Grant Title:

Proposal Submitted by:

(Agency Name)

Rating:  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

– 2 –

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 $      .

Signed:

Date: