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Page 1

Call for Applications:

Health Workforce Wellbeing Grants

Eligible Wisconsin-based community organizations are invited to submit the following application through the online form to apply for AHW’s Call for Applications: Health Workforce Wellbeing Grants funding opportunity.

The application must be completed and submitted using this online form and no paper or emailed applications will be considered. This application form only supports Plain Text and no text effects such as bold, italics, underlining, bulleting, numbering, etc. will be captured in the form fields in the final submission. No attachments beyond those requested in the call for applications and online form will be accepted.

Refer to the Health Workforce Wellbeing Grants funding opportunity page on the AHW website for additional instructions and requirements, including the AHW form templates to download, complete and attach in the appropriate fields in this online form.

The deadline for submission is January 20, 2025 by 5:00 p.m. CT. Late applications will not be accepted.

Please note that all fields marked with * are required.

AHW does not discriminate against individuals on the basis of age, race, creed, religion, color, disability, marital status, sex, national origin, ancestry, sexual orientation, gender identity, arrest record, conviction record, membership in the national guard, state defense force or any other reserve component of the military forces of the United States or the State of Wisconsin or use or nonuse of lawful products off MCW’s premises during nonworking hours.

Project Information

Project Title:

Goal Statement - Please provide a brief statement describing the goal of the proposed project, including the intended impact on health or health equity in Wisconsin. (maximum 400 characters, including spaces):

Project Summary – Please provide a brief project summary including Wisconsin-based health need and why it is a priority, the proposed approach to address the identified health need, and the intended impact that the proposed project will contribute towards achieving. (maximum 2,000 characters, including spaces)

Award Budget

Total Amount Requested:

(in whole dollars and

not to exceed $3,000,000)

Additional Funds:

(if applicable)

Source of Additional Funds:

(if applicable)

Start Date:

Duration:

(in months and

not to exceed 60 months)

Project Team Information

Primary Community Partner

Primary Community Partner – Projects must designate one (1) eligible primary community partner organization to serve as the fiscal agent for the project. Identify one (1) contact person at the primary community partner organization who will share responsibility with the MCW Principal Investigator (PI) for transferring all communications, notifications, and instructions from AHW to all members of the project team and will be responsible for the fiduciary and reporting requirements on behalf of the larger partnership. See the call for applications for eligibility requirements.

Primary Community Partner Organization Contact


Contact Name:	First	Middle	Last	Suffix/Credentials

Preferred Name:

For example, enter 'John' if that is your preference rather than Johnathan.

Pronouns:

Title:

Work Phone Number:

Cell Phone Number:

Email:

Authorized Signature Name (if different from contact):

Authorized Signature Email:

Community Partner Non-Supplanting Attestation

Attach completed Non-Supplanting Attestation (PDF) here:

Collaborators

Collaborators – Please list additional key members of the project team to demonstrate that the project team brings together individuals with the necessary skill sets, experience, influence, and expertise to carry out the project. Any individual and/or organization listed as a collaborator should be committed to the proposed project and ready to engage in the project based on their specified role, if funded. Collaborators are not subject to primary community partner or MCW PI eligibility requirements. Please note that the online form is limited to ten collaborators.

Name:	Organization/Department:

Do you have any additional project partners labeled as investigator within the application (including the collaborators, budget workbook, budget justification, etc.)?

YesNo

If yes, please attach a completed non-supplanting attestation form for each additional individual as a combined PDF here. Please note that any MCW faculty or staff listed as collaborators cannot be included in the community partner budget request.

Page 3

Call for Applications:

Health Workforce Wellbeing Grants

Narrative

Please see the Call for Applications: Health Workforce Wellbeing Grants for the narrative prompts and instructions.

Attach completed Narrative (PDF) here:

Budget and Budget Justification

Attach completed Budget Workbook (Excel) here:

Attach completed Budget Justification (PDF) here:

Hidden

Case ID

Comm Partner Contact ID

Comm Partner Account ID

PI Contact ID

PI Account ID

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Contact Information

All Wisconsin Counties	Adams	Ashland	Barron
Bayfield	Brown	Buffalo	Burnett
Calumet	Chippewa	Clark	Columbia
Crawford	Dane	Dodge	Door
Douglas	Dunn	Eau Claire	Florence
Fond du Lac	Forest	Grant	Green
Green Lake	Iowa	Iron	Jackson
Jefferson	Juneau	Kenosha	Kewaunee
La Crosse	Lafayette	Langlade	Lincoln
Manitowoc	Marathon	Marinette	Marquette
Menominee	Milwaukee	Monroe	Oconto
Oneida	Outagamie	Ozaukee	Pepin
Pierce	Polk	Portage	Price
Racine	Richland	Rock	Rusk
Sauk	Sawyer	Shawano	Sheboygan
St. Croix	Taylor	Trempealeau	Vernon
Vilas	Walworth	Washburn	Washington
Waukesha	Waupaca	Waushara	Winnebago
Wood

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Gender Identity – How do you publicly self-identify? FemaleMaleGender nonbinary/Genderqueer/Gender non-conformingOtherDecline to state	Gender Identity – How do you publicly self-identify? Transgender Not transgender (cisgender)Decline to state
Please describe:

Race – How do you publicly self-identify? Please select all that apply. Asian American/Pacific Islander/AsianBlack/African American/AfricanLatino/Latina/LatinxNative American/American Indian/IndigenousWhite/Caucasian/EuropeanMulti-racial/Multi-ethnic (two or more races or ethnicities)Different identityDecline to state	Ethnicity – How do you publicly self-identify? Hispanic or Latino/Latina/LatinxNot Hispanic or Latino/Latina/LatinxDecline to state
Please specify:

Sexual Orientation – How do you publicly self-identify? Heterosexual or straightGay, lesbian, bisexual (or other sexual orientations within the LGBTQIA+ community) Different identityDecline to state	Disability Status – How to you publicly self-identify? I identify as a person with disabilityI do not identify as a person with a disabilityDecline to state
Please specify: