LIFORNIA REGION – SACRAMENTO VALLEY
Northern California Region
South Bay Public Affairs
Community Benefit Program
2017 GRANT APPLICATION GUIDE
0
Northern California Region South Bay Community Benefit Program
Table of Contents
Introduction
2
Funding Priorities
2
Eligibility Guidelines
3
Selection Criteria
4
Application Submission Time Frame
5
Grant Request Submission Process
5
Required Documents
6
Application Questions
9
Questions
11
Contact Information
12
1
Northern California Region South Bay Community Benefit Program
Introduction
For over 70 years, Kaiser Permanente's social mission has been the foundation of its
community service programs. As a values-driven, not-for-profit integrated health care
organization, Kaiser Permanente is dedicated to improving the health of its members
and the communities it serves. Through partnerships with community organizations
and government entities, Kaiser Permanente strives to benefit the community by
addressing issues and concerns that affect overall community health. These
partnerships are built upon the sharing of knowledge and resources between Kaiser
Permanente and health-related community service organizations. Kaiser Permanente
brings a variety of resources to these partnerships: cash grants to support community
activities, volunteers, and in-kind donations.
Funding Priorities
Kaiser Permanente South Bay has identified priority health and social needs that
impact the lives of vulnerable populations through a Community Health Needs
Assessment (CHNA) that is conducted every three years. These priorities provide the
basis for the Kaiser Permanente South Bay Community Benefit Program and guide
the distribution of contributions to the community. To review the 2016 CHNA reports
for Kaiser Permanente – San Jose and Kaiser Permanente – Santa Clara, visit:
https://share.kaiserpermanente.org/article/community-health-needs-assessments/
Kaiser Permanente has identified the following priority needs in Santa Clara County
for 2017. Proposals must also be in alignment with one of the following strategies:
1. Healthy Eating Active Living (HEAL)
Strategy:
 Increase access to healthy, affordable foods, including fresh produce, and
decrease access to unhealthy food
 Increase enrollment in and use of federal food programs
 Increase access to physical activity opportunities in the community
 Increase access to physical activity opportunities in schools
2. Mental and Behavioral Health
Strategy:
 Provide screening and identification related to behavioral health needs among
low income, vulnerable and uninsured populations and connect them with the
appropriate services or support
 Support opportunities to prevent and reduce the misuse of drugs and alcohol
 Provide access to programs, services or environments that evidence suggests
improves overall social/emotional wellness
3. Community and Family Safety
Strategy:
 Increase availability of education, job training and enrichment programs for
youth
2
Northern California Region South Bay Community Benefit Program


Support programs that promote non-violent solutions to conflict and alternatives
to punitive responses
Support programs that prevent and address family violence through reducing
risk factors, enhancing protective (resilience) factors and linking to appropriate
resources
4. Access to Care and Coverage
Strategy:
 Support outreach, enrollment, retention and appropriate utilization of health
care coverage programs
 Increase access to primary and specialty care
Eligibility Guidelines
Kaiser Permanente will consider requests from organizations that serve underserved
populations in Santa Clara County, with the exception of Palo Alto which is in the
Kaiser Permanente San Mateo Service area.
Requests must target underserved populations and meet one or more of the grant
making priorities. Grants are awarded for specific programs, as well as system and
environmental changes based on the above identified priorities and needs. Grants are
not awarded for general operating support and must serve the general community
which is defined as a population served whereby 50% or more of the beneficiaries are
NOT Kaiser Permanente members, physicians or employees.
Organizations are strongly encouraged to apply for the program or project that most
closely aligns with one of the above Kaiser Permanente identified needs. If your
organization plans to submit more than one request, please consult with Kaiser
Permanente South Bay Community Benefit staff prior to submission by sending an
email to: [email protected].
Funding awards typically range from $10,000 to $50,000.
Kaiser Permanente charitable contributions are limited to organizations that are
exempt from taxation under section 501(c)3 of the Internal Revenue Code; or are
classified as a 509(a), government agency or a public entity.
Requests from the following types of organizations or activities and purposes are not
eligible for grant funding: religious activities; partisan political; fraternal, athletic,
international or social organizations; field trips or tours; endowments and memorials;
grants or scholarships to individuals; organizations that do not comply with Kaiser
Permanente’s anti-discriminatory policy; and fundraising events such as raffles,
telethons, walkathons, and auctions.
This application may be used to request funding for a community benefit program or
project but not for events. If you would like to request a sponsorship, please email
[email protected] to receive additional information about the
sponsorship process.
3
Northern California Region South Bay Community Benefit Program
Selection Criteria
All requests are reviewed and approved by a charitable contributions committee that
includes Kaiser Permanente representatives from various departments. Successful
grant applicants will demonstrate the project:









Supports at least one of the identified Community Benefit priorities
Supports the vision and mission of the applicant's organization with a proven
track-record of success within the Community Benefit priority area
Emphasizes collaboration among stakeholders aiming for systemic impacts
Engages Kaiser Permanente as a partner
targets a need within an underserved population
has the ability to track services and measure their impact through appropriate
evaluation measures
has a clear, detailed work plan with process and impact objectives
makes a strong, evidence-based case for the strategy chosen to achieve the
outcomes
has a reasonable budget that reflects actual direct costs of providing the
service, showing total costs and the KP-requested funding
Successful grant applicants also will demonstrate its organization has the ability to
monitor and evaluate the project, and the ability to deliver quality, timely interventions.
Grant Requirements







4
Funding must be used within a year of receipt of check
Grantees must submit a receipt-of-payment acknowledgement letter within 10
days of receiving payment
Grant recipients will be required to submit a six-month progress report and
12-month (year-end) final report
Grantees must provide immediate written notice to the Community Benefit
staff if significant changes or events occur during the term of the award that
could potentially impact the progress or outcome of the funded project,
including but not limited to, changes in grant recipient’s management
personnel, loss of funding, or revocation or suspension of the grant recipient’s
tax-exempt status (if applicable) or license
Funds shall be expended for the purpose(s) stated in the grant in accordance
with the submitted budget. Modifications may be made only with prior written
consent of the Community Benefit manager. Grantees shall keep accounting
records of receipts and disbursements of funds
Grantees must work with Kaiser Permanente Community Benefit staff or
Kaiser Permanente media relations staff for any planned media attention for
the funded program
Grantees will provide the Kaiser Permanente Community Benefit staff with
copies of all fliers, educational handouts, and materials that mention Kaiser
Permanente’s support prior to distribution
Northern California Region South Bay Community Benefit Program
Application Submission Time Frame
February 13, 2017
Grant application released
March 31, 2017
Grant applications due by 5:00 pm PST
June 29, 2017
Applicants are notified of grant status
Grant Request Submission Process
Requests are received using our online application request tool. In addition to the
online application, additional documents are required and must be submitted as part of
the application process. The full list of required documents can be found starting on
page 6.
Incomplete applications, including those that are missing required information and/or
required attachments/templates will not be considered for review.
Current Kaiser Permanente South Bay Community Benefit grantees must be in good
standing, having submitted all required reports, in order to be considered for renewed
funding.
Accessing the Online Grant Application
Grant Application Website:
https://www.GrantRequest.com/SID_946?SA=SNA&FID=35411
Create a login to access the Online Application - one contact per organization, please.
This can be the same login from 2016 if you already have an account.
If saving and returning to the Application at a later date, use the following URL to
return to your Online Application: https://www.GrantRequest.com/SID_946
If You Forget Your Account Password
Follow the on-screen instructions from the Account login page to retrieve your
password. If this method does not work, please send an email to:
[email protected] with IGAM Password Reset in the subject line to reset your
password.
Preparing and Saving Your Application
We strongly recommend that you prepare your information as a Word document
and then copy/paste it into the online application.
Please do not write your narrative in the first person (for example, use “Name of
organization offers…” vs. “We offer…”). Also, be sure to describe your project and
5
Northern California Region South Bay Community Benefit Program
how it will address the identified community need. It is helpful to imagine you are
explaining your project to a reporter or someone outside of your field.
You may save your work and return to the application at a later time. For your
convenience, the application questions are included in this document for your
reference. We encourage you to use this document in preparing your application.
In order to access the application that you have started and saved, use the following
URL: https://www.GrantRequest.com/SID_946
Prior to Submitting Your Online Application
You have the ability to review your grant application prior to submission. Please note
that once a grant application has been submitted, it cannot be edited.
Once you have submitted your application, you will receive an email that states
“Thank you for your Northern California South Bay Area Grant Application
Submission…” This is your record that your application has been received. If you do
not receive this email confirmation, please contact us at [email protected].
Required Documents
The following documents are required for submission and you will be asked to upload
them into your online application.
1. Request on Organization's letterhead
a. The request on organization's letterhead should include the legal name
of organization, organization's address, requested amount, project title
and how the funds will be used. If a fiscal agent is being used, then the
request and required information must also be submitted on the fiscal
agency's letterhead
2. Tax exempt status letter - the following documents must be submitted:
a. For nonprofit organizations, one of the following documents must be
submitted:
i. Copy of current IRS determination letter indicating appropriate
tax-exempt status with Tax ID number; OR
ii. Copy of IRS Form 1023 that documents recognition of tax
exemption under 501(c)(3) and that the organization is classified
as a public charity (not a private foundation), under section 509
(a)
b. For government/public entities, one of the following documents must be
submitted:
6
Northern California Region South Bay Community Benefit Program
i. A notarized letter from the organization's Chief Financial Officer or
Certified Public Accounting Firm indicating the government/public
agency has been granted tax exemption, OR
ii. A copy of IRS affirmation letter with the Federal Identification
Number, OR
iii. A copy of the statute or enabling legislation establishing the entity
c. If the applying organization has a fiscal agent, both of the following
documents must be submitted:
i. A copy of the memorandum of understanding between the fiscal
agent and the requesting organization; AND
ii. A copy of the IRS tax exempt status determination letter for the
fiscal agent or a copy of IRS Form 1023 for the fiscal agent; and a
copy of the tax exempt status determination letter for the applying
organization (if the applying organization has one)
3. A list of the organization’s directors, officers, or individuals on the governing
body and their affiliations. Please include any affiliations to Kaiser Foundation
Health Plan, Kaiser Foundation Hospitals or The Permanente Medical Group
and their subsidiaries
4. List of key project staff and volunteers by name, title and qualification
5. For requests $20,000 and above:
a. A copy of the most recent IRS Form 990 (required with the exception of
churches and government entities)
b. A copy of the most recent independent, audited financial statements
If an independent audited financial statement is not available, and the
organization’s operating budget is less than $750,000, the organization
can submit an independent Certified Public Accountant’s review of the
organization’s financial statement
6. Partnership agreements from collaborating organizations/agencies that play an
integral role in the project, if applicable (i.e. schools or organizations that will
implement portions of the proposed project). A satisfactory partnership
agreement would be a brief description of the roles of each partner in the
project that is submitted on the partnering organization’s letterhead and is
signed by the partnering organization (Note: There is no area to upload these
into the application. Please email your partnership agreements to
[email protected])
7
Northern California Region South Bay Community Benefit Program
Required Templates
The following templates are required:
Completed Workplan
Completed Budget
These templates are located within the online application and are available for
download.
Required Documents files must be labeled as follows:
"Organization Name_Document Title"
Example: Valley Clinic_Board of Directors
Uploading Instructions
Please note that these instructions are specific to Internet Explorer. Depending on the
browser you are using, you may see slight differences in upload tools.






8
Select from the pull down list the document that is ready to be attached
Click 'Browse' button and select the file
The file you selected will then be displayed
Click the 'Upload' button and your file will be attached
The maximum size for all attachments combined is 25 MB
Files that contain extensions such as "exe", "com", "vbs", or "bat" cannot be
uploaded
Northern California Region South Bay Community Benefit Program
Application Questions
The list of questions below is to serve as a guide in preparing your information for the
online application. We strongly recommend that you prepare and save this
information as a Word document, then copy/paste it into the online application.
The online application will include the following questions:
1. Organization Name
2. Street Address
3. City
4. State
5. Postal Code, 9-digit postal code if known (xxxxx-xxxx)
6. Phone (xxx) xxx-xxxx
7. Fax (xxx) xxx-xxxx
8. Organization's Email Address
9. Organization's Website Address
10. Agency ED, CEO or President Information
a. Prefix
b. First Name
c. Last Name
d. Title
e. Phone Number
f. Email Address
11. Organizational Funders
12. Year Founded (MM/DD/YYY)
13. Location of Main Office
14. Mission Statement (50 word limit)
15. Key Services Provided (200 word limit)
16. Gender of Population Served (check the appropriate box)
17. Age Group of Population Served (check the appropriate box)
18. Target Population Served (check the appropriate box)
19. Select the Kaiser Permanente hospital service area
NOTE: Select only Kaiser Permanente – Santa Clara (do not select San
Jose). We are a unique blend of hospital service areas (South Bay) but the
application system can only categorize by individual hospital area
20. Organization's legal name
a. This is the name that appears on your IRS determination letter or other
legal documentation, or Form 990
21. Organization's Tax ID# (EIN or TIN) xx-xxxxxxx
22. Tax status
23. Annual Total Organization Budget
24. Proof of Tax Exemption
25. Request on Organization’s Letterhead
26. Form 990 for requests above $25,000 (upload)
27. Compliance Verification
Do any Kaiser Permanente executives, managers, directors, physicians or
other employees or their family members:
9
Northern California Region South Bay Community Benefit Program
a. Serve as a board member, director, officer, manager, employee or
fiduciary agent of your organization; OR
b. Have a compensation arrangement or financial interest with your
organization
c. If yes to a or b, please provide the person(s) name and describe the
nature of the relationship
28. Non-Discrimination Policy
a. Does your organization have a non-discrimination policy? To be
answered by ALL APPLICANTS
29. Will your organization use any portion of awarded dollars to further religious
doctrine, offer programs solely for the congregation, members or students? To
be answered by RELIGIOUS AND FAITH-BASED AGENCIES ONLY
30. Board of Directors (upload)
31. Key Staff and Volunteers (upload)
32. Audited Financial Report for requests above $25,000 (upload)
33. Fiscal Agent – Complete this section ONLY if your organization will be using a
fiscal agent
a. Fiscal Agent's Organization Name
b. Fiscal Agent's Tax ID# (EIN or TIN)
c. Fiscal Agent's Mailing Address: Street Address, City, State, and Postal
Code (9-digit code if known)
d. Fiscal Agent's Contact: Prefix, First Name, Last Name
e. Fiscal Agent’s Contact Title
f. Fiscal Agent's Contact Phone Number (xxx) xxx-xxxx
g. Fiscal Agent's Contact Email Address
h. Fiscal Agent MOU (upload)
i. Request on Fiscal Agent Letterhead (upload)
34. Project Information
a. Project Title (same title listed on your LOI)
b. Project Start Date
c. Project End Date
d. Total Project Budget
e. Amount of funding you are requesting from Kaiser Permanente for this
project
f. Project Budget Template (upload)
List other funding received for this project, and other sources to which
this proposal has been submitted. Please provide the following and
follow this format – Funder name, Amount, Committed or Solicited
Example:
ABC Funder, $10,000, Committed;
EFG Funder, $5,000, Solicited
g. List Kaiser Permanente physicians and/or employees involved with your
organization and/or project. Please describe their involvement with your
organization
35. Primary Project Contact Information
a. Prefix
b. First Name
c. Last Name
d. Title
10
Northern California Region South Bay Community Benefit Program
e. Phone (xxx) xxx-xxxx
f. Fax (xxx) xxx-xxxx
g. Email
36. Select One Identified Health Need (priorities include: Access to Health Care,
Behavioral Health, Healthy Eating/Active Living, Violence Prevention)
37. Provide Rationale for Health Need Selected (200 word limit)
38. Project Description – please describe your proposed project and how it
addresses the priority funding area identified in #36. Do not write in first person
(200 word limit)
39. Project Workplan (upload)
40. Goals and Objectives – please copy/paste your goals and objectives from your
completed workplan template. List as bullets:
Example:
Goal 1:
Objective a:
Objective b:
Objective c:
41. Why have you selected this intervention strategy or model to address this
problem? Please describe the evidence-base that supports the chosen
strategy and how the individuals will benefit from this intervention (150 word
limit)
42. Communication
a. Partners – List and describe briefly the community partners who will be
involved in the coordination, provision or collaboration of this project
only (150 word limit)
b. How do you plan to acknowledge Kaiser Permanente’s support for this
project? (100 word limit)
c. Briefly describe your plans for communicating to stakeholders about the
award and progress of this grant (100 word limit)
43. Community Need
a. Number of People Expected to be Served by your Project
b. What data will you collect? What is your measurement(s) for success
based on the collected data? (150 word limit)
c. List the specific outcomes as stated in your Workplan (150 word limit)
Questions
To provide a higher level of transparency and make the grant submission process
equitable for everyone, all questions related to the 2017 Grants Process will be
accepted by email only. Please submit all questions to [email protected].
Questions, requests and application materials submitted to individual staff will not be
reviewed or considered. Questions will be answered in a timely manner.
11
Northern California Region South Bay Community Benefit Program
Contact Information
Kaiser Permanente South Bay Community Benefit Staff
Stephan Wahl
Community Benefit Manager – South Bay Hub
Amy Aken
Senior Public Affairs Representative
Judy Lloyd
Contributions Operations Specialist – South Bay
[email protected]
Thank you for your interest in the 2017 Kaiser Permanente South Bay
Community Benefit Grant process!
12