United Way of East Central Iowa Letter of Intent: Health Focus Area FY 2018- FY2020 Date:

Submission of this letter indicates an organization is interested in full participation in the United Way of East Central Iowa FY2018 – FY2020 funding and would like to be considered to submit an application for the Community Partner Fund.

Directions: Based on your understanding of the Community Partner Fund, please complete this form and submit to United Way office by Noon on Friday, October 21st, 2016.

Organization Name:
Address:
City, State, Zip code:
Organization is an IRS 501(c)(3) not-for-profit? Yes No	Forecasted Request Amount: $ (per year)
Name of Executive Director:	Phone:	E-mail:
Contact for this Letter of Intent:	Phone:	E-mail:

Agency Guidelines Compliance _

You will be requested to adhere to the Partner Agency Standards & Fundraising Guidelines these standards and guidelines should funding be granted.

Statement of Compliance

I have read and agree to comply with United Way of East Central Iowa’s Partner Agency Guidelines as outlined within the following link:

http://www.uweci.org/what-we-do/our-partners/partner-resources/

Signature of Executive Director: ____________________________________________

A signed Letter of Intent and completed Agency Profile must be received by e-mail (scanned PDF file) by

Noon on Friday, October 21st, 2016 and sent via e-mail communitybuilding@uweci.org

Proposed Strategy

Name of proposed strategy (Limited to 40 characters including spaces. Do not include the name of the focus area within the proposed strategy name. Example of a strategy name: Connecting to Kids)

Please provide a brief description of the proposed strategy including primary activities/services that will be provided, target population that will be impacted and proposed, unduplicated number of persons served. (Please limit description to 500 words.)

What intermediate outcome(s) will you focus on? Please select one or more from the list provided below:

Review the list of priority intermediate outcomes (on the next page) and select the outputs and indicators that best align with your proposed strategy. Please provide the following information on how you will measure your performance:

Outputs you will measure

Indicators you will measure

How long have you been measuring the above proposed outputs and indicator	measurements?

List tool(s) you will be using to achieve indicator measurements:

Intermediate Outcome(s)

Directions: Please select the Intermediate Outcome(s) to which your strategy aligns and include in your answer to question 3. You must select at least one output and at least one indicator and include in your answer to question 4. If you are proposing a measurement that is not listed, preference will be made for evidence-based tools.

Intermediate Outcome 1: PREVENTATIVE HEALTH -Increase factors that contribute to	long-term health by increasing education, screening, early detection and reducing	health barriers.

Types of activities that will be considered for funding include programs that:

Provide health education;

Promote preventative screenings; early intervention;

Address healthcare barriers;

Improve navigation and care coordination;

Promote well-being.

Output measurement(s) your strategy will be reporting:

# of unduplicated persons served per intervention type. (required)

# of households served per intervention type. (required)

# Others as approved through the letter of intent process(please list):

Indicator measurement(s) your strategy will be reporting on (must report on at least one):

# (%) with additional services based on screening

# (%) referred for severe/urgent care

# (%) with increased knowledge of risky behaviors

# (%) Others as approved through the letter of intent process (please list):

Intermediate Outcome 2: REDUCING ADVERSE EXPERIENCES – Prevent, mitigate and	treat main contributors of adverse childhood experiences for families

with children to build resiliency.

Types of activities that will be considered for funding include programs that:

Reduce levels of crisis and/or trauma;

Increase social connectedness and/or

Improve functioning at school, work and/or home.

Output measurement(s) your strategy will be reporting:

# of unduplicated persons served per intervention type. (required)

# of households served per intervention type. (required)

# Others as approved through the letter of intent process(please list):

Indicator measurement(s) your strategy will be reporting on (must report on at least one):

# (%) within increased feelings of social connectedness.

# (%) with improved functioning at school, work and/or home.

# (%) with decreased levels of crisis, depression, anxiety and/or stress.

# (%) of persons screening on ACEs, behavioral health problems and/or trauma.

# (%) who received services based on follow-up.

# (%) who completed treatment with goals met.

# (%) Others as approved through the letter of intent process (please list):

Intermediate Outcome 3: COMMUNITY LIVING –Support home-based services that increase well-being and independence for older adults and persons living with disabilities.

Types of activities that will be considered for funding:

Services that improve/maintain daily functioning and increase family and social supports.

Output measurement(s) your strategy will be reporting:

# of unduplicated persons served per intervention type. (required)

# of households served per intervention type. (required)

# Others as approved through the letter of intent process(please list):

Indicator measurement(s) your strategy will be reporting on (must report on at least one):

# (%) with improved/maintained daily functioning.

# (%) with increased feelings of social connectedness.

# (%) with increased family and social supports.

# (%) with increased skills on how to care for a loved one at home.

# (%) of caregivers with decreased levels of stress.

# (%) reporting increased access to nutritious, low-cost food.

# (%) with decreased sense of isolation and loneliness.

# (%) with increase knowledge of how to improve/maintain their health and	wellness.

# (%) Others as approved through the letter of intent process (please list):