Form – Grant Proposal Request – CPH Information Technology Support Services

Grant Proposal Form

This grant proposal form must be fully approved prior to starting the grant-writing process. This form is required for both new and continuation grants. This should be received 4 weeks prior to the proposal due date, at minimum. When completing this form, a short narrative explaining the purpose and intent of the application in addition to a preliminary budget must be attached.

In making the decision to pursue a grant, please consider the following questions:

How does this grant support core CPH services, CPH priorities and goals?
What is the potential for renewal? What are the plans to continue programming if funding is not renewed?
How will additional costs be covered, such as interpretation services, telephones, materials, etc.?

Fiscal - Grant Proposal Form

Title of the proposal

Funding organization/agency (CFDA#)

Funding amount requested

Funding period start

Funding period end

Date proposal is due

Program manager

Program

Is funding for translation and interpretation services included?

Yes

If no, explain how your program will absorb the cost of these services

Does the grantor allow funding for support costs (fiscal/HR support, rent, etc.)?

Yes

Estimate expenses which will not be reimbursed by grant and requesting general fund pickup:

Direct program personnel

Office/medical supplies

Mileage

Mobile devices

Computer hardware/software

Required cash match

Other

How will your program absorb these expenses?

Do you plan to hire personnel?

Yes

If yes, has office space been identified and approved by PH Admin - Support Services?

Yes

How will the proposed program continue when grant funding ends?

Attach all supporting documentation (narrative, preliminary budget, and other documents)

Maximum file size: 30MB

Requestor Information

Your Full Name

Phone Number

Division

Approvals

Please double check email address spelling for accuracy. Notifications will be sent to email addresses to request signatures.

Division Administrator's Name

Division Administrator's Email

Full Typed Name - Division Administrator

Date

Division Administrator Signature

Clear

Fiscal Analyst's Name

Fiscal Analyst's Email

Full Typed Name - Fiscal Analyst

Date

Fiscal Analyst Signature

Clear

Notify Additional Viewers

Yes, I would like to notify someone of this request

Additional email recipients (view only)

Add email recipients (separate multiple addresses by comma)

If you are human, leave this field blank.