HC - Program Questionnaire for National Network Program (Round 2)

Legal Agency Name*

City and State*

Street Address

Street Address Line 2

CityState

Name of Program Manager*

First NameLast Name

Email Address of Program Manager*

example@example.com

Phone Number of Program Manager*

Please enter a valid phone number.

Name of CEO*

First NameLast Name

Email Address of CEO*

example@example.com

Name of Agency Board Chair*

First NameLast Name

Email Address of Agency Board Chair*

example@example.com

1. Provide an executive summary of your National Network program. Please include how you and your sub-subgrantees will incorporate PCTI principles into all aspects of your program. (500 words max)*

0/500

2. Provide a brief description of the Holocaust survivor population in each of the communities that you plan to serve through this grant. (500 words max)*

0/500

3. Provide a brief description of the older adult population with a history of trauma in each of the communities that you plan to serve through this grant. (500 words max)*

0/500

4. Provide a brief description of the needs of family caregivers who are caring for Holocaust survivors and/or older adults with a history of trauma in each of the communities that you plan to serve through this grant. If you do not plan to serve family caregivers, please write “not applicable”. (500 words max.)*

0/500

5. How many individuals do you anticipate serving through this grant?*

	Year 1	Year 2
Holocaust Survivors
Older Adults with a History of Trauma
Family Caregivers

6. How will you ensure the sub-subgrantees implementing the program protect the health and safety of program participants as the COVID-19 pandemic evolves? (200 words max.)*

0/200

7. Describe any challenges you anticipate your sub-subgrantees might have implementing the program and how you can help them overcome those challenges. (200 words max.)*

0/200

8. Do you plan to promote or sustain this program in your network after JFNA funding ends? If so, how? If not, please explain why. (200 words max.)*

0/200

9. Do you plan to help your sub-subgrantees sustain their programs after JFNA funding ends? If so, how? If not, please explain why. (200 words max.)*

0/200

10. What outcomes would you like your project to achieve? (500 words max)*

0/500

11. What are indicators by which you will measure the outcomes of your project (e.g., how many projects have been implemented and their impact on participants? (500 words max.)*

0/500

12. What data collection tools and methods will you use to measure these outcomes? (500 words max.)*

0/500

13. Describe your organizational capacity to measure the outcomes of your project. This may include a description of staff assignments, evaluation resources, or other aspects needed to measure these outcomes. (500 words max.)*

0/500

14. How often will you communicate with sub-subgrantees and what mode of communication will you use to monitor program progress and challenges and collect information for JFNA reports? (200 words max.)*

0/200

15. If a sub-subgrantee is not in compliance with NJHSA and JFNA grant requirements, what corrective actions will NJHSA take? (200 words max.)*

0/200

Budget Application Workbook

The Budget Application Workbook includes separate tabs for:

Budget Questionnaire
Budget Template
Budget Narrative

The budget should be completed using the separate excel workbook template provided. Only completed budgets using this template, submitted in an Excel, not PDF, format will be reviewed.

Please upload your completed Budget Application Workbook here.*

Please use the following naming convention: Grant Number_Agency Name_Budget

Work Plan

The work plan should be completed using the template provided. It provides a schematic overview of the narrative, including anticipated timelines, objectives, and activities associated with the proposal. See directions in work plan template.

Please upload your completed 2-year work plan here:*

Please use the following naming convention: Grant Number_Agency Name_Work Plan

Financial Documentation

Please upload the following financial documents below

Entire organization budget for current fiscal year
Entire organization budget for most recent completed fiscal year
Independent Management Letter
FY2021 Organization Audit
FY2021 Organization Single Audit (also known as Subpart F or A-133), if applicable
A copy of the organization’s current IRS tax-exempt status determination letter or most current Form 990, or Certificate of Incorporation or equivalent document for qualified religious organizations not required to file Forms 990 and 1023
SAM registration confirmation or verification registration is in progress, and UEI number
Copy of the organization’s indirect cost agreement with the government, if applicable

1. Entire organization budget for current fiscal year (required)