attachment-14-proposed target pop wksht.pdf

PS11-1113 Attachment XIV: Proposed Target Population Worksheet REVISED 1-11-11

PS11-1113

Human Immunodeficiency Virus (HIV) Prevention Projects for YMSM of color and YTG persons of color

ATTACHMENT XIV: PROPOSED TARGET POPULATION WORKSHEET

AGENCY CONTACT INFORMATION:

DUNS Number: EIN Number:

Agency Name:

Mailing Address:

City:

State/Province: Zip Code:

Agency Website:

Executive Director: E-mail:

Phone:

Ext: Fax:

Board President/Chair

E-mail:

Phone: Ext: Fax:

Is your agency a Faith-based Organization?

Yes

No

NOTE: A faith-based agency is a non-government agency owned by religiously affiliated entities such as (1) individual churches, synagogues, temples, or other places of worship; or (2) a network or coalition of churches, mosques, synagogues, temples, or other places of worship.

Category Applying Under: (Select the category for which you intend to apply. (Applicants may apply for Category A and/or B).

Category A:

HIV prevention services for high risk

Young Men of color Who Have Sex with

Men (YMSM of color) and their partners regardless of age, gender, or race/ethnicity.

Category B:

HIV prevention services for high risk Young

Transgender (YTG) persons of color and their partners regardless of age, gender, or race/ethnicity.

PURPOSE: The purpose of this worksheet is for the applicant to provide the ESTIMATED NUMBER of clients the agency intends to serve for Year 1 (future), if selected for funding.

Target Population:

If you are selected for funding, what is the Primary Target Population that you plan to serve under PS11-1113? Please list by ethnicity, race, targeted risk behavior, gender, age, and HIV status.

Description of Primary Target Population:

Examples: Hispanic, White, IDU, Men, 18-24, who are HIV+ OR

Non-Hispanic, Black, Heterosexual, Women,25-34 who are HIV-

Ethnicity

Race

Risk Behavior

Gender

Age Group

HIV Status

Hispanic/Latino

Non-Hispanic

American

Indian/Alaska n Native

Asian

Black/African

American

Native

Hawaiian/Pac ific Islander

Legacy

Asian/Pacific

Islander

White

Multi-race

Unknown

Other

(specify):

Heterosexual

Men who have sex with men

(MSM)

Intravenous

Drug Use

(IDU)

IDU/MSM

IDU/

Heterosexual

Non-IDU Drug

Use

Other (specify):

Male

Female

Transgender

M>F

F>M

13-17 years

18-29 years

Negative

Positive

Unknown

PS11-1113 Attachment XIV: Proposed Target Population Worksheet REVISED 1-11-11

Proposed Program Model(s):

If you are selected for funding, what Program Models are you proposing to implement? Select a maximum of one program model per category.

Risk Reduction Interventions and Services:

HIV Testing:

Enhanced HIV Testing

Personalized Cognitive Counseling (PCC)

Other:

Public Health Strategy:

Counseling, Testing and Referral Services (CTR)

If CTR, what type of testing do you provide:

Conventional (blood)

Rapid Testing

Not Applicable

If Rapid Testing, what brands do you use:

UniGold

OraQuick

OraSure

Clearview Stat Pack

Not Applicable

For High-Risk Negative Individuals only

Community PROMISE d-up: Defend Yourself!

Many Men, Many Voices (3MV)

MPowerment

Popular Opinion Leader (POL)

Sisters Informing Sisters on

Topics about AIDS (SISTA) (for

YTG only)

For HIV Positive Individuals only

Healthy Relationships

Partnership for Health (PfH)

Willow (for YTG only)

For High-Risk Negative and HIV

Positive Individuals

Comprehensive Risk Counseling

Services (CRCS) with CLEAR

Theory-based, Locally-

Developed

Intervention

PS11-1113 Attachment XIV: Proposed Target Population Worksheet REVISED 1-11-11

Instructions: Please provide the ESTIMATED NUMBER of clients the agency intends to serve for Year 1 (future), if selected for funding.

Complete the data tables below illustrating your agency’s specific target population for Year 1 (future), broken out by ethnicity, race, risk behavior, gender age group and HIV status. Please identify at least one full target population for each program model, you plan to serve under this funding. Complete one row for each distinct population group.

*NOTE: Do NOT use PERCENTAGES when providing your client level data. Please only use whole numbers.

Within each row, check only one box within each column subheading to identify one complete target population (e.g., Non-Hispanic, Black/African American, IDU/Heterosexuals, Female, 35-44 years, HIV negative). In addition, in the final column of that row you will type in the total number of clients within this population that you will plan to serve for Year 1 (future) of your project.

Example: MPowerment, targeting 25 African American Males, with a risk of IDU/Heterosexuals, and of negative HIV serostatus between the ages of 35-44.

Program Model Name : MPowerment

Proposed Budget Amount for Program Model #1: $100,000

Ethnicity (Select only one)

Race (Select only one)

Risk Behavior (Select only one)

Gender (Select only one)

Age Group (Select only one)

HIV Status (Select only one)

Number of

Clients (Do not use percentages)

1. Hispanic/Latino

Non-Hispanic

American

Indian/Alaskan Native

Asian

Black/African

American

Native

Hawaiian/Pacific

Islander

Legacy Asian/Pacific

Islander

White

Multi-race

Unknown

Other (specify):

Heterosexual

Men who have sex with men (MSM)

Intravenous Drug

Use (IDU)

IDU/MSM

IDU/

Heterosexual

Non-IDU Drug

Use

Other

(specify):

Male

Female

Transgender

17 & under

(Youth)

18-24 years

25-34 years

35-44 years

45+ years

Negative

Positive

PS11-1113 Attachment XIV: Proposed Target Population Worksheet REVISED 1-11-11

Program Model #1 Program Model Name (e.g., MPowerment, CRCS):

Proposed Budget Amount for Program Model #1: $

Ethnicity (Select only one)

Race (Select only one)

Risk Behavior (Select only one)

Gender (Select only one)

Age Group (Select only one)

HIV Status (Select only one)

Number (Do not use percentages)

1. Hispanic/Latino

Non-Hispanic

American

Indian/Alaskan

Native

Asian

Black/African

American

Native

Hawaiian/Pacific

Islander

Legacy Asian/Pacific

Islander

White

Multi-race

Unknown

Other

(specify):

Heterosexual

Men who have sex with men

(MSM)

Intravenous Drug

Use (IDU)

IDU/MSM

IDU/

Heterosexual

Non-IDU Drug

Use

Other

(specify):

Male

Female

Transgender

18-24 years

25-34 years

35-44 years

45+ years

Negative

(Select only one)

Race (Select only one)

Risk Behavior (Select only one)

Gender (Select only one)

Age Group (Select only one)

HIV Status (Select only one)

Number (Do not use percentages)

2. Hispanic/Latino

Non-Hispanic

American

Indian/Alaskan

Native

Asian

Black/African

American

Native

Hawaiian/Pacific

Islander

Legacy Asian/Pacific

Islander

White

Multi-race

Unknown

Heterosexual

Men who have sex with men

(MSM)

Intravenous Drug

Use (IDU)

IDU/MSM

IDU/

Heterosexual

Non-IDU Drug

Use

Other

(specify):

Male

Female

Transgender

30-34 years

35-44 years

45+ years

Negative

PS11-1113 Attachment XIV: Proposed Target Population Worksheet REVISED 1-11-11

Program Model #2 Program Model Name (e.g., MPowerment, CRCS):

Proposed Budget Amount for Program Model #1: $

Ethnicity (Select only one)

Race (Select only one)

Risk Behavior (Select only one)

Gender (Select only one)

Age Group (Select only one)

HIV Status (Select only one)

Number (Do not use percentages)

1. Hispanic/Latino

Non-Hispanic

American

Indian/Alaskan

Native

Asian

Black/African

American

Native

Hawaiian/Pacific

Islander

Legacy Asian/Pacific

Islander

White

Multi-race

Unknown

Other

(specify):

Heterosexual

Men who have sex with men

(MSM)

Intravenous Drug

Use (IDU)

IDU/MSM

IDU/

Heterosexual

Non-IDU Drug

Use

Other

(specify):

Male

Female

Transgender

30-34 years

35-44 years

45+ years

Negative

(Select only one)

Race (Select only one)

Risk Behavior (Select only one)

Gender (Select only one)

Age Group (Select only one)

HIV Status (Select only one)

Number (Do not use percentages)

2. Hispanic/Latino

Non-Hispanic

American

Indian/Alaskan

Native

Asian

Black/African

American

Native

Hawaiian/Pacific

Islander

Heterosexual

Men who have sex with men

(MSM)

Intravenous Drug

Use (IDU)

IDU/MSM

IDU/

Heterosexual

Male

Female

Transgender

30-34 years

35-44 years

45+ years

Negative

PS11-1113 Attachment XIV: Proposed Target Population Worksheet REVISED 1-11-11

Legacy Asian/Pacific

Islander

White

Multi-race

Unknown

Other

(specify):

Non-IDU Drug

Use