DOCUMENT 1 HOWTO Proposer Information Form.docx

Document 1 HOWTO Proposer Information Form Please fill out the following information for your organization Tribe/ Organization Name:

Tribe/ Organization webpage (if applicable):

Organization doing business as (DBA) (if different from above): Fiscal sponsor organization (if applicable):

Organization Address:

Tax ID, EIN or FEIN:

Registered with the Secretary of State _____ Yes, Proposer is currently registered with the Oregon Secretary of State business registry.

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

Commercial General Liability Insurance (CGL) _____ Yes, we currently meet the CGL License insurance requirement _____ Do not currently meet CGL insurance requirements and will meet requirement prior to Contract execution.

Professional Liability Insurance (PLI) _____ Yes, we currently meet the PLI insurance requirement.

_____ Do not currently meet PLI insurance requirements but will meet requirement prior to Contract execution.

Automobile Liability Insurance (ALI) _____ Yes, we currently meet the ALI insurance requirement.

_____ Do not currently meet PLI insurance requirements but will meet requirement prior to Contract execution.

OregonBuys Number #S-44300-00008989 4 HOWTO Round 6

Contact name:

Contact email:

Contact phone number:

Authorized signature name:

Authorized signature email:

Current/former HOWTO Grantee?

Organization information:

1. Briefly tell us about your organization. Who are you? Who do you serve?

2. Briefly describe the ongoing actions taken by your organization to advance antiracism, equity, and inclusion:

3. Please list by region the counties served by your organization:

Example:

Coast

4. Service Populations and Target Populations:

Most programs/organizations serve a range of people and communities, with varying levels of engagement, fit and usage – from those involved once who never fully engage to others who participate enthusiastically even though they are not the primary program/organization target. This full set of people and communities that a Proposer’s program/organization serves throughout the year is defined as the “service population.”

American Indian/Alaska Native/Indigenous communities Asian communities Black/African American/African communities Latino/a/x communities Pacific Islander communities Slavic/Eastern European communities People with disabilities LGBTQ2SIA+ communities Immigrant and refugee communities Rural communities Faith communities Houseless communities People with behavioral health conditions Veterans Aging/Seniors/Elderly Children and Youth Teens Women Men

a. From the list above, list the top 3 (or fewer) populations served by your organization:

Other communities not listed above (please describe):

b. A program’s/organization’s “target population” is defined as the subset of those people and communities for whom the services are designed, that the program/entity likely actively recruits or retains, and for whom the entity generally holds itself accountable for achieving outcomes.

From the list above, list the top 3 (or fewer) “target populations” for your organization:

Other communities not listed above (please describe):

5. Language access provided by your organization:

In the table below, 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.

1.

2.

3.

4.

Other information about language access offered by your organization not already listed above:

Project information (specific to the project described in your proposal)

1. Estimated total project budget requested (total listed on DOCUMENT 3 “HOWTO Grant Program Budget Table”):

2. Brief project timeline (number of years):

3. List of organizations named in proposal as collaborators, subrecipients etc.:

4. Briefly describe how workforce participants in communities you serve will continuously guide and shape this work over the project’s life cycle. Include how you will address challenges, conflicts and/or power dynamics:

5. Where will workforce trainee participants benefit from this proposed project?

List counties (by region):

6. Is your project proposal focused on:

Recruiting new professionals into the health care workforce?

From rural communities?

Focused on individuals from diverse communities?

Adding new skillsets to current health care workforce professionals?

Retention of current health care workforce professionals?

7. Briefly describe what makes your proposed project innovative compared to other health care workforce development projects?

8. Project Summary (no more than 500 words):

The purpose of the summary will be to provide reviewers with an overview of the proposal and will form the basis for the proposal summary in grants management and program summary documents. If the project is funded, the Project summary may be published on the HOWTO Grant Program website and in other online and hard-copy publications.

The information in the summary should include: (a) a brief description of the proposed project, including workforce needs being addressed, goals, objectives, outcomes, and evaluation plan; and

(b) an explanation of how the project will center on advancing health equity and antiracism and contributing to increasing the diversity of Oregon’s health care workforce.

Add your project summary below (no more than 500 words):

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