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Health Related Social Needs (HRSN) Community Capacity Building Funding Application

Community Capacity Building Application

Instructions

In order to receive funding, Organizations must complete and sign this application form in its entirety. For this form to be considered complete, all components must be filled out, a budget request must be attached and the application must be signed by the authorized representative from the entity applying for funding.

Applicant Organization Information

The purpose of this section is to collect general information about the Applicant Organization. Please complete the information requested in the table below.

Asterisk (*) indicates a required field. 

Please fill out the following budget form and attach it to the submission.

Budget Attachment

Eligibility Criteria

Organizations must meet minimum eligibility criteria to receive Community Capacity Building Funding.

Please attest to the following: required *

The following organization types are eligible to apply for and receive Community Capacity Building Funding. Please select the box that most closely aligns with your organization type (select more than one, as needed):

Organization Types
Community-based organizations, including:
Provider organizations that include those that provide or coordinate HRSN services, including:

HRSN Community Capacity Building Funding Applicant Organization Questions

Who will be served

The purpose of this section is to collect information about the population served by your organization and to learn more about its culturally responsive and specific strategies to engage individuals.

1. Counties Served. Please indicate what counties your organization will provide HRSN services.

2. For each county marked above, your organization must provide specific details about: 1) the current working relationship and knowledge of that county 2) current or planned partnerships to support the work proposed and 3) the work being proposed in that county, including how their specific population(s) of focus in each county will benefit from the proposed work.

If your organization does not have existing relationships in the county, you must describe how you intend to build those relationships.

3. Populations to be served. Please select the populations to be served by your organization. Select only the specific populations you will serve from each list below:

HRSN Services Covered Populations: (See STCs for Population Description)
Priority Populations:

4. Language access provided by your organization. Please indicate your organization’s capacity to speak and write in languages other than English. Also indicate whether the language capacity comes from a native or non-native speaker.

Language 1:
Language 2
Language 3:
Language 4:

HRSN Community Capacity Building Funding Request and Justification

Organizational Background Information

7. Please check below which HRSN services initiative (Climate Support, Housing, Nutrition Supports, Outreach and Education (PDF) your organization has experience with. For each answer marked, 1) describe below your experience providing these services and 2) describe how your organization intends to provide this service as an HRSN service provider. Check all that apply.

HRSN services initiative-Check all that apply

Allowable Funding Uses3


The purpose of this section is to collect information about:

  • the purpose of your funding request;
  • funding need and justification;
  • and how funding will be utilized.

Eligible entities may request Community Capacity Building Funding to support the development and implementation of HRSN services across four categories:

  1. Technology
  2. Development of Business or Operational Practices
  3. Workforce Development and
  4. Outreach, Education and Partner Convening

8. Check the box for each category in which you are seeking funding. You must also provide a short description of 1) why funding is needed and 2) how it will be used to build capacity to participate in the HRSN program 3) your organizations experience in this category. Check all that apply.

A) Technology:
B) Development of Business or Operational Practices:
C) Workforce Development:
D) Outreach, Education, and Partner Convening:
9. Has your organization applied to or been awarded funds from other CCOs for the Community Capacity Building Funding? If yes, please provide detail as to which CCOs and for what activities (200 words max).

Attestations and Certification

As an authorized representative of the Organization, the Organization attests as follows and agrees to the following conditions:

  1. The funding received through the HRSN Community Capacity Building Funding initiative will not duplicate or supplant reimbursement received through other federal, state and local funds.
  2. Funding received for the HRSN Community Capacity Building Funding initiative will only be spent on allowable uses as stated above.
  3. The Organization will submit progress reports on HRSN Community Capacity Building Funding in a manner and on a timeframe specified by the CCO.
  4. The Organization understands that the CCO may suspend, terminate or recoup HRSN Community Capacity Building Funding in instances of underperformance and/or fraud, waste and abuse.
  5. The Organization will alert the CCO if circumstances prevent it from carrying out activities described in the program application. In such cases, the Organization may be required to return unused funds contingent upon the circumstances.
  6. As the authorized representative of the Organization, I attest that all information provided in this application is true and accurate to the best of my knowledge.

____________________________

3 Please note that the Infrastructure Protocol which outlines the allowable funding uses is pending CMS approval. Once approved, the final CMS approved Infrastructure Protocol will be updated and available on the OHA Waiver webpage.