(1) A completed face sheet.

(2) A description of the applicant and its capacity to manage and oversee the project.

(3) A description of the proposed project including:

(a) Health systems resources program goal(s) addressed; and

(b) Health systems resources program priority addressed.

(4) A statement of the problem, including:

(a) The duration of the problem or deficiency;

(b) The number of people affected;

(c) How the problem has been documented;

(d) The community involvement in identifying the problem; and

(e) Special needs of the population to be served.

(5) A description of the catchment area(s) to be served by the project. The catchment area(s) must be a reasonable service delivery area such that:

(a) Geographic conditions, health care delivery patterns, other social and economic relationship patterns, and population characteristics make it a reasonable market; or

(b) Residents are likely to go to the proposed catchment area as a preferred source for the proposed services.

(6) A description of any model(s) used in the proposed project.

(7) A description of the relationship between the proposed project and current or previous programs designed to solve related health care problems in the catchment area.

(8) A description of the other individuals and entities involved in the project and their relationship with the applicant to implement the project. A copy of an organizational chart for the proposed project, lists of roles and responsibilities, or other items that document the relationship between the applicant and the involved activities may be submitted with the application.

(9) A workplan for what is needed to accomplish the project. For all major activities, include a timeline, entity responsible, funds needed and source of funds, and measurable outcome(s).

(10) A description of the evaluation process including measurable outcomes.

(11) A description of the plan for dissemination of information about the project.

(12) A detailed budget and budget justification for the project period, including:

(a) The amount of state funds requested;

(b) The amount, by source, of other financial or in-kind support and evidence of cost participation by the applicant and other entities involved in the project; if the application includes recruitment and retention activities, amounts by source(s) of matching funds must be identified;

(c) The steps required to financially sustain the project activities after state support had ended.

(13) Letters of agreement, support, commitment and contribution from each entity identified as participating in the project.

(14) Any additional information requested by the department in the letter of invitation.