Eligibility for Funding: Intake Form

Childhood Obesity Rapid Response Fund Application

Grants from this fund are awarded through a two-step process—step one is the eligibility application below, and step two is a specific funding proposal submitted by those campaigns approved in step one. After completing ane submitting this form, you will be notified if your campaign is eligible. Eligibility, however, DOES NOT in any way guarantee future funds. Timely proposals from eligible entities will be considered on a rolling basis and will be awarded by committee decision based on both competitive criteria and fit to the fund. See a roster of committee members. Fund staff will work with eligible entities to understand the process and maximize the opportunity.

This funding is mostly targeted at passage of new public policy, however proposals for defense of existing critical policy as well as addressing policy implementation deficiencies are also eligible.

Find out more information on the fund and application process.

We have created a FAQ to help you understand the fund further.

A phone consultation prior to submitting a step-one application is now required. If you would like to schedule a consultation, or you have other questions about the Fund, please contact the following (be sure you have reviewed both the fund overview and FAQ document linked above prior to submitting inquiries or scheduling a consultation):

Aaron Doeppers
Manager for State and Local Obesity Initiatives
American Heart Association
aaron.doeppers@heart.org
(608) 886-2988

Step-one Eligibility Application:

Please complete and submit the step-one eligibility application. You may download and email the application in word format or use the web form below. If you use the web form, fill in each blank and then complete the verification word provided in the box at the bottom. After you click submit, you will be taken to a verification message. If you have technical problems with the web form, please contact the Fund manager.

Date
Name of Policy Campaign
City
State:
What is your public policy goal?
Name of projected fiscal agent 501c(3) organization (the fiscal agent can change prior to submitting a funding proposal in step two):
Contact Name
Phone
Email
Fax
Mobile
Address
Address 2
City
State:
Zip Code
Is the contact person employed by the projected fiscal agent (if not, explain):
If this fiscal agent is awarded a grant, does it have capacity to accept funds via electronic transfer?
What level of government are you seeking for public policy action (for example: school board, city council, or state legislature)?
Have you confirmed that this body has the legal authority/jurisdiction over this public policy (is not preempted)?
In what phase are you in your campaign (i.e. initial research, planning and stakeholder development, policy analysis, push for passage, post-passage implementation, or post-implementation evaluation)?
Are you aware that this fund does not provide funding for direct or grassroots lobbying? (if you have questions, do not proceed until you contact the fund manager, discuss the policy, and are comfortable checking “yes”)	Yes No
How did you hear about this fund?
Were you referred by a Steering Committee member? If so, who?
Do you or another entity closely involved in this effort currently receive funding of any kind from the Robert Wood Johnson Foundation or a grant from the American Heart Association?	Yes No
Intake Form Narrative Questions Please provide brief (approximately one paragraph) summary answers to every question below you can answer. Fact sheets or other limited summary information can be attached but does not replace the need to reply to the questions below. A written campaign plan is preferred but not required. If you are completing this application for policy implementation (rather than passage), please provided expanded answers to narrative questions 1-4 (particularly 4). You may also choose to skip question 6, 9, 10, and/or 16 if any are not relevant.
1. How will your organization/coalition define success in this campaign?
2. What will be the direct impact of policy success? How will that be assessed?
3. What high prevalence (of obesity) or high risk population would be impacted? How will that be assessed?*
4. Describe your plans for ensuring policy implementation/enforcement. Are there barriers to implementation/enforcement?
5. How does this campaign fit the wider childhood obesity movement in your community/state? And how would a policy victory contribute to wider/further growth or progress in the future?
6. What is the jurisdiction’s decision-making timeline (legislative session, council calendar, etc)?
7. Please describe your prospects for success.
8. Why is this the best time to work on this public policy?
9. Are you using a model policy (if so, a model policy from whom?) and are bottom-lines/deal-breakers set for what your organization and/or your coalition are willing to accept? Have you drafted/filed legislation (or similar)? If so, please attach using the link at the bottom of this form.
10. Does your policy preempt others from establishing future policies or otherwise limit policy development at another level of government
11. Describe the structure and decision-making process of the coalition (or, if you are not working in a coalition, describe how you are managing and making decisions on this effort).
12. Does your organization/coalition have a track record of public policy success? If so, please list past policy successes.
13. How are you engaging key stakeholders in your community or state? Who are key stakeholders already involved?
14. Please list your additional anticipated supporters of this campaign (other than coalition members).
15. Please list your anticipated opposition.
16. Do you have lobbying resources for this campaign? What other sources of funding and support do you have for the overall effort?
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