Opioid Grant Application

Opioid Grant Application

Proposal submissions related to the Opioid Settlement funds are open in Suffolk County. In compliance with the New York Opioid Settlement Agreement’s Approved Uses and Res. No. 961-2021, funds must be used to support programs that fall within the list of uses in Schedule C related to prevention, treatment, and other strategies. Please be sure to review the approved uses before submitting a proposal.

If you need to gather all information needed, click here to print a copy of this application for reference.

Progress on the application CANNOT BE SAVED. To avoid being timed out of the application, utilize the print copy to familiarize yourself with the application questions, and have your responses prepared. You do have the ability to copy and paste text into the application if needed.

Organization

Organization Name:

Address:

City:

State:

Zip:

Website Address / URL (if applicable):

http://

Agency Leadership Contact

First Name:

M.I.:

Last Name:

Title:

Phone #:

Email:

Fiscal Contact

First Name:

M.I.:

Last Name:

Title:

Phone #:

Email:

Lead Contact

First Name:

M.I.:

Last Name:

Title:

Phone #:

Email:

Current Programming:

0 / 1,500 characters

Which County Department are you applying for?

Health Services

Social Services

Police Department

Probation

Other

Other: (specify dept(s) you're contracting with along with any additional info)

State Licensure and/or Designation (indicate all that apply):

NYS Office of Mental Health

NYS Office of Addiction Services and Supports

NYS Department of Health

Federally Qualified Health Center (FQHC)

Drug-Free Community Support Program (DFC)

Non Applicable

Other

Other: (please specify)

If selected, would the proposed program require approval from a regulatory body?

Yes

If so, please list the regulatory body:

Are you on a monitoring plan by a funding source, state agency or any other governing body?

Yes

Schedule C Assignment of Proposed Program:
Select the Schedule C element that aligns with your proposed program.
Click here to view all Schedule C Elements

Select Category:
I. Treatment
II. Prevention
III. Other Strategies

Select Treatment Subcategory:
A. Treat Opioid Use Disorder
B. Support People in Treatment and Recovery
C. Connect People Who Need Help to the Help They Need (Connections to care)
D. Address the Needs of Criminal-Justice Involved Persons
E. Address the Needs of Pregnant or Parenting Women and Their Families, Including Babies with Neonatal Abstinence Syndrome

Select Prevention Subcategory:
A. Prevent Over-Prescribing and Ensure Appropriate Prescribing and Dispensing of Opioids
B. Prevent Misuse of Opioids
C. Prevent Overdose Deaths and Other Harms (Harm Reduction)

Select Other Strategies Subcategory:
A. First Responders
B. Leadership, Planning, and Coordination
C. Training
D. Research
E. Post-Mortem

Treat Opioid Use Disorder
Select the Schedule C element that aligns with your proposed program (1-15).

Support People in Treatment and Recovery
Select the Schedule C element that aligns with your proposed program (1-12).

Connect People Who Need Help to the Help They Need (Connections to Care)
Select the Schedule C element that aligns with your proposed program (1-15).

Address the Needs of Criminal-Justice Involved Persons
Select the Schedule C element that aligns with your proposed program (1-7).

Address the Needs of Pregnant or Parenting Women and Their Families, Including Babies with Neonatal Abstinence Syndrome
Select the Schedule C element that aligns with your proposed program (1-8).

Prevent Over-Prescribing and Ensure Appropriate Prescribing and Dispensing of Opioids
Select the Schedule C element that aligns with your proposed program (1-8).

Prevent Misuse of Opioids
Select the Schedule C element that aligns with your proposed program (1-11).

Prevent Overdose Deaths and Other Harms (Harm Reduction)
Select the Schedule C element that aligns with your proposed program (1-12).

First Responders
Select the Schedule C element that aligns with your proposed program (1-3).

Leadership, Planning, and Coordination
Select the Schedule C element that aligns with your proposed program (1-4).

Training
Select the Schedule C element that aligns with your proposed program (1-2).

Research
Select the Schedule C element that aligns with your proposed program (1-10).

Post-Mortem
Select the Schedule C element that aligns with your proposed program (1-8).

Number of Residents To Be Served Annually by Proposed Program:

Proposal Focus – which approved use does your proposal relate to?

Primary Focus:

Secondary Focus (if appl.):

Type of Program:

New Program

Expansion of Existing Program

Proposal Summary:
Be sure to include targeted need, plan to meet need, outcome measures for monitoring success.

0 / 1,500 characters

Program Goals:
Please provide a 1-2 sentence program goal statement. Up to 3 goals can be made. (300 characters max each)

Goal 1:

Goal 2 (if appl.):

Goal 3 (if appl.):

Proposal Description: (15,000 char limit)

0 / 15,000 characters

Program Sustainability:
Please consider and include how your agency can make its efforts sustainable, wherever applicable.

0 / 1,200 characters

Amount Of Funding Requested By Year:

Year 1:

Year 2:

Year 3:

3-Year Sum:

Please upload budget in support of proposal: (Must be excel file - .xls, .xlsx - 50MB limit):
Click here to download the pre-approved template of a budget proposal.

Please remember to delineate startup costs vs. ongoing costs. Funding from Opioid Settlement Grant funding should not supplant other funding sources; however may be used in concert to enhance services.

To the best of my knowledge, I am submitting accurate information. I am submitting a request on behalf of an organization, practice or agency that is currently in operation and providing essential services to residents of Suffolk County or New York State.

Organization

Agency Leadership Contact

Fiscal Contact

Lead Contact

Application

Reminder one (1) grant request per submission