Workforce Application
Notes for Applicants
Please answer all of the following questions.
Limit responses to each question to 850 characters or less.
CBOs that are not currently a registered company or non-profit may apply with a different, registered CBO as their fiscal sponsor.
Non-profit CBOs that are not registered with Medicaid for billing purposes, and would like to explore this option to provide services, may coordinate with us and UHA to determine how services may be designated within a billable category.
Projects that are funded will be required to report on the how the funds are expended. We will also request that the organization provide an estimate of the number of people expected to be served in the next year.
Contact Information
First Name
Last Name
Email
Phone
Address
Address 1
Address 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Payment
Same As Contact
Pay to Order of
Address 1
Address 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Application Questions
Project Name
Organization
Funds requested
$
Navigation and Coordination services provided
How Navigation and Coordination Grant funds will be used
Project timeline
Other community partners supporting the project and how (committed resources, funding, or collaborative effort)
How the project addresses community need
How the project addresses health equity
Does this application support providing navigation and coordination of services to a group more likely to experience a health disparity?
Yes
No
What groups are included?
Will this include recruitment and training for people to provide navigation and coordination services who are from this group?
Yes
No
Are there specific health or learning disparities you are trying to address in this work?
How does your organization incorporate a lens of equity into this project? Please provide a specific example.
If you plan to train/recruit people from specific populations you serve to become navigation or coordination workers, which ones will be represented?
People of color and tribes (Black, Indigenous, People of Color or BIPOC)
People who identify as LGBTQ+
People with low incomes
People with disabilities
Veterans
Which priority population would your project serve?
People of color and tribes (Black, Indigenous, People of Color or BIPOC)
People who identify as LGBTQ+
People with low incomes
People with disabilities
Veterans
How do you plan to sustain this project after the 2022 calendar year?
Expected outcomes (S.M.A.R.T. – Specific, Measurable, Attainable, Realistic, Timely):
Expected outputs, such as the number of people to be served and/or the number if services provided:
Summary of Expectations:
Upload Budget
Please upload a projected budget distribution including (at minimum) item, source, and amount.
Submit Application