MoCAP Potential Customer Worksheet

25% of survey complete.

Thank you for your interest in the Missouri Foundation for Health’s (MFH) MoCAP program. The MoCAP program is an effort to provide grant consultation and technical assistance to organizations pursuing federal and nationally competed private funding opportunities.

Please complete this worksheet to help MoCAP become more familiar with your organization’s experience with and interest in federal and nationally competed funding opportunities. Complete this worksheet as thoroughly as possible; it may be necessary to collect information from others at your organization.

Once completed, a MoCAP staff member will follow-up with you regarding next steps. See the MoCAP FAQ page for more information on the MoCAP program, or email questions to mocap@mffh.org.

Question Title

* 1. Background Information

Name of Organization (please spell out):

Contact Name:

Title:

Zip Code of Organization's Primary Office:

Email Address:

Phone Number:

Question Title

* 2. County/Counties served:
Note: To be eligible for MoCAP services, you must be serving the MFH service area, please click here for a map of our service area.

Question Title

* 3. Annual Operating Budget:

Question Title

* 4. Has your organization previously worked with MFH? (Note: MFH grant funding is not a requirement or prerequisite to receive MoCAP assistance.)

Yes, my organization is/has been a MFH grantee.

Yes, my organization has interacted with MFH but we have not been awarded funding.

No, my organization does not have previous history with MFH.

Don’t know

Question Title

* 5. Is your organization a previous MoCAP customer?

Yes

Don’t know

Question Title

* 6. How did you hear about the MoCAP program?

Question Title

* 7. Please briefly describe the mission of your organization and its primary activities.

Question Title

* 8. Does your organization do work in any of the following areas? (check all that apply)

Advocacy/Consumer Health/Local Policy

Asthma

Chronic Care

Health Professional Workforce Development

Substance Misuse

Primary Care Access

Health Literacy

HIV/AIDS

Mental Health

Obesity Prevention

Nutrition/Food Access

Oral Health/Dental

Tobacco Prevention/Cessation

Work Place Wellness

Women’s/Maternal Health

Gerontology/Seniors

School-based Care

Preventative Services

Violence/abuse

Immunizations/vaccines

Criminal justice/re-entry

Other (please specify)

Question Title

* 1. Background Information

Question Title

* 2. County/Counties served: Note: To be eligible for MoCAP services, you must be serving the MFH service area, please click here for a map of our service area.

Question Title

* 3. Annual Operating Budget:

Question Title

* 4. Has your organization previously worked with MFH? (Note: MFH grant funding is not a requirement or prerequisite to receive MoCAP assistance.)

Question Title

* 5. Is your organization a previous MoCAP customer?

Question Title

* 6. How did you hear about the MoCAP program?

Question Title

* 7. Please briefly describe the mission of your organization and its primary activities.

Question Title

* 8. Does your organization do work in any of the following areas? (check all that apply)

* 2. County/Counties served:
Note: To be eligible for MoCAP services, you must be serving the MFH service area, please click here for a map of our service area.