77 Ill. Adm. Code 630.APPENDIX A
A MCH Grant Proposal Review Form
Section 630.APPENDIX AĀ Ā MCH
Grant Proposal Review Form
MCH
Grant Proposal Review Form
Division
of Family Health
New
Applicant
Grant Title:
Proposal Submitted by:
(Agency Name)
Rating:Ā In each of the following categories please rate the proposal
according to the information provided in the written submission, with five
being high and one being low; circle the desired rating.
Category
Rating
I.
Merit of this proposal in
addressing the purpose and criteria for the grant (refer to scope and
standard of services in the Rules and Regulations).
1
2
3
4
5
a.
Narratives
b.
Objectives
c.
Resources/Program Operation
d.
Comprehensiveness
e.
Target Group/Eligibility
f.
Budget
(general review only)
II.
Ability of the agency to
provide services at a comprehensive single site or adequately coordinate
these services with other community agencies. This should include staff
capabilities (or capabilities to hire appropriate staff), physical facilities
and fiscal management capabilities.
1
2
3
4
5
III.
Level of community support for
project and maximum use of other funding sources.
1
2
3
4
5
IV.
General Comments:
a.
b.
Overall score of this application
ā
2 ā
V.
Conditions of Award if Funded:
Signed:
Dated:
MCH
Grant Proposal Review Form
Division
of Family Health
Continuation
Application
Grant Title:
Proposal Submitted by:
(Agency
Name)
Amount of Assistance Requested
in this Application:
Current Fiscal Year Funding
Level:
Ratings: In each of the following categories please rate the proposal
according to the information provided in the written submission in the
performance report with five being high and one being low; circle the desired
rating.
Category
Rating
I.
Previous performance based on
materials provided by program administrator (site review and summary of
previous statistics and fiscal data).
1
2
3
4
5
II.
Merit of this proposal in
addressing the purpose and criteria for the grant (Scope and standard of
services described in the Rules and Regulations).
1
2
3
4
5
III.
Reevaluation of need for
services within the area of service (refer to Rules and Regulations).
1
2
3
4
5
General Comments:
I.
Are there particular strengths
or weaknesses in the proposal?
Please elaborate:
II.
Does this proposed budget need
revision or further explanations?
Please elaborate:
Summary:
I.
Overall rank of of
continuation grants in this category reviewed by this reviewer.
II.
Overall score for this
continuation application
III.
Stipulations (if any):
IV.
Recommended grant award of
$Ā Ā Ā Ā Ā .
Signed:
Date: