North Dakota Comprehensive Cancer Control (ND CCCP) Sub-Contract Program

APPLICATION

A. Cover Page

*Project Title:

Applicant information: * Organization Name:

* Organization Address:

* Tax Exempt Identification Number:

* Data Universal Numbering System (DUNS) Number (A DUNS number is required since this application is for federal funds. Also, your organization’s DUNS number must be registered and currently active on www.sam.gov to receive a contract):

* Primary Contact Person (Project manager):

o * Primary Contact Person’s Phone:

o * Primary Contact Person’s E-mail Address:

Secondary Contact Person:

o Secondary Contact Person’s Phone:

o Secondary Contact Person’s E-mail Address:

* Authorized Contract Representative (Who will sign the contract):

o * Authorized Contract Representative’s Title:

o * Authorized Contract Representative’s E-mail Address:

Fax Number:

* Date of Proposal Submission:

* required

2017 NDCCCP Sub-contract Application

B. Project Narrative

Statement of Need, Capacity, and Sustainability (up to two pages)

1. Describe the geographical area and target population(s) you plan to reach with you proposed activities. Be as specific as possible.

2. Describe the identified need(s) and how the needs were determined for each unique target population addressed.

3. Describe your capacity and experience/training to implement the proposed project.

4. Indicate plans for sustainability of this project beyond the funded project period.

C. Workplan (use workplan template provided below, up to four pages)

Grantees must define and implement at least one objective and one intervention during this grant period. More than one objective or intervention may be proposed. Interventions selected should be new and should not describe something that is currently in place. If the selected intervention already exists, then the proposal must explain how the intervention will be expanded.

Objective(s)

Project objectives – SMART objectives (specific, measurable, achievable, relevant, and timely) are the foundation upon which you base your strategies or activities. You can think of objectives as tools you use to reach your goals. They are arrows you shoot towards your target (goal). Include a baseline and target measurement.

Specific: Cover the who, what, when, and how

Measurable: Have a source to measure progress

Achievable: Be guided by common sense

Relevant (or Realistic): Related to the results that you want to see based on your goal

Time-bound (or Timely): Have a reasonable end date

Example of SMART objective when baseline is known:

By June 17, 2018, 250 Grand Forks County residents 50 and older will report a 20 to 35 percent increase in knowledge of colorectal cancer.

Example of SMART objective when baseline is unknown:

By June 17, 2018, 150 community members will complete a fitness challenge program and report an increased knowledge of 20 percent of the connection between fitness and cancer.

Please delete any extra template space and instructions included in the document prior to submission.

2017 NDCCCP Sub-contract Application

Topic Area: Is this a new topic/project or expanded:

Is the target population considered disparate:

Project Period Objective 1:

Cancer Plan Strategy:

Evidence-Based Intervention 1.1:

Target Population:

Capacity (staff and partner(s) assigned):

Experience (with topic or population):

Data that supports the need for intervention:

Implementation of the Evidence-Based Activity (include timeline):

Program Monitoring and Evaluation Activity:

Evidence-Based Intervention 1.2:

Target Population:

Capacity (staff and partner(s) assigned):

Experience (with topic or population):

Data that supports the need for intervention:

Implementation of the Evidence-Based Activity (include timeline):

Program Monitoring and Evaluation Activity:

Evidence-Based Intervention 1.3:

Target Population:

Capacity (staff and partner(s) assigned):

2017 NDCCCP Sub-contract Application

Experience (with topic or population):

Data that supports the need for intervention:

Implementation of the Evidence-Based Activity (include timeline):

Program Monitoring and Evaluation Activity:

Topic Area: Is this a new topic:

Is the target population considered disparate:

Project Period Objective 2:

Cancer Plan Strategy:

Evidence-Based Intervention 2.1:

Target Population:

Capacity (staff and partner(s) assigned):

Experience (with topic or population):

Data that supports the need for intervention:

Implementation of the Evidence-Based Activity (include timeline):

Program Monitoring and Evaluation Activity:

Evidence-Based Intervention 2.2:

Target Population:

Capacity (staff and partner(s) assigned):

Experience (with topic or population):

Data that supports the need for intervention:

Implementation of the Evidence-Based Activity (include timeline):

Program Monitoring and Evaluation Activity:

2017 NDCCCP Sub-contract Application

Evidence-Based Intervention 2.3:

Target Population:

Capacity (staff and partner(s) assigned):

Experience (with topic or population):

Data that supports the need for intervention:

Implementation of the Evidence-Based Activity (include timeline):

Program Monitoring and Evaluation Activity:

Topic Area: Is this a new topic:

Is the target population considered disparate:

Project Period Objective 3:

Cancer Plan Strategy:

Evidence-Based Intervention 3.1:

Target Population:

Capacity (staff and partner(s) assigned):

Experience (with topic or population):

Data that supports the need for intervention:

Implementation of the Evidence-Based Activity (include timeline):

Program Monitoring and Evaluation Activity:

Evidence-Based Intervention 3.2:

Target Population:

Capacity (staff and partner(s) assigned):

Experience (with topic or population):

2017 NDCCCP Sub-contract Application

Data that supports the need for intervention: progress

Implementation of the Evidence-Based Activity (include timeline):

Program Monitoring and Evaluation Activity:

Evidence-Based Intervention 3.3:

Target Population:

Capacity (staff and partner(s) assigned):

Experience (with topic or population):

Data that supports the need for intervention:

Implementation of the Evidence-Based Activity (include timeline):

Program Monitoring and Evaluation Activity:

2017 NDCCCP Sub-contract Application

D. Estimated Budget and Justification

Category Requested Sub-contract Funding

Final Sub-contract Budget

In-kind Contribution

(Identify source and projected dollar

amount)

Final In-kind Contribution (Identify

source and dollar amount)

Printing, copying (average cost is $.05/sheet)

Itemized description:

Justification:

Supplies (e.g., purchase of materials, etc.)

Itemized description:

Justification:

Meetings (e.g., facilities/associated costs; mileage @ $0.535/mile)

Itemized description:

2017 NDCCCP Sub-contract Application

Justification:

Special events: (e.g., educational sessions, focus groups, etc.)

Itemized description:

Justification:

Personnel hourly wage (include fringe benefits)

Itemized description:

Justification:

Other expenses

Itemized description:

Justification:

Subtotals Total: Total: Total: Total:

Please delete any extra template space and instructions included in the document prior to submission.

2017 NDCCCP Sub-contract Application