COMPLETE EACH SECTION OF THE APPLICATIONIN THE ORDER PROVIDED. INCOMPLETE &/OR OUT OF ORDER APPLICATIONS MAY BE REJECTED BY THE REVIEW COMMITTEE.

Additional information can befound in the “Guidelines” document.

SUBMISSION INSTRUCTIONS:

One original, plus eight (8) copies of the applications must be postmarked by October 3, 2014.

All copies should be individual stapled packets and be in proper order. No paperclips or binders.

The original application should be one-sided. Copies may be double-sided, if desired.

Submit an electronic copy to by October 3, 2014.

Mail USPS regular delivery to:

Indiana Breast Cancer Awareness Trust, P.O. Box 8212, Evansville, IN 47716

No Certified Mail. No Overnight. No Signature Required for Release.

You may use Delivery Confirmation, if so desired.

Questions should be directed to the IBCAT office at 866.724.2228 or via email at .

THIS SHEET IS INFORMATIONAL ONLY.

DO NOT INCLUDE AS PART OF GRANT APPLICATION.

Indiana Breast Cancer Awareness Trust, INC.

Request for Grant funding: Cover Page

Organization Name
Project Director & Title
Street Address
City, State, Zip Code
Email
Phone / ( )Fax ( )
Federal Tax ID #
Grant Contact (if different from Project Director)
Phone / ( ) Fax ( )
Email
Patients in Need of Assistance should contact: / Name:
Phone: ( )
Title of Project
This Project is: (check one) / New Program for 2015 / Existing/Continuation
Total Amount Requested
(Maximum - $17,500.00 for existing programs. $5,000.00 for new programs.)
MUST match Budget Form – No Rounding
Grant Period / 01/01/2015 to 12/31/2015
Name & Title of Approving
Organization Personnel (Typed) / Date
Signature & Title of
Approving Personnel (Other
Than Project Director)

By signing this document permission is hereby granted to the Indiana Breast Cancer Awareness Trust to publish this award should your application be selected for funding.

Project/Organization Information

Title of Project:
Organization:

In addition to Low Income and Uninsured, your Target Population includes (check all that apply):

Caucasian / Urban / Under 40 (family history only)
African American / Rural / Ages 40-59
Hispanic / Ages over 60
Other: (specify)

Your program guidelines will be restricted to those falling into which poverty level?

200% & below / 250% & below(IBCAT Preferred Level) / 275% & below
Other: (specify/details)

*Must provide copy of patient application/intake form showing how patients are qualified for your program. See checklist at end of application.

County/ies to be served (list all):

This program is:

New for 2014 / An Existing/Continuation Program

If new, does your organization have experience developing and implementing programs for the specified target population? (Please briefly elaborate below.)

If this program is an existing/continuation program, how many years has the program existed?

# of Years / # of women served by this program in the past calendar year.

Are you an Indiana Breast & Cervical Cancer (BCCP) Provider?

Yes, we are a BCCP Provider / No, we are not a BCCP Provider

Are you a current grant recipient of (please check applicable programs) –

Susan G. Komen for the Cure / IBCAT / Avon
Other: (specify)

APPLICATION NARRATIVE

SECTION #1 – Address all topics below. (Not to exceed two (2) pages for this entire section.)

Project Description -

Statement of Need –On the chart below provide the requested information on the counties the grant intends to serve.*In addition, also provide narrative including local mammography rates, barriers to screening services, breast cancer diagnosis statistics, etc. (Do not give national statistics.)

County / Poverty Rate / Uninsured females ages 40-60 years at or below 200% poverty rate / Unemployment Rate (most current year)

*Available resources you may use are: Centers for Disease Control’s (CDC) Center for Chronic Disease Prevention and Health Prevention Survey using the Behavioral Risk Factor Surveillance results; US Census Bureau – Quick Facts; United Way; National Cancer Institute; Local Komen Community Profile data; and Indiana Cancer Facts and Figures from the American Cancer Society

List and describe the primary goals of the project and detailed plans to achieve these goals.

How is this project unique compared to other breast cancer screening programs in your service area?

SECTION #2 –Address all topics below. (Not to exceed one (1) page for this entire section.)

What resources does your organization (and your service provider, if applicable) have for this project – facilities, equipment, partnerships?

How will you recruit participants for your project? (Note: All applicants are required to submit a patient application/in-take form and or process for qualifying patients for the screening program. See attachment listing at end of application.)

What potential challenges do you foresee and how will you overcome them?

SECTION #3 –Address topic below. (Not to exceed one-half page.)

Provide a realistic, detailed timeline (by month or quarter) for implementing this program.

SECTION #4 –Address topic below. (Not to exceed one-half page.)

What evaluation methods will you use to define success of your program?

Project Budget

In addition to completing the Budget Form, please attach a narrative explanation justifying the proposed budget. Do not exceed one typed page.

*Please note – If requesting monies for personnel, please provide a clear demonstration of need for these salary dollars.Personnel requests must not exceed 10% of Patient Care Costs.

Detailed Budget for Entire Budget Period
From January 1, 2015through December 31, 2015
Personnel
(must be specific to project)
Personnel Expense Not To Exceed
10% of Patient Care Costs / Type
Contract
Hourly
Salaried / % Effort
on Project / Base
Salary / Grant Amount Requested
Name / Role
on Project / Salary
Requested / Fringe
Benefit / Totals
Subtotals / $
Supplies (Listeach requested item with cost)
Travel (Reimbursable at IRS rate in effect on September 1, 2014.) / $
Total Patient Care Costs:
Maximum Reimbursement*(includes both professional & Tech component):
Screening Mammogram (77057) - $80.00
Digital Screening Mammogram (G0202) - $130.00
Diagnostic Unilateral Mammogram (77055) - $85.00
Diagnostic Bilateral Mammogram (77056) - $110.00
Digital Diagnostic Unilateral Mammogram (G0206) - $125.00
Digital Diagnostic Bilateral Mammogram (G0204) - $155.00
Ultrasound (77645) - $95.00
*Based on Medicare Reimbursement rates as of 7/01/14
Note: IBCAT Provides a limited pool of additional funds for biopsy procedures. Initial screenings must be through your IBCAT Grant. Requests to be made on a case-by-case basis. Request as last source of funding. Exhaust other funding sources first. Approval of requests is NOT guaranteed.
_____ (# of) Screening Mammograms @ ______(rate)
_____ (# of) Diagnostic Unilateral Mammograms @ ______(rate)
_____ (# of) Diagnostic Bilateral Mammograms @ ______(rate)
_____ (# of) Ultrasonds @ ______(rate)
(Funding breakout may be reallocated by request to IBCAT.)
Total Funding Request
(Maximum $17,500.00 for existing/continuation programs. $5,000 for new programs.) / $

REQUIRED ATTACHMENTS

1.Patient Application/In-Take Form – All grant programs must have process for qualifying patients into their screening program.

2.If your facility is not the mammography/radiology provider, a Letter of Agreement clearly stating the other party’s acceptance of IBCAT reimbursement ratesmust be provided.

3.IRS Determination Lettershowing proof of Non-Profit Status. State Sales Tax Exemption Certificate is not applicable.

4.If requesting personnel funding, please include a resume for each individual. Do not include if not asking for personnel funding.

5.Grantee/IBCAT Compliance Checklist (See next page.)

THIS SHEET IS INFORMATIONAL ONLY.

DO NOT INCLUDE AS PART OF GRANT APPLICATION.

Grantee/IBCAT Compliance Checklist

(Include only one copy of this checklist attached to original application copy.)

Applicant
Completed / IBCAT / ITEM
Cover Sheet Fully complete
Cover Sheet – Signed & Dated by Approving Personnel
Project/Organization Information Fully Complete
Section #1 Narrative Fully Complete, Did not exceed 2 pages,
Not less than 12 point typeface.
Section #2 Narrative Fully Complete, Did not exceed 2 pages,
Not less than 12 point typeface.
Section #3 Narrative, Did not exceed ½ page, Not less than
12 point typeface.
Section #4 Narrative, Did not exceed ½ page, Not less than
12 point typeface.
Project Budget Form Completed
-Personnel Did not exceed 10% of Patient Costs
-Supplies are Itemized with Cost Breakdown
-Number of Mammograms Indicated
Project Budget Justification, Did not exceed 1 page, Not less
than 12 point typeface.Must include narrative explanation.
Patient Application/Intake Form with Qualifying Data
Letter of Agreement if Applicant is not Service Provider
stating provider acceptance IBCAT reimbursement rates.
IRS Determination Letter – Proof of Non-Profit Status
If Applicable, Resume of Funded Personnel Only
One Original, Plus 8 Copies Included – Each application should be stapled and in proper order. No Paper Clips or Binders.
Original must be single sided. Copies may be double-sided, if desired.
Electronic Copy Submitted

______

Project Coordinator SignatureDate

______

IBCATCompliance VerificationDate

This checklist should be included with the original application only.

Applications Must be Postmarked and Electronic Copy Submitted

No Later Than Friday, October 3, 2014.

See information on page 1 for specific submittal instructions.

IBCAT Grant ApplicationRevised 07/14