CT Health Horizons Grant Program - Narrative Response Form

Please submit your grant application via this form.  A PDF is also available here to assist with preparation.

Note the deadline to complete this application is October 21, 2022.  

Each CCIC Member Institution is eligible to submit one application.

(* Denotes Required Fields)

Institutional Information
Institution Name: *
Primary Point of Contact - Name: *
Primary Point of Contact - Title: *
Primary Point of Contact - Email: *
Mailing Address:
Phone Number: *
Grant Amount Requested: : *
FEIN #: *
Organization Overview
What nursing programs/degrees does your institution currently offer? (Check all that apply): *
Other Nursing Program/Degrees Offered:
What social work programs/degrees does your institution currently offer? (Check all that apply): *
Other Social Work Program/Degrees Offered:
Enrollment Information
What is the total number of students enrolled in the following programs at your institution (Answer those that apply):
Associate Degree of Nursing (ADN):
Bachelor Degree of Nursing (BSN):
Accelerated 2nd degree BSN:
Psychiatric Mental Health Nurse Practitioner:
Bachelor of Social Work (BSW):
Master of Social Work (MSW):
Advanced Standing Master of Social Work (MSW):
Other (please describe):
Please identify how many students currently enrolled in each program are eligible to receive tuition assistance (i.e., have home addresses from an Alliance School District as designated by the State Department of Education or meet the family income thresholds to be eligible for federal Pell grants):
Associate Degree of Nursing (ADN):
Bachelor Degree of Nursing (BSN):
Accelerated 2nd degree BSN:
Psychiatric Mental Health Nurse Practitioner:
Bachelor of Social Work (BSW):
Master of Social Work (MSW):
Advanced Standing Master of Social Work (MSW):
Other (please describe):
New Programs
If your institution is developing new nursing programs, please describe below. Please indicate: 1) Type of degree (LPN, ADN, BSN, Accelerated BSN, Psychiatric Mental Health Nurse Practitioner, BSW, MSW, Other); 2) Has accreditation been obtained? 3) Date first students will be admitted? 4) Number of students planned to be admitted (per cohort); 5) Number of students planned to be admitted (total):
New Program #1:
New Program #2:
New Program #3:
Tuition Assistance
Please note how many students you are proposing to receive tuition assistance in each program during the total project period:
Associate Degree of Nursing (ADN):
Bachelor Degree of Nursing (BSN):
Accelerated 2nd degree BSN:
Psychiatric Mental Health Nurse Practitioner:
Bachelor of Social Work (BSW):
Master of Social Work (MSW):
Advanced Standing Master of Social Work (MSW):
Other (please describe):
Please list the full cost of attendance for the following programs at your institution:
Associate Degree of Nursing (ADN):
Bachelor Degree of Nursing (BSN):
Accelerated 2nd degree BSN:
Psychiatric Mental Health Nurse Practitioner:
Bachelor of Social Work (BSW):
Master of Social Work (MSW):
Advanced Standing Master of Social Work (MSW):
Other (please describe):
Please describe other sources of tuition support for nursing students to leverage along with CT Health Horizons (state, federal, institutional resources as well as private donations):
Please describe other sources of tuition support for social work students to leverage along with CT Health Horizons (state, federal, institutional resources as well as private donations):
If requesting tuition assistance for accelerated BSN, MSW, or PMHNP programs, please describe your institution’s eligibility criteria and oversight process to ensure funds are received by the target population:

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