CFD

2012
NEW PROJECT PROPOSAL
FOC
Grant Requests must be turned prior to the November 8

Citizens for a Drug Free Ohio

County

Approved________________
Not Approved________________

th

Drug Free Meeting

Directions: Please complete the following information. Use additional sheets if necessary.
Implementing Agency: _____________________________ Name of
Proposal:____________________________________
Contact Person: _______________________________Title:
____________________________Phone_____________________
Type of Program (Please check one): Prevention/Education ( ) Treatment ( ) Justice ( )
Starting Date: _______________

Ending Date: ___________________

Target Population:___________________ Estimate # of Persons Served or

Impacted:_____________________________
Brief description of
program:________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Goals and Objectives for Program:
Goal
1:____________________________________________________________________________________________________
Objective
1:1_______________________________________________________________________________________
Objective
2:1_______________________________________________________________________________________
Goal
2:____________________________________________________________________________________________________
Objective
1:2_______________________________________________________________________________________
Objective
2:2_______________________________________________________________________________________
Goal
3:____________________________________________________________________________________________________
Objective
1:3_______________________________________________________________________________________
Objective
2:3_______________________________________________________________________________________
Steps for Implementation of Program:
1._________________________________________________________________________________________________________

2._________________________________________________________________________________________________________
3._________________________________________________________________________________________________________
4._________________________________________________________________________________________________________
Amount Requested:____________________
Implementing Agency Signature:
I, the undersigned, affirm that I am of, and support, this proposal for funding of this program from
the State Drug-Free Communities Fund.
Signature

Title

Date

________________________________________________________________________________________
To: All Applicants
From: Citizens for a Drug Free Ohio County
The Citizens for a Drug Free Ohio County is interested in the needs of your
organization. The County Commissioners are responsible for the allocation decisions of
the Drug-Free Communities Funds, with the County Council making the actual
appropriations to the Citizens for Ohio County Drug Free Community Committee.
These funds can only be used to carry out recommended actions contained in a
comprehensive drug-free communities plan approved by the Commission for a DrugFree Indiana. At least 25% of these funds must go to each of the following three service
areas:
Prevention and education
Intervention and treatment
Criminal Justice
Funds from the Prevention and Education service area will be limited to $1000.00 per
grant request.
The following are the guidelines for distribution of local funds.
A. Goals for proposed program must be established.
B. Objectives must be measurable and have a completion date attached to them
be specific.
C. Goals and objectives must satisfy requirements of the Governors Commission
for a Drug Free Community.
D. Methods for implementation must be listed.
E. Those requesting funds for the organization must attend 6 meetings per year.
F. A written evaluation and oral presentation is required within 2 months of the
completion date of program.
G. Additional funding will not be provided unless previous grants obligations
have been fulfilled.

CFD
FOC

Citizens for a Drug Free Ohio

County

Citizens for a Drug-Free Ohio County

Evaluation Report
Implementing Agency: __________________________ Project Title:
____________________________
Contact Person: __________________________Title: ___________________Phone:
________________
Date of Written Report: ___________________ Date of Oral presentation:
_____________________
Type of Program: Prevention/Education ( ) Treatment ( ) Justice ( )
Amount Requested:____________________ Amount Spent:___________________
Starting Date:__________________

Ending Date:____________________

Program Description:

Goals and Objectives of Program:

To what degree did you accomplish your established goals and objectives?

Did you experience any barriers that kept you from meeting your goals?

Population Served (indicate numbers)

Check all special target populations reached:
__________Parents
__________High-risk youth
__________Economically Disadvantaged

__________Elderly
__________Minorities
__________Other-specify:__________

Children: to grade 6____________

Young Adults__________________

Children: Middle/Jr. High_______

Adults 26 to 54_______________

Children: High School___________

Senior Adults 55 up___________

PLEASE ATTACH CLIPPINGS, FLYERS, BROCHURES, ETC. RELEVANT TO THE

PROJECT.

Report submitted by: ____________________________________ date

________________________
Telephone number of person submitting report:
________________________________________