1. Name of Hospital(s) applying
2. Name, title, and contact information (Phone, Email) of the individual submitting thisGrant Proposal
3. Project Title (AYA Facility, AYA Program Initiative, etc.)
4. Total program and grant request budget
5. Signature of Support of Chief Executive(s) (include date and printed name)

1. Describe your engagement, relationship with TCA to date.
2. Provide a brief description of your current AYA program, the population of patients being served, and how effective it is to both your patients and institution as a whole.
3. Provide insight into the objectives being pursued through this grant funding proposal, and the methods or strategies to accomplish them.
4. How does your existing AYA program reach rural, community, and satellite centers? How do you plan to further that reach and build upon those relationships in the future?
5. How will this proposal impact the regional and national picture?

If you are applying as an Existing Partner AYA Program, please see:
Comprehensive AYA Program Enhancement

If you are applying as an Cross Site AYA Collaborative Project across multiple institutions, please see:
Cross Site AYA Collaborative Project

1. Pediatric hospital or health care facility.
   1. Name
   2. Street address
   3. City, county, state, and zip code
2. Adult hospital or health care facility.
   1. Name
   2. Street address
   3. City, county, state, and zip code
3. Describe the progression of your AYA program subsequent to the acquisition of TCA funding
4. Elaborate on challenges throughout the development and implementation of your AYA program and share significant lessons learned.
5. How do pediatric and medical oncology collaborate to better serve AYAs at your institution? How do you implement processes of care for all AYAs served by your program?
   1. If your program has been historically divided or you do not currently have a partner, how will this grant facilitate bridging pediatrics and adult oncology?
6. Complete one AYA Oncology Services Worksheet for pediatrics and adult oncology and submit both with your grant application.
   1. You may not have all the listed services at your institution. Please add any not listed.
   2. If a service exists but is not AYA specific, it is still important to note its existence and how your AYAs gain access.
   3. If a service exists and could be improved, include ideas on enhancing in the notes column.
   4. Our evaluation of your proposal will NOT be based on how much exists at your institution(s) already. We would like to understand what your program can include and provide from both pediatric and adult sides.
   5. Comparing pediatrics and adult using your completed AYA Oncology ServicesWorksheet:
      1. How can patients gain access to services that exist only on one side?
      2. Which areas have gaps in both adult and pediatric oncology and how will you work together to address those gaps?
   6. Identify your most at-risk AYA subpopulations (e.g. houseless, LGBTQIA+, rural).
      1. What are the unique challenges they face that are distinct from your general AYA population?
      2. How are you engaging these young people and addressing their needs?

• Fill out for each partnering hospital, healthcare facility, and organization.
  1. Institution name:
  2. Street address:
  3. City, county, state, and zip code:
  4. Population served:Project lead name, title, and contact information (Phone, Email)
• Describe your collaborative project's projected outcomes articulating the proposed goal sand how you plan to achieve them by providing the following information in chart (see here) form:
  1. Measurable objectives
  2. Key activities
  3. Evaluation indicators
  4. Timeline and accountable leaders alignment.
  5. Provide evidence that supports the efficacy of the proposed intervention/service pathway.
• How do you plan to analyze, implement, and share your project findings?
• Describe how you will engage underserved AYA patients and survivors in the development and implementation of your project?
  1. What are the unique challenges they face that are distinct from your general AYA population?
  2. How are you planning to address their needs?E. What makes this specific project valuable to the larger field of AYA oncology?

• What specific programmatic or project need is TCA being asked to fund?

• Please include all current AYA program staff with true costs and/or supported estimates.
• If requesting financial support for:
  1. Positions - please provide job description(s), responsibilities, reporting structure, and FTE status. TCA does not pay for indirect costs such as dean's tax, fringe benefits, grant tax, etc. When applying for a grant with TCA you agree that these will not be included in your requested budget.
  2. Space - please provide description, goals, and plans of the facility if available.Outline which patients (in-patient, out-patient, pediatric, adult) will have access to the space.
  3. Project - A detailed account of all costs expected to be associated with the individual project.

• How might this project or role be financially supported after TCA funding is fully disbursed?
• What steps are needed to obtain support from your institution, the community, or other partners?
• Who are the key stakeholders to include in your sustainability plans?
• How do you plan to engage development in this process? What specific goals and responsibilities do they need to fulfill?