COVID-19 Community Health Project (CCHP) 3.0 Application

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To view a live walkthrough of the application submission process start video at 59:15

Links: English: https://youtu.be/X50SSDgQz9Q

Spanish: https://youtu.be/z0-6ilhqrA4

Applicant Information

(IRS qualifying organization; use legal name as registered with the IRS)

Organization Name

Street

City

State/Province

Zip/Postal Code

County

Country

Phone

Website

Check if you are a fiscal sponsor

Fiscally Sponsored Organization Information

Organization Name

Street

City

State/Province

Zip/Postal Code

County

Country

Phone

Website

Unique Entity Identifier

Tax Exempt ID # or Employer ID #

SAM Expiration Date

Organization Status

Organization Status - Other

Non Profit / Public Agency

Social Media

Facebook

Twitter

Application Contact

(primary contact for this application)

First Name

Last Name

Contact Phone

Data Contact

(primary contact for outreach data and reporting)

First Name

Last Name

Contact Phone

Financial Contact

(primary contact for budget and financial reporting)

First Name

Last Name

Contact Phone

Project Lead Contact

(primary contact for project implementation)

First Name

Last Name

Contact Phone

Application Response Name

CEO/Director

First Name

Last Name

Title

Office Phone

Extension

Primary Project Contact (for questions related to this proposal)

(primary contact for overall project oversight)

First Name

Last Name

Title

Office Phone

Extension

Additional Project Contact

First Name

Last Name

Title

Office Phone

Extension

Project Summary Information

Project Name (20 words or less)

Brief Purpose of Project (100 words or less) beginning with "To. . . "

Project Start Date

Project End Date

Amount Requested (Maximum $500,000)

Annual Operating Budget

% of Annual Budget (Maximum 20%)

Issue Areas

Issue areas of your organization (hold ctrl button and select)

Issue areas of your organization: Other

Deliverables and Outreach Approaches

Provide the projected total number of individuals reached per interactive approach over the entire service period (7/1/2022 – 12/31/2022)

High quality, interactive engagements

Interactive in-person approach - Ques 1

Door-to-door canvassing (number of door-to-door conversations in which script is completed)

Interactive in-person approach - Ques 2

Community canvassing (number of people interacted with via conversations with individuals in public spaces. This category does not include individuals reached through door-to-door canvassing)

Interactive in-person approach - Ques 3

Phone banking (number of successful phone conversations in which the individual is reached and a script is completed)

Interactive in-person approach - Ques 4

Trainings (number of people interacted with via in-person or digital group trainings that cover some aspect of COVID-19 for at least 20 minutes)

Interactive in-person approach - Ques 5

Events/meetings (number of people interacted with via in-person group events that cover some aspect of COVID-19 for at least 20 minutes)

Total number of individuals reached through high quality, interactive engagements

Cost per high quality, interactive engagement

Education focused, limited engagements

Interactive remote approach - Ques 1

Text banking - (total number of peer-to-peer and one-way mass communication texts sent to individuals)

Interactive remote approach - Ques 2

E-mails - (total number of peer-to-peer and one-way mass communication emails sent to individuals)

Interactive remote approach - Ques 3

Events/meetings (number of people interacted with via in-person or virtual group events/meetings that cover some aspect of COVID-19 for less than five minutes)

Interactive remote approach - Ques 4

Booths and tabling (number of people interacted with via booths and tabling that cover some aspect of COVID-19 for less than five minutes)

Interactive remote approach - Ques 5

Social media direct messaging (number of people interacted with via peer-to-peer and one-way mass communication social media direct messaging)

Interactive remote approach - Ques 6

Leaving behind materials (number of outreach materials, e.g. flyers and door hangers, dropped off at a location, not conversations)

Interactive remote approach - Ques 7

Mailer (number of mailer recipients)

Interactive remote approach - Ques 8

Public Service Announcements, interviews, or other media appearances (total number of radio appearances-interviews or PSAs)

Interactive remote approach - Ques 9

Social media posts (total number of times you will post on social media throughout the service period)

Total number of individuals reached through education focused, limited engagements

Interactive Contacts

Total number of contacts made through interactive in-person approaches

% of contacts made through in-person interactive approaches

Total number of contacts made through remote interactive approaches

% of contacts made through remote interactive approaches

Please indicate the TOTAL NUMBER OF TIMES you plan to conduct each interactive outreach activity over the CCHP 3.0 service period. Please note we are NOT asking for the number of people that will be reached.

Outreach Activity - Ques 1

Community Canvassing (number of times you will conduct community canvassing events)

Outreach Activity - Ques 2

Booth/Tabling (number of times you will table or have a booth at a specific location)

Outreach Activity - Ques 3

Trainings (number of times you will conduct digital and/or in-person trainings that cover some aspect of COVID-19 for at least 20 minutes)

Outreach Activity - Ques 4

Events/Meetings (number of times you will hold digital and/or in-person events/meetings that cover some aspect of COVID-19 for at least 20 minutes)

One-way outreach approaches

Outreach Approach - Ques 1

One-way text banking (number of recipients of mass texts or whatsapp messages)

Outreach Approach - Ques 2

Email newsletters (number of email newsletters you will send via a listserv, not the number of click throughs)

Outreach Approach - Ques 3

Social media posts (number of times you will post on social media per month)

Outreach Approach - Ques 4

Social media direct messaging (one-way mass communication)

Outreach Approach - Ques 5

Mailers (number of mailer recipients)

Outreach Approach - Ques 6

Flyer Drop-Offs: Number of flyers you will drop off at a location for another organization to distribute or for people to pick up (e.g. leaving a stack of informational flyers at a food truck or community center)

Outreach Approach - Ques 7

Radio appearances (total number of radio appearances-interviews or PSAs)

Outreach Approach - Ques 8

Other media appearances (total number of media appearances e.g. local television, print, etc.)

Outreach Approach - Ques 9

Flyer drop-offs (number of flyers you will drop off at a location for another organization to distribute or for people to pick up)

Outreach Approach - Ques 10

Door hangers/material distributed at households (number of door hangers and flyers distributed at households, not conversations with residents)

Total number of contacts made through one-way outreach approaches

Type of Vaccine Outreach (You may choose more than one option. Hold Ctrl and Select)

Project Geography

Alameda

Alpine

Amador

Butte

Calaveras

Colusa

Contra Costa

Del Norte

El Dorado

Fresno

Glenn

Humboldt

Imperial

Inyo

Kern

Kings

Lake

Lassen

Los Angeles

Mariposa

Marin

Mendocino

Merced

Madera

Modoc

Mono

Monterey

Napa

Nevada

Orange

Placer

Plumas

Riverside

Sacramento

San Benito

San Bernadino

San Diego

San Francisco

San Joaquin

San Luis Obispo

San Mateo

Santa Barbara

Santa Clara

Santa Cruz

Shasta

Sierra

Siskiyou

Solano

Sonoma

Stanislaus

Sutter

Tehama

Toulumne

Trinity

Tulare

Ventura %

Yolo

Yuba

Total Geography Percentage:

Total must equal 100%. Please adjust accordingly.

County Coverage

In this section, the applicant will provide additional information on the geographic coverage the organization can provide within each of the counties identified in the Project Geography section.

Full Coverage Indicate the counties where the organization has the capacity to conduct outreach in any geographic location within the county, upon request. Any counties selected should have a percentage greater than zero in the Project Geography section. (choose all that apply by holding Ctrl and selecting)

For the counties where the organization is only able to provide partial outreach coverage, list the names of the select cities and/or towns where the organization has the capacity to conduct outreach. Any counties selected should have a percentage greater than zero in the Project Geography section. Submit only one city/town name per entry. Click on “Add another response” for each additional city/town the organization can work in. For example, if the organization can work partially in Alameda County (only Berkeley and Oakland) and Santa Clara County (only San Jose), there would be three entries – two for Alameda County and one for Santa Clara County.

Partial Coverage

County

City Name

Race and Ethnicity

For the racial and ethnic populations that will be affected, provide your best estimate of the percentage of the total people will be each population (Total must add up to 100)

African-American / Black %	American Indian / Alaska Native %
Asian-American %	Indigenous (eg. Mixteco, Purepecha,etc) %
Latino / Hispanic %	Middle Eastern or North African %
Mixed race %	Pacific Islander %
White %	Other %
Other (please specify) Total Percentage of Race and Ethnicity % Total must equal 100%. Please adjust accordingly.

Additional Population
Select any of the following populations that are a primary focus of the project. You may select more than one option by holding Ctrl and selecting.

Other Additional Population:

Language
In which of the following languages can you provide outreach? (choose all that apply by holding Ctrl and selecting)

Other Languages:

Project Narrative Question

Project Activities

Please describe:

(a) The organization's past experience working with focus populations and target geography. Include any cultural and linguistic capacities.

(b) The organization's project strategy for reaching focus populations and geographical areas, including proposed activities and how they meet the program's deliverables and outreach approaches (listed above.)

(c) The organization's staffing plan to deliver the proposed services and meet monthly financial and activity reporting requirements.

Budget Template Use The Center's proposed budget form which can be found here. Complete the form and please upload it in excel format.

Applicant Organization's Form W-9. Download the fillable w-9 form here, insert your information, and upload

Annual Budget Documentation of applying organization Most recent IRS - 990 or Annual Operating Budget

CCHP 3.0 Certification Download the CCHP 3.0 certification document here. Please have CEO/Executive Director sign and upload in PDF format. Signature confirms the organization complies with the conditions of participation in CCHP 3.0 outlined in the certification form and program announcement.

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