San Francisco Community Benefit Program
2015 Grant LOI (Letter of Intent) Form
Community Benefit -
Submitting this form is Phase 1 of a two-phase process to apply for grant funding from Kaiser Permanente San
Francisco’s Community Benefit Program. Please see the 2015 Grant RFP – LOI Instructions for a full description of the
grant application process, available at our website: http://www.kp.org/communitybenefit/sf
The following must be submitted to comply with the Letter of Intent (LOI) process:
1) A one-page letter requesting funding, describing the program that is being applied for and the amount requested,
on the organization’s letterhead and signed by the organization’s Executive Director.
2) This completed LOI form, which can be expanded to four pages maximum.
The request letter and LOI form must be submitted via email to Nancy.Leung@kp.org by Friday, October 30, 2015, 5:00
pm PST in order to be considered eligible for review.
Date:
I.
ORGANIZATION & PROGRAM INFORMATION
Organization Name:
Executive Director:
This Organization is:
Email:
501(c)3 charity
government agency
using a fiscal agent – name:
Program Contact & Title:
Program Contact Info:
II.
Phone:
Email:
GRANT CATEGORIES
Indicate only one category for which you are seeking funding:
1.
2.
3.
4.
III.
Access to Care – Chronic Disease Management
Healthy Eating – Plant-Based Nutrition
Active Living – Increase Physical Activity and Fitness
Safe & Healthy Environments -- Prevent Intentional Injuries
INFORMATION ABOUT FUNDING AND KAISER PERMANENTE SUPPORT
Organization, Program and Proposed Grant – Expenses, Unduplicated Clients (UDC), Cost per UDC
Organization
Program
This Requested Grant
Total annual expenses
Annual # of UDC
Cost per UDC
(leave blank)
$
$
List current/prior funding received from Kaiser Permanente in last 5 years (add more lines if needed).
Date
Amount
Project Title
KP contact person or area
KP-SF Community Benefit LOI 2015 - Page 1 of 3
If you have a Kaiser Permanente employee or physician on your Board, list name and title:
List your organization’s top 5 funding sources by amount and percentage of the total budget:
Source and type of funding
Amount
IV.
Percentage
%
%
%
%
%
PROGRAM/PROJECT INFORMATION
Proposed grant-funded project title:
Brief description of grant-funded project (max 25 words):
Describe the health need you are trying to address, and the target populations and SF neighborhoods served by this
program/project.
Describe the program services now offered, and how this grant-funded project/activity fits into the current program.
Describe how you would spend the proposed grant funding.
KP-SF Community Benefit LOI 2015 - Page 2 of 3
V.
EVIDENCE-BASED STRATEGY
Describe the specific intervention strategy the program utilizes to achieve the expected outcomes.
What is the external evidence that shows this strategy is effective? Describe the evidence, and where you found it - is it a
published research study, best practice article, external program evaluation? What are the key elements of the successful
strategy that will be reflected in your workplan of activities.
VI.
OUTCOMES AND EVALUATION
What are the expected outcomes over the 12 months of this grant? Describe the numbers of persons served and specifically
how they will change as a result of your strategic intervention or activity.
How will you measure this change/outcome? Describe how you will gather baseline and followup data, and the means and
frequency of evaluation.
VII.
PROGRAM EXPERIENCE
Describe the step-by-step experience of a typical client of this program, including outreach & engagement, intake &
enrollment, type & frequency of activities, which staff/volunteers interact with the client, how long the client receives
services, etc.
How are you collaborating with other service providers for this population? What evidence do you have that this
collaboration is effective?
KP-SF Community Benefit LOI 2015 - Page 3 of 3