Iowa Foundation for Medical Care (IFMC)
Oklahoma or Colorado-based applications due by 3/1/2018
Illinois or Iowa-based applications due by 7/2/2018
2018Telligen Community Initiative– Letter of Interest
Organization Information
Applicant Organization Name:Address:
City, State, Zip Code
Phone Number: / Fax Number
Email: / Website:
Contact Person: / Contact Person Title:
Tax ID number: / Tax Status: 501(c)(3)
Governmental Entity / YesNo
YesNo
Summary of the proposed project seeking TCI funding support (2-3 sentences)
Projected TCI grant funding request(per grant award ceiling of $50,000): / $
Geographic impact of your grant (list either city, county, counties if multi-county focused, or state impacted – whichever is most applicable to your proposed work and its targeted geography)
Program/Project Information:
Program/Project Title:Project/program proposes to address this Telligen Community Initiative focus area (select theone that best fits the core of your work) / Social determinants of health / health equity
Health innovation
Healthcare workforce development
Grant Narrative: Maximum of three(3) total pages for the following Letter of Interest questions. The preceding cover page is not part of this page limit – allocate space to your responses as you see fit.
Summary of your organization – Provide a brief history and description of your current programs and organizational capacity to do the work plan you’ll be proposing.
Synopsis of need and project – Provide a succinct description of the community need shaping the project, as well as they project intervention for which you are requesting funding, including goals, target population.
Collaboration and evaluation summary– Introduce any collaborating organizations you’d intend to work with in successful implementation.Please also offer a brief overview of an evaluation/impact assessment plan for this LOI scope of work. If invited to the finalist stage, you’ll have more space to develop a full evaluation presentation.
Budget projection – Include the amount you’d anticipate requesting from TCI and an estimate of the overall budget of the project (both of these are subject to change and you’ll have an opportunity to go into greater detail if invited to the finalist application round. View your LOI response in this area as best guestimates at the time of submission). Provide the level of budget rationale you have developed at the time of the LOI.
Application Form Page 1