* 1. Organization Information

* 2. Which RFA do you plan on applying to for funding?

* 3. Summary statement. 
How will the proposed program reduce breast cancer mortality? What are the activities to be funded by the project? Give an overview of the activities conducted by the organization towards this goal that will be funded in-kind, or not requested in the budget? Does the organization have the capacity to incorporate a needs assessment and activate a navigator to create a pathway through any barriers for patients? What resources are needed to achieve that capacity? Indicate if there will be collaboration with other organizations, especially organizations applying for funding. (5000 character limit)

* 4. Target population and areas served.
Provide an estimate of your anticipated imact in each county. (You may leave fields blank.)
We understand these are preliminary numbers and may change before the full proposal is submitted.

* 5. Budget.
Provide an estimate of the budget request you will make.
We understand these are preliminary numbers and may change before the full proposal is submitted. Please enter a positive number with no dollar signs or commas or other punctuation.

* 6. What percentage of your budget, if any, do you estimate will be allocated towards the one or more of the following counties? Hocking, Vinton, Perry, Athens, Morgan, or Meigs

* 7. Please list any questions you have about the funding priorities, structure of your proposal and objectives, or topics you would like to learn more about at the grant application workshop.

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