5442 BHWI Round 2 Attachment A Proposer Information Sheet Final~6.docx

BHWI Clinical Supervision Expansion Program Round 2 Attachment A Proposer Information Sheet Part I. Proposer Information (Provide the following information for your organization)

1. Tribe/Organization:

2. Tribe/Organization webpage (if applicable):

3. Organization Doing Business As (DBA) (if different from above):

4. Fiscal sponsor organization (if applicable):

5. Address:

6. Tax ID, EIN, or FIN:

7. Contact name:

8. Contact email:

9. Contact phone number:

10. Authorized signature name:

11. Authorized signature email:

12. County(ies) served:

13. Population(s) served (i.e., specific genders, REALD, veterans, regions, rural/urban, etc.):

14. Estimated total budget requested (total amount listed on Attachment B “Budget Table”):

15. Project timeline (in months):

16. Is this a new initiative? Yes: ☐ No: ☐ *Please note: Maintenance of existing activities will not be funded.

17. List the organizations named in Proposal as collaborators, subrecipients, etc.:

*Please note: Current registration will be required should a Grant be awarded.

20. Is Proposer registered with OregonBuys.gov? (Registration will be required in order to receive an award). Yes: ☐ No: ☐ *Please note: Registration will be required should a Grant be awarded.

Part II. Problem Statement (Complete the following questions in the space provided below or attach in a pdf. If attaching a pdf, enter “see attached” indicating you have done so. In your attachment, reference Part II Problem Statement and the item number. Please adhere to the word count where indicated).

1. Please tell us about your organization.

a. What is your organization’s mission and vision?

b. How long has your organization provided behavioral health care services?

c. Does your organization employ 50 or more clinicians (does not include certified peers or case managers)? Yes: ☐ No: ☐

d. Which communities does your organization serve? (5-8 sentences)

2. Briefly list the social determinants of health the Proposal plans to address (For information on the Social Determinants of Health click here):

3. Please tell us about how the funding from this Grant will increase health equity outcomes in the culturally and/or linguistically specific communities your organization serves? (500 words or less):

4. Has your organization experienced a loss of accreditation, loss of liability insurance, or had any fiscal audit findings in the last 3 years? If so, please briefly explain the issues and steps taken to mitigate them. If not, enter N/A.

Part III Program Narrative, Key Personnel, Evaluation and Sustainability (Complete the following questions in the space provided below or attach in a pdf. If attaching a pdf, enter “see attached” indicating you have done so. In your attachment, reference Part III Program Narrative, Key Personnel, Evaluation and Sustainability and the item number. Please adhere to the word count where indicated).

1. Please provide the Program Narrative (500 words or less). The Program Narrative must provide a clear and concise description of the program, how the program will address shortages in supervisory capacity, and how funds will be used for a program that advances health equity.

2. Identify and list key personnel (including personnel title) responsible for ensuring the implementation of this program if funding is awarded:

3. How and how often will the program evaluate project components, track tasks and objectives, and monitor relevant program impact/outcomes during the funding period? (500 words or less):

4. Briefly describe how your organization will provide oversight of funds and fund expenditures. (250 words or less):

5. What is the program’s plan for short and long-term sustainability after funding has ended? Include any key partnerships that will aid in program sustainability. (500 words or less):

Part IV. Budget Narrative (The Budget Narrative is a detailed budget justification and is a key part of the Proposal. Ensure that the submitted Budget Table (Attachment B), and Budget Narrative items are in alignment. Refer to Section 3. Sub-Section d. “Funding Guidelines” of the RFGP for funding parameters. Please adhere to the word count where indicated).

1. Describe the necessity, rationale, and allocation of the proposed costs. Program budget calculations must include quantities, unit costs, and other similar quantitative detail sufficient to verify the calculations. Proposer must indicate the method being used to calculate overhead and indirect costs. (500 words or less):

RFGP OHA Number 5442 under OregonBuys Bid Number S-44300-00004435