Attachment B: Application Forms and Instructions



Attachment B: Application Forms and InstructionsAdult Sepsis Surveillance Implementation and Feasibility ProjectForm 1: Cover PageForm 2: Project NarrativeForm 3: Work PlanForm 4: Budget and Budget JustificationForm 5: Indirect Cost QuestionnaireForm 6: Due Diligence ReviewMinnesota Department of HealthPO Box 64975St. Paul, MN 55164-0975651-201-5276jp.mahoehney@state.mn.ushealth.state.mn.us09/30/2019To obtain this information in a different format, call: 651-201-5276.Form 1: Cover Page InstructionsPlease complete all fields in this application and submit via email to jp.mahoehney@state.mn.us by 4:30 p.m. on November 22, 2019 with the subject line “Sepsis Surveillance Grant Application.” Note: application must be typed, no written applications will be accepted. Please email J.P. Mahoehney with any questions you may have by Friday, November 15, 2019 by 4:30 p.m.You must include all application materials as a single attachment by the deadline to be considered. Please make sure to include all items on the checklist.Applicant InformationFunding Request: $ Organization: Click or tap here to enter text. Mailing Address: Click or tap here to enter text. Primary Application Contact: Click or tap here to enter text. Phone: Click or tap here to enter text.Email: Click or tap here to enter text. Executive Director/Chief Executive Officer: Click or tap here to enter text. Phone: Click or tap here to enter text.Email: Click or tap here to enter text. Federal Employer ID (EIN): Click or tap here Minnesota Tax ID: Click or tap here to Fiscal Agent (if applicable)Please provide the following information below. Organization: Mailing Address: Primary Application Contact: Phone: Email: Executive Director/Chief Executive Officer: Phone: Email: Federal Employer ID (EIN): Minnesota Tax ID: Form 2: Project Narrative (30 points)InstructionsCopy and paste answers into the corresponding statement. No other supplemental documents will be anizational Capacity (30 points), 5 page limitPlease describe how this project fits with your own efforts to improve your hospital’s sepsis surveillance.(5 pts) Please describe the staff and/or leadership that will be directly involved with the project. (5 pts)Please provide an overview of experiences working with your Information Technologist(s) to improve disease surveillance. (5 pts)Please describe the software and resources available to implement and evaluate the project. (5 pts)Please identify how this project will impact your hospital’s efforts to address the diverse needs of people that live within the community you serve. (5 pts)Please describe any experiences that demonstrate your hospital’s ability to work effectively on a collaborative project with a state or federal agency. (5 pts)Form 3: Work Plan (20 points)For each activity indicated in the work plan below please add the following elements:Staff at your hospital that will be responsible for implementing the activityThe outcome that you anticipate based on your hospital’s participation in the activity. Please use the format “By [when], [target #/%] of [who] will have [done what] as measured by [data source].” For example: By the end of the 15-month project, hospital staff will have participated in 100% of the trainings provided by MDH and CDC.) Please note, you may list more than one goal or outcome for each activity based on your hospital’s individual expectations and capacity. The timeline that you can reasonably perform the project. Please be as specific as possible. For instance, for building the ASE toolkit into the hospital EMR please provide a specific estimation of the length of time this will take for your IT staff to implement.ActivityStaff ResponsibleGoal(s)/Outcome(s)TimelineParticipate in training and communicate regularly with CDC and MDH staffClick or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Identify informatics staff with expertise to program in a language compatible with the hospital’s EMRClick or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Build ASE toolkit surveillance into hospital EMRClick or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Provide MDH staff with a dataset generated from implementation of the ASE toolkitClick or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Provide MDH with access to medical records, if appropriate, for data validation and quality assuranceClick or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Iteratively adapt programmatic code in order to optimize CDC ASE toolkit implementationClick or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Form 4: Budget and Budget Justification (15 points)InstructionsBudget and Budget Justification (15 points), no page limitPlease fill out the budget contact, narrative, and summary templates below and break down by line items. Make sure to fill in all gray boxes. For each line-item, include a detailed description of how funds will be used for the duration of the project. The subtotals that you list in your description of how you will use the funds should add up to the totals listed for each line-item. Please bold subtotals in the budget narrative. See sample line-item descriptions below and Indirect Cost Guidance (Form 5) for additional guidance in completing the budget templates.Sample line-item descriptionsSALARY & FRINGE BENEFITSProgram Manager @ $30/hour (40 hours)=$1200Program Coordinator @ $25/hour (80 hours)=$2000Community Health Worker @ $20/hour (160 hours)=$3200TOTAL=$6400SUPPLIESInk @ $50/cartridge (4)=$200Name tags @ $5/box of 15 (4)=$20 TOTAL=$220TRAVELMileage for workshops @ $0.58/mile *100 miles/month (4) = $232Parking @ $10/ramp (5) = $50TOTAL = $282OTHERFood @ $200/workshop (3)=$600 Room Rental @ $250/workshop (3)=$750 Projector @ $500//projector (1)=$500 Laptop = @$700/laptop (1)=$700Printing @ $.12/page (400)=$48TOTAL=$2598TOTAL EXPENSES=$9500 -------------------------------------------------------------------------------------------------------------------------------INDIRECTOffice Rent @ $175/month (4)=$700Cell phone @ $62/month (4)=$248TOTAL=$948 PROJECT COSTS=$10,448Budget ContactOrganization Name:Click or tap here to enter text.Total Amount Requested:Click or tap here to enter text.Budget Contact?Name:Click or tap here to enter text.Title:Click or tap here to enter text.Email:Click or tap here to enter text.Phone:Click or tap here to enter text.Budget NarrativeLINE-ITEMBudget NarrativeI. Salary & Fringe Benefits?Please list the titles, the full time equivalent, the expected rate of pay, and the total amount you expect to pay the position. Include a detailed description of how funds will be used in the gray box. The subtotals listed in this description should add up to the totals listed for each category in this line-item.Subtotal?Click or tap here to enter text.II. Supplies?Please briefly describe the supplies needed to conduct the project.Include a detailed description of how funds will be used in the gray box. The subtotals listed in this description should add up to the totals listed for each category in this line-item.Subtotal?Click or tap here to enter text.III. Travel?Please describe your expected in state travel costs, including mileage, hotel and meals. Include a detailed description of how funds will be used in the gray box. The subtotals listed in this description should add up to the totals listed for each category in this line-item.Subtotal?Click or tap here to enter text.IV. Other?Please describe any expenses that do not fit in any other category. Include a detailed description of how funds will be used in the gray box. The subtotals listed in this description should add up to the totals listed for each category in this line-item.Subtotal?Click or tap here to enter text.VI. Indirect Costs?Briefly explain the expected costs for items and services that are not directly servicing the program.Include a detailed description of how funds will be used in the gray box. The subtotals listed in this description should add up to the totals listed for each category in this line-item.SubtotalClick or tap here to enter text.?Budget SummaryI. Salary & Fringe Benefits?II. Supplies?III. Travel?IV. Other?Total Direct Costs?V. Indirect Costs?TOTAL COSTS?Form 5: Indirect Cost QuestionnaireBackgroundApplicants may request an indirect rate to cover costs that cannot be directly attributed to a specific grant program or budget line item. This allowance for indirect costs are a portion of any grant awarded, not in addition to the grant award. MDH Policy 243, “Grants, Indirect and Administrative Costs,” outlines how grant funds may and may not be used for indirect costs. MDH policy states that applicants should minimize administrative and indirect costs.DefinitionsIndirect costs are expenses of doing business that cannot be directly attributed to a specific grant program or budget line item. These costs are often allocated across an entire agency and may include administrative, executive and/or supervisory salaries and fringe, rent, facilities maintenance, insurance premiums, etc. MDH will accept an organization’s federally approved indirect cost rate or up to 10 percent of total direct costs. Grantees who wish to charge indirect at a federally negotiated rate must be able to provide a copy of the federal rate agreement. A copy of the agreement will be requested before a grant agreement is signed.Examples of indirect costs: A portion of the total cost of the organization’s annual audit.A portion of the organization’s total depreciation costs.A portion of the total cost of the organization’s security system.In contrast, administrative costs are expenses not directly related to delivering grant objectives but necessary to support a particular grant program. These are general expenses that can be attributed and appropriately tracked to specific awards. These items should be included in the grantee budget as direct expenses in the appropriate lines (Salary and Fringe, Supplies, Travel or Other). They should NOT be included in the Indirect line.Examples of administrative costs (should be included in direct lines of the budget):A portion of the organization’s monthly printer/copier lease and maintenance fees, calculated by tracking how many jobs were coded to the grant program and applying a percentage based on usage.A portion of the organization’s administrative support, accounting or human resources, calculated by tracking time spent by staff in these areas on the grant program.A portion of the organization’s occupancy costs, calculated by applying a square footage cost total to the amount of physical space used for grant program management and activities.InstructionsPlease complete the information below and return this form as part of the application.Name of applicant organization: Click or tap here to enter text. Are you requesting an indirect rate? ?Yes ? NoDo you have an approved Indirect Cost Rate Agreement with a Federal agency?? Yes – Please submit a copy of your current rate with this completed form. ? No – Please continue completing the rest of this form.Non-federal indirect rate being requested: Click or tap here to enter text.Up to 10% of the direct expenses in the budget for the grant program listed above can be used for indirect costs per CFR Part 200 - Uniform Administrative Requirements, Costs Principles, and Audit Requirements for Federal Awards, and per MDH policy for State funds.Please list the expenses included in your indirect cost pool below, or attach a copy of your current indirect cost allocation plan to this form.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Form 6: Due Diligence Review The Minnesota Department of Health (MDH) conducts pre-award assessments of all grant recipients prior to award of funds in accordance with federal, state and agency policies. The Due Diligence Review is an important part of this assessment.These reviews allow MDH to better understand the capacity of applicants and identify opportunities for technical assistance to those that receive grant anizationInformationOrganization Name:Click or tap here to enter anization Address:Click or tap here to enter text.If the organization has an Employer Identification Number (EIN), please provide EIN here:Click or tap here to enter text.If the organization has done business under any other name(s) in the past five years, please list here:Click or tap here to enter text.If the organization has received grant(s) from MDH within the past five years, please list here:Click or tap here to enter text.Section 1: To be completed by all organization typesSection 1: Organization StructurePointsHow many years has your organization been in existence?? Less than 5 years (5 points) ? 5 or more years (0 points)How many paid employees does your organization have (part-time and full-time)?? 1 (5 points)? 2-4 (2 points)? 5 or more (0 points)Does your organization have a paid bookkeeper? ? No (3 points)? Yes, an internal staff member (0 points)? Yes, a contracted third party (0 points)Section 1 Point TotalSection 2: To be completed by all organization typesSection 2: Systems and OversightPointsDoes your organization have internal controls in place that require approval before funds can be expended?? No (6 points)? Yes (0 points)Does your organization have written policies and procedures for the following processes?AccountingPurchasingPayroll ? No (3 points)? Yes, for one or two of the processes listed, but not all (2 points)? Yes, for all of the processes listed (0 points)Is your organization’s accounting system new within the past twelve months?? No (0 points)? Yes (1 point)Can your organization’s accounting system identify and track grant program-related income and expense separate from all other income and expense?? No (3 points)? Yes (0 points)Does your organization track the time of employees who receive funding from multiple sources? ? No (1 point)? Yes (0 points)Section 2 Point TotalSection 3: To be completed by all organization typesSection 3: Financial HealthPointsIf required, has your organization had an audit conducted by an independent Certified Public Accountant (CPA) within the past twelve months?? Not Applicable (N/A) (0 points) – if N/A, skip to question 10? No (5 points) – if no, skip to question 10? Yes (0 points) – if yes, answer question 9A9A. Are there any unresolved findings or exceptions? ? No (0 points) ? Yes (1 point) – if yes, attach a copy of the management letter and a written explanation to include the finding(s) and why they are unresolved. Have there been any instances of misuse or fraud in the past three years? ? No (0 points) ? Yes (5 points) – if yes, attach a written explanation of the issue(s), how they were resolved and what safeguards are now in place. Are there any current or pending lawsuits against the organization? ? No (0 points) – If no, skip to question 12 ? Yes (3 points) – If yes, answer question 11A 11A. Could there be an impact on the organization’s financial status or stability?? No (0 points) – if no, attach a written explanation of the lawsuit(s), and why they would not impact the organization’s financial status or stability.? Yes (3 points) – if yes, attach a written explanation of the lawsuit(s), and how they might impact the organization’s financial status or stability.From how many different funding sources does total revenue come from?? ? 1-2 (4 points) ? 3-5 (2 points) ? 6+ (0 points) Section 3 Point TotalI certify that the information provided is true, complete and current to the best of my knowledge.Signature: Click or tap here to enter text.Name & title: Click or tap here to enter text.phone number: Click or tap here to enter text.email address: Click or tap here to enter text.Additional Documentation Required for Non-Governmental OrganizationsIf you’re a Non-Governmental Organization with an annual income ofThen submit your most recentUnder $25,000Board-reviewed financial statementBetween $25,000 and $750,000IRS Form 990Over $750,000Certified financial auditNote: Applications will not be reviewed unless the above documents are included with the Due Diligence Form for Non-Governmental Organizations. ................
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