Community Grant Program
GRANTING GUIDELINES
2015-2016 Funding
Susan G. Komen Central and Northern Arizona® (Komen CAN AZ) along with those who generously
support us with their talent, time and resources—is working to better the lives of those facing breast
cancer in our community. We join more than 100,000 breast cancer survivors and activists around the
globe as part of the world’s largest and most progressive grassroots network fighting breast cancer.
Through events like the Phoenix Race for the Cure®, we have invested $24.2 million in local breast
health and breast cancer awareness projects in nine counties throughout central and northern Arizona.
Up to 75 percent of net proceeds generated by Komen CAN AZ stay in central and northern Arizona. The
remaining income goes to the national Susan G. Komen® grants program for energizing science to find
the cures.
About Susan G. Komen
Susan G. Komen® is the world’s largest breast cancer organization, funding more breast cancer research
than any other nonprofit while providing real-time help to those facing the disease. Since its founding in
1982, Komen has funded more than $800 million in research and provided more than $1.7 billion in
funding to screening, education, treatment and psychosocial support programs serving millions of
people in more than 30 countries worldwide. Komen was founded by Nancy G. Brinker, who promised
her sister, Susan G. Komen, that she would end the disease that claimed Suzy’s life. Visit komen.org or
call 1-877 GO KOMEN. Connect with us on Facebook at facebook.com/susangkomen and Twitter
@SusanGKomen.
STATEMENT OF NEED
Komen CAN AZ Community Profile is designed to give our community a comprehensive look at the state
of breast cancer throughout central and northern Arizona to be not only educational and informative,
but also inspirational and motivating.
Komen CAN AZ encourages grant applicants to develop alliances that leverage their combined assets to
maximize financial and human resources to extend the reach of community programs and serve more
individuals. These partnerships are capable of expanding service capacity and reducing duplication.
Komen CAN AZ seeks new initiatives and expanded partnerships among all grant requests.
Komen CAN AZ Community Profile defines medically underserved as Hispanic, African American/Black,
and Native American women; refugees; low income White women; undocumented Hispanic women and
underinsured and uninsured populations. Priority focus is placed on Hispanic, African American/Black,
and Native American women and the underinsured and uninsured populations.
Komen CAN AZ accepts multiple grant applications from the same organization and each application is
evaluated separately and on its own merit.
A grant application may be submitted for multiple funding categories. For example, an application may
allocate a majority of requested funds for screening but also include an education component. This
grant application is considered in the Screening and Diagnostic projects funding category which is
funded up to $75,000. The primary funding priority should identify the main purpose of the program
and match one of Komen CAN AZ’s current community grant funding categories.
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Another example is an application which may allocate a majority of requested funds for breast
cancer treatment but also includes a breast cancer support group component. This grant
application is considered in the Treatment Projects funding category which is funded up to
$150,000.
To determine the following priorities, Komen CAN AZ assembled a Community Profile Committee to
review the demographic data, the analysis of the health care system and the community perspectives on
breast cancer to uncover gaps in the system and other common themes. While the results are listed
below, in order of priority, it’s important to note that each of these objectives must be addressed by our
community in order to create a comprehensive and successful breast health system in Arizona. The 2011
Community Profile can be found on our website at www.komencanaz.org .
Komen CAN AZ Community Profile Report identifies the following funding priority areas:
Priority #1 (P1): Enhance education and outreach of breast self-awareness (BSA) message to
increase early detection
Priority #2 (P2): Improve access to direct care and the continuum of care
Priority #3 (P3): Improve quality of life through survivorship support programs
P1: Enhance education and outreach of breast self-awareness message to increase early detection by
 Creating messages that focus on breast health and the importance of early detection targeted to
the Native American and African American/Black populations who have demonstrated
disparities as far as later staged breast cancer presentation, lower five year survival rates and
lower breast cancer screening rates
 Creating a centralized breast health and breast cancer resource centers in rural areas that
include information on a range of subjects, from breast self-awareness to breast cancer
resources and available services for breast cancer survivors
 Presenting information to health care providers to increase their knowledge of the Well Woman
HealthCheck Program (WWHP) and its eligibility criteria to ensure those who are eligible enroll;
of the health care system, community resources and available services; of the fears patients
have and how to address those fears in a sensitive manner
 Creating programs that target the Hispanic population
P2: Improve access to direct care and the continuum of care by
As an organization, Komen wants to ensure quality care for all by eliminating and breaking
down barriers to people’s access to care.
 Improving uninsured people’s ability to get into the health care system
 Eliminating cost barriers to screening and treatment services
 Eliminating transportation barriers
 Supporting patient navigation and Promotora programs to assist patients through the
screening, diagnostic, treatment and post-treatment support process for those defined
as medically underserved
 Increasing access to screening by encouraging the use of mobile mammography units
 Creating collaborative partnerships with multiple agencies that maximize financial and
human resources to extend the reach of community programs and serve more individuals
 Creating a forum to advance public policy issues on a state level
 Creating programs that target the Hispanic population to increase screening utilization
and access to treatment
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P3: Improve quality of life through survivorship support programs by
Breast cancer survivorship begins on the day of diagnosis
 Supporting services that address the emotional, sexual, financial, physical and other impacts
that occur after a breast cancer diagnosis
 Creating a centralized location for information on available services after diagnosis, during
treatment and after treatment including resources for wigs, prosthesis, lymphedema treatment
and support groups
 Increasing availability of financial assistance
 Creating programs that educate survivors on the reduction of risk for breast cancer in an effort
to reduce the fear of reoccurrence
GRANT FUNDING CATEGORIES
Education, Community Outreach, Survivorship Support Projects- funded up to
$50,000
Komen CAN AZ funds education projects that are effective in promoting behavioral change or
empowering individuals to make good breast health decisions. Organizations requesting funding for
educational projects, community outreach and survivorship support projects should include
interventions that are evidence based and can demonstrate successful outcomes. These programs
should focus on priority populations and targeted geographic areas as outlined in the 2011 Community
Profile to:
o
o
o
o
o
o
Create messages that focus on breast health and the importance of early detection targeted to
the Native American and African American/Black populations who have demonstrated
disparities as far as later staged breast cancer presentation, lower five-year survival rates and
lower breast cancer screening rates (P1)
Create centralized breast health and breast cancer resource centers in rural areas thatinclude
information on a range of subjects, from breast self-awareness (BSA) to breastcancer resources
and available services for breast cancer survivors or (P1)
Create information for health care providers to increase their knowledge of
 the Well Woman HealthCheck Program (WWHP) and its eligibility criteria to ensure
those who are eligible for the program enroll in the program; (P1)
 the health care system, community resources and available services; (P1)
 the fears patients have and how to address those fears in a sensitive manner or (P1)
Create programs that target the Hispanic population (P1)
Create programs that improve uninsured people’s ability to get into the health care system (P2)
Create programs that improves quality of life through survivorship support such as support
services that address the emotional, sexual, financial, physical and other impacts that occur
after a breast cancer diagnosis; or a program that educates survivors on reducing the risk for
breast cancer in an effort to reduce the fear of reoccurrence(P3)
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Screening and Diagnostic Projects – funded up to $75,000
This funding category includes screening mammograms, diagnostic mammograms and all other breast
cancer diagnostic procedures. Screening and diagnostic grants must use Komen CAN AZ funding only as
“last resort” for those women or men who are medically underserved, uninsured or underinsured.
Screening projects must demonstrate knowledge of the Well Woman HealthCheck Program (WWHP) for
screening and Breast and Cervical Cancer Treatment Program (BCCTP) for treatment of breast cancer.
All screening applications must demonstrate the “next step” in the continuum of care with particular
attention on what happens after a diagnosis of cancer. It is not enough to give someone a list of
resources or refer to a Komen CAN AZ grantee for treatment. The project must ensure an individual is
continuing through the continuum of care by confirming appointments for follow up care or follow up
screening for the following year. Options and plans for treatment if a woman is diagnosed with cancer
must be in place prior and made clear in the application prior to submission.
These programs should focus on priority populations and targeted geographic areas as outlined
in the 2011 Community Profile to:
o Create programs that eliminate cost barriers to screening and diagnostic services (P2)
o Create programs that eliminate transportation barriers (P2)
o Create programs that support patient navigation and Promotora programs to assist patients
through the screening and diagnostic process for those defined as medically underserved
(P2)
o Create programs that increase access to screening by using mobile mammography units (P2)
o Create programs that target the Hispanic population to increase screening utilization (P2)
Treatment Projects - funded up to $150,000
Treatment project funds are used for women and men diagnosed with breast cancer and may include
some or all of the following: diagnostics testing, surgery, radiation, chemotherapy, lymphedema
treatment, or other treatments as indicated by a treating physician. All Komen CAN AZ funding for
treatment service projects must be used to serve medically underserved, uninsured or underinsured.
Applicants must demonstrate knowledge of the Breast and Cervical Cancer Treatment Program (BCCTP)
and outline how the proposed treatment program will complement the BCCTP program to treat those
who do not qualify. Komen CAN AZ funds must be used as last resort and must not be used in place of
any other program available that a patient may qualify for. These programs must focus on priority
populations and targeted geographic areas as outlined in the 2011 Community Profile to
o Create programs that eliminate cost barriers to treatment services (P2)
o Create programs that eliminate transportation barriers (P2)
o Create programs that target the Hispanic population to increase access to treatment (P2)
o Create programs that support patient navigation and Promotora programs to assist patients
through the treatment and post-treatment support process for those defined as medically
underserved (P2)
o Create programs that provide lymphedema treatment (P2)
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GENERAL RESTRICTIONS AND CONDITIONS FOR ALL APPLICANTS
A Few Key Points About Komen CAN AZ Grants Program
 Komen CAN AZ is like any other foundation in that we make grants to not-for-profit
organizations through a defined process.
 Komen CAN AZ is not an endowed foundation. This means that our giving can fluctuate from
year to year more than endowed foundations.
 Komen CAN AZ only funds in one program area – breast health and breast cancer related
projects.
 Sponsorship for the Phoenix Race for the Cure® has NO impact on determining if a program is
funded or not.
 Previous funding does not guarantee future funding. A first time applicant has the same
opportunity to be funded as an organization previously funded.
 Grants are funded for one year only.
 Komen CAN AZ grant funds are only permitted to be used as last resort when there are no other
resources available.
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Projects Must Focus on Breast Health and Breast Cancer
Komen CAN AZ will only fund projects that focus on breast health and/or breast cancer. For example, if a
project is a combined breast and cervical cancer project, the request can only include the breast cancer
section of the project.
Eligibility
Applicants must meet the following eligibility criteria to be considered for funding:
 Program must be specific to breast health and/or breast cancer. If a program includes other
health issues along with breast cancer, such as a breast and cervical cancer program, funding
may only be requested for the breast cancer portion.
 All past and current Komen-funded grants or awards to Applicant are up-to-date and in
compliance with Komen requirements. All past and current Komen CAN AZ funded grants or
awards to applicant are up-to-date and in compliance with Komen CAN AZ requirements AND
applicant must be “In Good Standing” status.
 Applicant has tax exempt status under the Internal Revenue Service code.
 Applicant must be a non-profit organization located in or providing services to one or
more of the following locations:
o Apache
o Coconino
o Gila
o La Paz
o Maricopa
o Mohave
o Navajo
o Pinal
o Yavapai
 If applicant, or any of its key employees, directors, officers or agents is convicted of
fraud or a crime involving any other financial or administrative impropriety, then applicant
is not eligible to apply for a grant during this current cycle and will not be eligible to apply
for a new grant until the later of 12 months after the conviction or until applicant can
demonstrate that appropriate remedial measures have been taken to ensure that any
criminal misconduct does not recur.
Allowable Expenses
Funds may be used for the following types of program expenses:
 Salaries and fringe benefits for program staff
 Clinical services or patient care costs
 Supplies
 Travel
 Other direct program expenses
 Indirect costs, not to exceed 5% of direct costs
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Funds may not be used for the following purposes:
 Research, defined as any project or program with the primary goal of gathering and analyzing
data or information.
o Specific examples include, but are not limited to, projects or programs designed to:
 Understand the biology and/or causes of breast cancer
 Improve existing or develop new screening or diagnostic methods
 Identify approaches to breast cancer prevention or risk reduction
 Improve existing or develop new treatments for breast cancer or to overcome
treatment resistance, or to understand post‐treatment effects
 Investigate or validate methods
 Development of educational materials or resources
 Construction or renovation of facilities
 Political campaigns or lobbying
 Endowments
 General operating funds (except indirect cost)
 Debt reduction
 Annual fund-raising campaigns
 Event sponsorships
 Projects completed before the date of grant approval
 Individuals
 Reimbursement for specific individuals’ direct services
 Building/renovation
 Capital campaigns
 Employee matching gifts
 Land acquisition
 Program-related investments/loans
 Scholarships
 Education regarding breast self exams/use of breast models
 Thermography
Important Granting Policies
Please note these policies before submitting a proposal. These policies are non-negotiable.
 No expenses may be accrued against the grant until the agreement is fully executed.
 Any unspent funds over $1.00 must be returned to Komen CAN AZ.
 Grantee will be required to submit a minimum of one semi-annual progress report and one final
report that will include, among other things, an accounting of expenditures. Additional reports
may be requested.
 At the discretion of Komen CAN AZ, the grantee may request one no cost extension of no more
than six months for each grant.
 Certain insurance coverage must be demonstrated at the execution of the grant agreement, if
awarded. Grantee is required at minimum to hold commercial general liability insurance with
combined limits of not less than $1,000,000 per occurrence and $2,000,000 in the aggregate for
bodily injury, including death, and property damage; workers’ compensation insurance in the
amount required by the law in the state(s) in which its workers are located and employers
liability insurance with limits of not less than $500,000; and excess/umbrella insurance with a
limit of not less than $5,000,000. In the event any transportation services are provided in
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connection with program, $1,000,000 combined single limit of automobile liability coverage will
be required. If any medical services (other than referrals) are provided or facilitated, medical
malpractice coverage with combined limits of not less than $1,000,000 per occurrence and
$3,000,000 in the aggregate will be required. Grantees are also required to name Komen CAN
AZ as an Additional Insured on the above policies. *Those applications for Education, Outreach
and Survivorship Support are permitted to request lesser insurance coverage. Each request will
be individually reviewed and determined.
Rates
Rates must not exceed current Medicare allowable rates (Please see www.komencanaz.org
for a list of current rates).
Educational Materials and Messages
Susan G. Komen is a source of information about breast health and breast cancer for people all over the
world. To reduce confusion and reinforce learning, we only fund programs that involve educational
messages and materials that are consistent with those promoted by Komen, including promoting the
messages of breast self-awareness-- know your risk, get screened, know what is normal for you and
make healthy lifestyle choices. The consistent and repeated use of the same messages will improve
retention and the adoption of the actions we think are important. Please visit the following webpage
before completing your application and be sure that your organization can agree to promote these
messages: http://ww5.komen.org/BreastCancer/BreastSelfAwareness.html.
We do not recommend monthly breast self-exams and therefore will not fund education programs
that teach or endorse the use of monthly breast self-exams or use breast models.
Komen CAN AZ grantees are eligible to receive preferred pricing for Komen educational materials.
Komen materials should be used and displayed whenever possible. To view our educational materials,
visit www.shopkomen.com.
Optional: Use of Komen’s Breast Cancer Education Toolkit for Hispanic/Latina
Communities
Susan G. Komen has developed a Breast Cancer Education Toolkit for Hispanic/Latina communities. It is
designed for educators and is a great resource that Organizations can implement in their communities.
Applications to this mechanism may seek funding for such implementation. Demonstrated need for
educational outreach for Hispanic populations in the Affiliate service area will be key to a successful
application, but is not necessary for access to the toolkit which is free online. This tool is available in
both English and Spanish versions. To access the Toolkit, please visit http://komentoolkits.org.
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Pre-Application Workshop
All applicants should attend a Pre-Application Workshop. Workshops are available September 25, 2014
9:30am to 11:30am and September 26, 2014 2:00pm to 4:00pm at the Flinn Foundation- 1802 North
Central Avenue Phoenix, AZ 85004.
Please plan on attending a workshop either in person or through web conferencing. Please RSVP to
skolb@komencanaz.org for the workshop you would like to attend and please indicate if you will be
attending in person or through web conferencing. You will then be sent location directions or web
conferencing information. The application will be available through GeMS
https://affiliategrants.komen.org beginning September 25, 2014.
Deadline and Submission Information
All applications are due no later than Monday, November 3, 2014 by 5:00pm and must be submitted
through GeMS at https://affiliategrants.komen.org. No paper or late submissions will be accepted.
The Community Grant Guidelines are available at www.komencanaz.org. Inquiries should be
directed to Frank Nagy at fnagy@komencanaz.org or by calling (602) 544-2873. Please allow adequate
time before the application deadline for response to any inquiry.
Review Process
Grant applicants which meet the minimum eligibility qualifications and whose organization is “In Good
Standing” status are submitted to an independent Grants Review Panel. For applicants who have
previously received funding from Komen CAN AZ, past performance and compliance with grant
requirements will be considered. All Progress and Final Reports of past grantees including current 20142015 Progress Reports will be reviewed and taken into consideration by the reviewers when evaluating
applications for 2015-2016 funding.
Contracts and Grant Period
A grant contract will be the legal mechanism for funding. The grant period is for one year only and
begins April 1, 2015 and concludes on March 31, 2016.
Payment and Reporting
The grant funds will be paid in two equal increments. The first increment will be paid within 30 days of
receiving the fully executed grant contract. The second increment will be paid after Komen CAN AZ
receives and approves the six-month Progress Report, due on October 31, 2015. A final report is due
May 15, 2016. Organizations shall maintain all fiscal, statistical and management books/records
pertaining to the program and service delivery for two years after the program ends.
Announcement of Grant Awards
Komen CAN AZ will announce the grants awarded for 2015-2016 funding in March 2015. Each applicant
organization will receive written notification by this date. The actual number of awards will depend on
the amount of funds available.
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Application Instructions
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Education/Outreach/Survivorship Support Application
Organization Summary
This section collects detailed information regarding your organization, including in-depth information
regarding your organization background and structure.
Provide a brief description of:
 the organization's history. If your program is part of a larger organization, briefly explain the
mission of the larger entity and your relationship to it;
 the mission of the organization;
 current programs and accomplishments;
 how your organization seeks to be diverse and inclusive; and
 the number of paid full time staff, volunteers and total annual organization budget.
Project Abstract and Narrative
The Project Abstract should provide a brief description of the proposal including the purpose of the
program, a description of key activities, a summary of evaluation methods and the expected or resulting
change(s) your program will likely bring in your community.
On the Project Narrative page of the application on GeMS, please address the requests below for each
section.
Organizational Capacity (Limit- 3,500 characters)
 Explain why the applicant organization is best-suited to lead the project and accomplish the
goals and objectives set forth in this application.
 Describe evidence of success in delivering breast health/cancer services to the proposed
population.
 Describe fiscal capability to manage the delivery of the proposed goals and objectives and
ensure adequate measures for internal control of grant dollars.
 Describe the organization’s current financial state. Has your organizational budget increased or
decreased from last year? Please explain why.
Statement of Need (Limit- 3,500 characters)
 Describe the population to be served and the patient eligibility criteria for the project.
 Describe evidence of the risk/need within that population.
 Provide statistics specific to the target population.
 Describe the measures taken to ensure outreach to the target populations.
Project Description (Limit- 3,500 characters)
 Explain how the project’s goals and objectives, as outlined in your Project Work Plan addresses
one or more of the priorities outlined in the Affiliate’s Community Profile/Statement of Need.
 Describe how this project is evidence based.
 Describe how Komen’s breast self-awareness (BSA) messaging will be included and promoted in
the project.
 Describe how the project will change attitudes and behaviors regarding breast health to
increase screening rates through education and outreach.
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If survivorship project, explain how the project will increase quality of life for survivors of breast
cancer? How will the project utilize or promote Survivorship Care Plans?
Explain how the project will increase the percentage of people who enter, stay in, or progress
through the continuum of care.
Collaboration (Limit- 3,500 characters)
 Describe the roles and responsibilities of all organizations or entities participating in the project.
 Explain how the collaboration strengthens the project and why these organizations are best
suited to carry out the project and accomplish the goals and objectives set forth in this
application.
• Explain how this project will connect individuals to screening? Explain how this project will
promote the Well Woman HealthCheck Program to connect those that qualify for free breast
and cervical cancer screening to the program.
Sustainability (Limit- 3,500 characters)
 Describe the plan to secure and allocate resources (financial, personnel, partnerships, etc.) to
sustain the program at the conclusion of the grant period. What are your organization’s plans to
support the project director to implement, manage and oversee all aspects of the proposed
project?
 What efforts will you take to communicate this project to your organizational leadership to
ensure buy-in?
Evaluation (Limit- 3,500 characters)
 Describe in detail how the organization(s) will measure progress against the stated project goals
and objectives. Please include any templates, logic models, or surveys in the attachments.
 Describe how the organization(s) will assess the impact of the project on the selected priority.
Please include any templates, logic models, or surveys in the attachments.
 Describe how the organization(s) will assess program delivery. Please include any templates,
logic models, or surveys in the attachments.
 Describe the monitoring and evaluation (M&E) expertise that will be available for this purpose.
 Described the resources available for M&E during the course of the project. Specify if these
resources are requested as part of this grant, or if they are existing organizational resources.
Budget
Provide a detailed total program budget. All funding for this program, including other grants and general
funds should be included in the budget. Please note that indirect costs may not exceed 5% of direct
costs. For each line item in the budget, provide a brief description of how the funds will be used and
why they are programmatically necessary. List all other committed and pending sources of support for
the program as In Kind. All reimbursable rates must be billed at 2014 Medicare reimbursable rates. A list
of current Medicare rates in a downloadable PDF format is located on Komen CAN AZ website at
www.komencanaz.org.
Attachments (MUST BE INCLUDED)
 Project Work Plan (Please visit www.komencanaz.org to download form)
 Information regarding Key Personnel – For key personnel that are currently employed by the
applicant, provide a resume or curriculum vitae. For new or vacant positions, provide job
descriptions (two page limit per individual).
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Proof of Non-Profit Status – To document your federal tax-exempt status, attach your
determination letter from the Internal Revenue Service. Evidence of state or local exemption
will not be accepted. Please do not attach your Federal tax return.
Letters of support, collaboration, MOUs, etc. demonstrating your partnerships. Must be
included. Must demonstrate partnership identification and agreement and terms of agreement
for services. Must be signed by partnering organization(s).
Evaluation forms, surveys, ect. the program will use to measure effectiveness of program.
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Screening and Diagnostic Application
Organization Summary
This section collects detailed information regarding your organization, including in-depth information
regarding your organization background and structure.
Provide a brief description of:
 the organization's history. If your program is part of a larger organization, briefly explain the
mission of the larger entity and your relationship to it;
 the mission of the organization;
 current programs and accomplishments;
 how your organization seeks to be diverse and inclusive; and
 the number of paid full time staff, volunteers and total annual organization budget.
Project Abstract and Narrative
The Project Abstract should provide a brief description of the proposal including the purpose of the
program, a description of key activities, a summary of evaluation methods and the expected or resulting
change(s) your program will likely bring in your community.
On the Project Narrative page of the application on GeMS, please address the requests below for each
section.
Organizational Capacity (Limit- 3,500 characters)
 Explain why the applicant organization is best-suited to lead the project and accomplish the
goals and objectives set forth in this application.
 Describe evidence of success in delivering breast health/cancer services to the proposed
population.
 Describe fiscal capability to manage the delivery of the proposed goals and objectives and
ensure adequate measures for internal control of grant dollars.
 Describe the organization’s current financial state. Has your organizational budget increased or
decreased from last year? Please explain why.
Statement of Need (Limit- 3,500 characters)
 Describe the population to be served and the patient eligibility criteria for the project.
 Describe evidence of the risk/need within that population.
 Provide population characteristics (race, ethnicity, economic status, and breast cancer statistics)
specific to the target population.
Project Description (Limit- 3,500 characters)
 Explain how the project’s goals and objectives, as outlined in your Project Work Plan addresses
one or more of the priorities outlined in the Affiliate’s Community Profile/Statement of Need.
 Explain how the project will increase the percentage of people who enter, stay in, or progress
through the continuum of care.
 Describe how Komen’s breast self-awareness (BSA) messaging will be included in the project.
 Describe your organization’s screening guidelines including women under age 40 and men. (i.e.
when annual mammography should begin, clinical breast exams, how often,
etc.).
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Describe your policy around follow-up care for individuals with abnormal findings and/or
diagnosed with breast cancer.
How has/will your organization respond to the increasing need in the community? Is there a
wait list for services?
Collaboration (Limit- 3,500 characters)
 Describe the roles and responsibilities of all organizations or entities participating in the project.
 Explain how the collaboration strengthens the project and why these organizations are best
suited to carry out the project and accomplish the goals and objectives set forth in this
application.
 What partnerships or relationships are in place to assist and insure a patient continues through
the next step in the continuum of care?
Sustainability (Limit- 3,500 characters)
 Describe the plan to secure and allocate resources (financial, personnel, partnerships, etc.) to
sustain the program at the conclusion of the grant period. What are your organization’s plans to
support the project director to implement, manage and oversee all aspects of the proposed
project?
 What efforts will you take to communicate this project to your organizational leadership to
ensure buy-in?
Evaluation (Limit- 3,500 characters)
 Describe in detail how the organization(s) will measure progress against the stated project goals
and objectives. Please include any templates, logic models, or surveys in the attachments.
 Describe how the organization(s) will assess the impact of the project on the selected priority.
Please include any templates, logic models, or surveys in the attachments.
 Describe how the organization(s) will assess program delivery. Please include any templates,
logic models, or surveys in the attachments.
 Describe the monitoring and evaluation (M&E) expertise that will be available for this purpose.
 Described the resources available for M&E during the course of the project. Specify if these
resources are requested as part of this grant, or if they are existing organizational resources.
Budget
Provide a detailed total program budget. All funding for this program, including other grants and general
funds should be included in the budget. Please note that indirect costs may not exceed 5% of direct
costs. For each line item in the budget, provide a brief description of how the funds will be used and
why they are programmatically necessary. List all other committed and pending sources of support for
the program as In Kind. All reimbursable rates must be billed at current 2013 Medicare reimbursable
rates. A list of current Medicare rates in a downloadable PDF format is located on Komen CAN AZ
website at www.komencanaz.org .
Attachments (MUST BE INCLUDED)
 Project Work Plan (Please visit www.komencanaz.org to download form)
 Information regarding Key Personnel – For key personnel that are currently employed by the
applicant, provide a resume or curriculum vitae. For new or vacant positions, provide job
descriptions (two page limit per individual).
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Proof of Non-Profit Status – To document your federal tax-exempt status, attach your
determination letter from the Internal Revenue Service. Evidence of state or local exemption
will not be accepted. Please do not attach your Federal tax return.
Letters of support, collaboration, MOUs, etc. demonstrating your partnerships. Must be
included. Must demonstrate partnership identification and agreement and terms of agreement
for services. Must be signed by partnering organization(s).
Evaluation forms, surveys, ect. the program will use to measure effectiveness of program.
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Treatment Application
Organization Summary
This section collects detailed information regarding your organization, including in-depth information
regarding your organization background and structure. Provide a brief description of:
 the organization's history. If your program is part of a larger organization, briefly explain the
mission of the larger entity and your relationship to it;
 the mission of the organization;
 current programs and accomplishments;
 how your organization seeks to be diverse and inclusive; and
 the number of paid full time staff, volunteers and total annual organization budget.
Project Abstract and Narrative
The Project Abstract should provide a brief description of the proposal including the purpose of the
program, a description of key activities, a summary of evaluation methods and the expected or resulting
change(s) your program will likely bring in your community.
On the Project Narrative page of the application on GeMS, please address the requests below for each
section.
Organizational Capacity (Limit- 3,500 characters)
 Explain why the applicant organization is best-suited to lead the project and accomplish the
goals and objectives set forth in this application.
 Describe evidence of success in delivering breast health/cancer services to the proposed
population.
 Describe fiscal capability to manage the delivery of the proposed goals and objectives and
ensure adequate measures for internal control of grant dollars.
Statement of Need (Limit- 3,500 characters)
 Describe the population to be served and the patient eligibility criteria for the project.
 Describe evidence of the risk/need within that population.
 Provide population characteristics (race, ethnicity, economic status, and breast cancer statistics)
specific to the target population.
Project Description (Limit- 3,500 characters)
 Explain how the project’s goals and objectives, as outlined in your Project Work Plan addresses
one or more of the priorities outlined in the Affiliate’s Community Profile/Statement of Need.
 Explain how the project will increase the percentage of people who enter, stay in, or progress
through the continuum of care.
 Describe your organization’s expertise to complete the program.
 Describe the charity care policy at your hospital or facility. How will it be leveraged to treat
patients requiring treatment beyond Komen CAN AZ funding?
 Describe your plan and ability to leverage other financial resources for patients and how you will
ensure that Komen CAN AZ funds will be used as payment of last resort behind that of AHCCCS,
WWHP, BCCTP, ACA market place, ect.
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Describe the quality assurance measure that will be taken for the execution of the program
(verification of patient’s eligibility for the program, continuity of care for patients, managing
funds, etc.).
Describe how this project currently utilizes or plans to utilize Survivorship Care Plans.
Collaboration (Limit- 3,500 characters)
 Describe the roles and responsibilities of all organizations or entities participating in the
program.
 Explain how the collaboration strengthens the project and why these organizations are best
suited to carry out the project and accomplish the goals and objectives set forth in this
application.
 What partnerships are you building and resources are you leveraging to ensure this program will
continue beyond the year of Komen CAN AZ grant funding?
Sustainability (Limit- 3,500 characters)
 Describe the plan to secure and allocate resources (financial, personnel, partnerships, etc.) to
sustain the program at the conclusion of the grant period. What are your organization’s plans to
support the project director to implement, manage and oversee all aspects of the proposed
program?
 What efforts will you take to communicate this program to your organizational leadership to
ensure buy-in?
 What is your sustainability plan if this program is not funded in the future? What will be the plan
for patients that are currently under treatment if this program is not funded in future years?
Evaluation (Limit- 3,500 characters)
 Describe in detail how the organization(s) will measure progress against the stated program
goals and objectives. Please include any templates, logic models, or surveys in the attachments.
 Describe how the organization(s) will assess the impact of the program on the selected priority.
Please include any templates, logic models, or surveys in the attachments.
 Describe how the organization(s) will assess program delivery. Please include any templates,
logic models, or surveys in the attachments.
 Describe the monitoring and evaluation (M&E) expertise that will be available for this purpose.
 Described the resources available for M&E during the course of the program. Specify if these
resources are requested as part of this grant, or if they are existing organizational resources.
Budget
Provide a detailed total program budget. All funding for this program, including other grants and general
funds should be included in the budget. Please note that indirect costs may not exceed 5% of direct
costs. For each line item in the budget, provide a brief description of how the funds will be used and
why they are programmatically necessary. List all other committed and pending sources of support for
the program as In Kind. All reimbursable rates must be billed at current 2013 Medicare reimbursable
rates. A list of current Medicare rates in a downloadable PDF format is located on Komen CAN AZ
website at www.komencanaz.org .
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Attachments (MUST BE INCLUDED)
 Project Work Plan (Please visit www.komencanaz.org to download form)
 Information regarding Key Personnel – For key personnel that are currently employed by the
applicant, provide a resume or curriculum vitae. For new or vacant positions, provide job
descriptions (two page limit per individual).
 Proof of Non-Profit Status – To document your federal tax-exempt status, attach
your determination letter from the Internal Revenue Service. Evidence of state or local
exemption will not be accepted. Please do not attach your Federal tax return.
 Letters of support, collaboration, MOUs, etc. demonstrating your partnerships. Must be
included. Must demonstrate partnership identification and agreement and terms of agreement
for services. Must be signed by partnering organization(s).
 Evaluation forms, surveys, ect. the program will use to measure effectiveness of program.
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