Download March of Dimes Texas Chapter Grants Program APPLICATION

March of Dimes
Texas Chapter Grants Program
APPLICATION COVER SHEET – 2013
Applicant Organization:
Address:
P.O. Box 34326
City:
San Antonio
Zeta Phi Beta Sorority, Inc. - Alpha Pi Zeta Chapter
State:
Texas
Zip:
78265
Website:
Main Phone:
210-651-9280
Fax:
Executive Director:
Gwendolyn Oquendo
Phone:
210-545-4214
Email:
[email protected]
Project Coordinator:
Virginia (Ginger) Pope
Phone:
210-651-9280
Email:
[email protected]
Project Title:
Stork’s Nest
Project Goal:
To present prenatal classes to pregnant women in the San Antonio,
Texas area and assist them in changing their behavior which will
decrease the number of premature births and infant mortality rates.
5253 Walzem Rd. San Antonio, TX 78218, 210 N. Rio
Location(s) of Proposed
Services:
Grande, San Antonio, TX 78202, 8455 Crestway Dr, Suite
119, Converse, TX 78109
Disadvantaged pregnant women: Caucasian, African-
Target Population:
(Include race/ethnicity)
American, Hispanic, Native Americans, others
Please indicate the positive impact that the project will measure and report on:
[x ] Increase in knowledge [x] Behavior change [x] Improved birth outcomes [ ] Other _____
Total unduplicated number of people to be served by this
project:
Total Amount Requested:
$7034.00
_________________________
Signature/Date
_________________________
Name/Title
90
Cost Per
Individual:
Year of Funding Requested:
(First, Second or Third)
$50.00
2013
_________________________
Signature/Date
_________________________
Name/Title
1
11. PROJECT NARRATIVE
A. Project Abstract
The Stork’s Nest Program, in conjunction with the Advanced Women’s Center (Baptist Health
System), Pregnancy Testing Center, Healthy Start, Phi Beta Sigma Fraternity, Inc., San Antonio
Metropolitan Chapter of Top Ladies of Distinction, Inc., local churches and numerous other
community organizations, seeks to enhance the quality of life for underprivileged pregnant women
in our community by offering prenatal classes to women. Since 1972 Zeta Phi Beta Sorority, Inc.
has enjoyed a partnership with the March of Dimes in an effort to encourage women to seek
prenatal care within the first trimester of pregnancy. Nationally the sorority has sponsored more
than 175 Stork’s Nest Programs and currently there are three (3) local programs in the San Antonio,
Texas area.
Stork’s Nest is designed to promote prenatal care participation and healthy behaviors during
pregnancy through incentives and education. Stork’s Nest participants “earn” points towards the
following incentives that are based on the lessons being taught. Lesson 1 provides an Insulated
Welcome Bag with Zeta Phi Beta Sorority and March of Dimes Logos printed on the bag. The bag
includes a March of Dimes Journal and a prepackaged Baby Toiletries set. Lesson 2 “Prenatal
Care” provides a set of Onesies and Baby Blanket. Lesson 3 “Eating Healthy” provides a Grocery
Shopping Card and Plastic Baby Food Containers. Lesson 4 “Stress” provides a bubble bath kit for
mom and a small case of water. Lesson 5 “Things to Avoid” provides a set of Diapers. Lesson 6
“The Big Day” provides a Grooming Kit for the baby. Lesson 7 “Caring for Baby” provides a
Baby Bib and Bank. Lesson 8 “Post-Partum” provides a Room Monitor and Lesson 9”Graduation”
provides the mother with a stroller for attending all nine sessions. The program’s education
component provides information, educational material and a variety of other resources such as
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location of WIC clinics and referral to medical service clinics (i.e. Healthy Start, Baptist Health
System). Stork’s Nest/Becoming a Mom/Comenzando bien Curriculum is used as the instructional
tool. Classes are held weekly and the average size of a class is eight (8) to twelve (12) women.
Expectant fathers, grandparents, and other family members are also encouraged to participate.
B. Description
The Storks Nest Program is a nine session program designed to teach pregnant women the
importance of early prenatal care and offer incentives as they attend sessions.
Of the target population in your area, what needs or problems are you addressing in this
initiative? Many of the pregnant women in this population have no formal prenatal instructions.
This program is designed to educate, change dietary behaviors and reduce the rate of prematurity
and infant mortality. How will the project have an impact on these needs or problems? The
project will demonstrate the important of early prenatal care.
What is the capacity of the
applicant to carry out the project (including agency’s mission, key staff, clientele, and
experience working with the target population group) The sorority has been presenting this
program for more than 40 years and is fully committed to the importance of early prenatal care. The
staff conducting the classes is trained medical personnel, with a thorough knowledge and familiarity
of the curriculum being taught. Sorority members also serve as volunteers.
What planning
activities will take place before project startup? A yearly planning retreat is held to discuss and
implement strategies for the programs. All MOD printed information brochures will be included in
Welcome Packets. Announcements of the startup will be displayed in community medical clinics,
churches, schools, community newspapers and brochures and flyers will be distributed to
collaborating partners and organizations. Are you implementing all nine ((9) sessions? Yes
3
If not, which sessions and topics are you covering? N/A What are the staff responsibilities?
1. The Program Coordinator will recruit program participants, community partners, solicit funding
and in-kind support, attend March of Dimes meeting and planning sessions, keep records of
activities of the program, collect data for distribution to requesting agencies and all other
administration duties. 2. Program Facilitators plan and teach the lessons, administer all test and
collect data. 3. Treasurer insures funds are accounted for and are disbursed as outlined in the
grants. All staff report to the Executive Director. What is the role of collaborating organizations
(if applicable)? The role is to supplement funds and in-kind supplies. Example: The Zeta Amicae,
Top Ladies of Distinction, Phi Beta Sigma Fraternity, Undergraduate College Student and other
collaborating agencies participate in a Baby Shower to donate baby items and services to the
project. How will the project be announced to the community? Announcements will occur at
regular meetings of the local Pan-Hellenic Council, local newspapers, church bulletins, Bexar
Necessities (an electronic bulletin board), word of mouth, schools, and medical clinics. How will
progress be monitored? Progress is monitored by completing quarterly progress reports as
requested by March of Dimes, site visits from Local March of Dimes Program Director, Sorority
Program Director, other collaborating partners and agencies as deemed necessary. How will the
project results be shared? Quarterly progress reports will be provided to the grant agency, sorority
and collaborating partners.
C. Project Objectives, Activities & Outcomes
See Pages 9 and 10
D. Evaluation Plan
The program evaluation plan will respond to the directives of the Sorority, Healthy Start,
Baptist Health System and the March of Dimes to ensure the programs objectives are
4
achieved. The plan will ensure the collection of high quality data is designed and
implemented.
A progress evaluation of the program will be conducted to show results
achieved are correct and appropriate and to insure from the data collected is used to make
adjustments to services rendered and to improve the overall program.
One measurable objective of this project is to increase the percentage of positive diet
habits to 95%. Baseline will be established when participants enroll in class and
state the behavior change of their choice. Measurement will be taken at the end of the
nine week session.
Another measurable objective of this project is that the number of women
participating in the program will gain knowledge about the importance of early
prenatal care to 95%. The base line will be established when the participant enrolls
in the program and completes a pretest and at the end of the nine (9) week sessions
by completing a posttest. Measurements will be extracted from these tests.
The final objective of this project is to decrease the low birth rate delivery among
African American and Hispanic women enrolled in the project, and to increase the
number of healthy babies delivered. The baseline will be established when the post
cards are returned.
How will you measure whether this objective was achieved? The objective will be measured
for achievement by actual participation in the program comparing the baseline with the end of
session posttest to determine knowledge gained, questionnaire to determine behavior changes,
post cards returned to determine the birth outcomes. What data or information will be
needed to measure this? The behavior change agreement, pre-test, post-test and post-partum
postcard.
How will this information be gathered? Information will be gathered at the
beginning and end of each nine (9) week session.
What tools will be used? The Behavior
Change Agreement, Pre-Test, Post-Test, Post-Partum Card Who will be responsible for
gathering this data? The Program Coordinator is responsible.
5
Please include any evaluation tools (i.e. pre and posttest, post-partum cards, behavior change
agreements, surveys, attendance sheets, and summary health information) you will use to
capture participant information, evaluate progress, etc. (all forms are included as attachments)
Who will design and carry out the project evaluation? (If at all possible, have someone
other than the program managers determine evaluation results.) The project will be
evaluated by the Program Committee that consists of Wynell Mann (Sorority 2nd Vice
President), Program Chairperson - Sheila Austin (March of Dimes Program Director), and
Michelle Hayes (Sorority Treasurer).
E. Project Impact, Visibility and Sustainability
Beyond the required press release, how will the project be announced to the community?
Marketing Brochures and flyers, Community Health Fairs, Collaborating Partners, Bexar
Necessities (electronic bulletin board). What ways will March of Dimes be visible? A March
of Dimes logo is displayed on all Storks’ Nest material.
In addition to scheduled progress
reports, how will project results be shared? The project results will be shared with the Local
March of Dimes Program Coordinator, Healthy Start, The Advanced Women’s Center, Baptist
Health System and the Healthy Families Network. In addition to the March of Dimes, with
whom and how will project impact be shared? Once data is collected, the impact of the
project will be shared with Zeta Phi Beta Sorority, Inc., The Advanced Women’s Center,
Healthy Start, Baptist Health System and the Healthy Families Network.
Describe the
potential for sustainability beyond the funding period through Alternate sources of
funding or a change in organizational systems or procedures that will sustain the project's
impact. We will continue to seek funding from local funding sources with In-Kind donations
from collaborating partners.
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F. BUDGET JUSTIFICATION
Funds are requested to conduct 4 nine week of classes pertaining to prenatal care. The targeted
audience includes underprivileged women. Classes will be offered in three medical clinics in the
San Antonio, Texas area and will include, a 2 hour session once a week.
Refreshments
Bottle water
Fruit
Granola Bars
288.00
400.00
324.00
Graduation
Certificates $2.00X90=
Certificate Holder $2.00X90=
Punch
$20.00 X 4=
Cake
$20.00X4=
180.00
180.00
80.00
80.00
Incentives
Stroller $39.00X90=
3510.00
Insulated Welcome Bag w/Logos $8.00X90= 720.00
Baby Toiletries Kit 2.77X90=
250.00
Pencils 2boxesX13.00each=
Pens 2 boxesX15.00 each=
Clipboards 1.99X40=
Computer Ink 39.00X4=
Computer Paper 24.99X2=
Postage
Printing
Instructional Material
TOTAL REQUESTED
26.00
30.00
80.00
156.00
50.00
80.00
450.00
150.00
$$7034.00
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March of Dimes
Texas Chapter Community Grants Program
BUDGET FORM
2013
Grant Period From: 2/2013 To: 1/2014
Check One: [ x ] Application [ ] Progress Report
Applicant Name: Zeta Phi Beta Sorority, Inc. - Alpha Pi Zeta Chapter
Project Title: Stork’s Nest
BUDGET (see application guidelines for
an explanation of allowable/not allowable
expenses)
APPLICATION
Total Budget
A. Salaries
(include name, position, and FTE)
Virginia (Ginger) Pope, Program
Coordinator
Evelyn Jean Lawrence, Facilitator
Virginia (Vergie) Bustellos, Facilitator
EXPENDED
(Progress Rpts Only)
9hrs/wk volunteering
6hrs/wk lesson prep
6hrs/wk lesson prep
Sub-total A
B. Expendable Supplies
Refreshments:(water, fruit, granola bars)
Graduation: (certificates punch, cake)
Incentives: (stroller, insulated welcome
bags with Zeta and MOD logos, baby
toiletries)
$0
$0
1012
520
4480
Collaborating Partners Donations
Sorority
Sub-total B
C. Other Expenses/Fees
Office Supplies: pencil, pins, clipboards ink
Postage
Instructional Materials
Printing
4000
4000
$6012
$0
342
80
150
450
Sub-total C
TOTAL AMOUNT REQUESTED
In-Kind Match from
Organization
(if applicable)
$1022
$7034.00
_________________________ ________
Signature - Executive Director Date
$0
8000.00
___________________________
Signature - Director of Operations
Please round figures to the nearest dollar and check budget totals.
8
$0
________
Date
March of Dimes
2013 Texas Chapter Community Grants Program
OBJECTIVES, METHODS/ACTIVITIES & OUTCOMES FORM
Project Title: Stork’s Nest
Applicant: Zeta Phi Beta Sorority, Inc. - Alpha Pi Zeta Chapter
Contact:
Virginia (Ginger) Pope
TO SUPPLEMENT (check one):
X Application
† 6 Month Report
Page: 10
_____
Project Objectives (please number)*#1.By the end of the
4 nine week program, provide 45 mothers in the San
Antonio area with a one (1) hour weekly session on
prenatal care. Methods/Activities To Achieve
Objectives. A pre and posttest will be given. A Behavior
Change Agreement will be completed session evaluation
and postcard completed.
Outcome Measures
EVALUATION OBJECTIVE # 1
To determine if baseline was met or exceeded
Person/Agency
Responsible
Stork’s Nest
Committee,
Healthy Start,
Woman’s Advanced
Clinic, Baptist
System
Grant Amount:
$7034.00
† Year-End/Final Report
Start/End Dates
1/2013-2/2014
Number of Individuals
Served/Reached/Educated
Goal
Actual
90
Baseline:80% of enrolled attend sessions
EVALUATION METHOD: data collected from enrollment applications
1. Activity
Recruit women that are patients of the Advanced Women’s
Clinic, surrounding clinics, schools, churches and
collaborating partners
Zeta Phi Beta
Sorority, Healthy
Start, Advanced
Women’s Center
1/2013-12/2013
90
2. Activity
Distribute brochures and flyer to medical clinics, churches,
collaborating partners, schools
Zeta Phi Beta
Sorority, Healthy
Start, Advanced
Women’s Center
1/2013-12/2013
90
3. Activity
Actual Outcomes for Objective #1 (change in knowledge, behavior and/or birth outcomes - progress reports only):
0
OBJECTIVE # 2 By December 2013, 95% of participants
will agree to make one positive dietary behavior change
as a result of attending the prenatal classes
90
Baseline:95% change in dietary behavior
EVALUATION METHOD: The Behavior Change Agreement will be evaluated at the end of the nine week session
1. Activity
Program
vary
90
95% of program participant will complete a Behavior
participant
Change Agreement after attending session number 3 of the
curriculum
2.
Program
1/2014
90
participant
3.Activity
Actual Outcomes for Objective #2:
OBJECTIVE # 3 on the delivery date of the participant
90
95% of the babies delivered will be a full term normal
delivery
Baseline:95% full term delivery
EVALUATION METHOD: 95% of program participants will complete and return Post-Partum post card
1. Activity - Return the Post-Partum post card
Program
vary
90
participant
2. Activity
3. Activity
Actual Outcomes for Objective #3:
10
Attachments Registration Card Behaviour Change Agreement Client Point Card Sign‐in Sheet Pre Test Eng. Pre Test Sp Post Test Eng. Post Test Sp Post Card Eng Post Card Sp Tax Exempt letter Budget FW9 STORK’S NEST CLIENT POINTS CARD
Client Name:
___________________________________________
Date
Lesson
1
2
3
4
5
6
7
8
9
Client’s
Points Earned
Partner
Total
Points
Notes
STORK’S NEST SIGN-IN SHEET
1.______________________________________________
2.______________________________________________
3.______________________________________________
4.______________________________________________
5.______________________________________________
6.______________________________________________
7.______________________________________________
8.______________________________________________
9.______________________________________________
10._____________________________________________
11._____________________________________________
12._____________________________________________
13._____________________________________________
14._____________________________________________
15._____________________________________________
16._____________________________________________
17._____________________________________________
18._____________________________________________
19._____________________________________________
20._____________________________________________
LOCATION_____________________________________
DATE_______________________
STORK’S NEST REGISTRATION CARD
Date of Initial Visit: ________________
Name: _______________________________________________ Date of birth:__________________ Age:___________
Race:
___ Black/African American___ White ___ Bi-racial ___Asian___ Native/Hawaiian/Pacific Islander___ American Indian
___Other________________
Ethnicity: _______ Non-Hispanic_______ Hispanic
Address: __________________________________________City:________________________________
State:__________________ Zip code:______________
Telephone # Home: ( ________)_______________________ Cell: (________)______________________
E-Mail:____________________________________________
Spouse/Primary Provider:
Name: _______________________________________ Phone #: (______)__________________________
Alternate Contact: ______________________ Relationship: ____________ Phone#: ________________
Prenatal Care Provider:__________________________________
Your Due Date: ___________________
Trimester?
1st_________ 2nd_________ 3rd___________
Level of education completed:
______Middle School ____High School ____ Trade School ____College
Is this your first time to join Storks Nest ___Yes ___ No
STORK’S NEST BEHAVIOR CHANGE AGREEMENT
After attending Sessions three (3&5) “Eating Healthy & Things To Avoid During Pregnancy”
of the Stork’s Nest Program, I____________________________________ agree to change
one (1) negative eating behavior.
Behavior that I will change______________________________________________
___________________________________________________________________
Name (please print)__________________________Signature _________________
Date_______________________________
Becoming a Mom/Comenzando bien Pretest
Lugar: _____________
Fecha: _____________
1. ¿A que raza o grupo étnico perteneces?
2. ¿Su edad?
Caucasian
Afro Americano
Hispanic
Otro ________________
American Indian/Alaskan Native
3. ¿Cuantos años de educación escolar tienes?
No termine la escuela superior
Solamente termine la escuela superior
Algo de universidad
Graduado de la universidad
Menos de 16
16-20
21-25
26-30
4. ¿Cuál es su sexo?
Femenino
Masculino
5. ¿En que trimester de embarazo esta usted?
1 Trimestre(1-12 semanas)
2 Trimeste (13-26 semanas)
6. ¿Es este su primer embarazo?
Si
Si
No
8. ¿Participas en el programa de WIC?
Si
No
10. ¿Donde recibes cuidado prenatal?
Proveedor de salud privado
Clínica de la comunidad
Otro ____________________
3 Trimestre (27-41semanas)
No
7. ¿As tendo su primera sita prenatal?
9. ¿Qué tipo seguro medico?
Tengo seguro de salud privado
No tengo seguro de salud
31-35
36-40
40+
Tengo Medicaid
Chip Perinatal
Otro ______________________
Clínica de la ciudad
Clínica del condado
11. ¿Tome usted medicinas o remedies que no son recetados por su medico? Si
12. ¿Por que no asisto a sus sitas prenatales?
No se donde ir
Transportación
Cuidado de hijos
Preocupada por el pago
13. ¿Si las respuesta es Si? (Escoja todos los que se aplican)
Comprados sin receta
Remedios caseros
Recetas de yerbas
No
Soy indocumentada
Otro
14. ¿Tiene usted alguno de los siguientes problemas de salud? (Escoja todos los que se aplican)
Diabetes
Asma
Hipertension Arterial
Oto
15. ¿Su proveedor medico le ha dicho que uste tiene un embarazo de alto riesgo?
Si
No
16. ¿Usted vas dar pesho a sus bebe? Si
No
17. Por favor contesta las siguientes preguntas:
a. Crees que una mujer que recibe cuidado prenatal tan pronto
sabe que esta embarazado, tendrá un embarazo mas saludable?
b. Crees que fumar durante el embarazo daña la salude del bebe?
c. Crees que tomar alcohol durante el embarazo daña la salud del
bebe?
d. Debe una mujer embarazada recibir cuidado prenatal si se
siente saludable?
Si
Si
No
No
Si
No
Si
No
18. ¿Cuales de los siguientes síntomas son señales de un parto prematuro?
(Escoja todos los que se aplican.)
Contracciones de útero (pueden ser sin dolor) cada 10 minutos o mas?
Liquido transparente, rosado o color café claro que sale de la vagina?
Dolor en la parte baja de la espalda?
Dolores en el abdomen como si fuera de menstruación?
Retorcijones con o sin diarrea?
19. ¿Que debes hacer si crees que tienes parto prematuro? (Escoja todos los que se aplican)
Llama a tu proveedor de cuidado de la salud inmediatamente
Deja de hacer lo que estabas haciendo y descansa sobre tu lado izquierdo
por un hora.
Toma 2-3 vasos de agua o jugo (no tomes café ni soda).
Espera una o dos horas para ver si los síntomas desaparecen.
20. ¿Usar drogas antes del embarazo o durante es peligroso para el futuro bebe?
Si
No
21. ¿Cree que “ESTA BIEN” dejar que las personas fumen cerca de un bebe or mujers embarazadas?
Si
No
22. ¿Uste fuma?
Si
No
23. ¿Pueden las mujeres decidir si usan medicamentos para el dolor durante el parto? Si
24. La leche materna es el alimento mas nutritivo para un bebe.
Si
No
No
25. Si usted le habla, le canta, acaricias o le sonríes a su bebe, esto le ayudaría que el/ella crezca como
un bebe y un niño seguro.
Si
No
26. Los bebes deben de acostarse:
Boca arriba
A un lado
Boca abajo
27. Los siguientes síntomas son normales después de un parto: (Escoja todos los que se aplican)
Dolores abdominals
No puede parar de llorar
Gran perdida de sangre
Esta exhausta
Perdida de control del orine
Sintiendo muy triste
Thank you for your time!
Becoming a Mom/Comenzando bien Pretest
Site: _____________
Date: _____________
1. What is your race?
Caucasian
African American
Hispanic
Other ________________
American Indian/Alaskan Native
2. What is your age?
Less than 16
16-20
21-25
26-30
3. How many years of school have you completed?
Did not complete high school
Completed high school only
Some college
Graduated college
4. What is your sex?
Female
Male
5. How far along are you in your pregnancy?
1st Trimester(1-12weeks)
2nd Trimester(13-26weeks)
6. Is this your first pregnancy?
Yes
31-35
36-40
40+
3rd Trimester (27-41weeks)
No
7. Have you had your first prenatal appointment?
8. Are you enrolled in the WIC program?
Yes
Yes
No
No
9. What type of insurance do you have?
Private insurance
Medicaid
Chip Perinatal
None
Other ______________________
10. Where are you going for prenatal care?
Private health care provider
Community health clinic
City
County
Other ______________________
11. What keeps you from going to prenatal appointments?
Don’t know where to go
Transportation
No documentation
Child Care
Worried about payment
12. Do you take medication or other remedies that are not prescribed by your doctor?
Yes
No
13. If yes, what kind? (Check all that apply)
Over the Counter
Home Remedies
14. Do you have any of the following health problems? (Check all that apply)
Diabetes Asthma High Blood Pressure Other
15. Has your healthcare provider told you that you have a “high Risk” pregnancy?
Yes
No
16. Are you planning to breastfeed?
Yes
No
Herbal Recipes
17. Please choose one answer for each of the following questions:
a. Will a woman who gets prenatal care as soon as she finds
out she is pregnant have a healthier pregnancy?
b. Does smoking during pregnancy harm the baby’s health?
c. Does drinking during pregnancy harm the baby’s health?
d. Should a pregnant woman go for prenatal care even if
she feels healthy?
Yes
Yes
Yes
No
No
No
Yes
No
18. Which of the following are signs of preterm labor? (Check as many as apply.)
Uterine contractions (may be painless) every 10 minutes or more
Clear, pink or brownish fluid (water) leaking from the vagina
Pelvic pressure (feels like the baby is pressing down)
Abdominal cramping, like a period
Cramps with or without diarrhea
19. What should you do if you think you are experiencing preterm labor? (Check all that apply)
Call your health care provider right away.
Stop what you are doing and rest on your left side for one hour.
Drink 2-3 glasses of water or juice (not coffee or soda).
Wait for an hour or two to see if the symptoms go away.
20. Will using drugs once, before or during my pregnancy, harm my baby?
Yes
No
21. Do you smoke?
Yes
No
22. Is it OK to let people smoke around a pregnant woman or baby?
Yes
No
23. Do women have a choice about whether or not to use pain medication during labor and delivery?
Yes
No
24. Breast milk is the most nourishing food for a baby.
Yes
No
25. Talking to, singing to, touching, and smiling at your baby will help him/her grow into a secure baby
and child.
Yes
No
26. Babies should be put to sleep on their:
Back
Side
Stomach
27. Which of the following postpartum symptoms are normal after delivery? (Check all that apply)
Abdominal cramps
Can’t stop crying
Very heavy bleeding
Exhaustion
Loss of bladder control
Feeling very sad
Thank you for your time!