H1N1 Preparedness Grant Application



H1N1 Preparedness Grant Application

West Virginia Higher Education Policy Commission

Office of the Vice Chancellor for Health Sciences

1018 Kanawha Boulevard East, Suite 700

Charleston, WV 25301

Deadline for Applications: November 13, 2009

Grantee Organization:

FEIN:

State Vendor No.:

Mailing Address:

Project: H1N1 Preparedness Program

Requested Amount:

Performance Period: August 1, 2009 through July 30, 2010

Chief Executive Officer and Title:

Mailing Address:

Phone Number: Fax Number:

Email:

Contact for Project and Title:

Phone Number: Fax Number:

Email:

Project Description: Briefly describe the H1N1 planning and response goals, objectives, and activities, including the target population (s) to be served through requested grant funds. Include information on the campus locations to be served.

Outcomes: List the actual impacts/benefits anticipated as a result of this project, and how you will measure progress in reaching these outcomes.

Outcome Performance Measure

1. 1.

2. 2.

3. 3.

Implementation Plan: List the phases of project implementation and related activities, including the target dates.

Activity Time Frame

1. 1.

2. 2.

3. 3.

Coordination with Local Health Department and other Community Partners: Describe your approaches with the local health department and other community partners to plan and coordinate H1N1 preparedness activities.

Project Budget

Grantee Name:

Preparer’s Name and Title:

Period Covered: August 1, 2009 – July 30, 2009

A. Personnel:

% Time

Position Salary/Rate on Grant Total Cost

B. Fringe Benefits:

Component Base Rate Total Cost

C. Equipment:

% Paid

Item Item Cost by Grant Total Cost

D. Supplies:

Item Number Price Total Cost

E. Contractual Cost:

Position Service Salary/Rate Total Cost

(Continued next page)

F. Other Expenses (for example, support for planning meetings, public education and communication strategies, etc.):

Item Total Cost

G. Indirect Administrative Costs (must not exceed 8% of Direct Costs)

Formula

Indirect

Base (Total Direct costs) Rate (%) Costs

* * * * * * * * * *

Total Direct Costs (Items A through F): _____________________

Total Indirect Costs (Item G): _____________________

TOTAL GRANT AWARD: _____________________

Grantee Preparer’s Signature Date

For the WV Higher Education Policy Commission Date

APPLICATIONS ARE TO BE SUBMITTED ELECTRONICALLY BY 5:00 P.M.

ON NOVEMBER 13, 2009

E-mailed: bowe@hepc.wvnet.edu

One signed hard copy also needs to be mailed to:

WV Higher Education Policy Commission / Office of Health Sciences

1018 Kanawha Boulevard, East; Suite 700; Charleston, WV 25301

Questions: Contact Becky King, H1N1 Coordinator

E-mail: bk0517@

Phone: 304-757-9456

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