(Not Scored)

What is the name of your organization?
If applicable, please provide the name as it is registered with the Oregon Secretary of State.

What is the name of your DBA (Doing Business As), if you have one that is registered with the Oregon Secretary of State?

What is your organizations’ tax ID employer identification number/tax identification number (EIN/TIN)?

What is the name of your Fiscal Sponsor if you have one (as it is registered with the Oregon Secretary of State)?

If you have a Fiscal Sponsor, what is your Fiscal Sponsors’ tax ID (EIN/TIN)?

If you are a partnership or coalition, list the organizations’ names and their roles.

Please provide a link to your organization’s website.

a. Mission (Not Scored)

(1) What is the mission of your organization?

(2) In a few sentences, tell us about the history of your organization.

(3) Describe the population(s) you will serve.
(a) Describe your organization’s experience working with this population.
(b) How will this funding support community needs? Feel free to include data (quantitative or qualitative) to support your response.

b. Staff (Not Scored)

(1) How do your staff or board members reflect the cultural and language needs of the population(s) that you will serve?

(2) Do you have community health workers (CHWs), traditional health workers (THWs), and/or health care interpreters (HCIs) on staff? As applicable, please describe the following:
(a) What positions will be filled by community health workers?
(b) What positions will be filled by traditional health workers?
(c) What positions will be filled by health care interpreters?
(d) If your organization had the opportunity, would you be interested in training a Community Health Worker (CHW) to support your mission?

c. Cultural Responsiveness (Not Scored)

What considerations or practices does your organization use to meet community needs in culturally responsive ways?