Wellness Fund Application Package

Deadline for Application Submission: November 1st, 2015 by midnight

Table of ContentsApplication Package

Page

Application Criteria 3

Application Form 6

Social Determinants of Health 11

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APPLICATION CRITERIA

The intention of the Wellness Fund (previously called the Community Development Fund) is to

support community-defined priorities through grants made to community groups and

organizations. Priority for funding will be based on community projects that address one or

more of the priorities identified in the Eastern Shore Musquodoboit Community Health Board’s

(ESMCHB) community health plan and promote healthy activities across the Eastern Shore

(Ecum Secum to Lake Echo) and Musquodoboit Valley (Meaghers Grant to Dean). See below

for priorities. Other projects that will impact the Social Determinants of Health (attached) in the

community will also be considered by the ESMCHB.

1. The projects applying for CHB Wellness Funds must not:

Fund programs that diagnose, treat or rehabilitate health problems.

Fund operational purposes by the Nova Scotia Health Authority (NSHA) or CHBs.

Publicly funded groups and organizations will be considered if they can demonstrate

need and community involvement in project planning and evaluation;

Duplicate existing community services or programs (may build upon existing services);

Fund a period of longer than 12 months;

Be an individual, for-profit organization or Government Department or Agency, e.g.,

Dept of Education (school boards are non-profit and can apply), or Municipalities

(community-led partnerships with towns can apply); or

Be solely for the purpose of fundraising.

2. Wellness Funds are provided for non-profit groups and organizations that have been

together a minimum of six months and are able to receive, manage, and track funding.

3. Funding can support existing activities and projects; however, organizations that receive

funding in one year cannot be guaranteed continuous funding in successive years.

4. Equipment or furniture that will outlive the life of the project may be purchased, at the

discretion of the CHB and NSHA, provided the requesting group can show that the item is

essential to the program and that if the program cannot be sustained and that said

equipment can be transferred to another like organization to sustain the use of said

equipment.

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5. It is the responsibility of the organization or individual receiving the grant to ensure that all

Provincial and Federal regulations are adhered to.  This includes the requirements of

Revenue Canada that a T4 or T4A is issued to all personnel being hired with an hourly

wage, or hired by contract of more than $500.  The organization or individual receiving the

grant should contact Revenue Canada to determine what is required to adhere to such

regulations. 

6. To ensure the funding will be spent as laid out in the application plan; reports, receipts and

a budget summary must be submitted to the CHB. Mid-Term Interviews may be conducted

with a CHB member. Final Reports must be received within 60 days of project completion.

Failure to submit reports will impact future funding decisions. In some cases, the NSHA

may conduct an audit of how funds were used should a final report not be received.

7. Each funding request from a community group or working group may be approved for some

or all of the funding being requested. Grants will typically be funded in amounts of under

$1500. Requests greater than this amount may be considered on a case-by-case basis.

8. Applicants are strongly encouraged to collaborate with other organizations and seek

financial support from multiple funders. Given the limited funding available, projects that

demonstrate collaboration and existing or potential funding partners will be considered

more viable.

9. Applicants may be expected to present to the CHB and sign contracts before funding is

disbursed. (Exceptions may be given in unusual circumstances).

10.Applications will be evaluated on the following criteria;

Does the proposal directly address any of the priority issues identified in our Community Health Plan?

Will the proposal have wide reaching results, or impact a lot of people? Is the proposal capable of offering long term benefits after the project is complete? Is it

sustainable? Is the proposal likely to build the capacity of individuals or groups to take positive

action? Is the proposal a good example of a new or innovative approach that addresses or

supports a priority health issue? Does the project involve partners or collaborate with community organizations? Does the project have clearly stated goals, activities, and outcomes? Does the project

have an evaluation component?

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In consultation with the community, the Eastern Shore Musquodoboit Community Health Board has identified key priority issues for increased community health. They are:

Mental health and stress Healthy eating and physical activity Access to health services and information Building a sense of belonging Reducing chronic conditions Supporting vulnerable populations

With reduced funding this year, our board has chosen to focus on; Access to health & community services and information, Mental Health, Healthy Eating and Physical Activity. Our distribution of funds will reflect this focus.

Before submitting your proposal, you are encouraged to contact your local CHB to discuss your project to ensure it meets the criteria outlined above. Deadline for submissions is November 1 st by midnight.

Please send completed applications to:Denise VanWychenEastern Shore Musquodoboit Community Health BoardPO Box 317907 #7 HighwayMusquodoboit Harbour, NS B0J 2L0Phone: (902) 889-4118 Cell: (902) 891-0372 Fax: 902-889-2599Email: denise.vanwychen@nshealth.ca

Wellness FundApplication Form 2015

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Contact informationOrganization Name:

*For processing cheques – the organization should have a bank account in its name.If the cheque should be issued in another name, please indicate here:

Project Title:

Contact Person/Title:

Address:

Phone:

Email:

About Your OrganizationType of Organization (Check all that apply):

Not for Profit

Local or community-based group

Charity

Publicly-funded organization

Other – specify:

Project Start Date: Project End Date:

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For Office Use Only:

Date received by office:_____________ Amount of funding requested :______________________

If funding has been allocated in the past, Final Reports(s) have been received:_______________ (Y/N)

Final Report Due: ______________________________

About Your Project

1. Please provide a brief overview of your organization and your areas of focus. (When it was established, who you serve, what programs and services you offer, number of staff if any, and volunteers. Please share brochures or other relevant information)

2. Is this a new project? Yes ____ No ____(If it is not new, is this another phase of a project that has previously received Community Development Funding?)

3. Please provide a description of your project (including goals and outcomes )

4. Who will participate in the development and implementation of the project? (Please list specific partners)

5. Who is the target group (population served) and how have they been involved in the planning of the project? Is this project inclusive of diverse populations? How?

6. Where will your project take place? (be specific)

7. Which CHB health plan priority areas and/or Social Determinants of Health will this project address? Explain.

Below are the health priorities identified in the 2013 Community Health Plan. What health priority (or priorities) does your project meet? (Check all that apply.)

Health Inequities Sense of Belonging Health Screenings Access to Health Services Mental Health Stress Chronic Conditions Physical Activity, Healthy Eating, Healthy Weights Other locally identified community health issue: ______________________

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What Social Determinants of Health does your project impact? (Check all that apply) Income and Social Status Social Support Networks Education and Literacy Employment/Working Conditions Social Environments Physical Environments Personal health practices and coping skills Healthy child development Biology and genetic endowment Health Services Gender Culture

8. Please list all sources of funding. Have you applied for funding from any other CHBs? If yes, please specify which CHB and the amount requested.

9. Who in your community will be partnering on this project, and how? Please identify other groups you will be working with, other funders, and groups who will be contributing in-kind to the project, for example, free use of expertise, equipment, and space.

Name of PartnerType of Assistance

(space, equipment, funds, etc)

10.How will you recognize the funding contributions of the ESMCHB?

11.What do you expect will be the greatest change or long term benefit of this project? How will you measure this change?

12.Will your project continue after the funding period? How is your project sustainable?

Please provide one letter of support for your project.

Finances

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Please provide budget details for your project. Include the total cost for the project and the amount requested from the Community Health Board Wellness Fund.

Item Brief Description of TotalWages/Honorarium/Travel Costs (for facilitators, staff, speakers, etc.)Materials and Supplies (e.g., printing, copying, miscellaneous supplies) Advertising and Promotion

Participant Support (child care, transportation, interpreters, etc.)

Food/Refreshments

Facility/Room Rental

Equipment Rental/Purchase

Other items

TOTAL PROJECT BUDGET $ TOTAL Funds Requested from Wellness FundsFunds from Other Sources

In-Kind Donations(estimated value of donations)

If your project is funded you will need to:

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Sign and agree to be responsible for the money;

Agree to a Mid-Term Interview, if applicable, and send in a completed Final Report

(copies of receipts must be sent with these reports);

Agree to use the money in the manner outlined in your application;

Agree that the CHB and/or NSHA have the right to audit the grants;

Agree that the CHB/NSHA/DHW (Department of Health and Wellness) may use

information about the recipients of these grants in press releases and for advertising

purposes; and

Agree to acknowledge the CHB in any promotion of the project.

Signature of Applicant: **Please note that signatures are not required if sending application via

email. The email will be kept on file for verification purposes.

________________________________ ___________________________________Signature of Applicant Date

How did you hear about CHB Wellness Funds?

Newspaper Ad _____

Press Release _____

Provincial CHB Website _____

Poster/Brochure _____

Email _____

Word of mouth _____

Social Media _____

Other ________________________

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