Asthma Friendly Schools Mini-Grant Application
Please complete the following information and return it by email or US mail to:
Susan Ross at [email protected] or mail to: MN Department of Health, Asthma Program,
P.O. Box 64882, St. Paul, MN 55164-0882.
Contact Information
Provide the name, position, address, email, and phone number for the person who will be the
primary contact for this mini-grant.
Name:
Position:
Address:
Email:
Phone number:
Provide the name of the school district, district number and the school(s) and grade levels that
will be involved in this project. Note if this is a district-wide project or being implemented in
one or more schools in the district at this time.
Provide the name, position, email, phone number and address for any other school or district
staff or volunteers that will have a key role in this mini-grant. Briefly describe how each
individual will contribute to your project.
Provide the name, position, email, phone number and address for people from any other
partner organization(s) that will have a key role in this mini-grant project and how they will
contribute to the success of your project.
Project Choice
Please put an X in front of the project(s) you are planning to do with this mini-grant. A
description of each project and the outcomes report form for each project is included on the
Asthma School Mini-Grants web page
(http:/www.health.state.mn.us/divs/hpcd/cdee/asthma/grants/). For questions about these
projects contact Susan Ross at [email protected]
A.
1.
2.
3.
Asthma Data Projects
Process for identifying students with asthma
School or district data report
Other asthma data project
B. Asthma Friendly Schools – Environmental Policy Project
1. Assess school or district policies that can promote asthma-friendly schools
2. Stakeholder event to review one or more policies
C. Partnering with Parents and Caregivers
1. Information sessions for parents about asthma and school health services
2. Event for students or students and parents to learn about asthma and asthma selfmanagement
1. Event for students or students and parents who are transitioning to middle school or high
school
D. Teaching an Asthma Self-Management Curriculum
1. Open Airways for Schools
2. Kickin’ Asthma
E.
1.
2.
3.
4.
Linking Schools and Health Care
Process to connect school health office and health care providers
Assess school or district school health policies related to asthma
Conduct in-service sessions for school personnel related to asthma
Conduct face-to-face event(s) for school health staff and health care providers
F. Health Office Staff Training
1. Plan and conduct one or more trainings sessions for school health office personnel to
increase knowledge and skills related to asthma, asthma self-management and current best
practices for asthma management based on EPR-3 guidelines.
Project Description
Tell us about your school. Describe how asthma uniquely affects the students in your school or
district. Include information you currently have about students in your school or district who
have asthma. Example: School statistics, describe your student population, challenges your
students face, health office staffing, etc.
How will this grant and the project(s) you have chosen to implement assist you in providing
help and support to students who have asthma in your school or district?
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Briefly tell us how you plan on implementing the project(s) you’ve chosen. If selecting multiple
projects, how will you tie those projects together? If providing education for students, parents,
or staff, tell us how many will participate.
Provide a timeline for your project. When do you plan to start work on this project? When do
you plan to complete the work on your project? Currently, the available time frame for these
projects can be start when your application has been approved in 2017 and ending any time
before August 31, 2017. We expect that your project may not cover that entire timeframe, so
describe your expected timeline.
Budget
Applicants can apply for awards up to $1500. Not all projects will require $1500 so please
budget accordingly.
Indicate the costs you are including in each of the categories below. Add any notes you think
are needed to explain these costs. Please break down hourly wages by discipline and number of
hours. Briefly describe what materials and supplies are needed and meeting expenses. Add any
additional cost categories. Any requests to cover food or beverages will require additional
justification. See Funding Criteria for Mini Grant Application
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Hourly wages
Printing and copying
Supplies and materials
Meeting expenses
Travel
IT expenses
Other – please describe
Total $____________________
Forms to Indicate Administrative and Partner Support
Attach the signature form that indicates support from a school administrator and the school or
district nurse. Also attach a signature form indicating commitment from any outside partner
organizations who will be participating in this project.
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Applicant Signature
I certify that the information presented here is accurate. If I am chosen to receive the award, I
will complete the project and return the outcomes report to the Minnesota Asthma Program by
the agreed upon date. I also agree to participate in a short telephone interview with program
evaluators about my experience with this project and to allow the Minnesota Asthma Program
to share any products developed and lessons learned with others in Minnesota.
Name – please print, position and contact information for the person signing this form.
Name:
Position:
Email:
Phone number:
Signature:
MDH Asthma Program, revised 1/23/2017
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