Delta Dental of Oklahoma



NOTE: The application for 2013 funding is not yet available. It will be very similar to the 2012 application, so you may want to use this one to begin gathering your data.

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APPLICATION FOR 2012 FUNDING

The mission of the Delta Dental of Oklahoma Oral Health Foundation

is to facilitate dental health and education in the state of Oklahoma

by funding programs and services that promote oral health.

FUNDING GUIDELINES OVERVIEW

The Delta Dental of Oklahoma Oral Health Foundation (DDOK-OHF) is the community service affiliate of Delta Dental of Oklahoma (DDOK). The Foundation aspires to partner with organizations and institutions that share our passion for promoting oral health in Oklahoma. The Foundation awards grants for projects and initiatives which advance dental education and research or provide access to dental care for the less fortunate and underserved throughout the state of Oklahoma. Priority is given to programs that provide free dental care services/education to indigent or underserved populations and those that utilize volunteer dental professionals. The grant application should include measurable goals and a method for measuring success. We highly recommend reading our Funding Guidelines & Priorities prior to applying. Grantees will be required to sign a grant agreement and submit a final grant report.

ELIGIBILITY REQUIREMENTS – 4-POINT TEST:

1. Grant-seeking organization must be a 501(c)(3) nonprofit organization with public charity status, an educational institution or a government agency. We cannot award grants to individuals.

2. We fund only dental health and education related projects, programs, and initiatives.

3. The program must serve Oklahomans.

4. The program must not discriminate on the basis of race, color, national origin or religion.

We welcome proposals which are in accordance with our Foundation goals, requirements and funding guidelines.

To ensure consideration for 2012 funding, grant applications must be postmarked or hand-delivered by August 31, 2011. (Our office closes at 5:00 PM.)

Grants will be awarded in December and funded during 2012.

For additional information or assistance, please contact:

Terrisa Singleton, Foundation Specialist

Delta Dental of Oklahoma Oral Health Foundation

16 N.W. 63rd Street, Ste. 201

Oklahoma City, OK 73116

Phone: 405-607-4771

Toll-Free: 800-522-0188 x 771

E-mail: foundation@

INSTRUCTIONS:

1. IMPORTANT: Save this file to your computer’s hard drive before you begin completing it.

2. Type answers in right column. Cell will expand as needed. Save, print, and sign application.

3. Mail completed, signed application along with required supporting documentation (NO staples please) to:

Delta Dental of Oklahoma Oral Health Foundation, 16 N.W. 63rd Street Ste. 201, Okla. City, OK 73116

4. E-mail this application only (not supporting documentation) to: foundation@

5. DEADLINE: To ensure consideration for 2012 funding, application must be postmarked by August 31, 2011.

|Enter Amount Requested: $ 0 |

|Enter Submission Date: 00/00/0000 |

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| |

|Section A: Organization Information |

|1 |Name of Organization | |

|2 |Legal name, if different | |

| |(as it appears on your IRS Determination Letter) | |

|3 |Name of Dental-Related | |

| |Program/Project/Clinic/Event | |

| |(Hereafter referred to as Dental Program) | |

|4 |Employer Identification Number (EIN) | |

|5 |Organization STREET address |Street address |

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| | | |

| | |City |

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| | | |

| | |ZIP |

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|6 |Organization MAILING address |Street address |

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| | |City |

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| | |ZIP |

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|7 |County (i.e., Cleveland) | |

|8 |Phone | |

|9 |Fax | |

|10 |Web site | |

|11 |Organization Type: Check all that apply |501(c)(3) Federally Qualified Health Center (FQHC) |

| |NOTE: To checkmark a box, double-click the box, |Educational Institution Public Agency/Unit of government |

| |then select “Checked” under Default Value. | |

| | |None of the above |

| | |If none of these designations apply, you must have a 501(c)(3) organization serve as your fiscal sponsor.|

|11a |List Fiscal Sponsor, if applicable |Organization |

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| | |Executive Director |

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| | |Phone |

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| | |E-mail |

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|12 |In what year was your organization founded? | |

|13 |Briefly describe your organization, its mission | |

| |and its goals. | |

| |(NOTE: Dental program will be described in | |

| |Section D.) | |

|14 |Is your organization affiliated with a religious | |

| |organization or political party or organization? | |

| |If so, please identify. | |

|15 |Do any Delta Dental of Oklahoma Oral Health | |

| |Foundation board members or staff serve your | |

| |organization in any capacity? | |

| |If so, disclose here. | |

|16 |Is any member of your organization’s board or | |

| |staff an immediate family member of a Delta | |

| |Dental of Oklahoma Oral Health Foundation board | |

| |member? | |

| |If so, disclose here. | |

|Section B: Contact Information |

|1 |Exec. Director/Top Paid Staff |Name |

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| | |Title |

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| | |Direct Phone |

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| | |E-mail |

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|2 |Grant Preparer |Name |

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| | |Title |

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| | |Direct Phone |

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| | |Cell Phone |

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| | |E-mail |

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|3 |Dental Program Director/Coordinator |Name |

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| | |Title |

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| | |Direct Phone |

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| | |Cell Phone |

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| | |E-mail |

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|Section C: Dental Program Information |

|1 |Dental Program name | |

|2 |Type (check one) |Ongoing program (year round operation) |

| | |Annual project or event |

| | |One-time or short-term project or event (includes major purchase projects) |

|3 |Which of the following funding criteria does this| Benevolent Dentistry/Access to Care: Clinics, programs, projects and events which provide dental care |

| |program fulfill? |and education to those unable to access the care they need due to financial, physical, or geographical |

| |(Check all that apply.) |barriers. |

| | | |

| | |Public Education: Programs that educate the public to improve oral health and establish life-long |

| | |self-care habits. |

| | | |

| | |Professional Education: Educational programs for dental health professionals. |

| | | |

| | |Oral Health Related Research |

|4 |If event, list date(s) | |

|5 |If clinic, list hours (and days) of operation | |

|6 |Clinic/Event location and contact info |Street address |

| | | |

| | | |

| | |City |

| | | |

| | | |

| | |ZIP |

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| | | |

| | |County |

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| | |E-mail |

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| | | |

| | |Website |

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| | | |

| | |Local phone |

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| | |Toll-free phone |

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| | | |

|7 |Does your program utilize volunteer dentists, |Volunteer dentists only Paid dentists only Both |

| |paid dentists, or both? |Our Dental Director/Coordinator is the only paid dentist. |

|8 |Total number of volunteer dentists utilized | |

| |(per year) | |

|9 |Total number of paid dentists utilized | |

| |(per year) | |

|10 |Paid Dentists. Please submit Dentist Payment | |

| |Schedule (by CDT code) OR list salary/hourly wage| |

| |here.) | |

| |(Does not apply to school faculty.) | |

|11 |Volunteer Dentists. List names of dentists | |

| |involved. | |

| |(If more than ten, list only ten names.) | |

|12 |Volunteer Hygienists. List any hygiene schools, | |

| |programs, or groups that will be providing | |

| |volunteers for this project. | |

|13 |Other Volunteers. List total number of any other | |

| |volunteers involved (dental assistants, dental | |

| |staff, lay volunteers, etc.) | |

|14 |Collaboration. Describe any community support or | |

| |other organizations with whom you are | |

| |collaborating. | |

|15 |HIPAA. Programs handling patients’ Protected | Our program does not handle PHI, so HIPAA laws do not apply. |

| |Health Information (PHI) must follow HIPAA laws. |Our program does/may handle PHI and we have policies and training in place to ensure our staff and |

| |Please check one. |volunteers are HIPAA compliant. |

| | |Our program does/may handle PHI but we do not currently have policies or training in place to ensure |

| | |HIPAA compliance. |

|16 |Civil Liability and Insurance. | Professional volunteers and organization are covered under the “Volunteer Professional Services Immunity|

| |Check all that apply. |Act”. |

| | |Organization has an insurance policy to cover professional volunteers and organization. (Submit proof of |

| | |insurance with supporting documentation.) |

| | |Organization has an insurance policy to cover paid dental staff and organization. (Submit proof of |

| | |insurance with supporting documentation.) |

| | |Other. Please explain: |

|17 |Property Insurance. | |

| |Is your dental equipment covered by insurance? | |

|Section D: Purpose, Evaluation, and History of Dental Program |

|1 |Mission Statement | |

|2 |Purpose: Please describe the overall purpose and | |

| |goals of the dental program. | |

|3 |Services. Which of these services are provided by| Dental screening by dentist X-rays |

| |your dental program? |Dental screening by hygienist Extractions |

| |Please check all that apply. |Dental screening by assistant Fillings |

| | |Dental screening by trained non-professional Root canals |

| | |Dental exams Crowns |

| | |Oral hygiene education Dentures/partials |

| | |Oral hygiene (cleanings) Sealants |

| | |Fluoride varnish |

| | |Others: |

| | | |

| | | |

| | | |

|4 |Estimated total number of people this program | |

| |will benefit during the grant year | |

|5 |Populations served (i.e., demographics such as | |

| |children, adults, seniors, at-risk, under-served,| |

| |uninsured, etc.) | |

|6 |Geographic area served (i.e., cities, counties, | |

| |etc.) | |

|7 |Specific qualifications/guidelines patient must | |

| |meet to be eligible for services (i.e., 150% FPL,| |

| |uninsured, local resident) | |

|8 |Proof of patient eligibility required (if any) | |

| |(i.e., proof of income, etc.) | |

|9 |Other Assistance: Do you have a method in place | |

| |to ascertain whether a prospective patient | |

| |qualifies for Soonercare or other assistance and | |

| |to connect him/her to those resources? | |

| |(Explain.) | |

|10 |If your program will likely provide services to | |

| |individuals who qualify for Soonercare (i.e. | |

| |low-income children), please explain why. | |

|11 |If your program will likely provide services to | |

| |individuals who qualify for Soonercare, will you | |

| |apply for Soonercare reimbursement? Why or why | |

| |not? | |

|12 |Fees: Do you charge for any of your services? (If| |

| |so, please submit your Fee Schedule (by CDT code)| |

| |with your supporting documentation.) | |

|13 |Evaluation: Describe the program goals and | |

| |outcome objectives (please be specific). | |

|14 |How will you measure/track your results? | |

|15 |When reporting the value of donated services, | |

| |upon what do you base your figures? | |

|16 |History: If project: Was it attempted | |

| |previously, if so describe the outcome. | |

| |If clinic: What year was it established? | |

| |Give brief history and outcomes. | |

|Section E: Grant Request and Dental Program Budget Information |

|1 |Grant amount requested | |

|2 |Total organizational budget | |

|3 |Dental program budget only |Total budget |

| | |$ |

| | | |

| | |Total dollars for salaries/benefits |

| | |$ |

| | | |

| | |Total dollars for “overhead” (building, rent, utilities, insurance, computers, etc) |

| | |$ |

| | | |

|4 |Percentage of dental program budget this grant | |

| |request represents | |

|5 |List other grants or sources of funding your | |

| |program has received or been awarded within the | |

| |past 12 months. | |

|6 |List other grants or sources of funding your | |

| |program is seeking. (What are you doing to | |

| |broaden your funding base?) | |

|7 |Do you receive United Way funds? | |

|8 |Period covered by grant |From (mm/dd/yy): 01/01/12 |

| | |To (mm/dd/yy): 12/31/12 |

| | | |

|9 |List specific items for which DDOK-OHF grant | |

| |funds would be used. | |

| |(NOTE: Include three competitive bids for any | |

| |single equipment item over $5,000.) | |

|10 |If awarded, do you have a preference or need | |

| |regarding when funds are dispersed? | |

|11 |If one-time or short-term project, list | |

| |completion date | |

|12 |If ongoing program, how long do you anticipate | |

| |needing our support? | |

|13 |Will any funds not expended during the grant year| |

| |be returned to DDOK-OHF? If not, explain plans | |

| |for use. | |

|14 |Describe how the DDOK-OHF grant would be | |

| |acknowledged. | |

|15 |Are there ways in which DDOK-OHF can help you be | |

| |successful? | |

|Section F: Supporting Documentation |

| |In order to receive consideration for funding, please submit the following items with your application. If you are a past grant recipient and the document |

| |we have on file is correct, you may check the “unchanged” column (except for those items listed as required) and not submit the item. |

| | |

| | |

| |Item |

| |Attached |

| |Unchanged |

| | |

| |A. |

| |Most Recent Financial Statement |

| | |

| |required |

| | |

| |B. |

| |Last Year’s Audited Statement (if available) |

| | |

| | |

| | |

| |C. |

| |Organization Annual Budget |

| | |

| |required |

| | |

| |D. |

| |Dental Program Budget |

| | |

| |required |

| | |

| |E. |

| |Current List of Board of Directors and Key Staff |

| | |

| | |

| | |

| |F. |

| |501(c)(3) IRS Determination Letter (yours or fiscal sponsor’s) |

| | |

| | |

| | |

| |G. |

| |IRS Form W-9 (click here to download form) |

| | |

| |required |

| | |

| |H. |

| |Brochure or Annual Report (if available) |

| | |

| | |

| | |

| |I. |

| |Fee Schedule (by CDT Code) |

| |(Note: Required only for clinics that charge fees to patients) |

| | |

| |see note |

| | |

| |J. |

| |Dentist Payment Schedule (by CDT Code) |

| |(Note: Required only for clinics that pay dentists on a fee for service basis) |

| | |

| |see note |

| | |

| |K. |

| |New Applicants only: 990 Forms from previous two years |

| | |

| | |

| | |

| |L. |

| |Proof of Insurance (if applicable) |

| | |

| | |

| | |

|Section G: Authorization (Signatures Required) |

| | |

| |I have reviewed the Application for Funding submitted on behalf of our organization and agree that it fairly represents the needs, governances, and |

| |finances of our organization. I understand a site visit will be conducted as part of the evaluation process. |

| | |

| |By signing below, I authorize the Delta Dental of Oklahoma Oral Health Foundation to use the name of our organization, details of the project, and the |

| |amount of any award for purposes of publicizing the grant. |

| | |

| |Further, I understand that a grant agreement and final report are required of all grant recipients. (Sample grant agreement and report available at |

| |munityservice/grantmaking.asp.) |

| | |

| | |

| |Executive Director/Top Paid Staff |

| | |

| |Title |

| | |

| | |

| |Print Name |

| | |

| | |

| |Signature |

| | |

| | |

| |Date |

| | |

| | |

| |Grant Preparer |

| | |

| |Title |

| | |

| | |

| |Print Name |

| | |

| | |

| |Signature |

| | |

| | |

| |Date |

| | |

| | |

| | |

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