ILLINOIS DEPARTMENT OF PUBLIC HEALTH



ILLINOIS DEPARTMENT OF PUBLIC HEALTH

OFFICE OF WOMEN’S HEALTH

REQUEST FOR APPLICATION

TICKET FOR THE CURE

COMMUNITY GRANT

FISCAL YEAR 2010

APPLICATION AND GUIDELINES

Illinois Department of Public Health

Office of Women’s Health

535 W. Jefferson St., First Floor

Springfield, IL 62761

Phone: 217-524-6088

Fax: 217-557-3326

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

OFFICE OF WOMEN’S HEALTH

TICKET FOR THE CURE

Application Guidelines for Fiscal Year 2010

Package Contents

* General Information

* Application and Instructions for FY 2010 Ticket for the Cure Community Grants

* Application Forms (with corresponding instructions)

APPLICATION GUIDELINES FOR FISCAL YEAR 2010 FUNDING

General Information

Title: Ticket for the Cure Community Grants

Issued By: Illinois Department of Public Health, Office of Women’s Health

Application Due: Applications must be received no later than:

* Monday, March 16, 2009

* 5 p.m.

* 535 W. Jefferson St., First Floor

Springfield, IL 62761

* Fax copies will not be accepted

* Submit one signed original and three (3) photocopies of the

application

Eligibility: Eligible applicants with not-for-profit status [501(c)(3)] include:

Local Health Departments

Universities

Hospitals

Social Service Agencies

Community-based Organizations

Funding Source: Ticket for the Cure Funds (State Dedicated Fund – 208)

Funding Period for FY2010: July 1, 2009 – June 30, 2010

I. Ticket for the Cure Community Grant Program Overview

On July 6, 2005, PA 94-0120 was signed into law, creating the Illinois Ticket for the Cure instant lottery ticket. Net revenue from the sale of this ticket will go to the Illinois Department of Public Health (IDPH), Office of Women’s Health, which will award grants to public and private entities in Illinois for the purpose of funding breast cancer research, education and services for breast cancer victims. (This application is for community grants related to education and services to breast cancer victims; a separate application must be submitted for research.)

This legislation also created the Ticket for the Cure Advisory Board. This board, in conjunction with the Illinois Department of Public Health, Office of Women’s Health (OWH), has the responsibility of consulting with the Illinois Department of Revenue in designing and promoting the Ticket for the Cure instant scratch-off lottery game; and reviewing grant applications, making recommendations and comments and consulting on grant awards from amounts appropriated from the Ticket for the Cure Fund.

II. Ticket for the Cure Community Grant Program Purpose

The OWH and the Ticket for the Cure Advisory Board recognize that breast cancer is the most commonly diagnosed cancer in women and sometimes affects men, as well. Awareness and education regarding early detection needs to be increased in every community, especially for low-income, underserved and uninsured women with special emphasis on reaching those who are geographically or culturally isolated, older and/or members of racial/ethnic minorities.

The OWH and the Ticket for the Cure Advisory Board have established the following goals and strategies to meet its mission:

1. Encourage healthier lifestyles among Illinois women by promoting activities that will increase awareness of breast cancer risk factors.

2. Increase knowledge about the risks of breast cancer by sponsoring educational programs focusing on breast cancer awareness and screening.

3. Improve communication and collaboration among OWH and other consumer and advocacy groups and health professionals by providing technical support and facilitating public/private partnerships.

4. Identify the unmet needs of breast cancer victims by enhancing data collection efforts focusing on Illinois women.

5. Advocate for better public health policy on matters affecting women’s health by serving as a resource on women’s health issues to public policy makers and by monitoring and analyzing proposed state and federal legislation that impacts women’s health.

6. Stimulate research on breast cancer and its risk factors by encouraging and supporting institutional research and by promoting clinical trial participation opportunities to the public. (A separate application must be submitted for research.)

III. Ticket for the Cure Community Grant Program Priorities

The OWH has funding available from the Ticket for the Cure Fund to provide one year grants that support community outreach, health promotion and/or education that is specifically designed to benefit breast cancer programs as well as to increase awareness through the sale of the Ticket for the Cure instant lottery ticket.

The OWH and the Ticket for the Cure Advisory Board are soliciting proposals which:

• achieve the intent of the legislation;

• follow the structure described in the application guidelines;

• demonstrate the need in the community;

• demonstrate community collaboration; and

• provide a 10 percent match (cash or in-kind) by the applicant and/or collaborative

partners, such as time (salaries), space (rent), an assigned value to donated items, etc.

IV. Ticket for the Cure – Community Grant Program

Description of Community Grant Program: The OWH and the Ticket for the Cure Advisory Board are interested in funding innovative proposals that will assist women in their fight against breast cancer. Applicants are encouraged to think creatively. Three types of community grants will be offered. You must choose one of the following. You will only be able to apply for one type of program:

1) Capacity Building – Capacity building efforts can include a broad range of approaches, e.g., grant operating funds or grant management development funds to provide training and develop sessions, to provide coaching, to support collaboration with other nonprofits, etc. Grants will be a maximum of $20,000. Organizations may receive funding in this category for one year only.

2) Community Education and Outreach – Funding will be provided to conduct educational workshops focusing on breast cancer or peer outreach programs to inform people about the risks of breast cancer, treatment options, and/or follow-up services. Grants will be a maximum of $40,000.

3) Supportive Services – Services to be provided by the grant include, but are not limited to: prosthetic assistance, transportation assistance, housing assistance (mortgage or rent, utilities, etc.), and childcare assistance. Organizations applying for these grant funds will have to demonstrate their need as well as the need of the individuals they will be serving and provide a plan to protect against fraud or abuse. Grants will be a maximum of $75,000.

Eligibility: Governmental entities and/or tax-exempt organizations with not-for-profit status [501(c)(3)].

Program Goals:

• Increase awareness about the risks of breast cancer

• Increase the number of women receiving mammograms

• Increase knowledge of the options available to manage breast cancer

• Increase knowledge of the services available to breast cancer victims

V. Eligibility

Only institutions and organizations based in Illinois are eligible to compete for these funds. Organizations include: Local Health Departments, Universities, Hospitals, Social Service Agencies, Community-based Organizations. Organizations must be not-for-profit under the internal revenue code 501(c)(3). Grant awards shall be commensurate with the proposed program activity.

VI. Overview of Proposal Requirements

a. Describe your program that covers a 12-month time frame beginning July 1, 2009, and culminating June 30, 2010.

b. Submit letters of commitment from each partner participating in the proposed program. Letters must clearly state the partners planned role in the program and what they anticipate will be achieved through their participation. Letters of commitment must be submitted with the application. They will not be accepted if they are sent separately from the organization’s application package.

c. Include a proposed budget with at least a 10 percent match (of the funds requested from the Ticket for the Cure) which can be cash or in-kind from the applicant and/or partners, such as time (salaries), space (rent), an assigned value to donated items, etc.

d. Agree to receive consultation and/or technical assistance from authorized representatives or staff of the OWH on behalf of the Ticket for the Cure Advisory Board.

e. Agree to submit quarterly reports and an end of year report to the OWH. (Reports due: October 15, 2009, January 15, 2010, April 15, 2010 and June 15, 2010. The end of year report is due August 15, 2010.)

Other proposal requirements are as follows:

• Applications must be received in the OWH’s SPRINGFIELD office by 5 p.m. Monday, March 16, 2009.

• Must submit one (1) original and three (3) copies of the application.

Must complete the cover page (FORM A) and have an ORIGINAL SIGNATURE FROM THE FISCAL OFFICER.

Must complete “Application and Plan for Public Health Program” and have an ORIGINAL SIGNATURE FROM THE AUTHORIZING AGENT.

YOUR APPLICATION WILL BE INELIGIBLE AND WILL NOT BE REVIEWED IF:

• the application is late;

• the application does not include original signatures on Form A and Form B;

• the required number of copies are not submitted (one (1) original and three (3) copies); and/or

• the application does not follow format instructions completely, using the required

format provided.

PROPOSALS THAT ARE INCOMPLETE OR FAIL TO FOLLOW THE CORRECT FORMAT WILL NOT BE CONSIDERED FOR FUNDING.

VII. Application Requirements

Using the format provided, applicants must submit an application that contains the information outlined below. Make copies of forms for second pages, as needed.

FORM A – Completed Cover Page. (Be sure to check the category for which your organization is applying.)

FORM B – Completed Application and Plan for Public Health Program

FORM C – Completed Contact Information

FORM D – Completed Collaborators List

FORM E1 – General Organizational Capacity (two (2) pages maximum, single-spaced) Using the format provided, address the following points:

• Provide an overview of the applicant’s organization including the overall mission and activities of the organization.

• Describe the scope of the need for this program in the communities served and the time commitments and job descriptions and qualifications of key staff members.

• Explain how the program is a collaborative effort – the partners involved; the role each partner will play; and why each partner is important to the success of the program. (Letters of support and commitment must be provided in the applicant’s grant package.)

FORM E2 – Program Specific Organizational Capacity (two (2) pages maximum, single-spaced) Use the format provided, keeping in mind you will only be filling out one of the forms (E2a, E2b or E2c). Please address the following points:

FORM E2a - Capacity Building - FOR NEW APPLICANTS ONLY:

• Describe your organization’s planning process as it relates to breast cancer programming.

• Describe your organizations goals for implementing breast cancer programs.

• Describe how this grant will position your organization to address its goals for breast cancer programming.

FORM E2b - Education and Outreach:

• Describe what your organization plans to do for education and outreach for breast cancer programming.

• Describe your target population and plans for recruitment and follow-up.

• Describe how your organization will implement its plans for education and outreach for breast cancer programming.

FORM E2c - Supportive Services:

• Describe the supportive services your organization plans to offer breast cancer patients and their families.

• Discuss how you will determine the need and ensure fair distribution of resources.

• If you are providing monetary assistance with household expenses such as rent/mortgage, utilities and groceries, please describe your safeguards against fraud and abuse.

FORM F - Project Work Plan (one (1) page maximum per goal (three goals minimum), single- spaced) Prepare an outline that describes the timeline for the planned activities, goals and objectives with the corresponding activity and describe the person responsible for each activity.

FORM G – Evaluation Plan (one (1) page maximum, single-spaced) Using the format provided, address the following points:

• Explain how the program will be evaluated, how will it be determined if the program met its goals and objectives (pre-/post-tests, questionnaires, focus groups, phone interviews, etc.).

• Include any existing base line data and information.

• Discuss the indicators, measures or tools that will be used to monitor progress in meeting the program objectives.

FORM H - Budget. Using the forms provided, prepare a budget with sufficient resources to

implement the program. If needed, additional copies of the forms can be made. The instructions for

completion of the forms are in the front of each budget page. A list of allowable costs is

included.

If there are allocated costs such as utilities or space charges to this program, they must be justified and a methodology for allocation must be explained in the Budget Justification section.

FORM I - Budget Justification (one (1) page maximum, single-spaced). Using the format provided, submit additional information and justification for specific line items listed in the detailed budget. Justifications should clearly indicate that the items being requested are essential to the achievement of the stated program objectives.

VIII. Scoring Criteria

The specific scoring criteria to be used for the review and selection of proposals for funding are as follows:

A. General Organizational Capacity – a maximum of 20 points

The extent to which:

• the applicant describes the organization, the overall mission and activities of the organization and the applicant provides adequate documentation of “not-for-profit” status.

• the applicant demonstrates the need for this program and communities served.

• the applicant describes the time commitments of staff members and provides job descriptions and resumes.

• the applicant describes the organization’s capacity to address the need and to carry out the program in the allotted time frame.

• if applicable, the applicant explains the roles of collaborating partners and explains their contribution to program success, describes the nature and role of their involvement in your program, and provides letters of support and commitment.

B. Program Specific Organizational Capacity – a maximum of 40 points

If you are applying for Capacity Building:

• Describe your organization’s planning process as it relates to breast cancer programming.

• Describe your organizations goals for implementing breast cancer programs.

• Describe how this grant will position your organization to address its goals for breast cancer programming.

If you are applying for Education and Outreach:

• Describe what your organization plans to do for education and outreach for breast cancer programming.

• Describe your target population and plans for recruitment and follow-up.

• Describe how your organization will implement its plans for education and outreach for breast cancer programming.

If you are applying for Supportive Services:

• Describe the supportive services your organization plans to offer breast cancer patients and their families.

• Discuss how you will determine the need and ensure fair distribution of resources.

• If you are providing monetary assistance with household expenses such as rent/mortgage, utilities and groceries please describe your safeguards against fraud and abuse.

C. Program Evaluation – a maximum of 10 points

The extent to which:

• the applicant explains how the program will be evaluated.

• the applicant sufficiently demonstrates that the proposed activity relates to the corresponding goal.

• the proposed activities demonstrate that there is a logical plan to achieve the program goal(s), discussing existing data and information, indicators, measures or tools to be used to assess and monitor progress of the program.

D. Program Budget - a maximum of 30 points

The extent to which:

• the budget is reasonable to support activities that achieve the objectives.

• the budget is calculated correctly and the required match is included.

• the budget items are clearly justified.

IX. Proposal Summary

Proposals that are incomplete or fail to follow the correct format will not be considered for funding.

X. Format Requirements

All forms must be typed using the format provided, 12-point or larger font, single-spaced and one-sided with one half-inch margin on left, right and bottom.

XI. Awarding of Funds

Final selection of fiscal year 2010 grants will be a multi-stage process:

• An eligibility review, based upon completeness and compliance with the RFP guidelines, will be conducted by OWH staff.

• Proposals that do not follow format instructions completely will not be reviewed for content. This directive is to ensure that all proposals, whether from large institutions or small organizations, are uniform. Applicants will be notified if their proposal is deemed ineligible.

• Each proposal will be assigned a primary and secondary reviewer. Using the criteria described above, each reviewer will score the proposals.

• Proposals will be rank ordered by score and applicants meeting a minimum score that falls within the limit of available funds will be considered for funding.

XII. Deadlines

All proposals for the Ticket for the Cure Community Grants must be received by 5 p.m. Monday, March 16, 2009. Applicants ineligible for review will be notified by Monday, March 23, 2009. Awardees and unsuccessful applicants will be notified prior to July 1, 2009. Funding begins on Wednesday, July 1, 2009.

XIII. Payment Methodology

Payments to successful applicants will be made on a reimbursement basis. The grantee will document actual expenditures incurred for the purchase of goods and services necessary for conducting program activities. The grantee will use the Department’s Reimbursement Certification Form to request reimbursement. Forms and instructions for their use will be mailed with each signed grant agreement. After Departmental review of all submitted Reimbursement Certification Forms received from the grantee and approved for payment, a State of Illinois Invoice Voucher will be prepared and processed through the Office of the Comptroller for payment to the grantee.

Reimbursement requests will be submitted monthly. The final reimbursement must be received by IDPH within 30 days (July 31, 2010) after the close of the grant period (June 30, 2010) to ensure reimbursement.

Included in the packet is “Allowable Costs for Reimbursement under IDPH/OWH Agreement.”

XIV. Source of Funds

Illinois Department of Public Health - Ticket for the Cure Fund (State Dedicated Fund – 208)

XV. Submission of Applications

Submit proposals in their entirety to:

Maureen Pennell Jennings

Illinois Department of Public Health

Office of Women’s Health

535 W. Jefferson St. - First Floor

Springfield, IL 62761

Proposals must be received by 5 p.m. Monday, March 16, 2009. Faxes or e-mails will not be accepted. NO LATE APPLICATIONS WILL BE ACCEPTED.

For more information about this program call: Office of Women’s Health

Phone: 217-524-6088

FORM A

ILLINOIS DEPARTMENT OF PUBLIC HEALTH - OFFICE OF WOMEN’S HEALTH

TICKET FOR THE CURE COMMUNITY GRANT PROGRAM

GRANT PROPOSAL COVER PAGE

LEAVE BLANK FOR IDPH USE ONLY

NUMBER _____________________________ DATE RECEIVED ____________________________

1. TITLE OF YOUR PROGRAM: (Please Type or Print Legibly)

2. PROGRAM APPLYING FOR: (Select only one)

( Capacity Building ( Education and Community Outreach ( Supportive Services

3. FISCAL CONTACT

NAME ______________________________________________________________________________

TITLE _______________________________________________________________________________

ORGANIZATION _____________________________________________________________________

ADDRESS ___________________________________________________________________________

_____________________________________________________________________________________

PHONE ____________________ FAX _____________________ E-MAIL _________________________

4. ORGANIZATION’S FEDERAL TAX ID (FEIN) NUMBER ______________________________

5. TOTAL AMOUNT OF FUNDING REQUESTED $ ______________________________

6. FISCAL OFFICER ASSURANCE I agree to accept responsibility for the fiscal conduct of this program and to provide the required financial reports if a grant is awarded as a result of this application.

ORIGINAL SIGNATURE OF FISCAL OFFICER ____________________________________

DATE __________________

FORM B

ILLINOIS DEPARTMENT OF PUBLIC HEALTH - OFFICE OF WOMEN’S HEALTH

535 W. JEFFERSON ST. - SPRINGFIELD, IL 62761

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM

IMPORTANT NOTICE: This state agency is requesting disclosure of information that is necessary to accomplish that statutory purpose outlined under 30 ILCS 105/1 et. seq. Failure to provide this information may prevent this application from being processed.

APPLICANT ORGANIZATION ________________________________________________________

PROGRAM CONTACT ________________________________________________________________

ADDRESS ___________________________________________________________________________

_____________________________________________________________________________________

TELEPHONE ______________ FAX __________________ E-MAIL _________________________

PROGRAM TITLE ____________________________________________________________________

AMOUNT REQUESTED ______________________________________________________________

TYPE OF ORGANIZATION Please check one of the following. Must also include documentation in appendix

Government Entity ___ Tax Exempt Organization ___

LEGISLATIVE DISTRICT State Senate District ____________________________________________

Congressional _________________________________________________

State Representative District ______________________________________

APPLICANT CERTIFICATION To the best of my knowledge, the data and statements in this application are true and correct. The applicant agrees to comply with all state/federal statutes and rules/regulations applicable to the program. My signature indicates that I have the authority to enter into contracts on behalf of the applying organization.

____________________________________ __________________________________

Name of Authorized Official Original Signature and Date

____________________________________

Title

FORM C

CONTACT INFORMATION

PROGRAM CONTACT

NAME ___________________________________________________________________________________

TITLE __________________________________________________________________________________

ADDRESS _______________________________________________________________________________

_________________________________________________________________________________________

TELEPHONE ___________________ FAX _____________________ E-MAIL _____________________

FISCAL CONTACT

NAME ___________________________________________________________________________________

TITLE ___________________________________________________________________________________

ADDRESS ________________________________________________________________________________

_________________________________________________________________________________________

TELEPHONE __________________ FAX __________________ E-MAIL _________________________

AUTHORIZING AGENT

NAME ___________________________________________________________________________________

TITLE ___________________________________________________________________________________

ADDRESS ________________________________________________________________________________

__________________________________________________________________________________________

TELEPHONE __________________ FAX ___________________ E-MAIL ________________________

FORM D

COLLABORATOR LIST

You may make as many copies of this page as necessary. You must also include a letter of support in this packet from each collaborator listed.

Program Title: ________________________________________________________________________________________________

Organization: _________________________________________________________________________________________________

ORGANIZATION ___________________________________________________________________________

CONTACT PERSON ________________________________________________________________________

TITLE ____________________________________________________________________________________

ADDRESS _________________________________________________________________________________

TELEPHONE _______________________ FAX _____________________ E-MAIL ___________________

PROGRAM ROLE ___________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

ORGANIZATION ___________________________________________________________________________

CONTACT PERSON ________________________________________________________________________

TITLE ____________________________________________________________________________________

ADDRESS _________________________________________________________________________________

TELEPHONE _______________________ FAX _____________________ E-MAIL ___________________

PROGRAM ROLE ___________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

FORM E1

GENERAL ORGANIZATIONAL CAPACITY

Program Title______________________________________________________________________________________

Please address the following items (maximum of two (2) single-spaced pages with 12-point font):

1. Provide an overview of applicant organization including overall mission and activities of the organization.

2. Describe the scope of need for this program in the communities served. Explain job descriptions, time commitments and responsibilities of key staff members. Please attach resumes to the section.

3. Explain how your program is a collaborative effort – partners involved; role each partner will play, why each partner is important to the success of the program. Please attach letters of support and commitment to this section.

FORM E2a

PROGRAM SPECIFIC ORGANIZATIONAL CAPACITY

Please complete the form which pertains to you – use this form, E2a if you are applying for a CAPACITY BUILDING grant, proceed to E2b for education and outreach and to E2c for supportive services.

Program Title______________________________________________________________________________________

(Maximum of two (2) single-spaced pages with 12-point font). Please remember to make answers specific to the program in which you are applying.

1. Describe your organization’s planning process as it relates to breast cancer programming.

2. Describe your organization’s goals for implementing breast cancer programs.

3. Describe how this grant will position your organization to address its goals for future breast cancer programming.

FORM E2a (con’t)

PROGRAM SPECIFIC ORGANIZATIONAL CAPACITY

Please complete the form which pertains to you – use this form, E2a, if you are applying for a CAPACITY BUILDING grant.

Program Title______________________________________________________________________________________

(Maximum of two (2) single-spaced pages with 12-point font). Please remember to make answers specific to the program in which you are applying (capacity building, education and outreach or supportive services).

Page 2 – Capacity Building

FORM E2b

PROGRAM SPECIFIC ORGANIZATIONAL CAPACITY

Please complete the form which pertains to you – use this form, E2b, if you are applying for an EDUCATION AND OUTREACH grant, go back to E2a for capacity building or proceed to E2c for supportive services.

Program Title______________________________________________________________________________________

(Maximum of two (2) single-spaced pages with 12-point font). Please remember to make answers specific to the program in which you are applying.

1. Describe your organization’s plans for Education and Outreach for breast cancer programming.

2. Describe your target population and plans for recruitment and follow-up.

3. Describe how your organization will implement its plans for Education and Outreach for breast cancer programming.

FORM E2b (con’t)

PROGRAM SPECIFIC ORGANIZATIONAL CAPACITY

Please complete the form which pertains to you – use this form, E2b, if you are applying for an EDUCATION AND OUTREACH grant.

Program Title______________________________________________________________________________________

(Maximum of two (2) single-spaced pages with 12-point font). Please remember to make answers specific to the program in which you are applying.

Page 2 – Education and Outreach

FORM E2c

PROGRAM SPECIFIC ORGANIZATIONAL CAPACITY

Please complete the form which pertains to you – use this form, E2c, if you are applying for a SUPPORTIVE SERVICES grant, go back to E2a for capacity building or E2b for education and outreach.

Program Title______________________________________________________________________________________

(Maximum of two (2) single-spaced pages with 12-point font). Please remember to make answers specific to the program in which you are applying.

1. Describe the Supportive Services your organization plans to offer breast cancer patients and their families.

2. Discuss how you will determine the need and ensure fair distribution of resources.

3. If providing monetary assistance with household expenses (rent/mortgage, utilities, groceries, etc.), please describe your safeguards against fraud and abuse.

FORM E2c (con’t)

PROGRAM SPECIFIC ORGANIZATIONAL CAPACITY

Please complete the form which pertains to you – use this form, E2c, is you are applying for a SUPPORTIVE SERVICES grant.

Program Title______________________________________________________________________________________

(Maximum of two (2) single-spaced pages with 12-point font). Please remember to make answers specific to the program in which you are applying.

Page 2 – Supportive Services

FORM F

PROJECT WORKPLAN

Program Title _____________________________________________________________________________________

(One (1) page maximum per goal (three goals minimum), single-spaced) Prepare an outline of the timeline of the planned activities, goals and objectives with corresponding person responsible for each activity. You may make as many copies of this page as necessary. When completing this form, please note the following regarding goals and objectives:

• Goals are broad; objectives are narrow

• Goals are general intentions; objectives are precise

• Goals are intangible; objectives are tangible

• Goals are abstract; objectives are concrete

• Goals can't be validated as is; objectives can be validated

Organization: _____________________________________________________________________________________

Goal:

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FORM G

EVALUATION PLAN

Program Title _____________________________________________________________________________________

Using the format provided, address the following items (maximum of one (1) single-spaced page with 12-point font):

1. Explain how you will evaluate your program – how will you determine if your program has met its goals and objectives.

2. Include existing base line data and information.

3. Discuss indicators, measures and/or tools that will be used to monitor your program’s progress.

INSTRUCTIONS to Budget Section, Page 1

INSTRUCTION TO APPLICANT

BUDGET SUMMARY

GENERAL BUDGET INFORMATION

The budget for this application or RFP is to reflect the total cost of the program from all sources. The Budget Summary provides a one-page compilation of these costs. Individual line-items are to be itemized in detail on the following pages. Additional information and justification are to be shown on the Budget Justification page(s).

The budget must comply with the allowable costs for the program, the applicable Administrative Rules and Regulations, the laws of the State of Illinois and any applicable federal guidelines or requirements.

All amounts are to be expressed in whole dollars; each line-item is to be rounded to the nearest $100 dollar amount.

If additional pages are required, please note applicant agency name and program name on each additional page and number all additional pages as appropriate using the following sequence: Page 1a, Page 1b, Page 2a, Page 2b, and so on. Applications are disassembled and copied by the Department and these page number references will assist reassembly and help to ensure all copies are complete.

BUDGET SUMMARY

Enter the totals from each detail line-item section and sum these amounts to show the TOTAL, Direct Costs for the program.

SOURCES OF FUNDS columns: The total estimated cost for each line-item of the program is to be broken out by funds to be provided from sources other than this application or RFP (Applicant and Other) and by the amount requested in this application (Requested from IDPH).

IDPH Components (specify): The amount requested in this application or RFP (Requested from IDPH) is to be further broken out by program component(s) as instructed in the Program Description section of the application package or RFP.

SOURCES OF FUNDS - Applicant and Other

Identify the source and amount of all funds shown in the Applicant and Other column of the Budget Summary. Enter the amounts proposed to meet the program's matching or cost participation requirements, if any, in the Required Match column; enter all other program support costs in the Other Support column. The total of the Required Match and Other Support columns must equal the total of the Applicant and Other column of the Budget Summary.

Examples of Applicant and Other fund sources include Applicant funds such as tax revenues; fees or other program income; donations; other corporate funds; and other program support such as other state and or federal grant awards (i.e. WIC, Title X,

Title XIX, and Title XX) both from the IDPH and from other agencies.

FORM H(1)

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM

BUDGET SECTION, Summary

APPLICANT AGENCY: FEIN: __________________________________________________________

PROGRAM: FOR THE PERIOD: THROUGH __________________________________________________

|BUDGET SUMMARY | |SOURCES OF FUNDS | |

| |Total for the Program |Applicant and Other |Requested from IDPH | | | |

|LINE ITEM (Category) | | | | | | |

| Personal Services | | | | | | |

| Contractual Services | | | | | | |

| Supplies | | | | | | |

| Travel | | | | | | |

| Equipment | | | | | | |

| Patient Care | | | | | | |

|TOTAL, Direct Costs | | | | | | |

|SOURCES OF FUNDS - Applicant and Other Sources |Required Match |Other Support |Total |

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USE ADDITIONAL SHEETS IF NECESSARY Budget Section, Page 1

INSTRUCTIONS to Budget Section, Page 2

INSTRUCTIONS TO APPLICANT

PERSONAL SERVICES BUDGET

PERSONAL SERVICES

Enter the position title and name of the current incumbent; if the position is new or currently not filled, enter "Vacant".

Example: Nurse - Mary Jones

Sally Smith

Vacant

Pgrm Coord - Joyce Johnson

Vacant

Enter the monthly salary for each position which will be filled for all or any part of the period. Enter the number of months the position will be filled by an incumbent working on the program. Enter the percent of time the incumbent will devote to the program during the months shown. Enter the total amount of support to be provided for the program, as computed from the information shown, using the following formula:

[Monthly Salary] times [Number of Months Budgeted] times [Percent of time on Program] =

[Total for the Program].

The Total for the Program is then broken out by the amount to be provided from sources other than this application (Applicant and Other) and the amount requested as part of this application (Requested from IDPH). The amount Requested from IDPH is further broken out by the various program components (IDPH Components) if the Program Description section of the Application Package requests that program components be identified separately.

FRINGE BENEFITS

(Fringe Benefit Worksheet – Budget Section, Page 6)

The components included in the applicant agency's fringe benefit rate are to be itemized (listed by component and rate) in the Budget Justification section. The total fringe benefits rate is entered on the Fringe Benefits line; this rate is then applied to the Personal Services, Subtotal shown as Total for the Program. If the applicant agency includes fringe benefits in the amount Requested from IDPH and the various IDPH Components, the amounts for fringe benefits may not exceed the fringe benefits rate times the Personal Services, Subtotal for those columns.

FORM H(2)

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM

BUDGET SECTION, Personal Services

APPLICANT AGENCY: FEIN: __________________________________________________________

PROGRAM: FOR THE PERIOD: THROUGH __________________________________________________

| PERSONAL SERVICES | |Number of |Percent of | |Sources of Funds | |

|(Position Title and | |Months |Time on | | | |

|Name of Incumbent) |Monthly Salary |Budgeted |Program |Total for the | | |

| | | | |Program | | |

| | | | | |Applicant and Other|Requested from IDPH|

|FRINGE BENEFITS (Rate: %) Components and rates must be itemized in budget | | | | | | |

|justification section. | | | | | | |

|PERSONAL SERVICES AND FRINGE TOTAL | | | | | | |

USE ADDITIONAL SHEETS IF NECESSARY Budget Section, Page 2

INSTRUCTIONS to Budget Section, Page 3

INSTRUCTIONS TO APPLICANT

CONTRACTUAL SERVICES BUDGET

CONTRACTUAL SERVICES

List the costs directly attributable to the program, estimated to be incurred during the period covered by this application. Examples of Contractual Services include conference registration fees; repair and maintenance of furniture and equipment; postage; United Parcel Service or other carrier costs; software; subscriptions; training and education costs; and telecommunications costs. See also the Allowable Cost section of the Application Package.

Payment (or pass-through) to subcontractors or subgrantees are to be listed here. All subcontracts or subgrants require an attached detail line-item budget supporting this contractual amount. The Department must approve, in writing, all subcontracts or subgrants.

FORM H(3)

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM

BUDGET SECTION, Contractual Services

APPLICANT AGENCY: FEIN: _________________________________________________________

PROGRAM: FOR THE PERIOD: THROUGH _________________________________________________

| CONTRACTUAL SERVICES (Itemize) | |SOURCES OF FUNDS | |

| |Total for the Program |Applicant and Other |Requested from IDPH | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| TOTAL, Contractual Services | | | | | | |

USE ADDITIONAL SHEETS IF NECESSARY Budget Section, Page 3

INSTRUCTIONS to Budget Section, Page 4

INSTRUCTIONS TO APPLICANT

SUPPLIES AND TRAVEL BUDGET

SUPPLIES

List the costs, directly attributable to the program, estimated to be incurred during the period covered by this application. Examples of Supplies include office supplies; medical supplies (consumable items such as syringes, tape and gauze, other than drugs); educational and instructional materials; cleaning supplies; copy paper and other paper supplies; and letterpress, offset printing, and other printing services. See also the Allowable Costs section of the Application Package.

TRAVEL

List the costs, directly attributable to the program, of applicant agency's employees' transportation, mileage, per diem, meals, etc. necessary for carrying out the activities described in the application. Unless specifically stated in the budget, the mileage rate will be assumed to be the same as that authorized for state employees by the Governor's Travel Control Board. See also the Allowable Costs section of the Application Package.

Travel costs for contractual consultants are to be included in the Contractual Services line.

FORM H(4)

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM

BUDGET SECTION, Supplies and Travel

APPLICANT AGENCY: FEIN: _________________________________________________________

PROGRAM: FOR THE PERIOD: THROUGH _________________________________________________

| SUPPLIES (Itemize) | |SOURCES OF FUNDS | |

| |Total for the Program |Applicant and Other |Requested from IDPH | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| TOTAL, Supplies | | | | | | |

| TRAVEL (Itemize) | |SOURCES OF FUNDS | |

| |Total for the Program |Applicant and Other |Requested from IDPH | | | |

|Mileage (Rate per mile: $. ) | | | | | | |

|Lodging | | | | | | |

|Meals/Per Diem | | | | | | |

|Commercial Transportation | | | | | | |

|Other: | | | | | | |

| | | | | | | |

| | | | | | | |

| TOTAL, Travel | | | | | | |

USE ADDITIONAL SHEETS IF NECESSARY Budget Section, Page 4

INSTRUCTIONS to Budget Section, Page 5

INSTRUCTIONS TO APPLICANT

EQUIPMENT AND PATIENT CARE

EQUIPMENT

List those items costing more than $100 each with a useful life of more than one year required for the successful completion of the activities described in the application. Equipment costs shall include all freight and installation charges. Equipment may include office furniture and equipment, such as desks, chairs, computers, printers and calculators; training materials; reference books; and films. All Equipment purchases must be approved by the Department, either through this budget or via specific request for items not included in the budget as submitted. See also the Allowable Costs section of the Application Package.

PATIENT CARE

List those patient care services necessary to the program which the applicant agency cannot provide through its own resources and which will be purchased from other agencies or individuals.

Patient Care includes laboratory tests or other diagnostic procedures; and transportation of patients or clients, including accompanying parents or guardians (or other escort).

Patient Care also includes services which applicant agency will provide and be paid an established fee-for-service, such as family planning services, Healthy Moms/Healthy Kids case management; dental sealants; and primary care services.

FORM H(5)

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM

BUDGET SECTION, Equipment and Patient Care

APPLICANT AGENCY: FEIN: _________________________________________________________

PROGRAM: FOR THE PERIOD: THROUGH _________________________________________________

| EQUIPMENT (Itemize) | |SOURCES OF FUNDS | |

| |Total for the Program |Applicant and Other |Requested from IDPH | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| TOTAL, Equipment | | | | | | |

| PATIENT CARE (Itemize) | |SOURCES OF FUNDS | |

| |Total for the Program |Applicant and Other |Requested from IDPH | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| TOTAL, Patient Care | | | | | | |

USE ADDITIONAL SHEETS IF NECESSARY Budget Section, Page 5

FORM H(6)

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM

FRINGE BENEFIT WORKSHEET

APPLICANT AGENCY: FEIN: __________________________________________________________________________

PROGRAM: FOR THE PERIOD: THROUGH __________________________________________________________________

Fringe Benefits -

FICA (Social Security) %

Pension/Retirement %

Group Health Insurance %

Group Life Insurance %

Unemployment Insurance %

Workmen's Compensation %

Other: %

%

%

%

TOTAL, Fringe Benefits Rate %

Budget Section, Page 6

FORM I

BUDGET JUSTIFICATION

Program Title _______________________________________________________________________________________________

Using the format provided, submit additional information AND justification for line items listed in the detailed budget. For example, all personal service contracts and sub-grants must be explained and justified IN DETAIL in the section. Justifications should clearly indicate that items being requested are essential to the achievement of the stated program objectives.

PERSONAL SERVICES

CONTRACTUAL SERVICES

SUPPLIES

TRAVEL

EQUIPMENT

PATIENT CARE

ALLOWABLE COSTS FOR REIMBURSEMENT UNDER IDPH/OWH GRANT AGREEMENT

To be reimbursed under IDPH/OWH Ticket for Cure Grant Agreement, expenditures must meet the criteria below:

• Be necessary and reasonable for proper and efficient administration of the program and not be a general expense required to carry out the overall responsibilities of the agency.

• Be authorized or not prohibited under federal, state or local laws or regulations.

• Conform to any limitations or exclusions set forth in the applicable rules, program description or grant agreement.

• Be accorded consistent treatment through application of generally accepted accounting principles appropriate to the circumstances.

• Not be allocable to or included as a cost of any state or federally financed program in either the current or a prior period.

• Be net of all applicable credits.

• Be specifically identified with the provision of a direct service or program activity.

• Be an actual expenditure of funds in support of program activities, documented by check number and/or internal ledger transfer of funds.

Examples of allowable costs include the following. This is not meant to be a complete list, but rather specific examples of items within each line item category.

Personnel Services:

• Gross salary paid to agency employees directly involved in the provision of program services.

• Employer’s portion of fringe benefits actually paid on behalf of direct services employees; examples include FICA (Social Security), life/health insurance, Workers Compensation insurance, unemployment insurance and pension/retirement benefits.

Contractual Services:

Conference registration fees

Contractual employees (requires prior program approval)

Repair and maintenance of furniture and equipment

Postage, postal services, UPS or other carrier costs

Software for support of program objectives

Training and education costs

Payments (or pass-through) to subcontractors or subgrantees are to be shown in the Contractual Services section - all subcontracts or subgrants require an attached detail line item budget supporting this contractual amount.

Travel:

Mileage (at state rate unless specifically noted otherwise)

Airline or rail transportation expenses

Lodging

Per diem and meal costs

Operation costs of agency owned vehicles

Commodities (Supplies):

Office supplies

Medical supplies

Educational and instructional materials and supplies, including booklets and reprinted pamphlets

Household, laundry, and cleaning supplies

Parts for furniture and office equipment

Equipment items costing less than $100 each

Printing (included in Supplies):

Letterpress, offset printing, binding, lithographing services

Photocopy paper, other paper supplies

Envelopes, letterhead, etc.

Equipment (requires prior written approval):

Items costing more than $100 each with useful life of more than one year

Equipment costs shall include all freight and installation charges

Office equipment and furniture

Allowable medical equipment

Reference and training materials and exhibits

Books and films

Telecommunications (included in Contractual Services):

Telephone services

Answering services

Installation, repair, parts and maintenance of telephones and other communication equipment

Unallowable costs include, but are not limited to:

• Indirect cost plan allocations

• Bad debts

• Contingencies or provisions for unforeseen events

• Contributions and donations

• Entertainment, food, alcoholic beverages and gratuities

• Fines and penalties

• Interest and financial costs

• Legislative and lobbying expenses

• Real property payments and purchases

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

OFFICE OF WOMEN’S HEALTH

TICKET FOR THE CURE COMMUNITY GRANTS

FY 2010 CHECKLIST

Applicant OWH

( ( Correct Format per RFP Specifications (font size, single-spacing and one-sided)

( ( FORM A - Completed Cover Page – Original Signatures

( ( FORM B–Complete Application/Plan for Public Health Program–Original Signatures

( ( Documentation of not-for-profit status

Not required of Local Health Departments

( ( FORM C - Completed Contact Information

( ( FORM D - Completed Collaborators List

( ( Letters of Commitment from Collaborating Partner(s)

( ( FORM E1 - Completed Organizational Capacity – 1 page

( ( FORM E2 - Completed Program Specific Organizational Capacity – 2 pages

( ( Resumes of Key Staff Member(s)

( ( FORM F - Completed Work Plan

( ( FORM G - Completed Evaluation Plan

( ( FORM H – Completed Budget

( ( FORM I– Completed Budget Justification

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