Piedmont Healthcare Community Benefit

Direct Services Grant Application Cycle 2018

Welcome

Before beginning the application process, please print the guidelines, which can be foundonline at If you have any questions about the application process, please email .

All applications must be submittedby October 11, 2017 by 5pm ESTvia e-mail to . Please carefully review and contact us with any questions. Thank you in advance for giving this funding announcement your consideration and we look forward to receiving your application.

Organization information

Organization Name:
Any other name(s) the organization may be known as:
Tax ID:
Tax Status:
Address
City, State, Zip Code:
Phone:
Website:
Year Founded:
Fiscal Year end date:
Current annual operating budget:
Organization Type:
Number of Full-time Staff:
Number of Part-time Staff:
Number of Volunteers:
Geographic county of applicant:
Primary county(s) served by applicant:

Contact information

List the CEO/Executive Director or person authorized to sign the grant agreement for your organization.

Name:
Title:
Email:
Office phone:

If primary contact is not the same person authorized to sign the grant agreement, please provide additional primary contact information below.

Name:
Title:
Email:
Office phone:

Hospital alignment and priority area identification

Please highlight the affiliated hospital location AND priority(s) to be addressed with this grant.

Piedmont Atlanta
  • Access to care
  • Reduce preventable readmissions and re-encounters
  • Increase access to and awareness of cancer-related programming
  • Reduce preventable instances of heart disease, hypertension, and stroke
/ Piedmont Fayette
  • Access to care
  • Reduce preventable readmissions and re-encounters
  • Increase access to and awareness of cancer-related programming
  • Reduce preventable instances of heart disease, stroke, obesity and obesity related diseases, such as Type II Diabetes
  • Support senior health

Piedmont Henry
  • Access to care
  • Reduce preventable readmissions and re-encounters
  • Increase access to and awareness of cancer-related programming
  • Reduce preventable instances of heart disease, hypertension, and stroke
/ Piedmont Mountainside
  • Access to care
  • Reduce preventable readmissions and re-encounters
  • Increase access to and awareness of cancer-related programming
  • Reduce preventable instances of heart disease, hypertension, and stroke

Piedmont Newnan
  • Access to care
  • Reduce preventable readmissions and re-encounters
  • Increase access to and awareness of cancer-related programming
  • Reduce preventable instances of heart disease, stroke, obesity and obesity related diseases, such as Type II Diabetes
/ Piedmont Newton
  • Access to care
  • Reduce preventable readmissions and re-encounters
  • Increase access to and awareness of cancer-related programming
  • Reduce preventable instances of heart disease, stroke, obesity and obesity related diseases, such as Type II Diabetes

Piedmont Athens
  • Access to care and health services
  • Combat obesity and diabetes
  • Support cardiovascular, cerebrovascular and respiratory health
  • Increase access to and awareness of cancer-related programming
  • Support maternal and infant health

Case Statement

As part of its grant making process, Piedmont requires each applicant organization to submit a written case statement in two parts. The first should include a summary of the applying organization’s vision and mission, as well as current successes and accomplishments. The second should detail the proposed grant program to be funded by this grant and should include such information as populations served and specific services to be provided.A concise, narrative style versus bullet-points or lists is preferred.

Part 1: Describe the organization’s vision and mission, as well as current successes (up to 300 words)

Part 2: Describe theprogramto be supported by this funding opportunity

Emphasis should be placed on linking the proposed program withPiedmont priorities and objectives.

Name of program:
Amount of funding requested:
Start date of program:
End date of program:
Number of people expected to reach/serve through program:
Is this a new or existing program?
Describe the population served, including gender, age group, and socioeconomic barriers:
Describe the program in detail (up to 300 words)

Goals and Objectives

Please describe one to threeSMART goals with objectives for the proposed grant program. To develop SMART outcomes, use the template below and fill in the blanks:

By_____/_____/_____, ______

[WHEN—Time bound] [WHO/WHAT—Specific]

from ______to ______

[MEASURE (number, rate, percentage of change and baseline)—Measurable]

Goal 1
  • Objective

Evaluation Plan

Describe the evaluation plan in detail, including evaluation methods, expected effects of the program, expected differences in the behaviors of key individuals, and expected differences in conditions in the community (up to 300 words)

Use the Community Toolbox resource listed below for assistance with developing anevaluation plan.

Budget

As part of its grant making process, Piedmont requires each applicant organization to submit a written budget in three parts:the organizational budget template, the program budget narrative, and a comprehensive list of other funding for the proposed program. Together, these narratives should provide a complete financial and qualitative description that supports the proposed program plan.A concise, narrative style versus bullet-points or lists is preferred.

Part 1: Organizational Budget Template

Please fill out the Organizational Budget template in Microsoft Excel, which includes the proposed program budget items, and submit it with your application. Other templates will not be accepted for review. Total program expenses should add up to the total dollar amount indicated in the total program cost. Funds must be allocated for evaluation. Be sure to note any other funding sources for the proposed grant program. Please refer to the spreadsheet for direction on preparing the budget.

Part 2: ProgramBudget Narrative (up to 300 words)

Describe how the proposed program budget cost elements are necessary to implement objectives and accomplish the goals listed in this application. The maximum dollar request for funding is $15,000.

Part 3: Other funding for the proposed grant program

Does the proposed program have other funders?
If yes, please list all other funders and amounts dedicated to the proposed program, including partial funders:
If this grant is a portion of a larger program, please describe the overall goals of this grant funding and how it fits into the larger funding goal of the program:

Attachments

Please submit the following documents with your application. Applications without the appropriate supporting documents will not be processed. If you have any questions about the documents to be submitted, please email . All documents should be provided as Word (.doc or .docx), Adobe (pdf) or Excel format (.xls or .xlsx). Please name each attachment accordingly. We are not able to consider any application that is incorrect, missing documentation or is incomplete.

Please provide the following:

●501c3 IRS Tax Exemption Letter

●A completed W9 form

●A completed application on the template provided

●A completed budget on the template provided. Please note that the budget narrative within the application should list all of the requested line items in the template.

●A comprehensive list of other funders for the requested activity.

Review and Submit

Prior to submitting your application, please review to make sure all information is correct and complete. Email application and all supporting documents in a .ZIP file to . We will contact you by email to inform you on the status of your application.