Download Detailed Program Description

Metastatic Breast Cancer Grants Program – Detailed Program Description Attachment for Full Application
Name of Applicant Organization: ______________________________________________________________________
1. Detailed Program DescriptionPlease answer the following questions and provide a narrative for your proposal.
Not every question may be applicable to your particular project; if a question does not apply, please enter N/A.
a. Provide your best estimate of the number of metastatic breast cancer patients living in your
organization’s catchment area, regardless of whether they receive services through your
organization.
b. What is the total number of metastatic breast cancer patients currently served by your
organization?
c. What percentage of metastatic breast cancer patients currently served would qualify as
medically underserved?
d. If funded, how many metastatic breast cancer patients would be served by the proposed
program/activities?
e. What percentage of metastatic breast cancer patients served by the proposed
program/activities would qualify as medically underserved?
2. What geographic area is served by your program? Is it considered rural, urban, periurban?
3. Needs AssessmentProvide a needs assessment for metastatic breast cancer patients in your area that
justifies the proposed program.
4. Briefly describe the racial/ethnic and socioeconomic demographics of the patients that would be served
through the proposed program. Specifically, state if your proposed program will provide services to medically
underserved patients, and, if so, describe those patients.
5. Will patients be charged a fee to access any of the services proposed? If so, will a discounted rate or sliding
scale be available to assist patients with limited financial means? Please outline the fees below.
6. Program NarrativeProvide a narrative that describes your program and addresses the following questions.
a.
Briefly describe your program for metastatic breast cancer patients prior to Avon support.
b.
If you have received Avon funding previously related to the proposed project, please summarize
past program aims, outcomes, achievements, and challenges.
c.
d.
e.
f.
Describe the program / activities you are proposing for funding in detail. Keep in mind that the focus of
this funding initiative is to support your organization’s ability to deliver high quality services to metastatic
breast cancer patients, with a focus on the underserved.
If you receive Avon funding through another program, please provide very detailed information about
how the activities proposed in this application will not duplicate what is already funded.
Outline how funding from this initiative will make a difference.
Funding offered though this program is one year in duration. Outline your plans to sustain a program that
is developed or expanded through this funding mechanism beyond the one-year period.
(i) If you are requesting support for expanding the role of current personnelDescribe the background, time
commitment and responsibilities of the current personnel. Describe how their efforts will increase the
number of MBC patients served, the quality of services delivered and/or address gaps in available services.
a. For programs providing Patient Navigation (PN) supportIf the current staff will be providing patient
navigation (PN) services, include where along the continuum of care will the PN be introduced to the
client, and what activities the PN will engage in with the client at different phases of care? Attach
Please limit your answers to a maximum of 15 pages (not including appendices).
1
Metastatic Breast Cancer Grants Program – Detailed Program Description Attachment for Full Application
curriculum vitae or resume of key personnel in the appendix. Please note that the hiring of new staff is
not an eligible request from this funding initiative. Review the RFA for more information.
(ii) If you are requesting funding for the creation of enduring materials (printed, web based, etc.)Provide an
overview of what collateral currently exists and how the proposed materials differ or fill an unmet need.
Include information on the ways in which the materials will be delivered to or accessed by patients, languages
it will be offered in, if information will be accessible to visually impaired patients and the steps you will take to
ensure the information is culturally appropriate for your audience and presented at an accessible literacy
level. In addition, discuss the scope of the information to be provided, and if/how care will be taken to
provide a comprehensive presentation of the information addressed, including information on benefits and
harms, if applicable.
(iii) If you are requesting funding for support groups/retreats/counselingInclude a description of how
metastatic breast cancer patients will be selected to receive services, in what languages the services will be
offered and any proposed fees for services. Include information on how the proposed program differs from
what is currently available.
(iv) Data collection and reportingPlease describe the method by which your organization maintains data on
patients served through its breast cancer program, including outcomes. How will you define and evaluate the
success of the activities to be funded through this initiative? What metrics (quantitative and qualitative) will
you use to determine success? How will funding improve data collection and reporting for your program?
7. CommunicationsIf funded, how would you spread the word about your program to your community and beyond?
8. Measurable GoalsPlease include a minimum of two measurable (quantitative) goals. These should be the same as
what is entered into the application form.
9. Other SupportList all active and pending grant support related to the programs/projects for which you are
seeking funding in this proposal.
 Source of support and identifying number
 Project title
 Annual total award amount
10. Detailed Program TimelinePlease provide a realistic 12-month timeline, starting January 1, 2017, for
implementing your program.
Please limit your answers to a maximum of 15 pages (not including appendices).
2