Вы находитесь на странице: 1из 7

Manitoba Keewatinowi Okimakanak

Inc.
Head Office
Nisichawayasihk Cree Nation
Nelson House, MB R0B 1A0
www.mkonorth.com

Thompson Sub-Office
206-55 Selkirk Avenue
Thompson, MB R8N 0M5

Winnipeg Sub-Office
Suite 1601-275 Portage Avenue
Winnipeg, Manitoba R3B 2B3

Proposal Form for Manitoba First Nation Wellness Teams


Issued: January 25, 2017
Please complete this proposal template and submit on or before 5:00 p.m. February 15,
2017 via e-mail to wellness@mkonorth.com or fax to 204-927-7509.
Both typed and handwritten proposals will be accepted. If you are submitting a
handwritten proposal, please ensure your printing is clear and easy to read and that all
the information requested in this template is provided.
If you have questions about completing this proposal template, please contact Theresa
Yetman at 204-927-7500 or by e-mail at theresa.yetman@mkonorth.com or

1. CONTACT INFORMATION Name of individual who will act as the main contact
throughout the project

Nam
e:

Position
:

Organizati
on:
Telephon
e:

Fax:

Email:
Address:
Contact Person (if other than applicant):
Telephon
e:

Fax:

Email
Signature of Main
Contact:

2. DESCRIPTION OF THE PROJECT


In this section, briefly describe

1. Projects main objectives,

4. Services that will be provided at the


local level,

2. High level overview of the


activities,

3. Positions that make up the


core team,

3. 5. Services that will be provided at the


Health Authority/Tribal Council, and

6. Positions that will be funded with MKO


funds.

3. COMMUNITIES, TRIBAL COUNCIL, TREATMENT CENTER PARTNERS &


OTHER QUALIFIED SERVICE PROVIDERS
1. List communities that will be in the catchment area of your proposed MWT.
2. What level of services will the communities, Tribal Councils, Treatment Centers and
other qualified service providers provide?

4. CASE MANAGEMENT AND COORDINATION OF SERVICES AND


REFERRALS
In this section, briefly describe what functions will be provided in your MWT and who
will be responsible for each of them.

5. INDIGENOUS KNOWLEDGE, CULTURE PRACTICES AND PRACTITIONERS


1. What indigenous practices are currently available in the communities that are
included in your proposed MWT?
2. What land base activities are included in your proposed MWT?
3. What additional indigenous practices will be provided as a result of the proposed
MWT?
4. Who will be the provider of each of these services (e.g. Core MWT team, incommunity staff, Health Authority/Tribal Council)

6. CLINICAL SERVICES AND POSITIONS


1. What clinical services are currently available in the communities that are included
in your proposed MWT?

2. What additional clinical services will be provided as a result of the proposed MWT?

3. Who will be the provider of each of these services (e.g. Core MWT team, incommunity staff, Health Authority/Tribal Council)

7. PARAPROFESSIONALS AND PARAPROFESSIONAL SERVICES


1. What paraprofessional services are currently available in the communities that are
included in your proposed MWT?
2. What new or different services will be provided as a result of the proposed MWT.
3. Where will the services and positions be located (in the core MWT or in each
community)?

8. PROJECT WORK PLAN


Please outline the proposed work plan for your project using the table below. Add more rows to the table if needed. Applicants
are encouraged to draw language or wording for their objectives and activities from the National Guidelines. See Attachment A
in the RFP document for this information. Please also include any evaluation activities that will be conducted as part of the
project in your work plan.
Objective
Activities
Outputs
Estimated Cost(s)
Person or
Time frame
Examples:
Example: Provide
Briefly describe
lead
Indicate the estimated
Estimate the cost
Improve access to
direct land based
outputs from the
Provide the
start and end dates for
involved with
indigenous and
healing and
activities.
name or
the activities. Note:
implementing the
cultural practices
treatment to the
Example:
position of
any activities beyond
activities. Where
communities of . . .
# of clients
individual who
March 31st, 2019
possible, make
receiving direct
will be
cannot be considered
sure the
land based
responsible for
for funding.
information in this
healing services
completing
column
and ensuring
corresponds to the
the activities
details provided in
are
Section 6 (budget).
completed.

9.

10.

BUDGET PLAN

Please prepare a budget for your project using the table below. Where directly related to an activity in your
project work plan, make sure the information corresponds to the details you provided in Section 5 (Project
Work Plan).
CATEGORY COMPLETE INFORMATION FOR ONLY THOSE
2016-17
2017-18
2018-19
Total
CATEGORIES THAT RELATE TO YOUR PROJECT; OTHERWISE
LEAVE BLANK.

Personnel wages or salaries. List amount for each individual


(or position title) on its own row. Add more rows if
necessary.
Travel (please include combined estimated costs of
transportation, accommodations, and meals for all
employees listed above).

Other
TOTALS:

11.

DOCUMENTATION CONFIRMING FIRST NATION LEADERSHIP SUPPORT FOR THE PROJECT

Please submit 1 piece of documentation with this completed Proposal Request for Manitoba First Nations Wellness Teams that
confirms First Nation leadership support the project. See documentation that will be accepted according to the types of funding
recipients and clients to be served by the project in the table below.
Type of recipient/
clients to be served
by the project

Documentation that will be accepted as confirmation of leadership support (in order of


preference1)

FN
community/members
of one community

1. Band Council resolution indicating full support for the project


2. Chief is the signatory on the proposal
3. Letter of support from the Chief

2 or more FN
communities/members
from two or more FN
communities

1. Band Council resolution from each community indicating full support for the project
2. Chiefs of the communities to be served are the signatories on the proposal
3. Letter of support from Chief of each community to be served

Tribal
Council/residents of all
member communities

1. Chiefs Resolution all members of the Tribal council indicating full support for the project
2. Chiefs of member communities are the signatories to the proposal
3. Letters of support from all member community Chiefs

Treatment Centres and


other Aboriginal
organizations/ clients
who use their services

1. (Depending on governance structure) Board of directors resolution indicating full support for the
project OR Band Council resolution from the community where the centre is located and/or where the
clients live
2. Letters of support from the Chief where the centre is located and/or where the clients live, and at
least one other Chief (ideally a Chief from a community where the majority of clients are expected to
originate)

Other qualified service


providers clients use

1. (Depending on governance structure) Board of directors resolution indicating full support for the
project OR Band Council resolution from the community where the shelter is located
2. Letters of support from the Chief where the shelter is located, and at least one other Chief (ideally a
Chief from a community where the majority of clients are expected to originate)

Thank you for completing this proposal and providing documentation confirming leadership support for your
project.
he Mental Wellness Selection committee will review and determine the approval of the designs and plans for Wellness
Teams.
1

12.

EVALUATION PROCEDURES

Please review evaluation procedures noted below to determine what evaluation


procedures your project will use.
Specify how you intend to evaluate the program or project in terms of:
a) Self-Evaluation Input from the program or project manager and staff.
b) User Evaluation Feedback from those involved in the program or project.
c) External Assessment Feedback from individuals who have knowledge of such
programs or projects and can provide an independent assessment.
d) Outcomes Analysis or Deliverables Be prepared to report on outcomes or
deliverables which were promised in the original proposal.
e) Quantitative Data Would include information such as the number of participants
involved in a program, the number jobs created, or specific documents or materials
which are produced.
Please specify what procedures you will use to evaluate your wellness services

13.

APPLICATION CHECKLIST

I understand that the Wellness Selection Committee will not accept this application
unless the following prerequisites are completed.

Answered all the questions


Completed Project Work Plan
Completed Budget Plan
Completed Evaluation Procedures
Documentation confirming First Nation Leadership support for the project
Financial Certification (a copy of the certification and the last audited financial
statement)

Evidence of the applicants past performance of consistently meeting reporting


requirements (e.g., most recent general assessment score from your funding
agency)