Alberta Community HIV Fund
Application
ACHF is a Joint Community/Federal/Provincial Initiative
Application Checklist
Complete and sign this checklist and include it with your final proposal.
 Step 1: Fully complete Sections 1-8 of this application.
Be sure to include the following documentation with your application:
 A list of your current board members
 Your organization’s most recent audited financial statement
 Your organization’s current overall operating budget
 Your organization’s current rental/lease agreements
 Your organization’s current employment/labour agreements for any positions
funded by ACHF
 Evidence of your Albertan organization’s eligibility as a not-for-profit
 Step 2: Submit to the ACHF Steward by 4:00 p.m. November 14, 2016:
 1 electronic copy of the complete application package (including Excel file –
see Section 7)
 1 original hardcopy of the complete application package (including Excel file
– see Section 7)
Checklist completed by:
Name:
Date:
Signature:
Reminder: Late or incomplete proposals submitted will NOT be considered
for further review.
Both copies are due to the ACHF Steward by 4:00 p.m. November 14, 2016.
ACHF Steward:
Kim MacKenzie
#308, 905 Blacklock Way SW
Edmonton, Alberta T6W 1M7
 780-430-0282
 [email protected]
Section 1: About Your Organization
1.1 Information about Your Organization
Organization’s Legal Name:
Organization’s Operating Name (if different from above):
Street Address:
Mailing Address (if different from above):
City:
Province:
Postal Code:
Telephone:
Fax:
E-mail:
Date business commenced:
Website:
1.2 Board Chair/President or Other Board Contact
Name/Title:
Street Address:
Mailing Address (if different from above):
City:
Province:
Postal Code:
Telephone:
Fax:
E-mail:
Provide a list of current board members:  Attached
1.3 Staff Contact
Name/Title:
Address (if different from organization’s address above):
City:
Province:
Postal Code:
Telephone:
Fax:
E-mail:
1.4 Incorporation
Date of incorporation:
1.5 Organizational Structure and Mandate
Provide your organizational mandate and a brief explanation of how your organization is well
suited to undertake the proposed program/project (e.g. credibility, relevant skills and staff
capacity) including two (2) years’ experience, the nature, and extent of previous experience
and/or expertise in the prevention and control of HIV, hepatitis C, other related STBBI. Also
explain your organization’s geographic coverage (max 650 words).
Assessment criteria include:
The proposal demonstrates that the applicant has sufficient practical knowledge and the capacity to carry
out the proposed work (e.g. previous work experience with priority populations, previous programming
experience and geographical coverage)
2.1 What is the need for your proposed ACHF activities?
How do you know? (max. 2000 words)
Assessment criteria include:
 The need for the proposed activities is well described
 Sufficient evidence was used to substantiate the proposed needs
 The methods or types of evidence used to identify the need are appropriate, valid and reliable
 The proposed activities are not a duplication of existing community services
 The proposed activities are complementary to existing community services
Section 2: Statement of Need and Target Populations
2.2 Please indicate which of the following priority populations and target
audiences you intend to reach with your proposed activities:
Priority populations:
□ Ethno-cultural communities, particularly those from countries with high HIV or HCV
prevalence, including immigrants, migrants and refugees
□ Gay men and other men who have sex with men
□ Indigenous people
□ People engaged in the sale, trade or purchase of sex
□ People living in or recently released from correctional facilities
□ People living with, or affected by, HIV and/or HCV
□ People who use drugs
□ Transgender people
□ Women and youth among these populations, as appropriate
Target audiences:
□ Health care practitioners/professionals/service providers
□ policy and decision-makers/leaders;
□ educators; and
□ non-governmental organizations.
2.3 How will your organization facilitate meaningful involvement from
these populations? (max. 350 words)
Assessment criteria include:
 There is appropriate and reliable evidence supporting the choice of priority populations/target
audiences
 The organization allows for meaningful involvement from the priority populations/target audiences
 The organization demonstrates previous capacity in working with the chosen priority
populations/target audiences
NOTE: The workplan must specify appropriate activities addressing all of the chosen priority populations
Section 3: Workplan(s) According to ACHF Priorities
3.1 Check () the ACHF Priorities you will be creating a workplan for:
 Primary Prevention
 Health Promotion of People living with or impacted by HIV and HCV
 Harm Reduction
 Creating Supportive Environments
 Harm Reduction Supply Program: experience in harm reduction and supply distribution,
substantiated need for the program, and projected resources.
3.2 Workplan(s) According to ACHF Priority


Complete the template as shown below for each objective in alignment with ACHF priorities and outcomes
Please delete the examples from the templates below and replace with your own text, adding rows as necessary
Assessment criteria include:
 The objectives link back to the identified needs of the priority
populations/target audiences

The outputs are appropriate for the activities outlined

The activities are realistic to accomplish within the identified time
frames

The activities outlined in the workplan are likely to result in meeting
the stated objectives

When the workplan is compared to the statement of need, there are no major gaps that should be addressed in the proposed programming

The activities are reasonable given the statement of need

The proposed activities are cost-effective, given the expected
results
The expected outcomes can be tied to the stated objectives.

Objectives
What you intend to
accomplish as a result of
your project
Activities
What actions will be
taken to meet the
objectives?
Priority
Population(s)/Target
Audience(s)
What population will benefit
from the activity?
Person(s)
Responsible
Time Line
Outputs
Who will be
responsible for the
activities?
(attach job
descriptions).
When and/or
how long will
the activities
occur?
(be specific)
What type of
products/
services will the
activities
produce?
Strategy for
Sharing
project
Outputs
Dissemination
plan for
learnings, etc.,
as appropriate
Expected
Outcomes
What you expect to
change or influence
as a result of
activities
Resources
What is the
breakdown of
funding
requested for
this activity?
ACHF Priority:
Primary Prevention: Reduce new HIV or HCV infections through targeted combination prevention interventions; Reduce the number of people who are unaware of their HIV, HCV, and other related
STBBI status.
Objectives
Activities
Priority
Population(s)/Target
Audience(s)
Person(s)
Responsible
Time Line
Outputs
Strategy for
Sharing
project
Outputs
Expected
Outcomes
Resources
e.g. Increase knowledge of
prevention strategies of HIV,
HCV and related
communicable diseases in
high risk populations
e.g. Develop HIV, HCV and
related communicable
diseases prevention
materials targeting each of
the high risk groups
e.g. Youth at risk
e.g. Outreach Coordinator
e.g. April 2016 –
March 2017
e.g. outreach
activities,
educational
workshops, referral
services.
e.g. provide
access to
education
materials to
service providers
serving youth at
risk
e.g how many
individuals
decreased their atrisk behaviours
e.g. Cost of personnel,
materials, and prorated
costs for
administrative/rent and
other expenses.
ACHF Priority:
Health Promotion: Implement prevention programming that is directed at people living with HIV and/or HCV (Positive Prevention or Poz Prevention); Assist individuals in accessing care and support.
Objectives
Activities
Priority
Population(s)/Target
Audience(s)
Person(s) Responsible
Time Line
Outputs
Strategy for
Sharing
project
Outputs
Expected
Outcomes
Resources
e.g. Increase support
networks for people living
with HIV/AIDS (PLWHA’s)
and those affected
e.g. Host regular activities and
events for PLWHA’s and those
affected
e.g. Create and maintain well
linked partnerships with wide
range of agencies and
organizations throughout the
community
e.g. PLWHA
e.g. Health Promotion
Worker
e.g. ED to take the lead but
all staff have a role to play
e.g. Ongoing
e.g. type of
activities, referrals,
partners
e.g. communicate
the activities and
partnerships that
solicit meaningful
engagement of
clients.
e.g. PLWHA
indicate increased
support within the
community
e.g. Cost of personnel,
materials, and prorated
costs for
administrative/rent and
other expenses
ACHF Priority:
Harm Reduction: Programs that improve the availability of knowledge, skills, resources, and supports for individuals, with the aim to decrease negative impacts of risk behaviours.
Objectives
Activities
Priority
Person(s)
Time Line
Strategy for
Expected
Resources
Outputs
Population(s)/Target
Responsible
Sharing
Outcomes
Audience(s)
project
Outputs
e.g. Increase access to
needle distribution services
e.g. Provide needle
distribution services on-site
and on the van 5 days a
week
e.g. People who use drugs
e.g. FTE Outreach workers
e.g. Ongoing
e.g. Number of
unique interactions
per supply
distribution
e.g. Statistical
tracking sheets,
surveys, anecdotal
evidence
e.g. share
successful
outreach
activities and
approaches with
other Harm
Reduction
programs
e.g. People who use
drugs are accessing
new supplies;
relationship
development.
e.g. Personnel costs
associated with this
activity; percent of
administrative costs
ACHF Priority:
Creating Supportive Environments: Address stigma related to HIV, HCV, other related STBBI , or populations affected by these infections; Identify evidence-informed solutions to addressing barriers to
prevention, diagnosis, and treatment services, including legal and policy barriers that impact efforts to slow the spread of HIV, HCV, and other related STBBI; Enhance collaboration with other sectors
in order to reduce barriers to prevention, diagnosis and treatment for HIV, HCV, and other related STBBI and/or to address social determinants of health.
Objectives
Activities
Priority
Person(s)
Time Line
Outputs
Strategy for
Expected
Resources
Population(s)/Target
Responsible
Sharing
Outcomes
Audience(s)
project
Outputs
e.g To reduce barriers that
prevent people living with
HIV/AIDS (PLWHA), those at
risk and those affected from
accessing prevention,
diagnosis and treatment
services
e.g. Partnership activities
involving joint programming
for persons living with
HIV/AIDS to
reduce/eliminate stigma
and discrimination
e.g. P/P/S
e.g. Program Coordinator
e.g. April 2016 –
March 2017
e.g. # and nature of
partnerships
e.g. successful
partnership
activities are
shared with
other agencies
e.g. Clients express
decreased stigma
and discrimination
e.g. Cost of personnel,
materials, and prorated
costs for
administrative/rent and
other expenses.
Section 4: Performance Measurement and Outcome Evaluation


Complete the template as shown below for each evaluation objective from your workplan
Please delete the examples from the template below and replace with your own text, adding rows as necessary
Assessment criteria include:
 Outcomes are realistic to accomplish within the identified time frames
 The methods to collect data are sufficient to measure the indicators

The SMART indicators are appropriate to measure the outcomes

Clearly demonstrates the impact of the ACHF activities for Albertans
Evaluation Objectives
Expected Outputs
Expected Outcomes
SMART Indicators
Data Collection Methods
Timelines and Frequency
Must be aligned with the
objectives of your workplan.
As listed in your workplan, the
products or services that
directly stem from the project
activities
What you expect to change or
influence as a result of
activities, and for whom.
The metrics used to
track/measure your results
How will you gather and analyze
the information and who will be
responsible?
How often will you collect
this data and for what time
period?
e.g. Decreased stigma and
discrimination by health care
providers at health clinics
# of staff trained,
Types of staff trained
Reduced stigma and
discrimination experienced by
clients visiting the clinic
% of client experiencing less
stigma and discrimination
% of staff with increased
knowledge of stigma and
discrimination
Client surveys pre and post clinic
education sessions. Surveys conducted
by outreach worker.
Staff surveys pre and post education
sessions
Twice a year for three years
Application Form Details
5.1 Provide a brief job description for each position supported by ACHF using the
table below:
Assessment criteria include:
 Job descriptions are provided for each
 The positions can be linked back to

of the positions that require ACHF
appropriate activities in the workplan
Funding
 The applicant adequately describe the role of volunteers in their proposed ACHF activities
Job Title:
Description of Role:
The proposed staffing is adequate to
carry out the activities outlined in the
workplan
Hours/week for
ACHF activities
Duties:
Position(s) they supervise:
Position they report to:
Existing or new position:
Duties:
Position(s) they supervise:
Position they report to:
Existing or new position:
Duties:
Position(s) they supervise:
Position they report to:
Existing or new position:
Duties:
Position(s) they supervise:
Position they report to:
Existing or new position:
Duties:
Position(s) they supervise:
Position they report to:
Existing or new position:
5.2 Describe the role of volunteers in your proposed ACHF activities (max. 350
words):
Section 6: Collaborative Partnerships
List other organizations, groups, coalitions, projects, etc. with whom your organization plans to partner with in
order to deliver your programs, and then describe the partnerships. Only list and describe those partners that fit
the definition of collaborative partnership (see below).
Letters from your partner(s) identified describing their contributions and their commitment to the ACHF activities
may be requested at a later date
Assessment criteria include:
 Identify collaborative partnerships with other stakeholders as a means of achieving its objectives
 The extent of each partnership and their responsibilities is clearly visible
Name of Partner
Description of Partnership
Contribution
Financial/In-Kind
Section 7: Budget and Budget Rationale
Complete and attach the Detailed Budget Form and Budget Rationale (separate
Excel document) for all of the proposed ACHF activities ONLY.
Assessment criteria include:
 The total funding requested is reasonable to support the proposed activities and demonstrates value for
money and the ability to leverage multi-sectorial financial and in-kind contributions
 The proposed activities are cost-effective, given the expected results and impact
 Any changes in cost categories year over year are adequately justified in the rationale (e.g. staffing
increases)
 The budget explanations provided are appropriate and clear to assess/support the amount requested in
each of the budget categories
Please see separate Excel worksheet to complete the Detailed Budget Form (Tab 1- Detailed Budget
Appendix B) and Budget Rationale (Tab 2 – Budget Justification).
Section 8: Authorization of Application
By my signature, I am submitting this application with the full authority necessary to make such
applications, and I am doing so with the full support of the organization described in Section 1 of this
application.
Name and Title of Authorized Person:
Signature:
Date of Application:
Name and Title of Witness:
Signature of Witness:
Go back to the checklist and make
sure you have completed all of the
necessary steps.