The Asian Health Coalition is selecting 3 community partners to activate our 2023-24 SCREEN breast/cervical cancer program. Each partner will receive up to $15,000, along with ongoing technical assistance, capacity building, and programmatic support, to engage 500 community members through virtual and in-person outreach, collect at least 100 completed knowledge assessments, and provide healthcare navigation for screenings to at least 50 community members. The full RFA can be found here: www.asianhealth.org/partnership-opportunities-1.
Organization

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* 1. What is the name of your organization?

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* 2. What is your organization's mission?

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* 3. What is your organization's address?

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* 4. What is your organization's zipcode?

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* 5. What is your organization's city?

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* 6. What is the first and last name for the person that will be the primary contact for this project?

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* 7. What is the phone number for the primary contact?

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* 8. What is the email address for the person that will be the primary contact for this project?

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* 9. What is the first and last name of the Executive Director for your organization?

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* 10. What is the email address of the Executive Director for your organization?

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* 11. What is the phone number of the Executive Director for your organization?

Tell us about the community that your organization serves.

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* 12. How many clients did your organization serve in the last fiscal year?

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* 13. Of those served in the last fiscal year, what percentage were women?

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* 14. Where do most of your organization's clients live?

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* 15. What primary language does the community members you serve speak and read? Please list up to 5 languages.

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* 16. Do you refer your clients to receive primary health care services or preventative health services to a local health care provider?

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* 17. Where do you refer your clients to for health care services?

Race/Ethnicity

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* 18. Please check all races/ethnicities that your organization serves.

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* 19. Make an informed guess of the percentage of clients you see that identify as Filipino.

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* 20. Make an informed guess of the percentage of clients you see that identify as Chinese.

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* 21. Make an informed guess of the percentage of clients you see that identify as Korean.

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* 22. Do you serve any other Asian ethnicities? If so, please list below.

Age

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* 23. Estimate the number of women you serve aged between 21-39.

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* 24. Estimate the number of women you serve aged between 40-65.

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* 25. Estimate the number of women you serve aged between 65-74

Insurance

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* 26. Please check all of the insurance types that the community members your organization serves utilizes.

Project Related Questions

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* 27. Which of the following services do you currently offer?

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* 28. In about 250 words, briefly describe how you plan to provide breast/cervical cancer education/outreach and increase breast/cervical cancer screenings.

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* 29. In about 250 words, tell us why members in your community need targeted breast/cervical cancer health education and support to access preventative and primary healthcare.

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* 30. In about 250 words, tell us what your organization is already doing to educate community members about their health.

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* 31. In about 250 words, tell us what your organization is already doing to connect members of your community to preventative and primary care. (E.g. referral processes, connection to healthcare services, etc.)

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* 32. In about 250 words, what are your community's biggest challenges when it comes to connecting community members with preventive and primary care?

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* 33. In about 250 words, what are your community's biggest challenges when it comes to learning about health issues?

Funding

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* 34. How much funding will your organization require to fulfill all project requirements (must be between $5,000 and $15,000)?

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* 35. What will this funding be used for?

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* 36. If funded, do you plan to hire/bring on someone new for this project?

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* 37. If funded, do you have dedicated staff members, such as community health workers, health educators, or program coordinators, who will be assigned to this project?

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* 38. On average, how many hours per week will your staff member(s) or intern(s) dedicate to this project?

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* 39. Thinking about the individual who will coordinate this project, tell us how much experience they have in doing each of the following for your communities.

Your answers will help us tailor our technical assistance, capacity building, and programmatic support to each funded organization.

  A great deal of experience Some experience No experience
Providing health education sessions in your community's language(s)
Reviewing health education materials in your community's language(s)
Educating your community on breast/cervical cancer
Providing health navigation/referrals to healthcare for community members
Conducting follow-up phone calls with community members
Collaborating with local healthcare providers
Collecting intake and evaluation forms
Completing tracking logs and monthly reports

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