Application Questionnaire

PART I. General Information


Please check one of the following:

PART II. Grant information


Provide a brief overview of your organization, a) when it was established, b) your organization’s mission, c) whom you serve, d) geographic area your organization covers, e) the types of programs you operate (300 words maximum)


Please describe your organization’s proposed project. The project should address issues of COVID-19 impact, affordable housing, food insecurity and healthy food access, healthcare access (availability/accessibility of care, costs, culturally appropriate provision), healthcare quality, health disparities and chronic disease, mental health and wellness, education, environmental pollution (i.e. air quality, climate change, water quality), labor conditions, job opportunities, legal aid, access to transportation, built environment (i.e. parks, walkability of neighborhood, lighting, recreation space, urban green). (300 words maximum)


Provide a brief description of the need, challenge or issue the project will address, and the target population(s) that will be impacted. Please include any data available. (200 words maximum)


What technical assistance would your organization benefit from in implementing this project? Technical assistance can be focused on program management, program tracking, outreach and recruitment, service delivery, capacity building, data collection and reporting. This information will help us plan training and one on one support. (200 words maximum)

List 3 expected outcomes resulting from your grant and 1-2 indicators that you are achieving this result. You may use the table included below as a template.

Example: Objective 1: Increase access to legal aid for families experiencing COVID-19 related issues.

  • Indicator a: 25 families impacted by COVID-19 received direct legal assistance from an attorney.
  • Indicator b: 100 families were referred to resources for legal support.

Please complete the following budget form for your project. You may use the template found here: http://bit.ly/HEALBudget_ENG