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SHIP 4 Mini-Grant Applications

Letter of Intent (Non-Binding)


This letter of intent is a non-binding agreement between organizations interested in receiving a SHIP minigrant (cooperative agreement) and Faribault, Martin & Watonwan Counties SHIP Project. Partners include
any public or private entity. This letter of intent will become part of your overall grant application, but does
not guarantee your site will receive funding. Additionally, information collected in the letter of intent will be
used to aid in development of the FMW SHIP 4 Grant Application, due August 31, 2015 to the Minnesota
Department of Health.
Upon completing the SHIP letter of intent, organizations will receive:
1 Information about applying for a SHIP mini-grant and/or as a SHIP site. Full application information
will be provided to sites completing the letter of intent by August 1st, 2015. SHIP mini-grants are a
competitive process decided by our Community Leadership Team. Once your letter of intent is
received, you will be contacted by a SHIP staff person to meet and develop your full application,
including a work plan and budget.
1. An assigned SHIP contact person will meet with you to answer questions related to allowable uses of
SHIP funding and assist with development of your SHIP mini-grant work plan and budget.

Instructions
PLEASE COMPLETE THIS FORM ON A COMPUTER (DO NOT HAND WRITE
FORM)
1

Complete all boxes under section 1: Organization Information. Identify the county(ies) impacted by
the proposed work by checking the corresponding box. List each site/building that will be impacted
by your SHIP work separately and provide each sites address. Determine one point of contact per
organization interested in a SHIP mini-grant. One intent form PER organization is allowed. Please
include all the sites wishing to work with SHIP on one form. Identify 1st and 2nd choice for meeting
dates with SHIP staff during the week of August 3rd.

1. Click to select the strategy(ies) your organization would like to work on. More detailed information
on each strategy and the requirements can be found by accessing the Strategy Implementation
Guides listed by each check box as well as SHIP funding requirements in the Financial Guide.

Check the corresponding box to each strategy your organization plans to apply to work on. Within
each of the strategies- select the activities (or sub-strategies) your sites plans to address.
2. Complete this form and letter of commitment and send as an attachment in an e-mail to
leeann.huebsch@fmchs.com with LETTER OF INTENT FORM: (Your Organizations Name) in the
subject heading. Letters of intent are due no later than 5:00p.m. on July 24, 2015.

SHIP 4
Letter of Intent (Non-Binding)
1. Organization Information
Organization Name:
Contact Person
Name/Title:
E-mail:
Phone:
County(ies) impacted:
(please check all counties
this organization will
work in with SHIP
Identify 1st & 2nd Choices
for Meeting with SHIP
Staff during the week of
August 3rd.

Faribault
Martin
Watonwan
1st Choice
Monday August 3
Tuesday August 4
Wednesday August 5
Thursday August 6
Friday August 7

2nd Choice
Monday August 3
Tuesday August 4
Wednesday August 5
Thursday August 6
Friday August 7

Site Name
(please list site name and address if multiple sites,
please list all sites and addresses i.e.- multiple school
buildings, multiple work sites, multiple clinics, etc.)

Site Address

2. We plan to apply for a mini-grant with SHIP in the following area(s):


Strategy Area

Strategy Activities

(check applicable
boxes)

(check applicable boxes)

Active Living
More information
on requirements

Anticipated
Number of
People
Reached (i.e.- #
of students, # of
staff, # of
community
members, #
patients in service
area, etc.):

Increase active living opportunities


through the following activities:
Master and Comprehensive Plans:
E.g., Pedestrian and bicycle master

Activities
Targeted to: (check
applicable boxes)

Target
Populations
Reached (i.e. %
of youth, % of lowincome (free &
reduced lunch), %
uninsured, %
Latino, %
population over 60,
etc.):

Age 60+
Hispanic/Latino
Low Income
Youth

and
implementation
activities can be
found here:
Active Living in
Communities
(PDF)
More information
on allowable uses
of SHIP funding
can be found
here: Financial
Guide (PDF)
Healthy
Schools
*Schools are
required to select
at least 1
physical activity
strategy and 1
healthy eating
strategy.
More information
on requirements

plans, Regional trails plan, Safe


Routes to School. (Requires grantee
to contract with planning or
demonstrate appropriate staff
capacity for planning.)
Land use and zoning regulations:
Includes streetscape and mixed use.
(preferred: emphasis on walking)
(Requires grantee to contract with
planning or demonstrate staff
capacity.)
Increased access to Facilities and
Opportunities (health equity focus;
can include SRTS)

People with
Mental Illness
Other:
____________________
_

Must select 1 Healthy Eating


Strategy From List Below:
Farm to School
School-based agriculture
Healthy snacks outside of the school
day through vending, concessions,
school stores or snack carts
Healthy snacks during the school day
through celebrations, special events or
non-food rewards
Smarter Lunchroom techniques
through such behavioral economic

Age 60+
Hispanic/Latino
Low Income
Youth
People with
Mental Illness
Other:
____________________
_

and
implementation
activities can be
found here:
Schools - Healthy
Eating and Active
Living (PDF)
More information
on allowable uses
of SHIP funding
can be found
here: Financial
Guide (PDF)

Worksites
*Required to
work on all
strategies:
Healthy Eating,
Physical Activity,
Breastfeeding

activities including, but not limited to


competitive pricing, product
enhancements
Must select 1 Physical Activity
Strategy From List Below:
Quality Physical Education (curriculum
review, new physical education content,
lengthening classes)
Active recess
Active classrooms
Before and/or after school through
physical activity opportunities
(intramurals, physical activity clubs,
integration with school child-care,
offering open gym opportunities)
Safe Routes to School (walking school
bus, Walk!Bike!Fun! curriculum, travel
plans).
Must select 1 Healthy Eating in
Worksites Strategy From List Below:
Increase access to healthy eating
through:
o Comprehensive healthy eating
planning
o

Vending or Healthy snack

Age 60+
Hispanic/Latino
Low Income
Youth
People with
Mental Illness
Other:
____________________

Support and
Tobacco
Policies/Cessation
.
More information
on requirements
and
implementation
activities can be
found here:
Workplace (PDF)
More information
on allowable uses
of SHIP funding
can be found
here: Financial
Guide (PDF)

stations
o

Cafeteria offerings

Catering

Must select 1 Physical Activity in


Worksites Strategy From List Below:
Increase access to active living
through:
o Access to opportunities and
facilities
o

Flexible scheduling

Active commuting

Must select 1 Breastfeeding Support


in Worksites Strategy From List
Below:
Breastfeeding support and facilities
Must select 1 Tobacco in Worksites
Strategy From List Below:
Cessation support
Tobacco-free environments

Optional Strategy in Worksites (can be


selected in addition to the required
strategies above):
Promote lifestyle and stress
management to increase healthy
behaviors that reduce chronic diseases
through evidence based programs
addressing obesity, healthy eating and
physical activity:
Work with insurers to incorporate
lifestyle programs as a covered
benefit

Facilitate employees participation


in community sponsored lifestyle
management programs

Offer ongoing on-site lifestyle


management programs for at risk
populations

Identify workplace and employee


opportunities to reduce stress by
assessing workplace climate,
policies and practices

Health Care
More information
on requirements
and
implementation
activities can be
found here:
Health Care
(PDF)
More information
on allowable uses
of SHIP funding
can be found
here: Financial
Guide (PDF)

Work with insurers to promote


benefits to support stress
reduction

Select at least one strategy and


accompanying activities from below:
Worksite wellness in health care
please complete worksite wellness
section above.
Clinic-Community Linkages: Screen
Counsel- Refer-Follow-up (SCRF) in
clinical setting
Increase Clinic-Community
Linkages through Supporting
access to health care prevention
services (Screen-Counsel-ReferralFollow up in clinical settings) to
address one or more of the
following activities:
Tobacco cessation
Pediatric obesity
Adult obesity
Falls prevention,
Breastfeeding support
Establishing a Community EBP

Age 60+
Hispanic/Latino
Low Income
Youth
People with
Mental Illness
Other:
____________________
_

Program
Establish evidence-based strategies to
support clinic-community linkages to
ensure access to the delivery of
preventive services through (Pick one or
more):
Tobacco cessation (e.g., Call It
Quits/Fax Referral Program)
Diabetes Prevention Program
(DPP) Obesity, Healthy Eating and
Physical Activity (e.g., DPP) in a
systematic manner utilizing
evidence-based clinical guidelines
and community referrals to
address Obesity, Healthy Eating
and Physical Activity
Chronic Disease Selfmanagement Program (Obesity,
Healthy Eating, and Physical
Activity (e.g., CDSMP) in a
systematic manner utilizing
evidence-based clinical guidelines
and community referrals to
address Obesity, Healthy Eating
and Physical Activity
Falls Prevention (Healthy Eating
and Physical Activity), in a

systematic manner utilizing


evidence-based clinical guidelines
and community referrals