Opioid Settlement Funds Application

PLEASE NOTE that it is recommended to review the application prior to completing any of the fields.

You will be uploading your organization’s documents, a Budget and a Project Work Plan, which are linked below. Therefore, it is recommended that you have all the required documents and complete all additional forms before completing the application. You will not be able to save your application and return to it later. Therefore, do not navigate away from the page or you will lose the information you have already entered.

Required Forms:

Your Organziation’s Forms that will be required:

Annual Operational Budget
Licenses or Accreditations (if required)

Please note that Word Documents and PDF files are excepted up to 8 MB.

Each application will be reviewed by the finance department and Opioid Settlement Committee and scored. Click here for a sample of the scoring form.

Organization Name:

Federal Tax ID#: (Only include numbers)

Street Address:

City:

Zip:

Project Contact Name:

Contact's Title:

Contact's Phone Number:

Contact's Email Address:

Type of Organization

Non-Profit and/or 501c3

For Profit

Government

Year Established:

Purpose of Organization:

Annual Operating Budget Amount (must attach documentation):

Upload Annual Budget

Is the organization licensed or accredited by the state of TN?

Yes

Upload License or Accreditation (if applicable)

Number of Employees:

Number of Volunteers:

Total Funding Request:

What percentage of the total project cost will the requested funds cover?

What percentage of funds requested will be used to serve residents of Anderson County?

Amount that organization is currently receiving from Anderson County: Government:

Purpose/Use of Funds Currently Receiving from Anderson County Government:

Budget Information

Budget Narrative-Please provide a detailed justification for each line item in the budget, explaining how these expenses support the project's objectives and goals. We recommend filling out the Budget Form linked above first and then filling out this section.

Upload Budget-Please note that the form is linked at the top of this application.

Sustainability-Please provide information about how this project will be sustained after the funding period. Include details such as other grants or funding sources that the organization has or plans to obtain.

Project Information

Project Title:

Strategies that will be addressed with funds (Select all that apply):

Primary Prevention

Recovery Support

Harm Reduction

Education & Training

Treatment

Research & Evaluation

Target population and geographical area:

Anticipated number of people served with requested funds:

Project description (It is recommended to complete the Work Plan lined at the top of this application first, then fill this section out):

Please note that the work plan should include measurable goals such as "treating 100 patients" or "educating 300 students."

Work Plan Upload-Please note that the form is lined at the top of this application.

Internal staffing for this project (Include names and titles):

External project partners or collaborators (Please attach letters of support if possible):

Support Letter(s) Upload-If you have multiple letters, please combine them into one word document or PDF file.

Is this a new or existing project? (Check one)

New

Existing

If existing, have/will you receive grant funding from any other source for this project?

YES

If yes, please list the grants and amounts:

If existing, how will the requested funds be used to supplement rather than supplant the project?

Supporting Data

Is the project evidence-based or based on promising practices?

YES

If yes, provide links to supporting evidence:

Please provide data to support the need for the project in the community:

Project Revenue

Will you charge a fee or bill insurances for the services provided with this project?

YES

If yes, please describe for what and the estimated amount:

Subcontracts

Will your organization subcontract for services?

YES

If yes, what organization will receive funds from you?

Subcontractor's Name

Subcontract Amount

Subcontractor's Email

Subcontractor's Phone Number

Expected Activities Conducted by Subcontractor

Data Collection and Use

What system or database will be used to gather and store information relevant to the project?

What methods will be employed to track grant-funded activities and specific assistance?

Who is responsible for the collection and quality assurance of this data?

Describe how your organization plans to use the gathered data to continuously evaluate the project's progress and effectiveness. Please address how this data will inform future planning.