Opioid Grant Application

Step 1 of 6

16%

Date of Application:*

Month

Day

Year

Section 1 Applicant Information

Organization Name*

Organization Address*

Street Address Address Line 2 City State ZIP Code

Legal Name of Entity*

UEI Number*

Put N/A if not applicable

Contact Information

Primary Organizational Contact (Project Lead)*

First Last

Primary Organizational Contact Address*

(if different from above)

Street Address Address Line 2 City State ZIP Code

Business Phone:*

Mobile Phone:*

Email*

Section 2 Project Overview

Project Title*

Proposed Start Date*

Month

Day

Year

Proposed End Date*

Month

Day

Year

Is the proposed project:*

New

Continuation

Estimated number of individuals indirectly impacted by the program*

Briefly explain how you arrived at/estimated the above numbers (Limit 150 words)*

Section 3 Program Information

Abstract: Briefly summarize your project. (Limit 500 words)*

How are the needs of your community informing your work? Provide an example of community data or community input that demonstrates the need for the project in the community served. (Limit 500 words)*

Explain how the proposed program fills a gap or identified need in the community. (Limit 500 words).*

Identify any community partners or stakeholders that are collaborating with your organization on the project. If none please put N/A. (Limit 500 words).*

Provide a detailed program/project description and include three key activities from your work plan. (Limit 500 words).*

Describe the expected outcomes of the program/project listed on your work plan. (Limit 500 words).*

How will you measure and evaluate the outcomes of the program/project? In other words, how will you determine if your project has been successful? (Limit 500 words).*

Explain how the grant funds would support your proposed program/project. (Limit 500 words).*

Explain how the scope of the project would change if not all of the requested funds are awarded. (Limit 500 words).*

Will the program/project continue after the grant funds end? If yes, please describe your plan for sustaining/continuing the program. (Limit 500 words).*

Indicate which counties will be served by this project:*

Adams

Blaine

Buffalo

Clay

Custer

Franklin

Furnas

Garfield

Greeley

Hall

Hamilton

Harlan

Howard

Kearney

Loup

Merrick

Nuckolls

Phelps

Sherman

Valley

Webster

Wheeler

Other

Section 4 Organization Information

Indicate the size of your entire organization:*

Large (Over 30 staff members)

Medium (16-29 staff members)

Small (2-15 staff members)

Individual Provider (solo practice)

Briefly describe your organization including mission, service area and number of years in existence? (Limit 500 words).*

What experience does your organization have securing, maintaining, and appropriately using grant funds?*

Very experienced (the organization has successfully obtained/maintained grant funding for over 5 years)

Somewhat experienced (the organization has successfully obtained/maintained grant funding for 2-5 years)

Limited experience (the organization has successfully obtained/maintained grant funding for less than 2 years)

Existing Organization no experience (the organization is not new but this is the first time the organization would be securing and maintaining grant funding)

New organization no experience (the organization is new and this is the first time the organization would be securing and maintaining grant funding)

What other organizational demographics would you like us to know? If none, please put N/A. (Limit 500 words).*

Section 5 Financial Overview

What is your total grant request?*

Provide any additional information you would like us to know about your budget, funders, or financial situation. If none, please put N/A. (Limit 500 words).*

Who is the financial contact person for your organization should your project be funded?*

Title*

Email*

Phone (Business)*

Phone (Mobile)*

Section 6 Uploads

Required Uploads:

Budget Justification - Excel*

Accepted file types: xlsx, xlsm, xlsb, xltx, csv, Max. file size: 50 MB.

Work Plan - Word*

Accepted file types: docx, doc, Max. file size: 50 MB.

W-9 Form*

Max. file size: 50 MB.

Optional Uploads:

Letters of Support*

Max. file size: 50 MB.

Other

Drop files here or

Max. file size: 50 MB.

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Opioid Response Grant

For Grant Period: 9/1/2026 – 8/31/2027

Closing Date: August 7th 2026

Section 1

Applicant Information

Contact Information

Section 2

Project Overview

Section 3

Program Information

Section 4

Organization Information

Section 5

Financial Overview

Section 6

Uploads

Required Uploads:

Optional Uploads:

How helps:

Region 3 Housing Assistance Program

Prevention

Professional Partner Program

Consumer Advocacy

Emergency Community Support

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