2 KAPPA Mini-Grant Applicaiton

KAPPA SAFE INFANT SLEEP COMMUNITY ENGAGEMENT PROJECT

Mini-Grant Application | 2018 Funding Cycle

Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), U.S. Department of Health and Human Services (HHS)

OMB # 0925-0701

Expiration Date: 02/2021

Kappa Safe Infant Sleep Community Engagement Project

Announcement Type: New Request for Applications (RFA)

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APPLICATION FORM

Please enter requested information in the spaces provided below. Required fields are marked with an asterisk (*).

Organization Information

• Name of Province:

• Name of Chapter:

• Mailing Address:

• Phone:

• Fax:

• Date When Chapter was established (MM/DD/YYYY):

• Type of Chapter ☐ Graduate ☐ Undergraduate ☐ Silhouettes

• IRS Classification of the Chapter

• Tax ID Number:

Contact Information

• Name of Authorized Contact Person:

• Title:

• Mailing Address (if different from above):

• Phone:

• Cell:

• Email Address:

• Name of Secondary Contact Person:

• Title:

• Mailing Address (if different from above):

• Phone:

• Cell:

• Email Address:

Project Information

*Date of Proposed Project (06/17/2018 through 08/31.2018):

*Mini-Grant Amount Requested: _________________ (Up to $1,000.00)

Proposed Date(s) of Activities (Please provide a description for each activity you are planning. If you are only conducting one activity please remember you have to reach a minimum of 25 community members)

Event 1:
Month__________________ Day__________________ Projected # attendees ________

Primary audience to be served (Please select all that apply)

☐ Men ☐ African American Parent(s) ☐ African American Grandparents ☐ Faith based

☐ Community Stakeholders ☐ Other (Please specify) _____________

Type of Activity

• Safe infant sleep training/education workshops

• Disseminating approved Safe to Sleep^® messages at health fairs and other community events via presentations

• Safe infant sleep demonstration activities

Do you plan to collaborate with other organizations? (if so, provide their names)

How will you conduct or carry out the Community Safe Infant Sleep Education Workshop with mini-grant funds?

Event 2: (If Applicable)
Month__________________ Day__________________ Projected # attendees ________

Primary audience to be served (Please select all that apply)

☐Men ☐African American Parents ☐African American Grandparents ☐Faith based ☐Community Stakeholders ☐Other (Please specify) _____________

Type of Activity

• Safe infant sleep training/education workshops

• Promoting Disseminating the safe infant sleep message at health fairs and other community events via presentations

• Safe infant sleep demonstration activities

Do you plan to collaborate with other organizations? (if so, provide their names)

How you will conduct or carry out the Community Safe Infant Sleep Education Forum with mini-grant funds?

Event 3: (If Applicable)
Month__________________ Day__________________ Projected # attendees ________

Primary audience to be served (Please select all that apply)

☐Men ☐African American Parents ☐African American Grandparents ☐Faith based ☐Community Stakeholders ☐Other (Please specify) _____________

Type of Activity

• Safe infant sleep training/education workshops

• Promoting Disseminating the safe infant sleep message at health fairs and other community events via presentations

• Safe infant sleep demonstration activities

Do you plan to collaborate with other organizations? (if so, provide their names?

How you will conduct or carry out the Community Safe Infant Sleep Education Workshop with mini-grant funds?

Project Sustainability

Please describe the changes you hope to bring to your community through the project:

How will the chapter continue to promote the Safe Infant Sleep Message once the funding ends?

Social Media

Do you plan to have a social media component? (if so, provide an explanation and include your plan to tag NICHD)

Budget Justification

Giveaway

Raffle Items: ($100.00 per every 25 event participants). Raffles prizes cannot be given to each attendee and prize recipients must be randomly selected. Example of giveaway items that may be purchased include Safe sleep items: wearable blankets or one-piece sleepers, fitted mattress sheets, pacifiers with nothing attached (i.e. string, pin, etc.)

Maximum $100.00 based on $1,000.00 allocations for 25 Community Participants

Amount $_______________________________

Justification:

Door Prizes: Items are considered door prizes and are subject to the $200.00 limit for 25 event participants (i.e. Safety-approved portable play yards may be purchased). All portable play yards must be given to prize winners unopened and in their original packaging.

Maximum $200.00 based on $1,000.00 allocations for 25 Community Participants

Amount $_______________________________

Justification:

Safe Sleep Demonstration: Grantees should budget to purchase one portable play yard to use for display at their events. Additional items to purchase for interactive demonstrations may include a doll, toys, and a pillow/blanket. These items will simulate an unsafe sleep environment.

Maximum $100.00 (including shipping and taxes)

Amount $_______________________________

Justification:

Design/Printing/Duplication of Project Promotion/Administrative Materials: Print color copies of the workshop flyer at a local printer. Create and print event posters. Print black and white pre-tests, post-tests, and post-training evaluation forms. Postage.

Grantees may design t-shirts, bags, pens, and other collateral to distribute to participants. However, the design must be sent in to Kappa and NICHD leadership for pre-approval before print.

SPECIAL NOTE: Educational Materials and Other Resources.

Printing of cobranded Kappa and NICHD educational materials, such as the new Safe Sleep for Your Baby Brochure. (Please note that publication/printing/purchase of any safe sleep materials not part of the Safe to Sleep^® campaign and/or Kappa Safe Sleep Outreach Project are not allowable expenses.)

Maximum $200.00 based on $1,000.00 allocations for 25 Community Participants

Amount $_______________________________

Justification:

Honoraria/Speaker Fees (may not exceed 5% of grant award)

Maximum $50.00 based on $1,000.00 allocation

Amount $_______________________________

Justification:

Healthy snacks for an activity or event

Maximum $100.00 based on $1,000.00 allocations for 25 Community Participants

Amount $_______________________________

Justification:

Event Support (facility fee/equipment rental/general supplies)

Maximum $200.00 based on $1,000.00 allocation

Amount $_______________________________

Justification:

Mileage (Transportation cost to support project activities at a mileage reimbursement rate of $0.535 per mile)

Maximum $50.00

Amount $_______________________________

Justification:

The application must be received by Monday, May 14, 2018. Applications submitted after this date will not be reviewed. Mini-grant applications can be sent by mail, email, or fax. Please use the contact information below to apply by mail.

Mail: (Postmarked Monday, May 14, 2018)

Global Infant Safe Sleep Center, Inc

Attn: Dr. Stacy Scott

P.O. Box 403

Toledo, Ohio 43697-1020

Email: [email protected]

Fax: 419 754-2424

REQUEST SUMMARY AMOUNT

Raffle Items

Door Prizes

Safe Sleep Demonstration

Design/Printing/Duplication of Project

Promotion/Administrative Material

Honoraria/Speaker Fees (may not exceed 5% of grant award

Health Snacks for an Activity or Event

Event Support _________________

TOTAL REQUEST

SAMPLE BUDGET

REQUEST SUMMARY AMOUNT

Raffle Items Door Prizes Safe Sleep Demonstration Design/Printing/Duplication of Project Promotion/Administrative Material Honoraria/Speaker Fees (may not exceed 5% of grant award Health Snacks for an Activity or Event Event Support Mileage TOTAL

$100.00 $200.00 $100.00 $200.00 $50.00 $100.00 $200.00 $ 50.00 $1,000.00

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