Appendix I

FIRST 5 LA

Dental Health Innovation Project Request For Proposals

QUALIFICATIONS REVIEW TOOL

STRENGTHENING THE DENTAL SAFETY NET TO PROVIDE SERVICES IN NON-TRADITIONAL SETTINGS

DATE: / REVIEWER NAME:
APPLICANT NAME:
POINTS POSSIBLE / TOTAL POINTS RECEIVED
155

The rating scale is 1 to 5, or 1 to 10depending on the question, with 1 = the lowest and 5 = the highestquality, etc.

Please provide comments for any scores at the lowest or highest of each range on a separate sheet of paper.

RECOMMENDATION
The applicant should be…
Approved for Interview / Not approved for Interview

The review framework does not necessarily correspond to the order of application materials. Reviewers are encouraged to consider the entire applicationprior to completing this document.

GENERAL QUALIFICATIONS / MAX POINTS / POINTS GIVEN
Degree to which the project targets underserved children prenatal to five years of age / 10
Degree to which project lead applicant demonstrates capacity to implement project, work with partners, oversee administrative activities related to sub-contracting work (ie. skills, experience). / 10
Degree to which project builds on previous demonstrated success via pilot/demonstration projects / 10
Budget forms – clarity, completeness and applicability to proposed project / 10
Degree to which lead applicant demonstrates experience working with proposed partners / 5
Degree to which project meets three out of the five OHN project objectives / 5
Demonstrated history and experience working with the proposed population / 5
Degree to which project demonstrates geographic diversity / 5
Sub-total / 60
Topic Area 2: STRENGTHENING THE DENTAL SAFETY NET TO PROVIDE SERVICES IN NON-TRADITIONAL SETTINGS
Feasibility of methodology/strategies to provide oral health services to children in non-traditional settings / 10
Degree to which children’s comprehensive oral health needs are met in non-traditional settings (both on-site and via linkages to a dental clinic home) / 10
Demonstrate that the proposed project will lower cost (or at least not increase cost) / 10
Demonstrate that the project will improve the quality of care and health outcomes for the 0-5 population / 10
Degree to which proposal demonstrates leveraging of resources for project / 10
Strength of outreach, recruitment, enrollment and retention strategies to establish children with a dental clinic home / 10
Strength of evaluation plan that demonstrates findings will be used for information sharing with key stakeholders and decision makers to inform changes in policy as needed to sustain efforts. / 10
Strength of sustainability plan. / 10
Does the project propose to use telehealth technology or portable equipment to deliver services in non-traditional settings? If yes, please rate the strength of the proposed strategies to deliver services to children ages 0-5 by rating the two additional criteria below. If not applicable, please mark the boxes N/A.
If applicable, strength of innovative modalities such as telehealth and/or portable equipment to deliver services in non-traditional settings. If N/A to the project, mark the box N/A. / 10
If applicable, degree to which proposal demonstrates that the project model will be integrated within a health home for children ages 0-5, which includes primary care services, behavioral health services, and any other relevant public health services. If N/A to the project, mark the box N/A. / 5
Sub-total / 95
TOTAL POINTS / 155

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*Reviewer: please provide any additional comments or questions on a separate sheet of paper*