COVID-19 Vaccine Equity Grant

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Organization Name* This field is required.

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Primary Location Address* This field is required.

Street Address

Street Address Line 2

City

State

Postal / Zip Code

Country

3

Website

4

Organization Phone Number

Area Code

Phone Number

5

Organization Fax Number

Area Code

Phone Number

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Name of Primary Grant Contact* This field is required.

First Name

Last Name

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E-mail of Primary Grant Contact* This field is required.

example@example.com

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Primary Grant Contact Phone Number (Office)

Area Code

Phone Number

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Primary Grant Contact Phone Number (Mobile)

Area Code

Phone Number

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Service Area(s): Please select all that applySee the RFP for descriptions of each service area

Vaccine Education/Outreach

Improving access to COVID-19 vaccines by expanding and diversifying opportunities for getting vaccinated

Strategies for identifying and addressing social conditions to eliminate barriers to vaccination

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Do you plan on using grant funding to directly administer vaccines to patients?You selected "Improving access to COVID-19 vaccines by expanding and diversifying opportunities for getting vaccinated". This can apply to organizations looking to administer vaccine. Does your organization plan on administering any authorized COVID-19 vaccines as an Enrolled COVID-19 Vaccine Provider?

YESNO

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To your knowledge, is your organization an Enrolled COVID-19 Vaccine Provider?

YESNO

13

Has your organization completed a COVID-19 Vaccine Provider Intent Form?

YESNO

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Has your organization been registered for use of the Virginia Electronic Registration for Immunization Programs (VERIP) or discussed with VDH directly your need for registration?

YESNO

15

Have providers of your organization been given access to and trained in the Virginia Immunization Information System (VIIS)?

YESNO

16

Has your organization established a Vaccine Management Plan (VMP)?

YESNO

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Has VDH created a VaxMax account for you as a provider using CDC-assigned VTrckS ID?

YESNO

18

Has a member of your organization completed registration in Vaccines.gov?

YESNO

19

Have you completed a CDC COVID-19 Vaccination Provider Agreement in VERIP?

YESNO

20

Is your organization interested in becoming an Enrolled COVID-19 Vaccine Provider?

YESNO

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Please Review the VDH COVID-19 Vaccine Provider Enrollment Processhttps://www.vdh.virginia.gov/covid-19-vaccine/healthcare-professionals/

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Do you provide vaccines for anything other than COVID-19?

YESNO

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List of Vaccines ProvidedPlease list the vaccines {ltdivClassinlinequilleditgtorganization34} provides

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Please describe your organization and any of its work relating to community health, education, and engagement.Use the button in the top right corner to expand this text box and it might make writing your response a little easier.

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Which populations does your organization have a history of serving or engaging with in the past five years?Select all that apply

People in racial and ethnic minority groups

People living in communities with high social vulnerability index

People living in rural communities

People who are immigrants and/or refugees

People with transportation limitations

People with disabilities

People who are homebound or isolated

People who are underinsured or uninsured

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Please provide a description of your organization's history of working with people in racial and ethnic minority groups (Non-Hispanic American Indian, Alaska Native, Non-Hispanic Black, Hispanic). Please be as descriptive as possible with any data you may have.

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Please provide a description of your organization's history of working with people living in communities with high social vulnerability index. Please be as descriptive as possible with any data you may have.

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Please provide a description of your organization's history of working with people living in rural communities. Please be as descriptive as possible with any data you may have.

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Please provide a description of your organization's history of working with people who are immigrants and/or refugees. Please be as descriptive as possible with any data you may have.

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Please provide a description of your organization's history of working with people with transportation limitations. Please be as descriptive as possible with any data you may have.

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Please provide a description of your organization's history of working with people with disabilities. Please be as descriptive as possible with any data you may have.

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Please provide a description of your organization's history of working with people who are homebound or isolated. Please be as descriptive as possible with any data you may have.

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Please provide a description of your organization's history of working with people who are underinsured and/or uninsured. Please be as descriptive as possible with any data you may have.

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If you selected "Other", please provide a description of your organization's history of working with this additional population. Please be as descriptive as possible with any data you may have.

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Please provide a description of your organization's rapport in Alleghany County.

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Please provide a description of your organization's rapport in Craig County.

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Please provide a description of your organization's rapport in Roanoke County.

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Please provide a description of your organization's rapport in Roanoke City.

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Please provide a description of your organization's rapport in Botetourt County.

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Please provide a description of your organization's rapport in Salem City.

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Please provide a description of your organization's rapport in Covington City.

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Proposal, Goal, and PurposePlease describe your proposed project, including the goals, activities, and purpose of each, as well as how they align with those your selected goal(s) of {name35}.

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Proposal ScopeDescribe proposed activities and strategies in each selected area of service. Please provide us with a measurable sense of what the work will entail. For example, how many events do you plan on hosting? How many people do you think you will be able to reach?

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Proposal OutcomesWhat outcomes are anticipated from this project?

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Social Determinants / ConditionsPlease describe any experience your organization has in addressing the social determinants / conditions that impact populations most severely affected by COVID-19, such as transportation or internet access.

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Upload Timeline Excel fileUpload the Excel file of your Proposal Timeline

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

48

Upload your Timeline PNG fileUpload the PNG Image file of your Proposal Timeline

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

49

Please download and complete the Budget Outline and upload your completed document. Instructions will be outlined in the template you download.

Budget Template

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Upload Completed Budget* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Reference ID

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The information provided in this application shall not be shared to anyone else and is kept confidential among designated members of RCAHD. Upon submission, both the applicant and RCAHD will receive a copy of this application.

After submission, your application will go through our Five Phases of the Review Process.

1. Initial Screening

Our grant manager will review your application and documents to ensure their authenticity before passing them along. This phase will be completed within 24 hours of submission, if not sooner.

2. Initial Review

Our team at RCAHD will look over your application and send you any questions we may have concerning your responses and/or documents. This step is designed to help your application look its best before being sent off to the Review Board. Members of this team will not be allowed to participate in the blind-review board that will later evaluate your organization's demonstrated capacity to support RCAHD's mission. Members of this team will, however, evaluate RCAHD's present need for your project later on.

3. Review Board

A blind review will be organized to evaluate your organization's capacity to support RCAHD's goal. Information on scoring can be found in the Appendix section of the RFP.

4. Needs Assessment

The same people who conducted the Initial Review will conduct a needs assessment for your organization's project idea. Using the latest health-related data, this phase will assess the demand for project ideas like yours in the current context of the pandemic.

5. Consultation

Once RCAHD has decided to finance your project idea, we will reach out for a meeting to discuss the amount that will be granted to your organization for relevant activities and the performance measures that will be used in quarterly reporting. Both matters will be entered into a Memorandum of Understanding (MOU) that must be completed before RCAHD can reimburse your organization for expenses relating to its relevant activities.

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Click agree to acknowledge statement below* This field is required.I, as a representative of {ltdivClassinlinequilleditgtorganization34}, have reviewed the Request for Proposal and the answers to this application, accept the requirements and expectations should the application be approved for a grant, and have answered each question to the best of my ability and agree that the information herein are true and correct.

Agree