Grant Application & Review Criteria

To download a printable version, click here. Please Note: Paper applications will not be accepted. We have included a printable version for you to reference prior to submitting online. As a friendly reminder, please create your document in Word, then transfer to the online form.
CHECKLIST
Please make sure you have ALL items on this list before beginning.
*
- Budget info
*
- Work Plan
*
- Organizational Chart for Lead Applicant
*
- Organizational Chart for Project
*
- 501c3 – Proof of Nonprofit Status
*
- One Year of Financials (Prior Year)
*
- Board of Directors

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Organization Name*
EIN*
Address*
Street Address City State / Province ZIP Code
Mailing Address (If different from above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How many locations do you operate?*
Counties Served Within THF’s Service Area
- Grayson
- Fannin
- Bryan
- Marshall
Counties Served Outside of THF's Service Area
Mission Statement*
Check Applicable*
- 1st Time Applicant
- Applied Previously
- Past Grantee
- Current Grantee
Current Award*
Are you current on your reporting?*
- YES
- NO
SORRY, BUT YOU ARE DISQUALIFIED FROM COMPLETING AN APPLICATION FOR THIS YEAR'S GRANT CYCLE. IF YOU HAVE ANY QUESTIONS OR CONCERNS, PLEASE CONTACT THF STAFF AT INFO@TEXOMAHEALTH.ORG OR 903.337.0755. THANK YOU!
Amount Requested from THF for proposed project*
Amount of Match from other sources for the proposed project:
Cash*
In-Kind*
THF Priority Area Your Project Will Address*
- To improve access to healthcare services for under and uninsured residents, as well as support community health education and healthy living
- To support programs and initiatives that are designed to increase the number of registered nurses in the Foundation’s service area
Focus Area: IF FOR A SPECIFIC PROJECT, PLEASE CHOOSE BASED ON FOCUS AREA FOR THE PROJECT.*
- Mental Health/Substance Abuse
- Nursing
- Primary Care
- Hospice - End of Life Care
- HIV
- Dental
- Diabetes
- Health Education and Other
BRIEF Description of Project (Limit to 1/2 page)*
Contact Info:
Name*
First Last
Title*
Email*
Phone*

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Applicants are asked not to contact Foundation Board Members regarding applications and to please direct all questions to info@texomahealth.org for routing to the appropriate representative.

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SECTION 1 of 7 - NEED
This section should clearly address the need for funding from the Texoma Health Foundation by answering the following questions:
A. What is the current gap(s) in THF’s four-county service area that requires financial support? Applicant’s MUST provide both quantitative and qualitative data to paint a picture of the need that includes county, state and national data.*
B. Please explain why funding is needed to address the need/gap identified?*
C. What demographic is most impacted as a result of the gap/need? How many residents do you project are currently impacted due to this gap?*
D. Who else is addressing this need in the community or region? Are you partnering with these agencies? If no, please explain?*
E. Please explain any collaboration in place for this project and include letters of support as an attachment.*
F. Please explain sharing of funds across collaborative partners – if the application includes partnerships.*
Attach Letters of Support or MOU"s
Drop files here or

Accepted file types: pdf, doc, docx.

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SECTION 2 of 7 - RESPONSE

This section should:
1. Describe in detail the overall project that is being proposed. What are you asking to implement? Who will implement it? What will it look like day-to-day? Who will it benefit?*
WORK PLAN Goal A Description:*
Goal A*
Activities Timeline / Due Date Person(s) Responsible
WORK PLAN Goal B Description:
Activities Timeline / Due Date Person(s) Responsible
WORK PLAN Goal C Description:
Activities Timeline / Due Date Person(s) Responsible
WORK PLAN Goal D Description:
Activities Timeline / Due Date Person(s) Responsible
WORK PLAN Goal E Description:
Activities Timeline / Due Date Person(s) Responsible
3. What will look different/change in the region when the project is fully implemented?*

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SECTION 3 of 7 - IMPACT

Applicant should explain how the proposed project will impact the community for the better and further the mission of the Texoma Health Foundation. The narrative should answer the following questions:
A. What specific geographical areas (communities, counties, etc.) will be impacted by the project?*
B. How will the proposed project improve the health of residents?*
C. How many residents will be directly impacted by the project?*
D. Is there an indirect impact? If so, please explain.*
E. What will happen if THF funds are not received?*
Additional Information:

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SECTION 4 of 7 - EVALUATION

This section should answer how the effectiveness or ineffectiveness of the project will be evaluated. It should include a detailed description of what data will be collected and how staff will assure reporting to determine the project’s impact on the community. THF is seeking evaluative plans that identify successes and/or lessons that not only support the applicant but assist future projects.
A. How will you know that change has happened? How will you monitor success and/or lessons to make adjustments and/or leverage opportunities?*
B. How will you collect baseline data? What indicators/measures will you use throughout evaluation?*
C. How will data be collected throughout the project? Who will be responsible?*
D. How often will you collect the data?*
Additional Information:
Please Upload an Evaluative Table that outlines processes (pdf, doc, or docx only).*
Accepted file types: pdf, doc, docx.
To view a sample evaluation table, click here.

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SECTION 5 of 7 - RESOURCES AND CAPABILITIES

Describe the organization’s resources and capabilities to successfully implement the proposed project.
A. Please describe the organizational structure relevant to the project, including a) the applicant’s experience/history with successful implementation and b) the availability of facilities.*
Additional Information:
B. Please complete the following Personnel Chart for employees directly supporting the proposed project.*
** Place X's in all that apply
Position Title % FTE to be dedicated to the project Existing Staff Member? Y/N Or New Staff to be hired if grant is awarded? Y/N % FTE paid by THF grant % FTE paid by other funding source
C. Please attach a current list of Board of Directors (pdf, doc, or docx only).*
Accepted file types: pdf, doc, docx.
D. Attach bios of all current employees who will be working on this project.*
Accepted file types: pdf, doc, docx.
E. How many hours per week will each current employee be contributing to the project? What is their current salary? (Please list)*
What is their current salary? (Please list)*
F. Attach job descriptions (including salary/hourly wage and hours per week) for new positions that will be created. If none, please state that no new positions will be created.*
Accepted file types: pdf, doc, docx.
G. Attach an organizational chart of the lead applicant.*
Accepted file types: pdf, doc, docx.
To view a sample evaluation table, click here.
H. Attach an organizational chart for the project (or that clearly includes the project).*
Accepted file types: pdf, doc, docx.
To view a sample evaluation table, click here.

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SECTION 6 of 7 - SUSTAINABILITY

This section should clearly address the applicant’s plans for sustaining the project beyond the grant year.
A. Describe in detail any cash-match and/or in-kind support that will be leveraged for the project outside of THF resources.*
B. Please list organizations that have financially committed to the project and the amount secured, as well as the names of organizations in which you are seeking additional support for the project but have not yet received approval/confirmation.*
C. Please describe how you plan to sustain the project long-term (revenue, funding, etc.).*
Additional Information:

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SECTION 7 of 7 - BUDGET

This section should include:
- a line-item detailed budget
- a budget narrative that clearly describes the amount, and calculation of support for each budget line-item requested from THF for purposes of the project

Personnel

Amount Requested from THF	Match/In-Kind Amount	Match/In-Kind Source	Position/Title (EX: Project Manager responsible for day-to-day oversight of the proposed project, data collection and reporting.)

Equipment
Amount Requested from THF Match/In-Kind Amount Match/In-Kind Source Items Requested
Supplies
Amount Requested from THF Match/In-Kind Amount Match/In-Kind Source Items Requested
Contractual
Amount Requested from THF Match/In-Kind Amount Match/In-Kind Source Items Requested
Other
Amount Requested from THF Match/In-Kind Amount Match/In-Kind Source Items Requested
Budget Narrative:*
Budget Narrative Format Ex:

Personnel: Project Manager: Responsible for day-to-day oversight of the proposed project, data collection and reporting. (0.5 FTE at $30,000/year = $15,000)

Equipment: One computer and one printer for Project Manager: $800…
Additional Information:
Attach copy of proof of 501c3 status. (pdf, doc, or docx only)*
Accepted file types: pdf, doc, docx.
Attach copy of the lead applicant’s financials (last fiscal year) (pdf, doc, or docx only).*
Accepted file types: pdf, doc, docx.

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Please review your submission before submitting

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Texoma Health Foundation

Grant Application & Review Criteria

Grant Application & Review Criteria 2018-2019

Step 1 of 11

CHECKLIST

Amount of Match from other sources for the proposed project:

Contact Info:

Applicants are asked not to contact Foundation Board Members regarding applications and to please direct all questions to info@texomahealth.org for routing to the appropriate representative.

SECTION 1 of 7 - NEED

SECTION 2 of 7 - RESPONSE

This section should:

SECTION 3 of 7 - IMPACT

SECTION 4 of 7 - EVALUATION

SECTION 5 of 7 - RESOURCES AND CAPABILITIES

SECTION 6 of 7 - SUSTAINABILITY

SECTION 7 of 7 - BUDGET

Please review your submission before submitting