Application Checklist and Form

Planners4Health

Application Checklist and Form

Through an overarching collaborative strategy that brings together members of theAmerican Planning Association(APA) and theAmerican Public Health Association(APHA), thePlan4Healthproject aims to build capacity to address population health goals and promote the inclusion of health in non-traditional sectors. Plan4Health is supported through the Centers for Disease Control and Prevention (CDC) as part of the National Dissemination and Implementation program within the Division of Community Health, Funding Opportunity Announcement #DP14-1418. This application form is fora newinitiative supporting cross-sector promotion of public health: Planners4Health.

Please submit completed applications, including all documents noted in the checklist below, in one email to by 11:59pm ESTon Friday, October 14th, 2016.

Additional project expectationsand application guidance are outlined in thePlan4Health: Planners4HealthRequest for Applications document. Please contact Plan4Health staff ith specific questions or concerns.

Application Checklist

Please find below the Planners4HealthApplication Checklist. All documents are required, unless otherwise noted; incomplete applications will not be reviewed.

Please submit the following as three separate attachments in Word or PDF format in one email:

Completed Application Form (this document)

1. Overview
2. Assessment
3. Narrative
4. Budget

Resumes (project manager and task force members)

Letter of Support (APA chapter Letter of Support required; additional letters of support optional)

Application Form

1. OVERVIEW

APA Chapter

Planners4Health Project Manager

Name:

Email:

Phone:

Mailing Address:

Task Force Members

At the time of submission, each task force must identify a project manager as well as one representative from planning and one representative from public health. Task force membership may expand during the project period.

Please list names and professional affiliations.

1)Project Manager:

2)Planning Representative:

3)Public Health Representative:

4)

5)

1. ASSESSMENT

APA will develop aPlanners4Healthcurriculum to disseminate findings from Plan4Health coalitions andto support the growth of members and chapters in developing skills to bring health into planning practice.

To help inform how the curriculum takes shape, please complete the assessment below to provide a picture of where the chapterand the task forcemembers are in terms of healthy communities work.

Chapter

Please limit each response to 250 words or less.

1)Is health a priority for chapter members at this time? Please explain particular areas of interest.

2)Has the chapter supported sessions or conference tracks on health in the past? If so, please describe conference activities or special sessions.

3)Has the chapter participated in Plan4Health Cohort One or Cohort Two? If so, please describe the chapter’s role (e.g. chapter leadership on coalition leadership team; dissemination of project activities through social media; presentation of Plan4Health at chapter conference).

4)Aremembers of the chapter involved in APA’s Healthy Community Interest Group? If so, please describe the level of engagement and member activities.

5)Please identify health-related planning projects in the state or region and indicate the chapter’s involvement in these projects.

6)Please provide other comments or additional information as appropriate, including any identified opportunities or barriers to healthy communities work.

Task Force

Please complete the following assessment for each task force member by ranking his/hercomfort level with the topic areas below.

A selection of “low” indicates that the task force member is not comfortable with the topic area and would benefit from additional training. A selection of “high” indicates that the task force member is comfortable in the topic area.

If additional members have been identified, please copy and paste a second table below.

Task force
Member #1 / Task force Member #2 / Task force Member #3 / Task force Member #4 / Task force Member #5
Collaboration, partner engagement, and developing coalitions / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High
Community Needs Assessment / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High
Communication Activities / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High
Developing Strategic Action Plans / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High
Identifying Sources for Community, State, and National Data / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High
Incorporating Health Equity Into Programs / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High
Using Policies, Systems, and Environmental (PSE) Change Approaches to Prevent Chronic Disease / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High / Low
Medium
High

Please identify other training topics or areas of interest below (optional).

1. NARRATIVE

Planners4Healthprovides a framework for supporting healthy community activities at the chapter level. Please respond to the following questions to describe the task force’s initial plans and where the chapter and task forcehope to be after completing the project.

Please limit each response to 500 words or less.

Project Management

1)Describe how the task force plans to complete the activities at the anticipated funding level. Describe and outline the task force’s approach to project management, including proposed staffing.

2)Describe how the task force will work together as a team. How do you complement each other? How do you represent the planning and public health sectors?

Initial Plans

3)Describe how the task force will start to identify colleagues and partners in other sectors. How will the task force cultivate health champions in the community?

4)The first portion ofPlanners4Healthwill be an assessment or asset map of the resources that the chapter could leverage. How will the task force begin to identify key stakeholders and/or resources at the chapter level (state, regional, or multi-state level)?

Project Impact

5)While plans will change throughout the project period, please identify what the chapter and task force hope to accomplish. How do you seePlanners4Health potentially impacting APA and local work?

1. BUDGET

Please complete the following budget charts with justifications of proposed expenses for an estimated budget of $40,000. Actual awards will vary and will be dependent on available funding.

Examples have been included as reference points and are italicized; please delete all information that is not related to the proposedchapter budget before submission.

PERSONNEL:$30,500

Position Title and Name / Annual Salary / Time / Months / Amount Request
Project Manager / $50,000 / 50% / 6 months / $12,500
Task Force Member Stipends / n/a / n/a / 6 months / $18,000
Total / $30,500

Justification

Description of responsibilities should be directly related to specific program objectives.

Project Manager: This position directs the overall operation of the project including overseeing project activities, coordination with partners and task force members as well as the development of project deliverables. This individual is responsible for ensuring reports are submitted to APA. This position relates directly to all program objectives.

Task Force Member Stipends: Task force members are responsible for participating in project activities and trainings as well as contributing to the completion of project deliverables.Task force members relate directly to all program objectives. Five task force members X $3,600 per task force members = $18,000.

Fringe Benefits(if applicable)

Provide information on the rate of fringe benefits used and the basis for their calculation.

Fringe Benefit Total: $______% of Total Salaries = Fringe Benefits

SUPPLIES:$2,000

Item Requested / Type / Number Needed / Unit Cost / Amount Requested
Office supplies / Pens, paper / 6 months / $50/month / $300
Infographic/Educational Pamphlet / n/a / 500 copies / $2/copy / $1,000
Software / Microsoft / 1 / $500 / $500
Roundtable Folders / n/a / 50 / $2/folder / $100
Report Printing / n/a / 50 / $2/report / $100
Total / $2,000

Justification

Provide a justification for the use of each item and relate it to specific program objectives.

Office supplies will be used by staff members to carry out daily activities of the program.

Infographic/Educational pamphlets: will raise project awareness and strengthen community engagement.

Word processing software will be used to document program activities.

Roundtable Folders: will be provided to attendees during the final partner roundtable presentation of project findings.

Report printing will be used to disseminate project findings.

TRAVEL (In-State and Out-of-State) Total: $3,671

Please include estimated travel costs to attend the National Planning Conference in May 2017 as well as APA’s Fall Leadership Meeting in September 2017.

Travel: In-State

Number of Trips / Number of People / Cost of Airfare / Number of Total Miles / Cost per Mile / Amount Requested
1 / 2 / n/a / 50 / $0.57 / $28.50
25 / 1 / n/a / 250 / $0.57 / $142.50
Total / $171
Per Diem/Lodging / Number of People / Number of Units / Unit Cost / Amount Requested
Per Diem / 1 / 2 days / $50/day / $100
Lodging / 1 / 1 night / $200/night / $200
Total / $300

Justification

The Project Manager and task force member will attend local planning conference.

The Project Manager will make an estimated 25 trips across the state to engage potential partners.

Travel: Out-of-State

Number of Trips / Number of People / Cost of Airfare / Number of Total Miles / Cost per Mile / Amount Requested
2 / 2 / $500 / n/a / n/a / $2,000
Total / $2,000
Per Diem/Lodging / Number of People / Number of Units / Unit Cost / Amount Requested
Per Diem / 2 (1/trip) / 3 days / $50/day / $300
Lodging / 2 (1/trip) / 2 nights / $200/night / $800
Total / $1,100
Ground Transportation / Number of People / Amount Requested
Yes / 2 (1/trip) / $100
Total / $100

Justification

The Project Managerand task force member will travel to New York City and Washington DC to attend national conferences to disseminate project findings.

OTHER:$3,829

Item Requested / Number of Months / Estimated Cost per Month / Number of Staff / Amount Requested
Roundtable Event Space / n/a / n/a / All / $500
Website support/Communications Support/Video production / 6 months / $221.50/month / n/a / $1,329
Conference fees / n/a / n/a / 2 / $2,000
Total / $3,829

Justification

Roundtable Event Space: A project deliverable, the roundtable will convene cross-sector partners to share findings and develop next steps for the project.

Website Support/Communications Support/Video Production:The chapter and task force will support communications activities throughout the project period, including website updates and use of social media.

Conference fees: Task force members will attend local and national conferences to disseminate project findings.

GRAND TOTAL: $40,000

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