Community Health Funder Alliance - 2021 Community Grant Application Questions
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Community Health Funder Alliance
2021 Community Grant Application Questions
This is not the actual grant application, just a list of questions from the online version.
Please use this document to familiarize yourself with the questions you will be asked in the online
version of the grant application. Although it isn’t necessary, you may also use this document to
prepare answers ahead of time in order to cut and paste them directly into the fields provided online.
Your answers will populate our database records, so please use proper capitalization and punctuation.
All fields are required unless otherwise indicated.
Form Contents
The Form contains the following sections:
1. Basic Organization & Contact Information
2. GIVING TOGETHER Summary
3. Request Information
4. Outcome Area & Priority Indicators
5. Core Questions
6. Performance Management
7. Financials Audited, Financial & IRS Attachments
8. Nonprofit Disclosure Statement & CertificationBasic Organization & Contact Information
1. Organization Name: [60 characters]
2. Federal Tax ID (EIN#): [10 characters]
3. Founding year of your organization (not your fiscal sponsor, if you have one): [10 characters]
4. Website Address:
5. Mailing Address:
6. Head of Organization:
Name
Title:
Email Address:
Phone Number:
7. Primary Contact for the Program/Project the Grant Will Support:
(Note: to be included in all grant-related communications including reporting)
Name
Title:
Email Address:
Phone Number:
IF USING A FISCAL SPONSOR/AGENT, PLEASE PROVIDE THE FOLLOWING INFORMATION FOR THE
SPONSOR ORGANIZATION
8. Sponsor’s Organization Name: [60 characters]
9. Sponsor’s Federal Tax ID (EIN#): [10 characters]
10. Fiscal Sponsor Point of Contact:
Name/Title: [60 characters]
11. Contact Information
Email Address: [50 characters]
Phone Number: [25 characters]
Additional Organization Information:
12. For the following four questions, please provide your organization’s or your fiscal sponsor’s:
170 type – [dropdown]
509(a) type – [dropdown]
Federal Tax ID (EIN#): [10 characters]
NM State Tax ID (CRS#) [14 characters]
-2-13. Board and Staff Diversity - Please provide updated racial/ethnic demographic of your
organization (this is the number, not a percentage, of board members or staff that are
applicable to each category) (IF USING A FISCAL SPONSOR/AGENT, PLEASE PROVIDE THE
FOLLOWING INFORMATION FOR YOUR PROGRAM/INITIATIVE, NOT THE FISCAL SPONSOR
ORGANIZATION).
Board
ED/CEO Staff Total
Members
White, non-Hispanic/Latino 0 0 0 0
Black, non-Hispanic/Latino 0 0 0 0
Hispanic/Latino 0 0 0 0
American Indian/Alaskan
0 0 0 0
Native
Asian 0 0 0 0
Native Hawaiian or other
0 0 0 0
Pacific Islander
Two or more races 0 0 0 0
Total 0 0 0 0
Comments: [optional]
14. Service Area - Please verify the New Mexico counties your organization serves. (select all that
apply)
☐ Colfax
☐ Los Alamos
☐ Mora
☐ Rio Arriba
☐ San Miguel
☐ Santa Fe
☐ Taos
☐ All the above
☐ Statewide
-3-GIVING TOGETHER SUMMARY
The information you provide below will be included in Santa Fe Community Foundation’s Giving
Together catalogue which is mailed out to all SFCF’s fundholders. Your Giving Together summary
does not need to reflect the same request as your competitive grant proposal.
15. Mission Statement (500 characters)
16. Provide a 1-2 sentence summary of your grant request (not your mission statement) that we
can include in our Giving Together Catalogue. (500 characters)
17. Please provide a statistic about the need your organization is trying to address (500 max.
characters):
Request Information
To provide flexibility to nonprofits, CHFA provides general operating support. These grant amounts
are calculated based on your organization’s annual operating budget. Please refer to the following
table to determine the grant size you may apply for.
Annual Budget for Organizations: Grant Request Amount:
$150,000 and below $5,000
$150,000 - $500,000 $10,000
Above $500,000 $15,000
18. Total annual organizational budget [15 characters]:
19. Grant amount requested [drop down] ($5,000, 10,000 or 15,000 only)
-4-Outcome Area & Priority Indicators
20. Please select an Outcome Area that is most relevant to your work or organization. Note: While
we ask that you choose one, we recognize that many organizations and projects address
complex and intersecting issues, so you will have the opportunity to select a secondary
Outcome Area, if needed.
Maternal Health & Early Childhood
Behavioral Health – Children and Adolescent Health
Behavioral Health - Adult
Physical Health - Adult
Women’s Health
Senior Health and Wellness
Social Determinants of Health – Housing and Homelessness
Social Determinants of Health Across the Life Span (Healthy Neighborhoods, Food Security)
Cross-Cutting - Please select from the following: Collaborative, Advocacy, Community Development,
Media & Information Sharing, Other Systems-level Change Efforts
21. Please check a Secondary Outcome Area that your organization or project addresses, if
needed.
22. Which of the CHFA’s Priority Indicators do you address the most? Note: In SM Apply, the
indicators that align with the outcome area selection(s) should appear. The question appears as a
ranked choice response.
Maternal Health & Early Childhood
- Rate of Prenatal Care in the First Trimester
- Rate of Babies Born with Low Birth Weight
- Neonatal Abstinence Syndrome Rate
Behavioral Health - Children & Adolescents
- Obesity Rate – Children & Adolescents
- Rate of Depression and/or Suicide Attempts in Youth
- Resiliency in Adolescents
Behavioral Health - Adult
- Drug Overdose Rate
- Alcohol Related Death Rate
- Suicide Death Rate – Adults
Physical Health - Adult
- Health Insurance Coverage Rate
- Heart Disease Rate
- Cancer Death Rate
-5-Women’s Health
- Obesity Rate – Women
- Domestic Violence Rate
- Homelessness Rate – Women
Senior Health and Wellness
- Fall Related Death or Injury Rate - Seniors
- Suicide Death Rate – Seniors
- Immunization Rate
Social Determinants of Health
- Homelessness Rate – Across life span
- Housing Cost Burden
Social Determinants of Health Across the Life Span (Healthy Neighborhoods, Food Security)
- Please indicate a custom priority indicator.
Cross Cutting (Collaborative, Advocacy, Community Development, Media & Information Sharing, Other
Systems-level Change Efforts)
- Please indicate a custom priority indicator.
Core Questions
23. Critical Need/Root Causes - What are the critical needs and root causes related to the issues
you are trying to address and what specific barriers does your target population face? [1500
characters]
24. Planned Work/Planned Activities - What are you proposing to do to address these barriers
(describe specific programs or work you do related to the selected indicators)? [3000
characters]
25. People You Serve [1,000 characters]
A. How many people did your organization or project serve overall in the last year? How
many people do you plan to serve in the next year?
B. Who are the people or target population most affected by the issue you are trying to
address? Does geography or neighborhood play a role in the issue?
C. What percentage of the total number of people you serve fit the description in [B] above?
Please provide the breakdown of your target population and communities served by your
organization/project if this information is available.
26. Inclusion - How are the people you serve informed, involved and/or represented in your
organization’s decision-making, program work and teams? How does your program or
organization reach them and build on the strengths and cultural assets of the community?
[1000 characters]
-6-27. Key Partners - Who are your key partners and what role do they play in your strategies,
programs, or services? How are you engaged in broader collaborations in the community to
align your strategies and contribute to desired collective impact or result? [1000 characters]
28. Advocacy - If your organization engages in advocacy work, please briefly describe. Feel free to
share what has worked and any challenges you face. [750 characters]
29. Equity - If your organization/project is presently engaged in any equity practices, trainings, or
programs, please describe. Feel free to share what has worked and any challenges you face.
[750 characters]
30. Major Changes - Has your organization experienced any major changes during this reporting
period, including changes at the board or leadership level and/or key program staff? [350
characters]
Performance Management and Results-based Accountability
Results Based Accountability (RBA) is a method used by the CHFA and increasingly adopted in this
community, to plan and assess progress towards improving outcomes. Key performance measures
help track that progress.
To learn more about RBA, please visit:
https://communityhealthfunder.org/wpcontent/uploads/2020/03/CHFA-RBA-Resource-Sheet-v2.pdf
Instructions: Please share how you plan to track progress for the future. If you receive funding, you
will be asked to briefly report on these performance measures.
For each of the three levels below, please list one to three primary performance measures your
organization will track to evaluate your contribution to turning the curve on the primary
indicator you selected in this application. See the examples below.
31. Quantity of Effort, Level 1: How “much” did you do? (How much service was provided?)
e.g. The number of clients/participants enrolled or served by the program. The number of
trainees in a job training program. The number of meals served. The number of events or classes
held.
-7-Performance Measure’s Description Target Value
Measure Type Name (1-2 (What is your
sentences #/goal for the
max.) grant
period?)
Level 1 Measure
A (REQUIRED):
Level 1 Measure
B (OPTIONAL):
Level 1 Measure
C (OPTIONAL):
32. Quality of Effort, Level 2: How “well” did you do it? (How well was the service provided? These
measures quantify the quality of service delivery, customer satisfaction, and the efficiencies
related to service delivery).
e.g. Participant retention rate in program. Retention rate of highly qualified staff. % of people
served who rate the program as helpful or who are satisfied with the quality of their experience
with the program. Waiting list size. Average time to next appointment. % of meals served that
include fresh fruits and vegetables. % of staff with advanced training or certification. Program
attendance rate.
Performance Measure’s Description Target Value
Measure Type Name (1-2 (What is your
sentences #/goal for the
max.) grant
period?)
Level 2 Measure
A (REQUIRED):
Level 2 Measure
B (OPTIONAL):
Level 2 Measure
C (OPTIONAL):
-8-33. Quantity and Quality of Effect, Levels 3: #/% Is anyone better off? [How many clients are better
off and what percent are better off? What changes were produced as a result of our efforts –
change in attitude, beliefs, behavior or circumstances?]
e.g. The number of individuals/ percentage of total number served that demonstrate
improvements in positive areas or decrease of negative areas. The number and percentage of
trainees who obtain and keep a job. #/% Enrolled who report decrease in depression. #/% People
served who report increased food security % of clients who show improvement in a skill area
taught through the program.
Performance Measure’s Description Target Value
Measure Type Name (1-2 (What is your
sentences #/goal for the
max.) grant
period?)
Level 3 Measure
A (REQUIRED):
Level 3 Measure
B (OPTIONAL):
Level 3 Measure
C (OPTIONAL):
FINANCIALS AUDITED, FINANCIAL & IRS ATTACHMENTS
34. Are your annual financial statements audited, and if so by whom? [60 characters]
Note: We may ask for additional information prior to a site visit or a grant decision, if we feel it is
necessary.
Please include as attachments:
• 501(c)3 letter of determination from the IRS (either applicant’s or fiscal sponsor’s)
• Budget for the current fiscal year
• Most recent Balance Sheet
• Most recent Profit & Loss statement
• Board Roster
35. If you do not have any of the financial documents listed above, please explain why. [500
characters]
-9-Nonprofit Disclosure Statement & Certification
Nonprofit Disclosure Statement
36. I verify that our organization is in current compliance regarding the following:
IRS Form 990 Filings
Yes ☐
No ☐
IRS 501(c)3 status
Yes ☐
No ☐
NM State tax filings, including Secretary of State and NM Attorney General (if required)
Yes ☐
No ☐
Not Required ☐
IRS tax requirements (payroll taxes, unrelated business income, etc.)
Yes ☐
No ☐
Please explain any "no's":
37. Please check below and add signature to certify the correctness of the information provided:
☐ I assert on behalf of our Board Chair that all information included in this application is true
and correct to the best of my knowledge. I understand that if any of these representations
are false, reimbursement for funding is demanded.
Name of Person Authorizing:
Title of Person Authorizing:
Authorization Date:
Name of Board Chair:
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