Prevention with Positives (PWP) Project Grant Forms A-I

HIV Prevention with Positives (PWP) Project Grant: Forms A-I

STD, hiv and tb section

Form A: Notice of Intent

All applicants who are interested in submitting a proposal for the Prevention with Positives grant are required to submit Form A by email to 4:30 p.m. on or before Tuesday, April 21, 2017.

1.Agency Information

Agency name:
Agency address (Line 1):
Agency address (Line 2):
Agency general phone:
Agency website:

2.Person authorized to sign official agency grant agreements

Executive Director’s name:
Executive Director’s phone:
Executive Director’s email address:

3.Contact person for proposal

Contact name:
Contact title:
Contact phone:
Contact email address:

4.We plan to work with the following population(s):

5.We plan to work in the following geographical area(s) of Minnesota:

6.If applying as a collaboration list all partners and specify lead agency

Person authorized to sign grant agreements approved the submission of this notice of intent.

Name:Signature:Date:

FORM A: NOTICE OF INTENT

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Form B: Agency Cover Page

Please include all of the required information in the proposal including all attachments. Please do not submit any materials that are not requested.

Agency information

Agency name:
Project name:
Amount requested:

Checklist

A complete proposal must include the following materials.

Use this form as a checklist to ensure you have all the required materials for submission.

__ Form B: Agency Cover Page

__ Form C: Table of Contents

__ Form D. Project Organization Capacity Narrative (5 page limit)

__ Form E: Project Activities Narrative (5 page limit, excludes work plan table and partner chart)

__ Form F: Project Evaluation/Quality Improvement Narrative (3 page limit)

__ Form G: Project Budget Plan/Narrative

__ Form H: Agency Information Certification

__ Form I: Due Diligence Review Form

One of the following items is required for non-government agency:

__ Financial statement - (For organizations with less than $50,000 in revenue)

__ IRS Form 990 - (For organizations with $50,000 - $750,000 in revenue)

__ Certified Financial Audit - (For organizations with more than$750,000 in revenue)

__ If applicable, submit a copy of Federally Approved Indirect Rate

I certify that all the above documents are included in this proposal.

Name:Signature:Date:

FORM B: AGENCY COVER PAGE

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Form C: Table of Contents

FORM C: TABLE OF CONTENTS

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Form D: Project Organizational Capacity Narrative

Maximum 60 points

Agency Name:
Project Name:

Instructions:

▪All questions must be answered

▪Type your answer below the question, do not delete the question

▪Form D cannot be longer than five pages

▪Use 11-12 point Calibri font only

▪Use one-inch margins and single line spacing

▪Separate paragraphs with a blank line in between

Please describe:

The organizational background including mission and major programming. Describe your experience providing medical and/or social support services for individuals living with HIV (Include the number and demographics of clients served, length of time services have been in operation, location where services are provided, access to public transportation and or transportation services provided by the agency).
Agency’s organizational structure and administrative capacity, including executive management, fiscal management, involvement of board members (if applicable). Identify the expertise of your agency’s board members. Identify and describe the staff responsible for program management, administrative/fiscal management, and information technology. (May attach organizational chart - will not count against maximum page limit.)
Experience in effective oversight of administrative, fiscal, and programmatic aspects of government grants. Provide a brief HIV funding history for your organization for the past three years.
Capacity to collect and report client-level data through computer-based applications. Identify the staff responsible for data collection and reporting, evaluation and quality improvement.
What makes your organization well-suited to provide peer support programming and other related services you are proposing? Describe any success your agency has had providing peer support.
Describe your organization’s social media expertise including capacity to develop and implement marketing for peer support services.
If currently providing HIV services describe your sources of funding and how your proposed programming will be monitored for avoidance of funding duplication.

Project organizational capacity narrative:

FORM D: PROJECT ORG. CAPACITY NARRITIVE

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Form E: Project Activities Narrative

Maximum 100 points

Agency Name:
Project Name:

Instructions:

▪All questions must be answered

▪Type your answer below the question, do not delete the question

▪Form E cannot be longer than five pages

▪Use 11-12 point Calibri font only

▪Use one-inch margins and single line spacing

▪Separate paragraphs with a blank line in between

Please describe:

Describe what you propose to do in this project, include the project goals and objectives you plan to address, the targeted population(s) intend to reach and why this/these activities are needed. Using the work plan table (completed work plan template is not included in page limit), describe in detail: how you propose to accomplish each step necessary to implement the project proposed. Include specific activities – potential topics proposed for group sessions.

▪Dates by when you will complete activities

▪Who is responsible for implementing or accomplishing each activity

▪Projected number of individuals to be reached per proposed activity

▪How each activity will be monitored and evaluated

Describe the population(s) that this peer support project will serve. In what capacity is this population currently served at the agency? Describe the strategies that will be used to recruit (venues, social marketing) and/or refer a minimum of 50 unduplicated individuals (attending a minimum of three sessions each within a 12-month period) to the peer support group.
Describe how eligibility for Ryan White services will be determined.
How will the project engage the population served? Give specific examples of how input is gathered from the target population and how consumers will be involved in decision-making processes.
Describe how your agency will ensure that services are culturally and linguistically relevant to the population(s) you intend to serve.
Identify and describe how each expected activity/service funded through this program will be integrated into existing service delivery at the applicant organization.
Describe your agency’s experience and successes working collaboratively with other agencies providing services to your target population.

Project activities narrative:

FORM E: PROJECT ACTIVITIES NARRITIVE

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Form E: Work Plan Table

Agency Name:

Project Name:

Target Population(s):

Activities / Date(s) / Person Responsible / Projected number of individuals / How activity(s) will be monitored and evaluated

Geographic Area:

FORM E: WORK PLAN TABLE

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Form E: Partner/Collaborator Form

Use this Partner/Collaborator form to identify current or potential partners and collaborators for this project, both formal and informal, and describe the roles and responsibilities they will have in this project. Include any letters/agreements of collaboration with service organizations, networks and planning bodies. If your organization does not provide HIV testing and/or PrEP include referral partners for these services.

Complete Partner/Collaborator form for each partner/collaborator.

▪You may duplicate the form if needed, or delete unused forms.

Organization Name:
Contact Person:
Telephone Number:
Organization’s Type: (for profit or nonprofit)
Relationship Status: (New/potential or current. If current, for how long?)
Organization’s role in project: (within the partnership)
Any additional information:

Organization Name:
Contact Person:
Telephone Number:
Organization’s Type: (for profit or nonprofit)
Relationship Status: (New/potential or current. If current, for how long?)
Organization’s role in project: (within the partnership)
Any additional information:

FORM E: PARTNER/COLLABORATOR

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Form F: Project Evaluation/Quality Improvement Narrative

Maximum 30 points

Agency Name:
Project Name:

Instructions:

▪Answer all questions.

▪Type your answer below the question, do not delete the question.

▪Form F cannot be longer than three pages.

▪Use 11-12 point Calibri font only.

▪Use one-inch margins and single line spacing

▪Separate paragraphs with a blank line in between

Please describe:

Describe your management and/or supervisory structure for this project and the staff person(s) who will be responsible for the overall implementation and evaluation of this project. Include, each staff person’s role in the monitoring and evaluation of proposed project, as well as their qualifications and expertise and whether this person is an existing staff person.
For each activity proposed, describe how you will collect the following data, including frequency and instrument to be used:

▪Number of individuals enrolled

▪Documentation of eligibility for Ryan White services

▪Number of sessions each individual attends

▪How you will assess and track if participants are linked to care and/or retained in care

Describe indicators and measures that will be used to determine whether services are meeting the needs of clients and the goals of the project.
How, and at what frequency, will your agency ensure that client input is part of the overall service/project evaluation plan?

Project evaluation/quality improvement narrative:

FORM F: PE/QI NARRITIVE

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Form G: Project Budget Plan/Narrative

Agency Name:
Project Name:

Instructions:

▪Answer all questions

▪Type your answer below the question, do not delete the question.

▪Use 11-12 point Calibri font only.

▪Use one-inch margins and single line spacing.

▪Separate paragraphs with a blank line in between.

Questions:

Describe in-kind contribution your agency will provide to support this project. There is no minimum or maximum to your in-kind contribution.

Complete a Budget Plan using the table provided. The Budget plan shall show the line items (i.e., salaries and wages, fringe benefits, travel, supplies, contractual, other expenses, administrative costs, etc.)

Ensure:

▪That the information in the budget narrative complete, correct, and consistent with the proposed activities.

▪That the costs projected for the proposed activities and staffing levels are reasonable.

Consider the following when completing the budget narrative form. Please provide a brief narrative justification for each line or subline item.

▪Assume a twelve (12) month budget with a start date of July 2017.

▪All costs must directly relate to the provision of this RFP and be reasonable, cost effective and consistent with the scope of services described in project narrative.

▪For all existing staff, including peers, the budget Justification must identify how the percentage of time devoted to this project was determined.

▪Funding may not be used to supplant existing activities but may be used to increase current FTE to reflect proposed activities in your proposal.

▪Funds may not be used to make cash payments to clients

▪Funding may be requested under the administrative cost line to support a portion of the agency’s overall organizational structure to the extent that it allows a funded applicant to implement project activities. This includes funding for administrative and fiscal staff, supervisors and support personnel and other than personal service costs such as a share of space, supplies, telephone, and other expenses indirectly associated with project implementation and service delivery.

▪Agencies without a federally approved rate may request up to 10% of total direct costs.

▪Agencies with a federally approved rate greater than or equal to 10% may request up to 10%

▪Agencies with a federally approved rate of less than 10% may request their approved rate.

FORM G: PROJECT BUDGET PLAN NARRITIVE

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Form G: Project Budget Plan Table

Agency name:
Agency address: (If more than one location use the address of the fiscal office)
Name of budget contact person: (ForJuly 1, 2017 through June 30, 2018)
Contact person phone number:
Contact person e-mail address:

# / Line Item / Dollar Amount / Budget Justification
1. / Salaries / $
2. / Fringe Benefits / $
3. / Travel and Subsistence / $
4. / Supplies / $
5. / Contractual (if applicable) / $
6. / Other Expenses / $
7. / Subtotal / $
8. / Administrative Costs / $
9. / TOTAL / $ / Proposed Amount

Budget Narrative: (Provide a brief justification for each budget item requested below, including how costs were determined.)

Notes: Please ensure that mathematical calculations are accurate.

Remember that evaluation must account for 10% of your overall budget. This can be included in Salaries if evaluation will be conducted by staff, or in contractual if an external contractor will conduct the evaluation. Please indicate where evaluation funds are being allocated in the budget justification.

FORM G: BUDGET JUSTIFICATION INSTRUCTIONS

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Form G: Budget Justification Instructions

Instructions for filling out the Budget allocations/narrative form.

▪Type agency’s name

▪Type agency’s address

▪Type the phone number of the person responsible for completing the budget plan

▪Type the email address of the person responsible for completing the budget plan

▪July 1, 2017 through June 30, 2018

Salaries:

For each position indicate the name, title, the full time equivalent on this project and the total amount for the budget period.

▪Funds can be used for salary of staff members directly involved in the planning, developing, delivering, or supporting of the proposed project

Fringe Benefits:

All other costs, except for compensation, for full- or part-time employees listed in “Salaries” above. These may, but are not required to, include: employer portion of FICA and Medicare, medical and dental insurance, long-term disability insurance, life and accidental death and dismemberment insurance, workers compensation insurance, and unemployment insurance.

▪State each staff person’s fringe per year.

▪State total fringe amount and percent for the budget period.

Travel and Subsistence:

All costs related to the in-state and out-of-state transportation of project employees for approved project activities. Client travel is reported under Other Expenses.

▪Both in-state and out of state travel (mileage & parking) should be calculated here. Mileage should be calculated at a maximum of the current IRS allowable amount.

▪If applicable, in-state travel subsistence (meals, hotel) is listed separately as a sub-line item.

▪Out of state travel should be listed as a sub-line item under travel line item.

Supplies:

All project costs related to the purchase of items with a cost of less than $5,000 must be itemized.

▪Examples: condoms & lube, office supplies, copying costs, brochures & educational material, computer, software, etc.

▪If you provide incentives such as gift cards, list the value of each incentive, the number to be distributed, and the total value. The maximum value of an incentive instrument is limited to $50.00 with one instrument disbursed per individual per occurrence.

Contractual:

If you plan to hire independent contractors for specific services on a fee basis, please indicate: (1) the name(s) of the contractor(s) or consultant(s); (2) the dollar amount(s); (3) the specific expense line items; and, (4) the service(s) being provided.

▪Contract states, “GRANTEE shall develop documentation of subcontracts and any other documents that includes, but is not limited to: 1) description of the contracted activities; 2) budget; and, 3) signatures of appropriate staff from both the GRANTEE and the subcontractor.”

Note: Sub-contracts require prior written approval by MDH.

Other expenses:

All project cost items, not included in the previous definitions must be specified.

▪Examples: office phone, cell phone, internet access, postage, advertising, translation/interpretation costs, costs associated with staff training (fees).

Subtotal:

Total items 1- 6 above.

Administrative costs:

MDH will accept the applicant’s current federally approved indirect cost rate. Applicant must submit proof of their federally approved rate. If an applicant does not have a federally approved indirect cost rate, MDH will allow up to 10% of the total grant award for indirect cost on both federal and state funded program.

▪Administrative costs percentage must match the cost allocations of the PWP project in relationship with other programs in the agency.

▪Administrative Costs are defined as costs that represent the expenses of doing business that are not easily identified with a particular grant, contract, project, or activity but are necessary for the general operation of the organization and the conduct of activities it performs.

Note: Administrative expenses will not be provided to other government agencies or universities.

Total
Total of 7 + 8 above

FORM G: BUDGET JUSTIFICATION INSTRUCTIONS

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Form H: Agency Information Certification

Please answer the following.

Agency name:

Project name:

Mailing address:

Agency website:

Primary contact person:

E-mail Address:

Phone:

Fax:

Agency type:

Nonprofit Status: (Yes or No)

Federal tax identification number:

Or Minnesota tax identification number:

Total budget amount requested:

Proposed target population(s):

Proposed target region/geographic area:

Certification:

I certify that the information contained in this proposal is true and accurate to the best of my knowledge, does not include any trade secrets, and that I have the authority to submit this application.

Name and Title:Signature:Date:

FORM H: AGENCY INFORMATION CERTIFICATION

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Form I: Due Diligence Review

Agency Name:
Project Name:

The Minnesota Department of Health (MDH) must conduct due diligence reviews for non-governmental organizations (NGOs) applying for grants, according to MDH Policy 240. Due diligence refers to the process through which MDH researches an organization’s financial and organizational health and capacity (MDH Policy 240). The due diligence process is not an audit or a guarantee of an organization’s financial health or capacity. It is a review of information provided by a NGO and other sources to make an informed funding decision.