Appendix A Work Plan Template Non-COVID 19 Project.docx

Center for State, Tribal, Local, and Territorial Support Health Department Program Branch

YEAR 4 WORK PLAN

CDC-RFA-OT18-18030401SUPP21 Comment by Daub, Teresa L. (CDC/DDPHSIS/CSTLTS/DPPS): Kim request the NOFO # for FY 21 on 2/3. Confirm this is the correct #.

SUPPLEMENTAL NOTICE OF FUNDING OPPORTUNITY (NOFO) for CDC-RFA-OT18-1803: Tribal Public Health Capacity-Building and Quality Improvement Umbrella

Applicant Name* (Enter the same name used when applying to CDC-RFA-OT18-1803.)

Applicant Award Number*

Applicant POC Name*

Applicant POC Phone Number*

Applicant POC Email Address*

Applicant POC Mailing Address

Applicant POC Backup Name*

Applicant POC Backup Email Address*

Applicant Geographic Category* (Select the same Geographic Category used when applying to CDC-RFA-OT18-1803.)

YEAR 4 CIO PROJECT PLAN INFORMATION

Project Title* (Enter the CIO Project Plan’s title for which this Work Plan will address.)

CIO*

(Enter name of CIO from the CIO Project Plan’s for which this Work Plan will address.)

Division* (Enter name of Division from the CIO Project Plan’s for which this Work Plan will address.)

PROJECT APPROACH

Describe the target population to receive the capacity-building and quality improvement assistance under this CIO Project Plan, as well as the key strategies to accomplish the objectives of the project. (275 words max).

Target Population Description* (This should be consistent with the target population identified in the CIO Project Plan [25 words max].)

Project Strategies* (This should be consistent with the Program Strategies identified in the CIO Project Plan [250 words max].)

WORK PLAN

Describe the activities, outputs, performance measures (both process and outcome), and outcomes related to the selected NOFO strategies and NOFO outcomes on the CIO Project Plan. (5,000 words max). Please use bullets.

Objectives* Please use bullets (1,000 words max)

Activities*

Outputs*

Performance Measures

Process Measures*

Outcome Measures*

ORGANIZATIONAL CAPACITY*

Describe your capacity to successfully complete this project. Include your organization’s relevant staffing, systems, and resources. (1,000 words max)

PROGRAM EXPERIENCE*

Describe your experience as it relates to this project. Include products developed; services, training and technical assistance provided; and relevant target populations supported. (1,000 words max)

COLLABORATIVE WORK*

Describe your plan for collaboration as it relates to this project. Include specific organizations or entities as applicable. (1,000 words max)

SUB-CONTRACTUAL WORK*

Describe your plan for sub-contractual work. Include recommended criteria for identifying and selecting subcontractors. (1,000 words max)

BUDGET INFORMATION

Enter the whole dollar amount for each field. Ensure the proposed budget is reasonable and consistent with the approach outlined in the work plan. If a funding amount greater than the CIO Project Plan’s ceiling (see “Proposed Project Funding” on the CIO Project Plan) is requested, the application will be considered non-responsive and will not be entered into the review process.

PERSONNEL SALARIES AND WAGES TOTAL*

FRINGE BENEFITS TOTAL*

CONSULTANT BENEFITS TOTAL*

EQUIPMENT TOTAL*

SUPPLIES TOTAL*

TRAVEL TOTAL*

OTHER TOTAL*

CONTRACTUAL TOTAL*

DIRECT COSTS TOTAL*

INDIRECT COSTS TOTAL*

BUDGET TOTAL*

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