QIF Project Plan Form

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration 
QIF Project Plan Form
FOR HRSA USE ONLY

Grant Number
Application Tracking Number



Instructions

The Project Plan form is divided into two sections: (1) Project Overview and (2) Project Details.   
    • In the Project Overview section, provide information that applies to the entire project including: project name, problem statement, population of focus, and community engagement approach.   
    • In the Project Details section, describe your proposed project and activities in detail.   
Align all sections of the Project Plan with your responses provided in the Project Narrative.  
You can find an example Project Plan form on the QIF technical assistance webpage.  

Project Overview 
Project Name
Provide a brief title for your entire project.

Problem Statement
Provide a brief description of the current barriers and challenges your proposed project will address.  

Goal
Provide a brief description of the overarching goal(s) your proposed innovation(s) will achieve. Tell us how the project will address the needs and barriers for your population of focus. Goals should be specific and measurable. Goals should also reflect input from health center patients and community members. 

Population of Focus
Briefly describe your population of focus for the proposed innovation(s). The description should align with the information provided in the NEED section of the Project Narrative. 




Needs Summary  
Select the needs your project will address. You must select at least one critical health need and at least one health-related need. You may select multiple.  




□ 
Which of the following health-related needs will your project and corresponding innovation(s) address? (select all that apply)
□ Housing insecurity
□ Food insecurity
□ Financial strain
□ Lack of transportation/ access to public transportation
□ Intimate partner violence
□ Other – please describe
 
Project Details  
Click on the “Add Project” button below to open up a separate window and add information about your proposed project. After you save information about the project, you will be redirected to this screen. You must add information for at least one project. You can add multiple projects by clicking on the “Add Project” button again.  
  
Provide a detailed description of the proposed project. Include:  
    • A brief overview of your project, including the evidence-based model(s) you will use,   
    • Goals you intend to accomplish,  
    • Critical health and health-related needs the project will address,   
    • The innovative activities you will implement, and  
    • The evaluative measures you will use to assess the success of the project.  
  
Descriptions in the Project Details section should align with responses provided in the Project Narrative and with the Project Overview section of this Project Plan Form.   
After you have entered all information about your project, click “Save and Continue” to return to the Project Plan Form. The information you entered will appear in a table format on the main Project Plan Form. You may choose to add more than one project. Projects will be assigned a number according to the order in which they are added.
Innovation


Innovative Activities  
List and describe the specific activities you will implement to adapt or build upon evidence-based model(s) of care to address the identified needs and barriers for your population of focus.  





Select at least one of the following critical health needs your project will address.   
□ Managing chronic conditions  
□ Prevention, screening, diagnosis and treatment of infectious disease  
□ Reducing risk of drug overdose  
□ Addressing mental health and substance use disorder treatment needs  
□ Other

Community Engagement Approach  
Briefly describe your plan to gather input from and meaningfully engage with patients, community members, and community partners throughout the period of performance.  

Evaluative Measures
List the evaluative measures you plan to use to assess the success of your innovation. You must include at least one measure of patient experience and one measure of community engagement below.




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