5562-0 Attachment A Application Sheet.docx

Attachment A Application Sheet

BHWI Tuition Assistance and Stipends for Graduate-level Behavioral Health Students Information Sheet Please complete in detail, the following information for your Institution.

Part I. Information Form

· Legal Name of Applicant Institution:

· Institution Doing Business As (DBA) (if different from above):

· Institution website address (if applicable):

· Address:

· Tax ID, EIN, or FIN:

· Contact name:

· Contact email:

· Contact phone number:

· Authorized signature name:

· Authorized signature email:

· Estimated total budget requested (total amount listed on Attachment B “Budget Table”): Number of programs applying for funding:

· Name of all programs applying for funding:

· Number of academic years for which Institution is applying:

· Number of students in each program: (e.g.) 350 students in Master of Social Work, 20 Students in Master of Clinical Rehabilitation.

· Number of students in each program by Race/Ethnicity for each program:

· Number of students in each program who are from rural communities:

· Number of students in each program who are veterans:

· Number of students in each program who are low-income:

· Number of students in each program who identify as having a disability:

· Number of students in each program by graduation year: (e.g.) 35 students enrolled in the Master of Clinical Psychology Program.

· Number of students in each program by full-time and part-time status:

· Number of students in each program attending online only:

Part II. Problem Statement

Complete the following in the space provided below or attach in a PDF.

1. Tell us about your Institution. Provide the current demographics of your professors in the Graduate-level Behavioral Health Programs. (5-8 sentences):

2. Describe how your Institution will use funds to advance anti-racism, diversity, equity, and inclusion in selecting students for incentive awards. Include examples using an equity framework when making decisions. (no more than 500 words):

3. Describe how your Institution will split the total requested award amount for each Graduate-level Behavioral Health Program.

4. Provide the estimated administrative cost to run this incentive program. Please provide any details for how administrative costs will be utilized.

5. How does your Institution assist Graduate-level Behavioral Health students with internship placement? If so, please provide details. (no more than 500 words):

6. How does your Institution assist Graduate-level Behavioral Health students with job placement? If so, please provide details. (no more than 500 words):

7. How will your Institution collect REALD/SOGI data from students who are awarded incentives? How will your Institution fill in any gaps in data collection when awarding students? (no more than 500 words):

8. What is your institutions plan to award Graduate-level Behavioral Health incentives to students? Please indicate the payment schedule to students.

9. How will your Institution focus on and support students who come from Oregon’s Communities Who are Underserved? Awards for tuition assistance and stipends for Graduate-level Behavioral Health students shall prioritize students who will increase support and access for Oregon’s Underserved Communities. Include the number of students who will benefit from each incentive and potential average award for each incentive requested. (750-word limit)