CHECKLIST OF INFORMATION
HEALTH PROGRAMS
Customarily, when a nonprofit group decides to begin an aggressive grant writing program, they don't realize how much information will need to be conveyed to the person charged with putting
their request on paper. Many of the items listed below are considered common knowledge within your organization, and putting them in writing for your "grant writer" is very helpful. Be sure to emphasize any health related information about your program.
| 1. | Name of your Organization (as it appears on your 501(c)(3) ) and any AKAs |
| .2. | Complete Address |
| 3. | County in which your main office is located |
| 4. | Telephone Number |
| 5. | Fax Number |
| 6. | E-Mail Address |
| 7. | Web Site Address (if applicable) |
| 8. | Name of the Executive Director and date hired |
| 9. | When was your organization established? |
| 10. | Purpose (mission statement) |
| 11. | Date of 501(c)(3) certification and IRS number |
| 12. | Date of 509(a) certification |
| .13. | Date of State tax exemption and document number |
| 14. | Board structure and numbers (How involved are they) |
| 15. | Fiscal year |
| 16. | Number of full time employees |
| 17. | Number of part time employees |
| 18. | Number of volunteers |
| 19. | Description of population served |
| 20. | Number of people served in an average year |
| 21. | Geographic area(s) served |
| 22. | Names of other programs in your geographic area that provide similar services to the same population you serve |
| 23. | What makes your organization different from theirs? |
| 24. | Organization's primary source of income |
| 25. | Annual Budget for last fiscal year |
| 26. | Annual Budget for current year |
| 27. | Projected Budget for next year (if applicable) |
| 28. | Reasons for any Significant Budget deficits/changes, etc. |
| 29. | Names of other nonprofit organizations your program works with (partners with) in the community |
| 30. | Is your program an active member of any coalitions and/or community action groups? |
| 31. | Previous grant history |
| 32. | Previous fund raising history |
| 33. | Major accomplishments of your organization |
| 34. | Areas in which your organization is interested in obtaining grants |
| 35. | Health related certifications with local, state and/or federal governments |
| 36. |
Specific Health care related programs offered by your organization. Please explain your |
| 37. | What are the specific health care needs in your community? |
| 38. | Anything additional you would like to add: |
This form was developed by Penny Goforth of Grant Writing Specialists, for free distribution
For more information, visit our website at GrantWritingSpecialists.com