Information

This proposal form is based on the Guidelines and Rules Governing CHIO Incentives Payments for Healthy Hearts for Oklahoma dated 9/29/2016.  It can be used as a tool (but not required, you may create your own project document) for the CHIOs and the H20 practice facilitation coordinator (PFC) to create their proposal to receive funds for evidence-based community initiatives to promote cardiovascular health. CHIO proposals and invoices to receive H20 funds need to be turned in by May 15, 2017.
 
The PFC must approve and sign-off on this project/form. 

To officially request your funds:  Email an approved proposal and an Invoice to PHIO from your fiscal agent to Jill Hazeldine at jill@publichealthok.org.  If you need a pdf copy of your completed online form, please email her and she will send it to you. 

* 1. Applicant's Contact Information

* 2. Name of the non-profit 501(c)(3) fiscal entity responsible for receiving and managing the funds? (your CHIO's designated fiscal agent)

* 3. Total amount you are requesting:

* 4. The name and contact information of the person responsible for the project:

* 5. 1 - 2 Paragraph summary of the proposed project:

* 6. An itemized budget including justifications for personnel expenses and for items > $1,000:

* 7. Proposed timeline for implementing and completing the planned activities: (Please allow at least 4 - 6 weeks of planning prior to receiving funds requested for the project).

* 8. The name of the PFC and the date she/he approved the project:

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