Attachment #1

Applicants must meet the Minimum Requirements, as described in Request for Application (RFGA):

OREGONBUYS NUMBER: S-44300-00018213

RFGA-OHA-6287

Applicants must comply with the RFGA and submit this completed Application Form to be considered for an Agreement.

Applicant info for Hospital-based Violence Intervention Program Learning Community

Individual/Organization Name Including DBA if applicable:

Fiscal Sponsor Organization Name if applicable:

Fax ID, EIN or FIN:

Mailing Address:

City: State: County: Zip Code:

Phone:

Facsimile:

Website Address:

Type of Organization

|_| Nonprofit organization Required - Provide copy of your IRS determination letter or other proof of non-profit designation.

|_| Health system including at least one emergency department and/or urgent care center serving people in Oregon and located in a county other than Multnomah

Responsible Applicant Requirements

|_| Yes, Applicant is currently registered with the Oregon Secretary of State business registry.

|_| No, Applicant is not currently registered with the Oregon Secretary of State business registry but will meet requirement prior to Agreement execution.

Applicant Insurance

Commercial General Liability Insurance

|_| Yes, we currently meet the CGL insurance requirement.

|_| Do not currently meet CGL insurance requirements and will meet requirement prior to Agreement execution.

Automobile Liability Insurance

|_| Yes, we currently meet the ALI insurance requirement.

|_| Do not currently meet PLI insurance requirements but will meet requirement prior to Agreement execution.

Applicant Agreement Administrator

Name and Title:

Phone:

Email:

Authorized Applicant/Application Signature:

Authorized Applicant email:

Applicant Information Part 1

Geographic area served. Please describe the geographic catchment area your organization serves (city, county, region, etc.)

Primary populations to be served. Please describe the populations served by your organization.

Language access provided by your organization. Please indicate your organization’s capacity to speak and/or write in languages other than English. Also indicate whether the language capacity comes from a native or non-native speaker.

Language 1: ______________ |_|Spoken fluently by native speaker(s) |_|Spoken fluently by nonnative speaker(s) |_|Written by native speaker(s) |_|Written by nonnative speaker(s) or access to translation service Language 2: ______________ |_| Spoken fluently by native speaker(s) |_| Spoken fluently by nonnative speaker(s) |_| Written by native speaker(s) |_| Written by nonnative speakers or access to translation service Other language access offered by your organization not already listed above:

Applicant Information Part 2

Which of the following activities is your organization planning to undertake with funds from this opportunity?

Required Activities |_| Regular attendance at, and active participation in, the HVIP Expansion Community of Practice for all Track 1 grantees. This group will meet at least monthly to build supportive connections between organizations interested in HVIP development/implementation and to receive training and technical assistance related to HVIP partnership development, planning, and eventual implementation.

|_| Participating in program evaluation as requested by OHA, including preparing and submitting one midpoint financial and progress report and one final financial and progress report; participation in surveys, 1:1 meetings, focus groups and key informant interviews and other means of collecting quantitative and qualitative information on grant activities.

Optional planning activities |_| Convening meetings to explore and develop HVIP partnerships between community-based organizations and health systems with emergency department/urgent care facilities.

|_| Strategic planning for HVIP program development.

|_| Hosting community meetings to gather input on needs and concerns related to HVIP program implementation.

|_| Reviewing data from multiple sources to identify the community or communities to be served by the HVIP, current annual number of community members receiving emergency room or urgent care for incidents of community violence, types of injuries to be included in the program (firearm, assault, stabbing, etc.), estimated number of community members to be served per year, and other metrics.

|_| Identifying inclusion criteria and a community of focus.

|_| Reaching agreement between program partners about background check requirements for peers.

|_| Identifying existing related services available in the community and remotely. These can include domestic violence resources, youth outreach, street outreach, tele-mental and tele-behavioral health, and others.

|_| Identifying culturally specific and culturally responsive service providers to receive referrals for HVIP clients to specific services. Examples include psychotherapy, substance abuse and alcohol misuse screening and treatment, legal and financial services, educational support, conflict resolution and social-emotional learning, employment services, and housing support.

|_| Business planning to identify program expenses and revenue streams.

|_| Identifying program evaluation metrics.

Optional: Violence Prevention Professional training and certification |_| Development of position descriptions and hiring standards for peer HVIP providers.

|_| Recruitment of trusted community messengers to become peer Certified Violence Prevention Professionals, sufficient to meet the standard of response within four hours following an incident of community violence.

|_| Conducting background checks for potential Certified Violence Prevention Professionals, using standards that avoid unnecessary disqualification of peers with criminal history or history of incarceration.

|_| Training peer Violence Prevention Professionals through the Health Alliance for Violence Intervention or other training providers approved by OHA. Training costs may include registration fees, travel costs and per diem.

|_| Developing and implementing standards for on-the-job training (orientation, shadowing).

|_| Continuing education for Certified Violence Prevention Professionals (at least six hours every two years).

Optional: Building capacity to serve communities of need |_| Development of contractual relationships with Certified Violence Prevention Professionals.

|_| Development of referral agreements with culturally responsive service providers.

|_| Holding trainings for hospital/urgent care administrative staff, medical and social service providers, security personnel and administrators to ensure smooth integration of HVIPs into system operations |_| Documentation and standards for program processes, including intake, risk assessment, services rendered, etc.

|_| Developing grant writing and other organizational capacity building skills to support sustainable funding for HVIPs.

Would your organization like to be notified by OHA when funding becomes available in the future to support continuing or related violence intervention or prevention initiatives?

|_| Yes |_| No

Does your organization currently receive funding for any work related to violence prevention, interruption, or intervention?

|_| Local public health authority (please list county:) ______________________________ |_| Oregon Department of Justice |_| Portland Opportunities Industrialization Center |_| Other source (please list): ______________________________

Please specify which track you are applying for under:

|_| Track 1: Readiness and Capacity Development |_| Track 2: Program Implementation

Applicant Information Part 3 Our intention is to make this application as easy as possible to complete.

Clear and concise answers are welcome. There is a two-paragraph maximum per question and no minimum word count to describe your project.

1) Describe your organization’s experience related to violence prevention.

a. If you are a returning grantee, please describe how your agency will use this new round of funding in ways that are different from your previous grant. In what ways will your agency build on lessons learned to adapt and strengthen your work in this new funding cycle?

2) Does your organization have experience in community violence prevention, interruption or intervention? If so, please describe. For the purposes of this application, community violence is defined as an intentional act of interpersonal violence committed in public by someone who is not the victim’s family member or domestic/intimate partner.

3) Describe your community’s need for hospital-based violence intervention services. What type of violence is happening in your community, who is it affecting, and how? If known, describe the rate/frequency/number of community members affected (monthly/annually?) by community violence.

4) Describe the population(s) you intend to serve with future hospital-based violence prevention programming, how long you have worked with that population and your relationship with this community/communities.

5) Are any other organizations in your community working to reduce violence? If so, please briefly describe their work and your organization’s relationship to it, if applicable.

6) Describe any existing or potential organizational partner(s) for proposed activities and the role each will play. CBOs are encouraged to partner with hospitals and vice versa. Additional partners could include other community-based organizations, hospitals, city government, local public health authorities, or partners in other sectors. Please describe the nature of your organization’s current relationship with these partners.

7) What kind of support would your organization need to carry out proposed activities?

8) Please provide a brief summary of a project your organization has successfully completed- this may be a paid project, a community-based effort or work supported through a grant or contract.

9) Please share an organizational chart (a picture or diagram) that identifies the structure of your agency, key staff and reporting/communication pathways.

Applicant Information Part 4

Applicants must submit a line-item budget for the grant period (November 1, 2026 -June 30, 2027) and a high-level justification using the Attachment #2 Budget Worksheet.

As you complete the Proposed Budget, consider budget items and justifications such as staff time, funding for food, childcare for community conversations, contractor/facilitator, advertising for social media, gift cards for community members to participate in community conversations, etc. In alignment with national best practices, grantees are asked to follow standards of care by recognizing violence prevention as a professional service and ensuring Violence Prevention Professionals are paid for the essential work they provide.

Reporting

Reports should include…

· One midpoint financial report due February 28, 2027.

· One midpoint progress report due February 28, 2027.

· Final financial and progress reports are due at end of grant period.

Everyone has a right to know about and use Oregon Health Authority (OHA) programs and services. OHA provides free help. Some examples of the free help OHA can provide are:

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