CFVPI-0004 Grant Application Template_Three Pillar Grant.pdf

Application CFVPI-0004: Reducing Gun Violence in Maryland Through Prevention, Assessment, Intervention, and Response

This application template is available in Word and PDF. The content can be copied and pasted into a word processing program of the Applicant’s choosing. All fields and questions should be retained.

Basic Information Organizational Information

1. Organization Name (as it appears on W-9 form):

2. Mailing Address 1:

3. Mailing Address 2:

4. City:

5. State:

6. ZIP Code:

7. County (where physically located):

8. Federal Employer Identification Number (FEIN):

9. Organization Type:

Non-Profit Organization (Note: 501(c)(3) status required: Submit IRS tax exempt status determination letter with application)

Government Entity in Maryland

Points of Contact

10. Primary Contact (first and last name):

11. Primary Contact Title:

12. Primary Contact Email Address:

13. Primary Contact Phone Number:

14. Secondary Contact (first and last name):

15. Secondary Contact Title:

16. Secondary Contact Email Address:

17. Secondary Contact Phone Number:

Identified Pillar (select one pillar and one subcategory under the selected Pillar) Pillar I: Prevent & Assessment

Protective Order Firearm Surrender Implementation Safe Storage Program Violence Reduction Plan or Council Lethal Means Safety Counseling Other Prevention or Assessment Project

Pillar II: Intervention & Response Community Violence Interruption or Street Outreach Group Violence Intervention or Focused Deterrence Cognitive Behavioral Approaches Hospital Violence Intervention Crisis Intervention Teams Other Intervention & Response Projects

Pillar III: Community Resilience and Healing Direct victim/survivor services

Project Narrative

1. Project Title:

2. Summary Statement: Briefly summarize the proposed project and expected impact. Note: If awarded, this summary will be made publicly available. Length suggested: 3 sentences; 100 words

3. Data-driven Needs Justification: Describe the need for the program/project in the state or identified jurisdiction(s). Specify if the project will focus on one type of gun violence (homicide, suicide, nonfatal shootings, et.), or all forms, supported by data or evidence. Cite sources used.

Length suggested (for all sections listed below): 600 words

a. Data: Inclusion of rate(s) and/or count(s) are required. Use of public health data is required. Use of MD Firearm Violence Data Dashboard is encouraged. Additional data sources (criminal, court, research, qualitative) may be used to complement quantitative public health data. Local demographic and/or geographic breakdowns are encouraged to the extent that local data are available.

b. Type(s) of Gun Violence: Use data to identify and justify the type(s) of gun violence that the project/program will aim to prevent.

c. Population of Focus: Use data to identify and justify the specific population/community that the project will focus on.

4. Project Description (Detail the goals, objectives, activities, and target population of your proposed project)

a. Pillar & Category: Identify the chosen pillar and category, describing how the program fits into that category. Length suggested: 100 words

b. Plan Summary & Activities: Provide a detailed description of the project plan and specific activities. Length suggested: 500 words

c. Rationale: Describe how the designed program/project will reduce firearm violence (include evidence, research, theory, and/or logic to support the argument). Length suggested: 400 words https://health.maryland.gov/dataoffice/mdh-dashboards/Pages/firearm-violence.aspx

d. Community: Describe outreach, communication, and/or dissemination methods that have occurred or what will occur as the program/project is developed and implemented..

How will the population or stakeholders be informed of the program or the resources developed through the program? How will input be obtained from impacted stakeholders and the affected community? Length suggested: 200 words

e. Challenges & Solutions: Identify any barriers or challenges that may occur. For each barrier or challenge, describe potential solutions and how the grant funds could be used to address the anticipated challenges. Length suggested: 150-300 words

f. American Disabilities Act: Identify and describe relevant accommodations that may be needed and will be provided for successful project implementation. Length suggested:

100 words

Required Certification of ADA Compliance I certify my organization will provide accessibility to people with disabilities and language barriers, including acknowledged agreement to meet the American with Disabilities Act Statement in the Scope of Work requirements and affirmation to meet all requirements.

5. Organizational Capacity

a. Overview & Subject Matter Expertise: Describe your organization's relevant history, mission/vision, and priorities as it relates to firearm violence prevention and the proposed project/program. Describe your organization’s subject matter expertise in relation to the form(s) of violence being addressed, relationships with the community and partners, and experience implementing similar projects/programs serving the population of focus.

Note: Organization’s annual budget is required to be submitted with the application.

Length suggested: 500 words

b. Key Partners: Identify and describe the partnerships that will support successful project implementation. (Note: At least one letter of support is required to be submitted with your application.) Length suggested: 150 words

c. Staffing: Provide names, titles, credentials, and brief bios for key personnel, including project management, fiscal management, and all project implementation roles. For vacant roles, briefly summarize the position description and recruitment/hiring plan and timeline. Length suggested: 600 words

Work Plan Template The Work Plan is required and may be submitted as a separate document using the word processing platform/software preferred by the Applicant. Required elements of the Work Plan are as follows:

Proposed Activities Deliverables (if applicable)

Proposed Metrics of Effectiveness

Timeframe Estimates /

Completion Dates

Team Members Responsible

Budget Form

The Budget Narrative shall contain all price information in the format specified on these pages. Do not amend, alter or leave blank any items on the Budget Form. Failure to adhere to any of these instructions may result in the Budget Narrative being determined non-responsive and rejected by the Department.

Submitted By Authorized Signature:

Date:

Printed Name and Title:

Organization Name:

Company Address:

Location(s) from which services will be performed (City/State):

FEIN:

Telephone:

Email:

Budget Summary (7/1/26-6/30/27)

Line Item Total Cost Salary Fringe Contractual Travel Operating Costs Supplies Indirect Costs (not to exceed 15%) Other Other Other

TOTAL

Budget Narrative Sample

Sample Line-Item Justification (repeat for each budget category and line item)

Category: Salary Total Requested: $15,600

Preventionist, to be hired: $15,600

Justification: The Preventionist will be responsible for: conducting project-related relationship-building activities with new and existing partners; developing informational materials for community leaders and the public, including fact sheets and social media posts related to the project topic; coordinating and facilitating monthly project meetings with partners; conducting awareness-building activities within key demographic areas in the community to engage the project target audience; developing and providing professional training at targeted local governmental agencies and private businesses; attending community events relevant to the project and the project’s partners. The Project Coordinator will also attend RISEMD meetings, collect data, conduct evaluation activities, prepare reports, and act as a liaison with the MDH Grant Monitor.

Sample Calculation Methods:

● Calculate Hour Salary and Number of Anticipated Hours (e.g. $30/hr. x 520 hours = $15,600), or

● Percentage of Salary for Salaried Staff (e.g. 30% of Preventionist’s Time = $15,600)

Grant Application Checklist Refer to the Request for Applications to ensure that all application requirements are met. Documents should be submitted as PDFs.

IRS non-profit designation letter (if needed) Letter of Support Annual organizational budget Grant Application Budget Form (if separate) Budget Narrative Work Plan

Budget Narrative Sample