Overdose Data to Action-States Community Health Worker Program
Organizational Information
Organization Name:
Please list the organization name as it should appear on a contract if awarded.
Organizational Mailing Address (as it should appear on a contract if awarded)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Project Contact Person:
Please include professional title.
Project Contact Person Email
example@example.com
Project Contact Person Phone Number
Please enter a valid phone number.
Contract Signatory
Please include professional title and list as it should appear on a contract if awarded.
Contract Signatory Email
example@example.com
Contract Signatory Phone Number
Please enter a valid phone number.
Which of the following categories best describes your organization?
Federally Qualified Health Center
Health System (Hospital or Clinic)
Independent Hospital
TribalProgram/Tribal Health
Youth-ServingCommunity-based Organization
Adult-ServingCommunity-based Organization
Other
Population of Focus
Target Population(s): (Geography, race, age, gender, etc.)
Please provide a thorough description in narrative format.
Describe how your project will address health equity and health disparities among the target population(s)?
Please provide a thorough description in narrative format.
What is your experience working with this population?
Please provide a thorough description in narrative format.
Estimated number of South Dakotans to be reached by the project:
Please provide a thorough description in narrative format.
Organization Narrative
Describe the staff that will be responsible for providing CHW/CHR services for grant-funded activities to include name/title and percentage of a full-time employee that will be dedicated to the project.
Please provide a thorough description in narrative format.
Describe the process by which clients with OUD will be screened and referred to the CHW/CHR by your organization and the timeframe and frequency in which services will be provided, to identified clients.
Please provide a thorough description in narrative format.
Describe your organization’s experience in working with clients with Opioid Use Disorder in providing prevention education and referral to treatment and recovery services in the state.
Please provide a thorough description in narrative format.
Describe how will the CHW/CHR become familiar and connect with providers of prevention, treatment, and recovery resources in each client’s community?
Please provide a thorough description in narrative format.
Describe how your organization is actively engaging persons with lived experience with substance use in planning and key decision-making processes for overdose prevention programs within the organization.
Please provide a thorough description in narrative format.
Describe the plan to sustain the project and related staff beyond the funding cycle.
Please provide a thorough description in narrative format.
Required File Uploads
Budget Justification
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W-9 Form
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Proof of Insurance
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Documentation of CHW/CHR certificate level or Indian Health Service Training
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