AIDS FOUNDATION OF CHICAGO

FY 2017 Request for Proposals for

Ryan White HIV/AIDS Treatment Modernization Acts Part A

Non-Medical Case Management Services

Issued: Wednesday, November 1st, 2017

Submission Date: Thursday, November 30th, 2017 by 4:00 p.m. CST

RFP Forms Workbook

AIDS Foundation of Chicago

200 West Jackson Blvd., Suite 2100

Chicago, IL 60606

(312)-334-0951

(312)-784-9052 fax

www.aidschicago.org/RyanWhite2017

RFP Forms Workbook Instructions

AFC provided a separate MS Word file “RFP Narrative Workbook” and “RFP Forms Workbook”. Use these documents to format your proposal submission. Download these workbooks from the AFC website aidschicago.org/RyanWhite2017.

Workbook Formatting

Delete the Workbook title and instruction pages included in this workbook. DO NOT submit these pages. Section Breaks are included at the end of each form. Page numbers were not inserted.

Proposal Formatting

The following table lists required forms and appendices for this RFP. Be sure to follow the formatting guidelines on pages 8-9 of the RFP.

Table 7. Proposal Organization

Sections / Proposal Section Order
Title Page / Title Page
Table of Contents / Table of Contents
Section 1 / Agency Experience
Section 2 / Target Populations
Section 3 / Cultural & Linguistic Capacity
Section 4 / Program Description/Scope of Services
Section 5 / Non-Medical Case Management
Section 6 / Payer of Last Resort
Section 7 / Agency Collaborations
Section 8 / Quality Management
Section 9 / Technology & Systems Capacity
Section 10 / Budget Justification
Appendix 1 / Internal Revenue Service 501(c)3
Appendix 2 / Articles of Incorporation
Appendix 3 / Organizational Chart
Appendix 4 / Relevant agency certifications and licenses (if applicable or leave blank)
Appendix 5 / Client Demographics Template
Appendix 6 / Program Work Plan Template
Appendix 7 / Memorandum of Agreement Matrix (for joint proposals and agency linkages)
Appendix 8 / Most recent financial statement or independent audit, OMB Circular A-133 Audit

AIDS Foundation of Chicago

FY 2017 Ryan White CARE Act Request for Proposals

Non-Medical Case Management

Intent to Apply

Organizations interested in applying for funding under the AFC Ryan White CARE Act Request for Proposals are required to submit this “Intent to Apply” form. The submission of the Intent to Apply does not guarantee funding, nor does it require the agency to submit a proposal.

Due Date: November 17th, 2017, by 4:00 p.m.

This form must be submitted to via email or fax to

Organization Name:
Corporate Name if Different:
Administrative Address:
Primary Contact for this RFP:
Email Address:
Phone Number:
Executive Director’s Name: /
Executive Director’s Signature: /

AIDS Foundation of Chicago

FY 2017 Ryan White CARE Act Request for Proposals

Non-Medical Case Management

Proposal Title Page

Organization Name:
Corporate Name if Different:
Administrative Address:
Primary Contact Name:
Email Address:
Phone Number:
Tax ID Number:
DUNS Number:

Counties Served

Select which counties your facility is located in and/or where services will be delivered. Select all that apply.

X / County / X / County
Cook / Kendall
DeKalb / Lake
DuPage / McHenry
Grundy / Will
Kane

Letter of Commitment:

This signature certifies that the Executive Director and/or Board of Directors has reviewed and approved the enclosed proposal in consideration under the Ryan White CARE Act funding.

Executive Director’s Name: /
Executive Director’s Signature: /

AIDS Foundation of Chicago

FY 2017 Ryan White CARE Act Request for Proposals

Non-Medical Case Management

Client Demographics Template

Narrative Section: Target Populations

Organization Name:
Service Category:
Percentage of Clients are: / Client Profile / HIV/AIDS / Affected
Hispanic/Latino / % / %
Non-Hispanic / % / %
White Non-Hispanic / % / %
Black Non-Hispanic / % / %
Asian / % / %
Pacific Islander/Native Hawaiian / % / %
Native American/Native Alaskan / % / %
Percentage of Clients are: / Male / % / %
Female / % / %
Transgender / % / %
Percentage of Clients are: / Less than 2 years / % / %
Children (2-12) / % / %
Youth (13-24) / % / %
Adult (25-64) / % / %
Adult 65 and over / % / %
Percentage of Clients whose mode of transmission is: / Men who have sex with men (MSM) / % / %
Injection Drug User (IDU) / % / %
Men who have sex with men (MSM)/Injection Drug User (IDU) / % / %
Heterosexual / % / %
Perinatal Transmission / % / %
Hemophilia/Coagulation Disorder / % / %
Recipient of a blood transfusion, blood components or tissue / % / %
Unknown/unreported / % / %
Other: / % / %
Other: / % / %
Percentage of clients presenting with other co-factors / Mental Health / % / %
Food/Nutrition / % / %
Housing / % / %
Legal / % / %

AIDS Foundation of Chicago

FY 2017 Ryan White CARE Act Request for Proposals

Non-Medical Case Management

Program Work Plan Template

Narrative Section: Program Work Plan

Organization Name:

Document the primary goals and objectives in this section. Ensure that this template is aligned with and supports narrative descriptions.

Goal A:
Objectives / Target Dates / Lead Staff Person
1
2
3
4
5
Goal B:
Objectives / Target Dates / Lead Staff Person
1
2
3
4
5

AIDS Foundation of Chicago

FY 2017 Ryan White CARE Act Request for Proposals

Non-Medical Case Management

Program Work Plan Template

Narrative Section: Program Work Plan (continued)

Goal C:
Objectives / Target Dates / Lead
1
2
3
4
5
Goal D:
Objectives / Target Dates / Lead
1
2
3
4
5
Goal E:
Objectives / Target Dates / Lead
1
2
3
4
5

AIDS Foundation of Chicago

FY 2017 Ryan White CARE Act Request for Proposals

Non-Medical Case Management

Memorandum of Agreement Matrix

Narrative Section: Collaborations

Organization Name:

Use additional sheets as necessary:

Collaborating Agency / Services Coordinated / Number of Years in Partnership / Lead Staff / Priority Areas Addressed

AIDS Foundation of Chicago

FY 2017 Ryan White CARE Act Request for Proposals

Budget Template for Non-Medical Case Management Services

Narrative Section: Budget Justification Case Management

Organization Name:

Instructions:

Please prepare the following budget based on a 12-month award. Use or adapt this template to add more rows. Do not change the column/row headers or font sizes. Submit additional templates if needed.

1. Percentage of Time on Project - Input this figure as a decimal point. For example, 50% = .50.

2. Salary Request - Multiply the annual salary by the percentage of time, prorate if # of months is less than 12

3. Fringe Benefits Rate - Enter the percentage in the blank provided. If rates vary use an average rate. Multiply this rate by the total of salaries.

4. Grand Total - Sum Total Salary with Total Fringe Benefits lines.

5. Travel – AFC sets standard rates for travel for all FTE’s. Chicago/Cook County is $500.00 per FTE and $750.00 is for each Suburban Cook/Collar Counties FTE. Multiple the total number of FTE’s by the appropriate amount. Sum all travel costs for Total Travel.

I. Program Personnel & Fringe
Name and Title / Annual Salary / # of Months on Projects / % Time on Project / Salary Requested
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
Total Salary
Total Fringe Benefits (______% of Salary) for all staff listed / $
Grand Total Personnel Costs / $

ALL COLUMNS AND ROWS MUST BALANCE

BLANK