event sponsorships Projects completed before the date of grant approval Payments/reimbursement made directly to individuals Land acquisition Program-related investments/loans Scholarships Thermography Overhead/Administrative Costs

o Program Staff/Personnel SCREENING Mammograms

1 To remove financial barriers for receiving diagnostic care, the Komen Fund can be used as a payment of last resort towards the patient’s share of cost for diagnostic procedures for insured women and men who are economically stressed. Please see Attachment A for specific details on approved procedures and maximum amounts allowable under the Komen Fund.


Program Supplies Equipment Treatment

Important Granting Policies Please note these policies before submitting a proposal. These policies are non-negotiable.

No expenses may be accrued against the grant until the agreement is fullyexecuted.

Any unspent funds over $1.00 must be returned to Komen Orange County. Grantee will be required to submit a minimum of one semi-annual progress report

and one final report that will include, among other things, an accounting ofexpenditures. Additional reports may be requested.

At the discretion of Komen Orange County, the grantee may request one no costextension of no more than six months for each grant.

Certain insurance coverage must be demonstrated through a certificate ofinsurance at the execution of the grant agreement, if awarded. Grantee isrequired at minimum to hold:

o Commercial general liability insurance with combined limits of not lessthan $1,000,000 per occurrence and $2,000,000 in the aggregate forbodily injury, including death, and property damage;

o Workers’ compensation insurance in the amount required by the law in thestate(s) in which its workers are located and employers liability insurancewith limits of not less than $1,000,000; and

o Excess/umbrella insurance with a limit of not less than $5,000,000.o In the event any transportation services are provided in connection with

program, $1,000,000 combined single limit of automobile liability coveragewill be required.

o If any medical services (other than referrals) are provided or facilitated,medical malpractice coverage with combined limits of not less than$1,000,000 per occurrence and $3,000,000 in the aggregate will berequired.

o Grantees are also required to name Susan G. Komen Breast CancerFoundation, Inc., Susan G. Komen Orange County, its officers,employees and agents as Additional Insured on the above policies.

No funds will be awarded to support operating or overhead costs to administerthe program.

Grant payments will be made in installments pending receipt of satisfactoryprogress reports.

Applications selected to be awarded will only be allowed to utilize grant funds fordiagnostic breast health procedures including the patient’s share of cost up to theallowable cost of the procedure.

With the expansion of health care coverage through the Affordable Care Act,many women and men who were previously uninsured are now insured butunable to afford the patient’s share of cost associated with receiving diagnosticcare. In an effort to remove the financial barrier to seeking diagnostic care, grant


funds can also be used as a payment of last resort towards the patient’s share of cost for diagnostic procedures (up to the allowable cost of the procedure) for insured women and men who are economically stressed. See Attachment A for specific details on approved procedures and maximum amounts allowable under the Komen Fund for Breast Health Care.

If awarded, it is the sole responsibility of the applicant-organization to establish a partnership with imaging centers and/or entities that will provide diagnostic breast health services prior to the execution of the grant contract.

o The partnership(s) MUST be demonstrated by a Memorandum of Understanding (MOU) signed by all parties involved, such as the applicant-organization, radiologist and/or pathologist.

If the agreed upon reimbursement rates exceed Komen’s allowable amounts in Attachment A, it is the responsibility of the applicant-organization to find other sources of funding to cover the remaining balance for any and all diagnostic breast health procedures.

If awarded, grantees will be required to follow the patient/individual eligibility criteria and health services protocol set forth in the RFA and Grant Contract.

THE INDIVIDUAL ELIGIBILITY CRITERIA: 1. Male or Female 2. Resident of Orange County 3. Uninsured or underinsured (including the inability to pay patient’s share of cost) 4. No age restriction 5. Self declared annual income at or below 300% FPL 6. Immigration status is irrelevant 7. All other sources of funds or coverage must be exhausted before using the

Komen Fund. (For example: Every Women Counts and MediCal/Medicare)

ADDITIONAL GRANTING POLICIES AND EXPECTATIONS: Grantee must provide breast health services in a timely manner in accordance with California’s Cancer Detection Program policies and procedures: 1. Diagnostic consultation services are provided to eligible individuals within 30 days

of initial request. 2. Individuals are notified of negative results within 30 days of service. 3. Individuals are notified of abnormal test results within 10 working days of the receipt

of test results. 4. The maximum elapsed time between initial service and diagnosis is 60 days. 5. The maximum elapsed time between a diagnosis of cancer and a referral for

treatment is 10 working days. 6. Individuals are notified of a diagnosis of cancer within three to five working days of

receipt of test result. 7. The maximum elapsed time between a diagnosis of cancer and initiation of

treatment is 60 days. 8. The provider must assist individuals with a diagnosis of cancer to secure treatment.


9. Individuals return for annual follow-up, ONLY if individual is not eligible for other available programs.

10. A provider must document three unsuccessful attempts to contact the individual before designating lost to follow-up. The third attempt must be certified mail.

Submission Requirements All proposals must be submitted online through the Komen Grants e-Management System (GeMS): https://affiliategrants.komen.org. Applications must be received on or before August 19, 2016 by 5 p.m. PT. No late submissions will be accepted. Review Process Each grant application will be reviewed by at least three independent reviewers. They will consider each of the following selection criteria, weighted equally:

Statement of Need (20%): Does the program provide services to one or more of the target communities described in the Affiliate’s Community Profile? How closely does the program align with the funding priorities stated in the RFA? Program Design (20%): Is the program culturally competent? Is the program evidence-based? How likely is it that the objectives and activities will be achieved within the scope of the funded program? Is the program well planned? Is the budget appropriate and realistic? Does the budget justification explain in detail the reasoning and need for the costs associated with the program? If the proposed program includes collaboration with other organizations, are the roles of the partners appropriate, relevant and clearly defined? Impact (20%): Will the program have a substantial positive impact on increasing the percentage of people who enter, stay in, or progress through the continuum of care? Will the program have a substantial impact on the need described in the funding priority selected? Is the impact likely to be long-term? Organization Capacity (20%): Does the applicant organization, Project Director and his/her team have the expertise to effectively implement all aspects of the program? Is there evidence of success in delivering services to the target population? Is the organization fiscally capable of managing the grant program, including having appropriate financial controls in place? Does the applicant organization have the equipment, resources, tools, space, etc., to implement all aspects of the program? Does the organization or staff have appropriate licenses, certifications, accreditations, etc. to deliver the proposed services? Does the organization have a plan to obtain the resources (financial, personnel, partnerships, etc.) needed to sustain the program beyond the grant term (if awarded)? Are collaborations (if proposed) likely to be sustained beyond the grant term? Does the applicant organization have long-term support from organizational leadership?


Monitoring and Evaluation (20%): Is there a documented plan to measure progress against the stated program goal and objectives, and the resulting outputs and outcomes? Is there sufficient monitoring and evaluation (M&E) expertise for the program? Are there sufficient resources in place for M&E efforts?

The grant application process is competitive, whether or not an organization has received a grant in the past. Funding in subsequent years is never guaranteed. Applicant Support: Questions should be directed to: Jennifer Nguyen (714) 957-9157 ext. 41 [email protected]


IMPORTANT ONLINE APPLICATION INFORMATION

The application must be submitted via Komen’s Grants Online Management System (GeMS) at https://affiliategrants.komen.org. For an application instruction manual, please visit the Affiliate’s Grants webpage, http://komenoc.org/, or contact Jennifer Nguyen at [email protected]. All applicants must follow the application submission instructions, including character counts, and submission of required application materials. All application materials must be in English and must be submitted online in GeMS. NO paper applications or applications sent by email will be accepted. Failure to adhere to these instructions will result in applications being administratively withdrawn from consideration prior to peer review, without appeal. Applications must be received on or before Friday, August 19, 2016 by 5 p.m. Pacific Time. Applicants are strongly encouraged to complete, review and submit their applications with sufficient time to allow for technical difficulties, human error, loss of power/internet, sickness, travel, etc. Extensions to the submission deadline will not be granted to allow for lateness, corrections, or submissions of missing information, with the rare exception made for severe extenuating circumstances at the sole discretion of Komen Orange County. SUBMISSION REQUIREMENTS: Step 1: Go to https://affiliategrants.komen.org and log in or create new user.

For Returning Applicants, you may create a new username OR use an existing

username from Komen Orange County’s previous grant cycles (a username from another Affiliate CANNOT be used for Orange County, for example if using LA County Affiliate’s username, the Orange County Affiliate’s grant application will not be visible/accessible on GeMS).

For NEW Applicants, you must register at minimum two (2) users with the

following roles: o Project Director (REQUIRED for submission)

The role of Project Director should be assigned to the individual at your organization that will serve as the project’s lead contact for the Komen Orange County Affiliate.

This individual is responsible for validating/approving all new users when they register for the system under their organization.


This individual will have the highest level of access in the system and will be responsible for overseeing all of the administrative functions available such as application creation and completion.

o Authorized Signer (REQUIRED for submission) The role of Authorized Signer should be assigned to the individual

at your organization that has the authority to sign legal documents on behalf of the organization.

This individual is responsible for electronically signing the application before submission and the grant contract if the organization is awarded funds.

o Viewer (Optional) The role of viewer should be assigned to any individual at your

organization that needs access to view the organization’s information but does not need the functionality to save, add, edit, or change anything within the organization’s information.

o Writer (Optional) The role of writer should be assigned to any individual that needs

access to an organization’s application process to help complete the application but does not have the authority to complete the submission process.

This individual cannot change the status of an application and will not have administrative function availability.

Step 2: To register, refer to the Applicant User Guide.

Step 3: Once your new Username is approved, log in and go to View Available Opportunities on your homepage to begin the Application process. For additional grant application information, please refer to the GeMS App User Guide, available to download on www.komenoc.org > Community Impact > Grant Programs > Apply for Komen Fund or email Jennifer Nguyen at [email protected].


APPLICATION INSTRUCTIONS

Make sure to SAVE your work in EVERY SECTION of the APPLICATION

The application will be completed and submitted via the Komen Grants e-Management System (GeMS), https://affiliategrants.komen.org. The required sections/pages in GeMS are listed in ALL CAPS and described below. For an application instruction manual, please visit the Affiliate’s Grants webpage, http://komenoc.org/, or contact Jennifer Nguyen at [email protected]. PROJECT PROFILE This section collects basic organization and project information, including the title of the project, contact information and partner organizations. Attachments for the Project Profile page (if applicable):

Letters of support or memoranda of understanding from proposed collaborators– To describe the nature of the collaboration and the services/expertise/personnel to be provided through the collaboration.

ORGANIZATION SUMMARY This section collects detailed information regarding your organization’s history, mission, programs, staff/volunteers, budget, and social media.

PROJECT PRIORITIES AND ABSTRACT (limit – 1,000 characters) This section collects important information to classify the focus of the project, the priorities to be addressed and a summary of the project (abstract). This abstract should include the target communities to be served, the need to be addressed, a description of activities, the expected number of individuals served and the expected change your program will likely bring in your community. The abstract is typically used by the Affiliate in public communications about funded projects. PROJECT NARRATIVE This section is the core piece of the application. On the Project Narrative page of the application on GeMS, please address the requests below for each section. Statement of Need (limit – 5,000 characters)

Describe the population to be served. Describe evidence of the risk/need within that population, using the RFA funding

priorities and the 2015 Community Profile as a guide. Provide population characteristics (race, ethnicity, economic status, and breast

cancer statistics) specific to the target population. Describe how this program aligns with Komen Orange County’s target

communities and/or RFA funding priorities. Program Design (limit – 5,000 characters)

Explain the program’s goal and objectives, as outlined in your Project Work Plan.


Explain how the program will increase the percentage of people who enter, stay in, or progress through the continuum of care.

Explain how the program is culturally competent. Explain if and how the program is evidence-based and/or uses promising

practices (please cite references). Describe program collaboration and the roles and responsibilities of all

organizations or entities participating in the program. Explain how the collaboration strengthens the program and why partnering

organizations are best suited to assist in carrying out the program and accomplishing the goal and objectives set forth in this application.

Provide a list of referral specialty providers that will be utilized to refer patients for diagnostic procedures and the specific diagnostic procedures that they will be providing. The list may be uploaded onto GeMS, please be sure to reference in the narrative, if uploaded.

Provide copies of letters of collaboration or signed Memorandums of Understanding (MOU) between both parties to ensure they accept the allowable amounts for specific diagnostic procedures.

Explanation of the process to determine patient eligibility for the Komen Fund for Breast Health Care Program and evidence of success in delivering services to the proposed population.

Description of recent trends in patients’ social demographics such as age; most common types of diagnostic procedures prescribed at clinic site(s); and shifts in access/availability of programs.

Organization Capacity (limit – 5,000 characters)

Explain why the applicant organization, Project Director and staff are best-suited to lead the program and accomplish the goals and objectives set forth in this application. Please include appropriate organization or staff licenses, certifications and/or accreditations.

Describe evidence of success in delivering breast health/cancer services to the proposed population. If the breast health/cancer program is newly proposed, describe relevant success with other programs.

o Evidence of success in delivering services to proposed population; in this section, ONLY report data from the Komen Fund for Breast Health Care (do NOT include clients and procedures covered by the Cancer Detection Program or other sources of funding). Be sure to include:

Komen Breast Health Fund Provider since: [insert year] # of patients served: # of procedures conducted: # of cancers detected:

NOTE: If your organization is a new applicant and does not have Komen Fund data to report, please clearly demonstrate how your organization has been successful in providing diagnostic services to the proposed population.


Describe the equipment, resources, tools, space, etc., that the applicant organization possesses or will utilize to implement all aspects of the program.

Describe fiscal capability to manage the delivery of the proposed goals and objectives and ensure adequate measures for internal control of grant dollars.

Describe the organization’s current financial state. How has your organizational budget changed over the last three years? Please explain increase or decrease.

Describe the plan to secure and allocate resources (financial, personnel, partnerships, etc.) to sustain the program at the conclusion of the grant period.

Describe the efforts you will take to communicate this program to your organizational leadership to ensure long-term support/buy-in.

In addition, does your organization provide culturally appropriate assistance with applying for Covered California, a provision of the Affordable Care Act, MediCal, or other health care coverage programs?

If no, explain how your organization determines eligibility for other health care coverage programs?

Demonstrate/Illustrate ability to navigate patients to prescribe diagnostic services as it relates to the breast health continuum of care. In other words, what is your workflow process for ensuring that individuals receive the diagnostic care they need? A visual diagram with an explanation is acceptable.

Please also indicate if there will be an approximate charge of co-pays for an initial consultation and/or other diagnostic procedures as it relates to this program.

Monitoring and Evaluation (limit – 5,000 characters) Grantees will be required to report on the following outputs and outcomes in the progress and final reports: successes and accomplishments, challenges, lessons learned, best practice example, story from an individual that was served with the funding and number of individuals served for each objective (county, race and ethnicity, age and population group).

Describe in detail how the organization(s) will measure progress against the stated program goal and objectives. Please include any templates, logic models, or surveys as attachments in the Project Work Plan – Objectives page.

Describe how the organization(s) will assess how the program had an effect on the selected priority. Please include any templates, logic models, or surveys as attachments in the Project Work Plan – Objectives page.

Describe how the organization(s) will assess program delivery. Please include any templates, logic models, or surveys as attachments in the Project Work Plan – Objectives page.

Describe the monitoring and evaluation (M&E) expertise that will be available for this purpose.

Describe the resources available for M&E during the course of the program. Specify if these resources are requested as part of this grant, or if they are existing organizational resources.

PROJECT TARGET DEMOGRAPHICS


This section collects information regarding the various groups you intend to target with your program. This does not include every demographic group your program will serve but should be based on the groups on which you plan to focus your program's attention. PROJECT WORK PLAN In the Project Work Plan component of the application on GeMS, you will be required to submit the goal and objectives:

Goals are high level statements that provide overall context for what the program is trying to achieve.

Objectives are specific statements that describe what the program is trying to achieve to meet the Goal. An objective should be evaluated at the end of the program to establish if it was met or not met.

The project goal should have at least one objective; there is no limit to the number of objectives. Please ensure that all objectives are SMART objectives: Specific Measurable Attainable Realistic Time-bound You will also be required to submit the timelines, the anticipated number of individuals to be served, and the evaluation method you will utilize for each objective. Write your Project Work Plan with the understanding that each item must be accounted for during progress reporting. The Project Work Plan should only include a goal that will be accomplished with funds requested from Komen Orange County. Objectives that will be funded by other means should not be reported here, but instead, can be included in your overall program description. Example Work Plan GOAL: Provide patient navigation to women with screening abnormalities in order to reduce delays in and barriers to diagnostic care. OBJECTIVE 1: During grant period, patient navigator will contact all women with an abnormal screening within three business days to schedule follow-up appointment. OBJECTIVE 2: By end of grant period, provide 30 uninsured/underinsured women free/reduced cost diagnostic procedures. Attachments for the Project Work Plan page:

Monitoring and Evaluation forms, surveys, logic model, etc. – To monitor progress and determine the effectiveness of the proposed program.

BUDGET


Provide a detailed total program budget for the entire requested grant term. Diagnostic procedures are any procedure used for persons with abnormal screening results or breast cancer symptoms. Ex: Diagnostic Mammograms, biopsies, ultrasounds.

Amount of funds requested must be based on past expenditures and current projections, if applicable. If not applicable, you must provide evidence/justification for the amount

requested. ALL Applicants must provide rationale/data for anticipated increase in number of patients served, procedures conducted, and requested amount in the Written Justification section at the bottom of the budget/patient care section in GeMS.Indicate the percentage of total funds allocated between categories. The total must equal 100%. It must be 100% Diagnosis. REMINDER: No funds will be awarded to support operating or overhead costs to administer the program. Attachments Needed for Key Personnel/Salaries Section:

Resume/Job Description – For key personnel that are currently employed by the applicant organization, provide a resume or curriculum vitae. For new or vacant positions, provide a job description (Two page limit per individual).

Attachments Needed for the Project Budget Summary Section:

Proof of Tax Exempt Status – To document your federal tax-exempt status, attach your determination letter from the Internal Revenue Service. Evidence of state or local exemption will not be accepted. Please do not attach your Federal tax return. To request verification of your organization’s tax-determination status, visit the following page on the IRS Web site:

http://www.irs.gov/Charities-&-Non-Profits/EO-Operational-Requirements:-Obtaining-Copies-of-Exemption-Determination-Letter-from-IRS

REMINDER: Required Supporting Documentation: Must upload the following documents in GeMS

Information regarding Key Personnel – attach in Key Personnel/Salaries Section Proof of Non-Profit Status – attach in Project Budget Summary Section Letters of support, collaboration, MOUs, etc. demonstrating

partnerships/collaborations, only if applicable – attach in Project Profile Section Blank Patient In-take form used to determine eligibility, evaluation forms,

surveys, logic model, etc. At least one attachment is required – attach in Project Work Plan Section

Insurance Documentation required – attach in the Project Budget Summary Section

Optional Attachments:


Financial Documentation is optional for the Komen Fund for Breast Health Care grant program, but it is highly recommended for organizations that are applying for the first time to include a copy of the organization’s most recent 990 or organizational budget.

IMPORTANT REMINDERS: Applications selected to be awarded will only be allowed to utilize grant funds for

diagnostic breast health procedures. See Attachment A for specific details on approved procedures and maximum amounts allowable under the Komen Fund for Breast Health Care.

Grant funds can now be used towards the patient’s share of cost for diagnostic procedures (up to the cost of the procedure indicated in Attachment A) for insured women and men who are economically stressed. The clinic will use their judgment and use the Komen Fund as a method of last resort.

If awarded, it is the sole responsibility of the applicant-organization to establish a partnership with imaging centers and/or entities that will provide diagnostic breast health services prior to the execution of the grant contract.

o The partnership(s) MUST be demonstrated by a Memorandum of

Understanding (MOU) signed by all parties involved, such as the applicant-organization, radiologist and/or pathologist. If the agreed upon reimbursement rates exceed Komen’s allowable

amounts in Attachment A, it is the responsibility of the applicant-organization to find other sources of funding to cover the remaining balance for any and all diagnostic breast health procedures.

APPLICANT SUPPORT: Questions should be directed to Jennifer Nguyen at (714) 957-9157 ext. 41 or [email protected] CONTRACTS: A grant contract will be the legal mechanism for funding. PAYMENT AND REPORTING: All grants over $5,000 will be made in four equal payments. The first payment will be made upon receipt of the fully executed contract at the start of the grant period. The second payment will be made after receipt and approval of a satisfactory progress report of the first quarter; subsequently, the third payment will be made after receipt of a satisfactory 6-month progress report. The final/fourth payment will be made after receipt of a satisfactory progress report for the 3rd quarter.


A final report will be due within thirty (30) days of completion of the entire grant period. Organizations shall maintain all fiscal, statistical, and management books/records pertaining to the program and service delivery. Reporting will include, but not be limited to, an update on progress on completing grant objectives and a detailed accounting of grant funds spent to date. Each grantee will be required to submit a data spreadsheet that will include the following data fields for each individual served:

1. Facility Name 2. Patient ID Number 3. Age of Patient 4. Date of Birth 5. Ethnicity 6. Annual Household Income 7. Total Number of Persons in the

Household 8. Zip Code

9. Date of Service Received 10. Referral Source-(Open-Ended) 11. Specific approved procedure name

with corresponding CPT/SGK code 12. Specific amount paid for each

procedure or patient’s share of cost 13. Person disposition (diagnosis

outcome) 14. Stage of Breast Cancer

REMINDER OF IMPORTANT DATES: Application System Open On or around Friday, July 15, 2016 Grant Writing Workshop Tuesday, July 26, 2016 from 2 p.m. to 4 p.m. PT

Application Deadline Friday, August 19, 2016 by 5 p.m. PT

Award Notification On or before Tuesday, November 1, 2016

Award Period January 1, 2017 to December 31, 2017

Make sure to SAVE your work in EVERY SECTION of the APPLICATION


ATTACHMENT A: The purpose of this list of approved breast cancer-related diagnostic procedures is to serve as a guideline for allowed procedures to be administered through this grants program. All diagnostic procedures including patient’s share of cost MUST not exceed these approved costs. If awarded, grantee-clinics are responsible for any and all costs that exceed allowable amounts listed below.


Attachment B: Writing SMART Objectives Project planning includes developing project goals and objectives. Goals are high level statements that provide overall context for what the project is trying to achieve. Objectives are specific statements that describe what the project is trying to achieve and how they will be achieved. Objectives are more immediate than goals and represent milestones that your project needs to achieve in order to accomplish its goal by a specific time period. Objectives are the basis for monitoring implementation of strategies and/or activities and progress toward achieving the project goal. Objectives also help set targets for accountability and are a source for project evaluation questions. Writing SMART Objectives To use an objective to monitor progress towards a project goal, the objective must be SMART. A SMART objective is:

1. Specific: Objectives should provide the “who” and “what” of project activities. Use only one action verb since objectives with more than one verb imply that

more than one activity or behavior is being measured. Avoid verbs that may have vague meanings to describe intended

output/outcomes (e.g., “understand” or “know”) since it may prove difficult to measure them. Instead, use verbs that document action (e.g., identify 3 of the 4 Komen breast self –awareness messages).

The greater the specificity, the greater the measurability. 2. Measurable:

The focus is on “how much” change is expected. Objectives should quantify the amount of change expected.

The objective provides a reference point from which a change in the target population can clearly be measured.

3. Attainable: Objectives should be achievable within a given time frame and with available

project resources. 4. Realistic:

Objectives are most useful when they accurately address the scope of the problem and projectmatic steps that can be implemented within a specific time frame.

Objectives that do not directly relate to the project goal will not help achieve the goal.

5. Time-bound: Objectives should provide a time frame indicating when the objective will be

measured or time by which the objective will be met. Including a time frame in the objectives helps in planning and evaluating the

project.

SMART Objective Examples Non-SMART objective 1: Women in Green County will be provided educational sessions.

This objective is not SMART because it is not specific, measurable, or time-bound. It can be made SMART by specifically indicating who is responsible for providing the educational sessions, how many people will be reached, how many sessions will be conducted, what type of educational sessions conducted, who the women are and by when the educational sessions will be conducted.


SMART objective 1: By September 2017, Pink Organization will conduct 10 group breast cancer education sessions reaching at least 200 Black/African American women in Green County. Non-SMART objective 2: By March 30, 2018, reduce the time between abnormal screening mammogram and diagnostic end-result for women in the counties of Jackson, Morse and Smith in North Dakota.

This objective is not SMART because it is not specific or measurable. It can be made SMART by specifically indicating who will do the activity and by how much the time will be reduced.

SMART objective 2: By March 30, 2018, Northern Region Hospital breast cancer patient navigators will reduce the average time from abnormal screening mammogram to diagnostic conclusion from 65 days to 30 days for women in the counties of Jackson, Morse and Smith in North Dakota.

SMART Objective Checklist

Criteria to assess objectives Yes No

1. Is the objective SMART?

Specific: Who? (target population and persons doing the activity) and What? (action/activity)

Measurable: How much change is expected?

Achievable: Can be realistically accomplished given current resources and constraints

Realistic: Addresses the scope of the project and proposes reasonable projectmatic steps

Time-bound: Provides a time frame indicating when the objective will be met

2. Does it relate to a single result?

3. Is it clearly written?

Source: Department of Health and Human Services- Centers for Disease Control and Prevention. January 2009. Evaluation Briefs: Writing SMART Objectives. http://www.cdc.gov/healthyyouth/evaluation/pdf/brief3b.pdf

Documents

2017 Request for Applications (RFA) KOMEN FUND FOR …komenoc.org/wp-content/uploads/2012/08/2017-KF-RFA-FINAL_Orange-… · The Affiliate’s goal is also in accordance with Komen’s