Plan4Health – Cohort Two
Application Checklist and Form
Through an overarching collaborative strategy that brings together members of the American Planning
Association (APA) and the American Public Health Association (APHA), the Plan4Health project aims to
build local capacity to address population health goals and promote the inclusion of health in nontraditional sectors. Plan4Health is supported through the Centers of Disease Control and Prevention
(CDC) as part of the National Dissemination and Implementation program within the Division of
Community Health, Funding Opportunity Announcement #DP14-1418.
Please submit completed applications, including all documents noted in the checklist below, in one
email to [email protected] by 11:59pm EST on Friday, July 31st, 2015.
Plan4Health project expectations and scoring rubric are outlined in the Plan4Health – Cohort Two –
Request for Proposals document.
Please complete the Letter of Intent by 11:59pm EST on Wednesday, July 1, 2015:
https://www.surveymonkey.com/s/S7TRSD6
A Letter of Intent is required in order to be eligible to apply for this funding opportunity. Information
requested via survey includes:

APA Chapter and APHA Affiliate – please spell out complete state/region name

Target Community – please indicate city, county, or region

Focus Area

Award Type

Primary Contact for Application

Approximate budget request – applicants will not be held to this amount, but the
information will assist APA in assessing available funds
Please see the APA’s Planning and Community Health FAQ webpage for additional information on this
funding opportunity as well as recordings of introductory webinars. Please contact the Plan4Health
staff at [email protected] with specific questions or concerns.
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Plan4Health – Cohort Two – Application Checklist
Please find below the Plan4Health Application Checklist. All documents are required, unless otherwise
noted; incomplete applications will not be reviewed.
Please submit the following as four separate attachments in Word or PDF format in one email:
Completed application form (this document)
I.
Overview
II.
Narrative – Community Action Plan Template
III.
Map
IV.
Budget
Additional Narrative Sections (10 page limit; single spaced – 12 point font)
1)Demonstrated Need
2)Strategies
3)Activities
4)Project Management
5)Sustainability
Resumes (leadership team only)
Letters of Support:
1) APA Chapter
2) APHA Affiliate
3) Key Coalition Members (those listed on application form)
4) Additional letters (optional)
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Plan4Health – Cohort Two – Application Form
I.
OVERVIEW
APA Chapter
APHA Affiliate
Coalition Name
Organizational Members of Coalition
Please list organization names only.
Primary Contact Information
Name
Email:
Phone:
Mailing Address:
Leadership Team
Please list names, professional affiliation, indicate APA or APHA membership.
1)
2)
3)
3
**Leadership team resumes are required.
Focus Area (select one or more)
Inactivity
Unhealthy diet
Award Type (select one)
Capacity building
Implementation ready
Target Community
Community name
Geographic boundary (name of neighborhood, city, county, or region)
Census tracts
Project strategies
Please limit strategies descriptions to 25 words or less. Please include one communications-related
strategy. Additional strategies may be added.
1)
2)
3)
4)
5)
**Strategies and activities will be outlined in more detail in the narration section of the application.
Project Abstract
Please provide a brief overview of the project; please do not exceed 250 words.
4
Coalition Description
Briefly outline the strengths of the coalition, its members and/or how the member organizations
complement each other and will support project goal achievement:
Please limit responses to 500 words or less.
5
II. NARRATIVE (10 page limit; single spaced – 12 point font)
Please include the following components in the narrative section. Please submit a separate Word or
PDF document that includes responses for sections one through five:
1) Demonstrated Need
Describe why the target community has been selected by the coalition. Please provide
supporting data and/or evidence from a recently completed community health needs
assessment or similar tool.
Please identify the priority population(s) within the geographic area.
2) Strategies
Please outline the key project strategies, rationale for strategy selection, and how coalition
members are qualified to implement the strategies.
Capacity building
Proposed strategies include capacity building activities as well as potential policy,
systems, and environment (PSE) approaches.
Implementation ready
Proposed strategies include PSE approaches that will begin implementation at the start
of the project period.
3) Activities
Please outline key activities that will support the implementation of project strategies.
4) Project Management
Describe how the coalition plans to complete the activities at the funding level requested.
Describe and outline the coalition’s approach to project management, including proposed
staffing.
5) Sustainability
Please discuss how the project work will continue after the project period and/or how the
impact of this opportunity will increase the capacity of the target community to implement
future interventions.
6) Draft Community Action Plan (pages do not count toward 10 narrative pages)
Please complete a draft Community Action Plan (CAP) using the template below for the first five
months of the project period. Successful applicants will prepare a final CAP within the first 60
days of the project period.
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Community Action Plan (CAP) – Template
Please complete the charts below for the first five months of the project period. Successful coalitions will
have the opportunity to edit CAPs during the initial months of the project as well as to develop the full
project period plan. Additional strategy charts may be added, if necessary.
For more information about the CAP template and definition of terms, please review the Plan4Health –
Community Action Plan document available at APA’s Planning and Community Center.
1. Project Strategy:
Activity/Intervention Challenges
Resources/Supports
Setting &
Population
Reach
(baseline,
target)
1.1
1.2
1.3
1.4
1.5
ID
Tasks
Lead
Staff
Support
Staff
Completion
Date
1.1
1.2
7
Outputs/Measures
1.3
1.4
1.5
8
2. Project Strategy:
Activity/Intervention Challenges
Resources/Supports
Setting &
Population
Reach
(baseline,
target)
2.1
2.2
2.3
2.4
2.5
ID
Tasks
Lead
Staff
Support
Staff
Completion
Date
2.1
2.2
2.3
9
Outputs/Measures
2.4
2.5
10
3. Project Strategy:
Activity/Intervention Challenges
Resources/Supports
Setting &
Population
Reach
(baseline,
target)
3.1
3.2
3.3
3.4
3.5
ID
Tasks
Lead
Staff
Support
Staff
Completion
Date
3.1
3.2
3.3
11
Outputs/Measures
3.4
3.5
12
III. MAP
Please attach or paste a visual representation of the target community, including geographic boundaries.
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IV. BUDGET
Please complete the following budget charts with justifications of proposed expenses.
Examples have been included as reference points and are italicized; please delete any information
that is not related to the actual coalition budget before submission.
Position Title and
Name
Annual Salary
Time
Months
Amount Request
Project Coordinator
$35,000
25%
15 months
$10,938
Total Personnel
Justification
Description of responsibilities should be directly related to specific program objectives. Please identify
APA and APHA members.
Project Coordinator: This position directs the overall operation of the project including overseeing the
implementation of project activities, coordination with other agencies, development of materials,
program evaluation and staff performance evaluation. This individual is responsible for ensuring reports
are submitted to APA. This position relates directly to all program objectives.
Fringe Benefits
Provide information on the rate of fringe benefits used and the basis for their calculation.
Fringe Benefit Total: $______
% of Total Salaries = Fringe Benefits
If fringe benefits are not calculated by percentage, itemize amounts:
Fringe Benefit
% of Salary
Amount Requested
Total Fringe
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SUPPLIES
Item Requested
Type
Number Needed
Unit Cost
Office supplies
Pens, paper
15 months
Educational
pamphlets
Software
n/a
5,000 copies
Amount
Requested
$20/month/person $4,500
for 15 people
$1
$5,000
Microsoft
1
$400
$400
Total Supplies
Justification
Provide a justification for the use of each item and relate it to specific program objectives.
Office supplies will be used by staff members to carry out daily activities of the program. Educational
pamphlets will raise project awareness and strengthen community engagement. Word processing
software will be used to document program activities.
TRAVEL (In-State and Out-of-State)
Total: $ 1,571_
APA advises that additional funds be budgeted for potential travel to trainings, regional conferences, and
other dissemination activities.
Please include estimated travel costs to attend the project kick-off meeting for two coalition
representatives.
Travel: In-State
Number of
Trips
1
25
Total
Number of
People
2
1
Cost of Airfare
n/a
n/a
Number of
Total Miles
50
250
Cost per Mile
$0.57
$0.57
Per Diem/Lodging
Number of People
Number of Units
Unit Cost
Per Diem
Lodging
Total
1
1
2 days
1 night
$50/day
$200/night
15
Amount
Requested
$28.50
$142.50
$171.00
Amount
Requested
$100
$200
$300
Justification
The Project Coordinator and Outreach Supervisor will attend local planning conference.
The Project Coordinator will make an estimated 25 trips to local sites to monitor implementation.
Travel: Out-of-State
Number of
Trips
1
Total
Number of
People
1
Per Diem/Lodging
Cost of Airfare
$500
Number of People
Per Diem
1
Lodging
1
Total
Ground Transportation
Yes
Total
Number of
Total Miles
n/a
Number of Units
3 days
2 nights
Number of People
1
Cost per Mile
n/a
Amount
Requested
$500
$500
Unit Cost
Amount
Requested
$50/day
$150
$200/night
$400
$550
Amount Requested
$50
$50
Justification
The Project Coordinator will travel to Washington DC to attend a national conference to disseminate
project findings.
OTHER
Item Requested
Staff training
Number of
Months
n/a
Estimated Cost
per Month
n/a
Total
Number of Staff
All
Amount
Requested
$500
$500
Justification
Staff training will focus on health equity and cultural competency, strengthening modification of project
strategies to meet the needs of vulnerable populations.
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SUBCONTRACT
Name/Organization
Time/Months
Unit Cost/
Amount Request
Contract
ABC organization
5 months
1 guide
Total Subcontract
$5,000
$5,000
Justification
Subcontract with ABC organization will leverage the expertise of local planning consultants and ensure
the creation of a Bike-Metro Guide is created with community input and culturally competent language.
GRAND TOTAL: _________________________
In-Kind Support
Please include any in-kind support, volunteer time or donated materials, provided by individual
members or organizations. In-kind totals do not need to be exact calculations, but summarize additional
project support not included in budget above. Please limit responses to 500 words or less.
If in-kind support is not applicable, please enter N/A below.
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