Oregon Health Authority HIV/STD/TB (OHA HST) Section - End HIV/STI Oregon Mini Grant Application

Oregon Health Authority HIV/STD/TB (OHA HST) Section - End HIV/STI Oregon Mini Grant Application

Prior to starting this application, please carefully read the End HIV/STI Oregon Mini Grant application requirements on the End HIV Oregon website.

Contact Person Information

Applicant Name*

Job Title*

Phone number*

Phone

Email address*

Organization Information

Name of the Organization*

Street address*

Apt, suite, unit, etc. (Optional)

City*

ZIP code*

Organization website*

Organization mission statement*

What is the primary geographic region your organization serves?*

Which communities are your organization’s priority populations?*

Mini-Grant Information

Are you or your fiscal sponsor a 501(c)3?*

Yes

Organization tax ID number*

If you answered yes, please list your organization tax ID number.

Have you received a grant from the OHA HIV/STD Prevention Program in the past?*

Yes

If yes, what date did you receive the grant? *

If yes, what amount did you receive?*

How does this project differ from the project funded before?*

Proposed Mini Grant Project

What category best describes the main goal of your project?*

If you selected other, please list your project's main goal.*

If you selected other, please list which communities are your project's priority populations.*

How did you hear about this funding opportunity?*

Application Questions

Please answer the following questions about the project you are proposing. You will be asked to upload several documents at the end of the application, including answers to questions 1-5, resumes/CVs for project key staff (optional), and a budget. Please limit your answers to Questions 1-5 to no more than 3 pages total.

1. In a few sentences, please describe the main goal of your project.

2. Please describe the main things you plan to do with these funds that will lead to achieving your project goal.

3. Please describe your timeline for completing the work (NOTE: funds must be spent within one year of award).

4. Please describe who will benefit from this project (for example, the number of people served or affected, the proposed demographics of people served or affected, etc.).

5. Please identify the key staff who will be doing the work on this project, including their names, work experience, and job titles. You may submit resumes or other descriptive information (resumes/CVs will not be counted in the page total).

Budget Template

Please submit a brief budget for this project using the attached template and guidance provided. We request a total amount (up to $10,000) and a brief description of how the money will be used (line items). There are some restrictions on the use of these funds, so even if your project is approved for funding, budgets may need to be negotiated before allocation of funds. Some examples of expenses that are not allowable include food and beverages, equipment, and furniture.

Upload Files*

Please upload the following:

1. Responses to Questions 1-5 (required)

2. Budget document (required)

3. Key staff resumes/CVs (optional)

Drag and drop files here or

Send me a copy of my responses

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