Abstinence Education Application



FY2016Abstinence Education ApplicationINDIANA STATE DEPARTMENT OF HEALTHDivision of Maternal and Child HealthPlease use the Abstinence Education RFP to complete this documentAPPLICATION DUE DATEFriday, May 15, 20155:00 PM ESTMQuigleyState of IndianaFY2016section 1: instructionsPlease refer to the RFP for detailed instructions on how to complete this document. For each section, refer to the corresponding section in the Abstinence Education RFP.This is an electronic application. The entire application cannot exceed 50 pages (including this entire Application attachment, forms, etc.). Applications that exceed the page limit will be considered non-responsive and will not be entered into the review process.IMPORTANT: REFER TO ABSTINENCE EDUCATION RFP FOR DETAILED INSTRUCTIONS ON HOW TO COMPLETE THIS APPLICATION.section 2: COMPLETION CHECKLISTthis checklist is to assist in assuring each section of the application is complete. before submitting, please confirm that each section is completed in its entirity. FORMCHECKBOX Section 3: Important Information FORMCHECKBOX Section 4: Summary FORMCHECKBOX Section 5: Application Narrative FORMCHECKBOX 5-1: Organizational Background/Capacity FORMCHECKBOX 5-2: Evidence-based Programming FORMCHECKBOX 5-3: Statement of Need FORMCHECKBOX 5-4: Project Goals and Objectives FORMCHECKBOX 5-5: Activities FORMCHECKBOX 5-6: Staffing Plan FORMCHECKBOX 5-7: Resource Plan/Facilities FORMCHECKBOX 5-8: Evaluation Plan FORMCHECKBOX 5-9: Sustainability Plan FORMCHECKBOX 5-10: Literature Citations FORMCHECKBOX Section 6: Budget FORMCHECKBOX Section 7: Required Attachments FORMCHECKBOX 7-1: Bio-sketches FORMCHECKBOX 7-2: Job Descriptions FORMCHECKBOX 7-3: Timeline FORMCHECKBOX Section 8: Additional Required Documents FORMCHECKBOX 8-1: IRS Nonprofit Tax Determination Letter FORMCHECKBOX 8-2: Org Chart & Program-Specific Org Chart FORMCHECKBOX 8-3: Letters of Support / Agreement / MOUsSection 3: important informationproject InfoRmationProject Title: FORMTEXT ?????Amount Requested: $ FORMTEXT ?????Agency Name: FORMTEXT ?????City: FORMTEXT ?????Zip: FORMTEXT ?????County: FORMTEXT ?????Agency Email: FORMTEXT ?????Agency Phone: ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????Agency Fax: ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????Agency Website: FORMTEXT ?????Contact InformationPrimary Contact: FORMTEXT ?????Contact Address: FORMTEXT ?????City: FORMTEXT ?????Zip: FORMTEXT ?????County: FORMTEXT ?????Contact Email: FORMTEXT ?????Contact Phone: ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????Contact Fax: ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????Required SignaturesSignature of Applicant Authorized Executive Official*: FORMTEXT ?????Name: FORMTEXT ?????Position Title: FORMTEXT ?????Signature of Project Director*: FORMTEXT ?????Name: FORMTEXT ?????Position Title: FORMTEXT ?????Signature of Person Authorized to Make Legal and Contractual Agreements*: FORMTEXT ?????Name: FORMTEXT ?????Position Title: FORMTEXT ?????*Typed signature will be acceptedSection 4: Summary summary (2000 Character limit) FORMTEXT ?????section 5: Application Narrative Section 5-1: Organization Background / Capacity (2000 character limit) FORMTEXT ?????Section 5-2: Evidence-based programming (2000 character limit) FORMTEXT ?????Section 5-3: Statement of need (4000 character limit) FORMTEXT ?????Section 5-4: Project Goals and Objectives (2000 character limit) FORMTEXT ?????Section 5-5: Activities (6000 character limit) FORMTEXT ?????Section 5-6: staffing plan (4000 character limit) FORMTEXT ?????Section 5-7: resource plan / facilities (2000 character limit) FORMTEXT ?????Section 5-8: evaluation plan (6000 character limit) FORMTEXT ?????Section 5-9: Sustainability plan (2000 character limit) FORMTEXT ?????Section 5-10: literature citations (2000 character limit) FORMTEXT ?????Section 6: BudgetThe Budget excel spreadsheet is to be completed as a separate Microsoft Excel workbook. Please be sure to complete all three tabs:SummaryFY16 Schedule AFY16 Schedule BSection 7: Required Attachments Section 7-1: Bio-sketchesName: FORMTEXT ?????Position Title: FORMTEXT ?????Education/ Training: (Begin with most recent. Also include other initial professional education, such as nursing)Institution and LocationMM/YY of GraduationDegree (if applicable)Field of Study FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Relevant Employment Experience (Begin with most recent and include the three most relevant experiences.)Agency/ CompanyPeriod of EmploymentPosition TitleResponsibilities FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name: FORMTEXT ?????Position Title: FORMTEXT ?????Education/ Training: (Begin with most recent. Also include other initial professional education, such as nursing)Institution and LocationMM/YY of GraduationDegree (if applicable)Field of Study FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Relevant Employment Experience (Begin with most recent and include the three most relevant experiences.)Agency/ CompanyPeriod of EmploymentPosition TitleResponsibilities FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name: FORMTEXT ?????Position Title: FORMTEXT ?????Education/ Training: (Begin with most recent. Also include other initial professional education, such as nursing)Institution and LocationMM/YY of GraduationDegree (if applicable)Field of Study FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Relevant Employment Experience (Begin with most recent and include the three most relevant experiences.)Agency/ CompanyPeriod of EmploymentPosition TitleResponsibilities FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name: FORMTEXT ?????Position Title: FORMTEXT ?????Education/ Training: (Begin with most recent. Also include other initial professional education, such as nursing)Institution and LocationMM/YY of GraduationDegree (if applicable)Field of Study FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Relevant Employment Experience (Begin with most recent and include the three most relevant experiences.)Agency/ CompanyPeriod of EmploymentPosition TitleResponsibilities FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name: FORMTEXT ?????Position Title: FORMTEXT ?????Education/ Training: (Begin with most recent. Also include other initial professional education, such as nursing)Institution and LocationMM/YY of GraduationDegree (if applicable)Field of Study FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Relevant Employment Experience (Begin with most recent and include the three most relevant experiences.)Agency/ CompanyPeriod of EmploymentPosition TitleResponsibilities FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Section 7-2: Job descriptionsPosition Title RolesResponsibilities Qualifications FORMTEXT ?????1) FORMTEXT ?????1) FORMTEXT ?????1) FORMTEXT ?????2) FORMTEXT ?????2) FORMTEXT ?????2) FORMTEXT ?????3) FORMTEXT ?????3) FORMTEXT ?????3) FORMTEXT ?????4) FORMTEXT ?????4) FORMTEXT ?????4) FORMTEXT ?????5) FORMTEXT ?????5) FORMTEXT ?????5) FORMTEXT ?????Position Title RolesResponsibilities Qualifications FORMTEXT ?????1) FORMTEXT ?????1) FORMTEXT ?????1) FORMTEXT ?????2) FORMTEXT ?????2) FORMTEXT ?????2) FORMTEXT ?????3) FORMTEXT ?????3) FORMTEXT ?????3) FORMTEXT ?????4) FORMTEXT ?????4) FORMTEXT ?????4) FORMTEXT ?????5) FORMTEXT ?????5) FORMTEXT ?????5) FORMTEXT ?????Position Title RolesResponsibilities Qualifications FORMTEXT ?????1) FORMTEXT ?????1) FORMTEXT ?????1) FORMTEXT ?????2) FORMTEXT ?????2) FORMTEXT ?????2) FORMTEXT ?????3) FORMTEXT ?????3) FORMTEXT ?????3) FORMTEXT ?????4) FORMTEXT ?????4) FORMTEXT ?????4) FORMTEXT ?????5) FORMTEXT ?????5) FORMTEXT ?????5) FORMTEXT ?????Position Title RolesResponsibilities Qualifications FORMTEXT ?????1) FORMTEXT ?????1) FORMTEXT ?????1) FORMTEXT ?????2) FORMTEXT ?????2) FORMTEXT ?????2) FORMTEXT ?????3) FORMTEXT ?????3) FORMTEXT ?????3) FORMTEXT ?????4) FORMTEXT ?????4) FORMTEXT ?????4) FORMTEXT ?????5) FORMTEXT ?????5) FORMTEXT ?????5) FORMTEXT ?????Position Title RolesResponsibilities Qualifications FORMTEXT ?????1) FORMTEXT ?????1) FORMTEXT ?????1) FORMTEXT ?????2) FORMTEXT ?????2) FORMTEXT ?????2) FORMTEXT ?????3) FORMTEXT ?????3) FORMTEXT ?????3) FORMTEXT ?????4) FORMTEXT ?????4) FORMTEXT ?????4) FORMTEXT ?????5) FORMTEXT ?????5) FORMTEXT ?????5) FORMTEXT ?????Position Title RolesResponsibilities Qualifications FORMTEXT ?????1) FORMTEXT ?????1) FORMTEXT ?????1) FORMTEXT ?????2) FORMTEXT ?????2) FORMTEXT ?????2) FORMTEXT ?????3) FORMTEXT ?????3) FORMTEXT ?????3) FORMTEXT ?????4) FORMTEXT ?????4) FORMTEXT ?????4) FORMTEXT ?????5) FORMTEXT ?????5) FORMTEXT ?????5) FORMTEXT ?????Section 7-3: TimelineFY 2016Activities1 234PLANNING ACTIVITIES FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX IMPLEMENTATION ACTIVITIES FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX EEVALUATION/ REPORTING ACTIVITIES FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Section 8: Additional required documents Section 8-1: IRS Nonprofit Tax Determination Letter Section 8-2: Org Chart & Program-Specific Org Chart Section 8-3: Letters of Support / Agreement / MOUs ................
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