Northwest Region HEAL Communities Grant Initiative Improving chronic disease outcomes through Healthy Eating Active Living and disease self- management Letter of Intent (LOI) To be completed and returned to [email protected] by April 20, 2015

Project Title: Lead Organization Name: Date:

Organization Mailing Address: Tax ID Number: must be a qualified non-profit organization

Project Director Name: County covered by applicant organization: must be within KP service area as noted in RFP

Project Director Title: Number of people served by this project:

Project Director Phone: Project Director Email:

1. Project Goal: a. What behavioral chronic disease risk or protective factor(s) (i.e. related to nutrition, physical activity, disease self-management) does this project seek to impact at the end of the 3.5 year initiative? b. How will changes in these targeted behavioral chronic disease risk or protective factors be evaluated? List potential method or measure. c. What placed-based and/or system changes will be pursued to influence the proposed chronic disease risk or protective factors? 2. Target Community or Population: a. What population(s) will be targeted and in what geographic area(s) will the intervention(s) take place? b. Why is this project targeting the proposed population and/or geographic area? Briefly describe the chronic disease health disparities of the target population.

3. Collaborative/Coalition: a. Briefly describe the existing collaborative/coalition’s purpose, goals, and any current relevant projects or efforts. b. List the committed collaborators/members for the proposed project and their role/s. c. Who is the anticipated lead organization? Briefly describe this organization’s qualifications to serve as lead.

No more than 3 pages in length As part of the LOI please include the information box above and succinct answers the questions for each of the three sections. Completed LOI should be electronically submitted to [email protected] by 5pm April 20, 2015