See, Test & Treat - Program/Grant Application Grant FundingThe CAP Foundation provides grants (up to $20,000 to support) See, Test & Treat® program expenses that other grants and in-kind donations do not cover. Grant funding is only provided to 501c3 organizations. This grant typically pays for items such as exam and laboratory supplies, equipment rental, promotional materials, educational aids, interpreters, translation of materials, patient transportation, and meals (Reference: Appendix 5 in the See, Test & Treat Standard Operating Procedures).CAP Foundation See, Test & Treat Program Grants: CAP Foundation encourages volunteerism whenever feasible and supports See, Test & Treat programs by procuring in-kind donations of testing kits and supplies, loaner equipment whenever possible, as well as knowledge sharing in terms of running effective programs.• Medical equipment – (clinic site only) transporting or renting equipment to perform breast and cervical cancer screening• Laboratory support personnel – laboratory staff necessary to perform the screening/tests during the program• Testing/screening supplies necessary to perform breast exam, mammogram, fine-needle aspiration (FNA), pelvic exam Pap testing, HPV testing, colposcopy, and LEEP• Marketing/Promotion – promotional activities and materials, such as posters and flyers to reach target patient population• Temporary program coordinator – to plan and coordinate program logistics• Interpreters and translated promotional and educational material• Patient transportation vouchers• Supplies for children’s activities• Healthy breakfast and lunchAs See, Test & Treat continues to expand, we look to repeat programs to become more self-sustaining and actively pursue other sources of funding in addition to securing in-kind donations in the areas of refreshments/food, supplies, promotion and publicity.Application SubmissionAs See, Test & Treat continues to demonstrate its impact on communities across the United States, we are experiencing an overwhelming response to host programs in many communities.The 2019 See, Test & Treat Request For Application period will open on Friday, June 1, 2018 and close at 5:00 pm CST on Friday, August 31, 2018. All sites wanting to host a program and apply for See, Test & Treat funding in 2019 must submit the Prescreening Questionnaire and Program/Grant Application by the August31, 2018 deadline.The CAP Foundation Grants Committee will review all applications and award funds on behalf of the CAP Foundation Board of Directors. Programs are evaluated on their ability to: Reduce barriers to cervical and breast cancer screening and follow-up care Advance early detection and treatment of cervical and breast cancers Provide measurable results and outcomes Utilize standardized procedures set forth by the CAP Foundation Funding ScheduleAll organizations applying for See, Test & Treat program grants from the CAP Foundation must demonstrate solid financial and program management.The grant recipient will receive 50% of the award upon official approval of the application by the CAP Foundation Grants Committee. Each program is required to submit the See, Test & Treat outcomes data worksheet no later than 30 days following the program along with documented program costs to receive the balance of the funds. This aggregate-blind program data will be used to develop a formal research protocol to track and monitor the impact of See, Test & Treat and to improve the program design.The CAP Foundation will not provide See, Test & Treat grants to the following entities: Individuals Social organizations Trade or business associations Memorials, such as cultural exchange programs or program to benefit any particular individual, including individual travel and/ or study Requirements of all See, Test & Treat programs: CAP member pathologist program leader(s) or co-leaders Underserved patient population Hospital or clinic program host site/location Partnership between pathologists and Multispecialty Volunteer- clinical team Host site for care of patients Capacity to provide a pelvic and breast exam, Pap test and mammogram to eligible women. Provision of same-day Pap test results delivered personally to patients on-site. Provision of same day or prompt mammogram results (within one week) A. Program Host Information Question Title * 1. Name and address of Institution/Organization applying for See, Test & Treat grant Question Title * 2. Contact Information Name of person filling out the application Email Address Phone Number Name of CAP Member (pathologist lead) for this program Email Address Phone Number Question Title * 3. See, Test & Treat Program Location Question Title * 4. Facility Type Clinic Hospital Other (please specify) Question Title * 5. Date(s) and duration of See, Test & Treat program Question Title * 6. If this is a repeat program, tell us about: Number of See, Test & Treat Programs previously held by this host (at this site) Past event(s) including information about program components, patient findings and any other interesting outcomes that occurred Which program components will remain unchanged, what (if any) new processes and services be will implemented or changed as a result of lessons learned from a past See, Test & Treat program that will improve your program Based on the list below, discuss any Identified processes that would enable you to grow the program specific to:1. Patient recruitment/registration - 2. Number of women served (including additional untapped populations) - 3. Screenings and/or testing services offered (excluding cervical and breast) - 4. Community partners - 5. Community attendees - Outside funding/support sources (area companies/employers, community grants, in-kind donations, discounted services, etc…) that you have identified and/or applied for that could reduce the amount of CAP Foundation grant funding needed for your program B. Target Patient Population Question Title * 7. Describe the programs anticipated impact on the community: Question Title * 8. Describe your target population and why is there a community need. Question Title * 9. Does the organization already host a health fair of which See, Test & Treat would become a part of? Yes No Question Title * 10. Are the screenings that would be offered at this See, Test & Treat a current part of this organization's community outreach? Yes No Question Title * 11. Will See, Test & Treat be secondary to other events taking place on the program day? Yes No Question Title * 12. What is preventing patients from receiving adequate care? What data/evidence do you have supporting this? Underinsured No Insurance Inability to afford co-pays (poverty/income statistics) Lack of education Availability of child care Access to transportation Scheduling/work conflicts Weak social/family support Language barriers C. Patient Outreach Question Title * 13. Explain the role of area social workers, social service agencies, community leaders, local health providers and/or advocacy groups in helping to support this program. How will these groups support your program; if you haven't contacted these groups please explain why. Question Title * 14. Indicate which of the following will be part of your patient recruitment efforts (check all that apply) Word of mouth Group meetings Personal visits Community announcements Media exposure Social Media Other (please describe) D. Screenings and Other Services Question Title * 15. Does the program host site have the capability to screen, provide same-day results and education to a minimum of 50 women? Yes No Question Title * 16. Screening goal (number of women to be served). Question Title * 17. What screenings or preventive services will be provided? Clinical Breast Exam Pelvic Exam Pap Testing Screening Mammogram HPV Testing FNA Colposcopy Diagnostic Mammogram LEEP Other (please specify and explain the medical need in the targeted community) Question Title * 18. What screenings or preventive services will be provided with same-day results? Clinical Breast Exam Pelvic Exam Pap Testing Screening Mammogram HPV Testing FNA Colposcopy Diagnostic Mammogram LEEP Other (please specify and explain the medical need in the targeted community) Question Title * 19. Number of estimated tests/screenings Clinical Breast Exam Pelvic Exam Pap Testing Screening Mammogram HPV Testing FNA Colposcopy Diagnostic Mammogram LEEP Question Title * 20. What patient testing guidelines will be followed for: Pap testing Mammography HPV testing Question Title * 21. Describe how you plan to ensure same-day results are available (Pap and Mammogram). If same-day results are not available, describe how you will manage the delivery of results to patients: Question Title * 22. If you find positive diagnosis (abnormal pap or mammogram), how will you treat the patient? Specifically: What is the usual and customary treatment followed for women requiring further diagnostic services? Where are women being referred if they need additional care and/or follow-up services? What is your institution's policy on providing and/or referring a woman requiring further medical services? Question Title * 23. Describe how women will be triaged into long-term, reliable primary care and/or sustainable family care? Question Title * 24. Describe the role of the pathologist in planning, coordinating, and participating in the program; including specimen management, interpretation, patient education, and result reporting Question Title * 25. How will the required See, Test & Treat outcomes data be collected? E. Patient Education Question Title * 26. Indicate what type of patient education will be offered during the See, Test & Treat program (Modes of delivery can include: Handouts, classroom lectures, interactive/touchable exhibits, translated materials and bilingual presenters). Breast Health Cervical Health Healthy Lifestyle (eg: exercise, smoking cessation) Nutrition Pathologists and their role in diagnosing disease Financial counseling/Health insurance enrollment Information on other available community resources Please identify the educational materials that will be translated and in what languages F. Funding Request Using the budget form, provide a detailed budget to indicate the requested funding amounts along with a corresponding breakdown of the items to be funded in each category. Grants are available up to $20,000 for each program site (specific amounts to be awarded will be determined by the CAP Foundation Grants Committee). Question Title * 27. Please attach your finalized budget Save the first tab of the budget worksheet as a pdf and upload your finalized budget here. PDF, DOCX, DOC file types only. Choose File Choose File No file chosen Remove File Save the first tab of the budget worksheet as a pdf and upload your finalized budget here. G. Need for Program Funding Question Title * 28. Describe your organization; explain why your organization needs this funding. Question Title * 29. Is this program being funded by any other organization than the CAP Foundation? Yes No If yes - please provide additional detail (e.g. the source of funding, type of funding {monetary or in-kind}, amount and purpose)If no - have you identified community funders/partners you intend to pursue? Who, and in which ways would they support your program (e.g. monetary support or in-kind donations)? Question Title * 30. Describe the impact on the community if this program is not funded: Question Title * 31. Please share any additional information that you feel should be considered in evaluating your request to host a See, Test & Treat Program (e.g. unique features or services your institution offers that would strengthen the overall program, special impact the program would have on the community, ability to gather critical data related to population health, etc.) H. Volunteers and Supporting Partners Question Title * 32. Please list the names of key leadership within your institution(s) that have committed to the program along with any community partners. Lead Pathologist Lead Radiologist Lead Oncologist Lead Ob/Gyn Director of Nursing Chief Operating Officer Chief Marketing Officer Chief Executive Officer Executive Director Other Administrator(s) Community Partner(s) Thank you for taking the time to thoughtfully prepare this See, Test & Treat program and grant application. We hope it has given you and your team a chance to think through and evaluate the specifics involved in hosting a program and that you now feel even more confident as you move forward. The CAP Foundation Strategic Programs Committee will review and reach out to you with the next steps in the See, Test & Treat hosting process. If you have questions, please do not hesitate to contact CAP Foundation Director of Programs, Marci Zerante (847-832-7656 or mzerant@cap.org).The submission of this signed application indicates your commitment to hosting a See, Test & Treat® program. CAP Foundation staff will assist you and your team in the planning and execution of the program. If there are any changes or issues that significantly impact your ability to continue with hosting the program after this point, please inform CAP Foundation staff. Question Title * 33. By typing your name next to the I Accept field, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. I Accept - Lead Pathologist I Accept - Authorized Institutional Leadership Done