Drug Strategy Community Initiatives Fund - Proposal Application Form

Table of Contents

1. Proposal Application Form
2. General Information
3. Project Data
4. Project Summary
5. Rationale / Need for the Project
6. Project Description
7. Workplan
8. Evaluation Plan
9. Knowledge Sharing
10. Sustainability
11. Organization's Capacity
12. Project Budget
13. Budget Checklist
14. Final Checklist

• Project Budget
• Workplan Year 1
• Workplan Year 2
• Workplan Year 3

1. Proposal Application Form

1.1 Introduction

Take a few moments to read the following important information about the proposal submission process under Health Canada's Drug Strategy Community Initiatives Fund (DSCIF). Before completing this form, please also read the DSCIF Guide for Applicantsand the DSCIF 2009-2010 Call for Proposalsinformation at www.healthcanada.gc.ca/dscif to learn about the DCSIF Program priorities and applicable regional priorities for this Call for Proposals.

STOP: Is your organization an eligible applicant? Is your project activity eligible for DSCIF funding? If you are not sure, contact the Health Canada Regional Office within your region to discuss prior to submitting your proposal (a list of contacts is available on DSCIF Website at www.healthcanada.gc.ca/dscif).

Your project must target health promotion and prevention of illicit drug use and reach the primary target population of youth ages 10 – 24. It is mandatory to comply with the DSCIF Program priorities and, when applicable, also with regional priorities.

The following Proposal Application Form must be completed before your request can be reviewed. Please be certain that you have completed all the information and attached all necessary supporting documents . (Refer to section 14 for the documents final checklist). To complete this form you may either:

• Download the electronic copy of the Proposal Application Form from the DSCIF Web site at www.healthcanada.gc.ca/dscif

OR

• Contact your Health Canada Regional Office to obtain electronic or printed copies of these documents.

2. General Information

2.1   Information about your organization (N.B. If you are a coalition or an ad hoc committee, the information you should provide below is about the organization that will be the legal sponsor of the project on your behalf)

Applicant Organization:
Street Address:
Mailing Address:
City, Province:
Postal Code:

Telephone:
Fax:
E-mail:

Organization Web site address (if applicable)

2.2   Previous name of organization, if applicable:

2.3   Person who has legal authority to enter into an agreement/sign on behalf of the organization: (This may be the President/Board Chair or other Board contact. Please include a list of current Board Members)

Name/Title:
Street Address:
Mailing Address:
City, Province:
Postal Code:

Telephone:
Fax:
E-mail:

2.4   Contact for the project: (the project coordinator or the person in charge of the day-to-day activities of the project, unless this is the same person as above)

Name/Title:
Street Address:
Mailing Address:
City, Province:
Postal Code:

Telephone:
Fax:
E-mail:

2.5   Preferred language for correspondence

English French

2.6   Please provide the following information:
Date of incorporation:
Incorporation number:
If not incorporated, what is the status of your organization?

Date of registration as a non-profit or charitable organization and registration number from Revenue Canada (GST #):

2.7   Identify your type of organization

• Not-for-profit health organization
• Not-for-profit organization
• Registered not-for-profit charitable organization
• Canadian Institution
• Business Sector Association
• Government Provincial/Territorial
• Government Municipal
• Band / Tribal Council
• Inuit Organization
• Métis
• Self-governing First Nations
• Other organization, please specify
  

2.8   Briefly describe the mandate of your organization, and, if available, please attach a copy of your organizational chart, constitution and by-laws. In doing so, please demonstrate how your organization is involved in prevention and/or health promotion of illicit drug use among youth.

2.9   Please define the geographic region/area your organization has the mandate to serve (please include socio-economic information or community demographics):

3. Project Data

3.1   Project Title:

3.2   Anticipated Start Date of Project:
Anticipated Completion date of Project:
Duration of Project:      months (maximum of 36 months)

3.3   Scope of Project

• Local
• Municipal
• Regional
• Provincial/Territorial
• Inter-provincial
• National
• Multi-jurisdictional

3.4   Your project activities must support at least one of the following DSCIF outcomes for the target population or community. Please indicate which one applies to your project.

• Increased awareness and understanding of healthy lifestyle choices, and of illicit drugs and their negative consequences.
  
  This outcome is based on the premise that increasing awareness and understanding of healthy lifestyle choices will help prevent youth from using illicit drugs.
• Acquired/improved capacity (knowledge and skills development) to avoid illicit drug use.
  
  This outcome builds on, and beyond the awareness and understanding that is achieved at the immediate level by focusing more specifically on developing or improving the targeted population's capacity to avoid illicit drug use.
• Increased engagement of community structures, and networks in activities to promote healthy lifestyle choices and prevent illicit drug use among youth.
  
  This outcome is linked to the extent to which both existing and/or newly engaged community structures / networks have been involved in activities to promote healthy lifestyle choices & prevent illicit drug use among youth.

A logic model providing a visual picture of the DSCIF Program is available upon request. The DSCIF logic model describes the Program activities, outputs and outcomes (immediate, intermediate and long term). To obtain a copy of the DSCIF Logic Model, please contact your regional DSCIF Program representative

3.5   Type of Project

• Conference
• Educational
• Public Awareness
• Training
• Resource Material
• Evaluation
• Needs Assessment
• Networking
• Outreach and Access
• Peer Support
• Other:

3.6   Please indicate the populations you intend to reach with your project.

(please indicate all those that apply)

• Aboriginal
• Urban Aboriginal
• Ethnocultural Groups
• First Nations - Off Reserve
• Gays/Lesbians
• Inuit
• Métis
• Official Language Minority Group (refer to section 7 – Workplan)
• Parents
• Professional - Health Sector
• Street / Homeless
• Youth
• Transgendered
• Other, specify:

Number of participants to be directly impacted by project

• 0-20
• 21-40
• 41-60
• 61-80
• 81-100
• 100-999
• 1000-9999
• 10000 +

Sex of Target Population

• Both
• Female
• Male
• Predominantly Female
• Predominantly Male
• Transgendered

Age group(s) of target population (check all that apply)

• Children 7-12
• Youth 13-18
• Young Adult 19-24
• Adult 25-64
• Seniors 65+

3.7   Participation of the target population in the development, delivery and evaluation of a project is a key element of community initiatives. Please describe how your project allows for meaningful involvement of your target population(s) in the project.

Please describe:

(A) the intended target population (including number of individuals impacted by the project) and; (B) how the target population will be meaningfully involved in the planning and implementation of the project.

4. Project Summary

Please provide an overall summary giving a snapshot of the project (one page maximum). The summary should provide information about the following: the objective of the project, activities to be undertaken, expected results, outputs / products, outcomes, evaluation, dissemination and sustainability.

5. Rationale / Need for the Project

5.1   Please describe how you have assessed the need for this project. Explain any formal and/or informal information you may have supporting the need for this project along with any evidence you may have (e.g. needs assessments, literature review, previous evaluation or assessment results, consultation reports, project relevant statistics, etc.).Why is this project needed? Why do you believe the proposed activity will address the need(s) you have identified? You need to clearly demonstrate in your application documented evidence that supports the need for this type of project.

5.2   Whether you are applying for regional or national project funding, your project must support health promotion and/or prevention activities targeting illicit drug use reaching the primary target population of youth ages 10 to 24. Please demonstrate how your project addresses the mandatory DSCIF Program priorities and related regional priorities.

6. Project Description

6.1    Measurable Project Objective(s)

Objectives are time-limited, concrete, realistic and measurable. Please clearly set out the objectives for your project.

6.2   Project Activities

Activities are specific actions to achieve the objectives. Please clearly describe the activities for each of the above listed project objectives that will be undertaken. Include the Timeframe and the person(s) that will be responsible for overseeing or doing the activity.

6.3   Project Outputs

List and describe all products, goods or services you expect to produce or deliver as part of your project. Often these deliverables take the form of, training sessions, workshops, focus groups, manuals and/ or publications. You are expected to provide outputs that are clearly defined and quantifiable. These outputs must support the attainment of your project outcomes.

6.4   Project Outcomes and indicators of success

Please clearly state the anticipated outcomes for each of your project objectives ( including the expected results and expected change) : . Also demonstrate how your expected outcomes feed into the appropriate DSCIF program outcomes (see question 3.4).

6.5   Partnerships

Please indicate other organizations, groups, coalitions, projects, etc. with whom your organization plans to partner in order to deliver this project, and provide a description of each partner's role (e.g. strategic planning, knowledge/expertise, delivery (administration and/or implementation of project activities, linkages/networks and/ or resources (in-kind, staff, $). Describe how the partnership(s) enhance your ability to develop and deliver this project.

You must also provide all letters of partnership from each of the partners involved in the project. Letters of partnership detail the roles and responsibilities of the project partners, and what they will contribute to ensure the success of the project (e.g. strategic planning, knowledge/expertise, delivery (administration and or implementation of project activities, linkages/networks and/ or resources (in-kind, staff, $) ).

7.    Workplan

Please outline the proposed WORKPLAN for your project as it relates to DSCIF priorities and applicable regional priorities. Your WORKPLAN should be based on information provided in section 6, including the project's objective(s), the activities to be undertaken (by both staff, volunteers and partners)and related timetable persons responsible for the activities and the expected results. (You must complete the attached WORKPLAN form.)

N.B.:

• The Federal Government Budget Year (Fiscal Year) runs from April 1 to March 31.
  
  
• Have you considered the Official Languages Act? The Act states that where "numbers warrant", announcements, services, documents, conferences, meetings, workshops etc., be in both official languages and that community members of both official languages be encouraged to participate in the project. Please consult the following Web site for more information: http://www.tbs-sct.gc.ca/pubs_pol/hrpubs/OffLang/CHAP1_4_e.asp

8.    Evaluation Plan

You must provide a detailed evaluation plan for your project. The aim of an evaluation is to determine the extent to which your project's objective(s) are being met and to find out what helped and hindered the project. It is recognized that evaluation results may not always reflect the initial intent of the project. Organizations are encouraged to see evaluation as a learning tool and to understand that all outcomes, including those that are different from the original proposal, can be educational and useful in the development of enhanced community efforts to reduce and prevent illicit drug use among youth.

The Evaluation Plan should be based on information provided in section 6 and should include:

1. clear evaluation criteria that fit with DSCIF program outcomes and expected results;
2. suitable methods for collecting and analyzing information; and
3. reasonable and measurable performance indicators to evaluate both the process and the outcome of the initiative.

As a result of your evaluation you will be able to answer the following questions:

• Why the project should be developed (objectives);
• What will be it involved (project activities);
• What will be expected as a result of these activities;
• What in fact will happen (actual results or outcomes);
• To what extent will the objectives be achieved; and
• What this information will tell us about the project (conclusions).

The evaluation plan should be realistic given the scope of the project.

DSCIF funding can support the hiring of an outside evaluator to assist you with your evaluation.
Are you planning to hire an external evaluator?

• yes
• no

If yes, please provide a description and include the costs associated with this activity in your budget.

9.   Knowledge Sharing

Please describe how you will share the results of your project. Please also describe the types of organizations and individuals that may benefit from the knowledge sharing. Remember to indicate any costs associated with these activities in your project budget.

10.   Sustainability

How do you plan to sustain the momentum of the project beyond DSCIF funding and what additional sources of funding will be in place?

11.    Organization's Capacity

Please demonstrate your organization=s capacity to carry out the project by answering the following questions:

11.1   Priority group (specific population)

• Good knowledge of the priority group?
• Previous working experience with priority group?

11.2   Project implementation

• Previous experience with proposed type of activities?
• Actual expertise in implementing such activities?
• Proposed work plan and time-lines are realistic?

11.3   Project management

• Previous successful project implementation of similar scale project?
• Financial management capacity for requested contribution?

11.4   Organizational strength

• Active in the community?
• Sound administrative and financial system?

12.    Project Budget

12.1   What is the total cost of project?

12.2

1. What is the total amount requested from the Health Canada DSCIF?
2. What amount of in-kind contributions are you receiving from project partners? (This should be reflected in the project budget.)

If yes, please complete the following:

Funder:
Amount Requested
Confirmed: Yes/No

12.3    Are you receiving or have you applied to other sources of funding for this project?

Yes/ No

If yes, please specify:

12.4   Are you currently or have you previously received funding from Health Canada or the Public Health Agency of Canada (PHAC)?

Yes/ No

If yes, under which program? Please provide the title of the Program, the name of the Program Officer and contact information:

12.5   Have you previously received funding from other federal departments? Yes/No
If yes, please provide the title of the Program, the name of the Program Officer and contact information:

12.6   Does your organization owe any funds to the federal government?

Yes/ No

If yes, please provide details:

13.    Budget Checklist

• you must complete the Project Budget Form;
• ensure that all costs in the budget relate to the project's activities;
• clearly detail each contribution, whether financial or in-kind (this must be quantified), made by the applicant or by a partner (e.g., financial, services, office space);
• applicants are expected to secure other sources of support, including in-kind, towards the costs of the project;
• include costs for project evaluation and dissemination of results;
• include budget notes (these can be attached to the budget and provide a narrative explanation/rationale, as appropriate);
• breakdown by fiscal year (April 1 - March 31).

Reminder: Purchase of land, buildings, vehicles or other major capital costs over $5,000 are not eligible expenses.

14.   Final Checklist

Checklist and Documentation Required
Did you attach the following documents?

• A list of Board of Directors and a list of staff, if applicable
• A list of the names and titles of the individuals conducting the project
• Your organization's audited financial statements for the last two fiscal years (if available)
• Documents describing the mandate, objectives, activities and structure of your organization (e.g. constitution, charter, by-laws, etc.)
• The completed workplan form
• An evaluation plan for the project
• The completed project budget form
• Letters of partnership and letters of support from relevant stakeholders
• Documentation disclosing any conflict of interest or any contingency fee arrangement (when reviewed and signed by the appropriate person in your organization, the declaration found on the next page can be used to provide this documentation.)
• Signed completed proposal application form

Have you completed all sections of the Proposal Application Form including the project summary page?

You must provide an original signed copy of this completed form to the Health Canada 's DSCIF P rogram consultant in your region (please visit the DSCIF Website at www.healthcanada.gc.ca/dscif for your region Program contact). Your proposal will be deemed incomplete if it is not appropriately signed.

Declaration

As a person with authority to sign on behalf of the organization, I am submitting this proposal with the full authority necessary to make this application, and

I hereby declare that:

• the information in this application is accurate and complete;
• the application is made on behalf of the organization(s) identified herein and with their full knowledge and consent;
• no person involved in this project is in conflict with the post-employment guidelines* of the federal government*

* Refers to the Treasury Board policy on Conflict of Interest and Post-Employment Code for Public Office Holders and the Values and Ethics Code for the Public Service. http://www.tbs-sct.gc.ca/pubs_pol/hrpubs/TB_851/vec-cve_e.asp

I acknowledge that should a contribution for this project be approved for funding, I will be required to enter into a formal contribution agreement which will outline the funding terms and conditions.

Name:
Signature:
Date:
Title
Witnessed By: (print name)
Signature:

NOTE: Please fax or mail this signed page to your Health Canada Regional or National Office, if sending the application form electronically.
Office Use only:
Date Application Received:

Health Canada's Drug Strategy Community Initiatives Fund Project Budget

Budget Categories

• Salaries
• Honoraria
• Travel and accommodation
• Rent and utilities
• Materials and supplies
• Equipment rental
• Evaluation
• Other (please specify)
• Totals
  

Amount Requested by Fiscal Year (April to March)

• Year 1
  • DSCIF
  • Other Sources
    • Financial
    • In-Kind
• Year 2
  • DSCIF
  • Other Sources
    • Financial
    • In-Kind
• Year 3
  • DSCIF
  • Other Sources
    • Financial
    • In-Kind

Health Canada's Drug Strategy and Community Initiatives Fund (DSCIF) Workplan -- Year 1

• Activities
• Timelines
• Who is responsible
• Partners and their contribution
• Other Resources required (eg. space, equipment, personnel)
• Objective (which project objective is this activity meeting)
• Outputs
• Outcomes

Health Canada's Drug Strategy and Community Initiatives Fund (DSCIF) Workplan -- Year 2

• Activities
• Timelines
• Who is responsible
• Partners and their contribution
• Other Resources required (eg. space, equipment, personnel)
• Objective (which project objective is this activity meeting)
• Outputs
• Outcomes

Health Canada's Drug Strategy and Community Initiatives Fund (DSCIF) Workplan -- Year 3

• Activities
• Timelines
• Who is responsible
• Partners and their contribution
• Other Resources required (eg. space, equipment, personnel)
• Objective (which project objective is this activity meeting)
• Outputs
• Outcomes