* 1. Organization Information

* 2. Summary statement. 
Provide a brief outline of the navigation pathway to be funded, including who is eligible and how clients will be identified, the steps along the pathway to be implemented by the proposed program and any barriers to be addressed, including in partnership with other agencies meeting SDOH or non-breast related needs. (2000 character limit)

* 3. Target population and areas served.
Provide an estimate of your anticipated impact in each county. (You may leave fields blank if the county is not addressed by your project)
We understand these are preliminary numbers and may change before the full proposal is submitted.

* 4. Which priorities will the program be designed to focus on?

* 5. Describe how patients’ needs will be assessed in order for navigation to take place. (500 character limit)

* 6. Name and briefly describe collaborative relationship with any existing or potential partners for breast health services or meeting the needs of patients through collaboration with other agencies offering services to help overcome barriers. Be sure to name collaboration with any organizations also applying for funding. (500 character limit)

* 7. Budget.
Provide an estimate of the budget request you will make. As a reminder, please see the RFA for funding range recommendations.
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.

* 8. 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