C.M.R. 10, 144, ch. 502, app 144-502-A

Current through 2024-51, December 18, 2024

Appendix 144-502-A - COMMUNITY HEALTH PROGRAM

APPLICATION INSTRUCTIONS

This application is to be developed in two sections. The first section will consist of narrative description of the project and the second section will consist of financial information. It is important that both sections be submitted simultaneously. The application must be submitted as an original and with two copies. A signed cover letter by an authorizing organization official should accompany the application. The cover letter should be a brief abstract describing the objective of the proposal and the basic approach or methodology to reaching the proposed objectives.

Quarterly reporting should be milestones accomplished in accordance with your responses to the narrative questions.

All questions in this section should be answered as completely as possible.

SECTION 1 - PROGRAM DESCRIPTION

This section of your application must be typewritten and double spaced. ALL APPLICANTS must answer the questions in this section.

1 Describe your organization and its structure, identifying principals and their backgrounds.

2 Describe Your current available services, and your organizations' potential to provide the proposed services from Your current base.

3 Describe in detail the community commitment to this project. Evidence of support would be in-kind services, equipment, space, etc.

4 Explain how you propose to make this program self-sustaining after the maximum allowable grant funding period.

5 Explain whether or not this program is a replica from another community or if it can be replicated in another community.

6 Describe any source of local financial support for the proposed program that will exist and provide documentation for source.

7 Describe other funding sources you intend to use or share with the proposed Program.

8 Describe any subcontracted services you anticipate utilizing in this program and Your basis why the services are being subcontracted and not provided by you. Please note the requirements in Appendix D of this document which your subcontract must meet.

SECTION 1a - PRIMARY HEALTH CARE APPLICANTS

Primary Health Care applicants must answer the following questions in addition to the questions in section 1:

9 Describe the problem you are addressing in this Proposal. Include documented need, address community hardship and describe any Problems with access your constituents may have.

10 Provide a detailed statement of how you propose to address the problem described in item 9. You must include a clear statement of goals and achievable objectives; a management plan and timetable (not to exceed the 3 year maximum) specifying strategies to accomplish your objectives, key actions and milestones, roles and capabilities of responsible individuals and organizations.

Demonstrate the ability to coordinate services and programmatic efforts with local primary care providers. Also include a management plan showing objectives, tasks needed in order to achieve those objectives and timetable with measurable milestones, roles of responsible individuals and organizations.

11 Describe with measurable objectives. the impact your proposal will have to improve your community's access to health care. You should address such things as diversification of services, health professional recruitment, transportation, community economics and others.

SECTION 1b - HEALTH PROMOTION AND EDUCATION APPLICANTS

Applicants for the Health Promotion and Education awards must answer the following questions in addition to the questions in section 1.

9 Describe the risk factors you are addressing in this proposal. Identify the prevalence of the risk factor relative to other factors among a targeted population.

10 Describe your target group's special needs and characteristics and address whether or not access and participation will be a problem in your proposed program.

11 Provide a detailed management plan with a clear statement of goals and measurable objectives. Include a, description with timetables of the tasks necessary to meet your objectives. You must also include organizational resources, capabilities of responsible individuals for a 3 year period.

APPENDIX A SECTION 2 B UDGETARY AND FINANCIAL - INFORMATION

All grantees receiving Public funds must disclose all related financial information prior to approval of any grant. Further, all CHP funds must be limited to costs associated with the delivery of the service. A financial glossary explaining allowable and non-allowable expenses is enclosed as Appendix C.

The financial section is comprised of a series of forms designed to summarize and justify a provider organization's financial plan. It is necessary for the grantee to determine the following:

(1) all income which may reasonably be expected to be received by the provider organization during the grant year; and

(2) all expenses which may reasonably be expected to occur during the grant year.

All budgets should be prepared for a three (3) year period unless the program is for a lesser limited time period which should be stated.

The Community Health Program shall determine allowable grantee expenditures based upon the principle of functional accounting (cost sharing). Only balanced budgets will be approved.

INCOME BUDGET FORM (CHPF-003)

On this form, list all anticipated program income for the period of performance of the proposed grant. Include both restricted and non-restricted income. The amounts of the income listed must actually be available to the program.

EXPENSES BUDGET FORM (CHPF-004)

On the Expense Form list all anticipated Program expenses for the period of performance of the grant on an annual basis. Be sure to fill in each years' expense and total all three columns in column 4.

Sub-total each category as requested and provide a total program expense amount on the last line as requested in total program amount column.

All expenses in the Community Health Program must be Justified-on a budget Justification form Expenses such as salaries and fringe benefits which are direct expenses will be documented on CHPF-005. All other direct expenses shall be documented on either CHPF-006, Basis of Distributing Shared Direct Expenses, or on CHPF-007, Other Direct Expense Justification. Indirect costs shall be documented on CHPF-008, General and Administrative Expenses or other approved format.

COMMUNITY HEALTH PROGRAM

PROGRAM INCOME - BUDGET

PERIOD OF PERFORMANCE_____________________________________________

FUNDING SOURCE	YEAR 1	YEAR 2	YEAR 3
1) STATE/FEDERAL
a)
b)
c)
TOTAL
2) LOCAL FUNDING
a.
b.
c.
TOTAL
3) PRIVATE FUNDING
a)
b)
c)
TOTAL
4) PROGRAM INCOME
a) Client Fees
b) Consult Fees
c)
d)
TOTAL
5) OTHER INCOME
a)
b)
c)
TOTAL
TOTAL INCOME

COMMUNITY HEALTH PROGRAM

PROGRAM EXPENSES-BUDGET

(CHPF-004)

LINE ITEM	YEAR 1	YEAR 2	YEAR 3
PERSONNEL EXPENSES
1. Salaries & Wages
2. Fringe Benefits
3. Consultant Fees
4. Providers' Fees
5. TOTAL PERSONNEL EXPENSES
EQUIPMENT
6. Purchases
7. Rental
8. TOTAL EQUIPMENT EXPENSES
SUBCONTRACTS
9. TOTAL SUB-CONTRACTS
ALL OTHER
10. Occupancy Expense
11. Depreciation
12. Utilities
13. Heat
14. Maintenance
15. Telephone
16. Materials & Supplies
17. Travel
18. Insurance
19. Postage
20. General and Administrative (indirect)
21. Other (attach detail)
22. TOTAL ALL OTHER EXPENSES
23. TOTAL EXPENSES (lines 5, 8, 9, & 22)

PERSONNEL. EXPENSES FORM (CHPF-005)

This form provides back-up documentation for lines and 2 of the Expenses Budget Form (CHPF-004).

Complete the form as follows:

Column I Is used to show the number of people to be employed for a particular position at one salary level. Full time persons should be listed. Part-time employment should be indicated by the number of hours spent per week rather than by 1/2 or 1/4 person;

Column 2 Give persons title who will be involved directly in the program.

Column 3 This rate is for one individual. if rates differ, use another line

Column 4 This is the total number- of hours worked for a week for-all personnel listed on that line.

Column 5 Is determined by multiplying column 3 by column 4

Column 6 Is the total number of weeks during the period of performance of the grant that that the individual will be working;

Column 7 Is determined by multiplying column 5 by column 6

Column 8 Self-explanatory

Column 9 Is determined by multiplying column 7 by column 8 by column I

Total Salary Enter column 7 total in Summary Section, Total Salary for proposed year.

In the fringe benefits section, fill in the name of the benefit in the first column; the percentage applied in determining expenses in the second column; and the dollar amount for each benefit in the third column. Total the percentage and expense columns. Enter total expense for fringe benefits in the proposed year column of the summary section.

Add the Total Salary and Total Fringe. Enter the Total Number of Personnel. Total Salary and Total Fringe should be the same as on lines and I and 2 respectively of the Expenses Form CHPF-004.

COMMUNITY HEALTH PROGRAM

PERSONNEL EXPENSES

(CHPF-005) PROGRAM____________

PERIOD OF PERFORMANCE____________

(1) No. of Personnel

(2) Position or Title

(3) Hourly Rate

(4) Total Weekly Hours

(5) Weekly Salary

(6) Number Weeks

(7) Total Salary for Grant Period

(8) % Time Spent on this Program

(9) Total Program Salary for Grant

FRINGE BENEFITS
Type of Benefit	% Payroll	Expense	SUMMARY	PROPOSED YEAR
Total Salary
Total Fringe
Total Salary & Fringe
Total Number of Personnel

BASIS OF DISTRIBUTING SHARED DIRECT EXPENSES (CHPF-0 06)

Direct-costs are costs which can be identified with a particular pro-gram of the sponsoring agency. All direct costs shall be charged directly to the applicable program. Occasionally, a direct cost may be applied to more then one program. CHPF-006 is used to document all direct costs (excluding salaries) listed on the Program Expense form CHPF-004, that are shared between one or more programs.

Complete the form as follows:

(1) Part A, Type of Pool and Part B, Distribution of Base: Some common examples of cost pools and allocation bases are:

Cost Pools	Distribution Base
Administrative Costs	1. Number of personnel
2. Accumulated costs
3. Percentage of total payroll
Operation and Maintenance of Building	1. Square feet of area occupied
2. Number of personnel

(2) Part C, Components of Pool:

List all line items (line items should correspond to line items on Program Expense Form) which are associated with cost pool and are allocated using the some base distribution. In addition, list the total expenses for the line items within the cost pool for the period of the proposed grant.

(3) Part D, Allocation of Pool:

All programs sharing in these expenses must be listed. The number of base units assigned to each must be identified and the percentage of total base units assigned to each must be determined.

(4) Part E, Program Costs:

The percentage of units assigned to the Program is multiplied times each line item amount in Part C, Total Expenses, to arrive at the Program costs. The resulting amounts must equal those listed on the corresponding lines of the Program Expense form.

COMMUNITY HEALTH PROGRAM

BASIS OF DISTRIBUTING SHARED DIRECT EXPENSES

A. TYPE OF POOL:	B. DISTRIBUTION BASE:
C. COMPONENTS OF POOL:	TOTAL EXPENSES	CHP PROGRAM EXP
1.
2.
3.
4.
5.
6.
7.
8. TOTAL	$	$
D. ALLOCATION OF POOL:
PROGRAM OR COST CENTER	DISTRIBUTION OF BASE UNITS	% OF TOTAL UNITS
1.
2.
3.
4.
5.
6.
7.
8. TOTAL

OTHER DIRECT EXPENSE JUSTIFICATION (CHPF-007)

This form is used to explain all direct line item expenses listed that are-not shared with another program. Expenses should be briefly and clearly explained.

COMMUNITY HEALTH PROGRAM

OTHER DIRECT EXPENSES (CHPF-007)

PROGRAM: PERIOD OF PERFORMANCE

line item no. -

Description of line item - Basis of Expense

Total line item exp

GENERAL AND ADMINISTRATIVE EXPENSES (CHPF-008)

A simplified form (CHPF-008) is included for your use, OTHER FORMATS MAY BE USED UPON APPROVAL OF THE GRANT MANAGER.

a. In Section 1, column 1, Total Agency Expenses, record all anticipated expenses of the sponsoring agency for the period of performance of the proposed grant. In column 2, Exclusions and Unallowables, list any expenses not allowable. In column 3. General and Administrative Expenses specify the amount of total allowable agency expenditures that will be used for general and administrative expenses and that will be shared among the sponsoring agency's program.

b. From the total general and administrative expenses listed in column 3, line 22 subtract line 23, G & A credits applied to general and administrative expenses. G & A CREDITS ARE defined as specific purpose funds applied against general and administrative expenses. These funds must be deducted from the total allowable general and administrative costs to determine net allowable general and administrative expenses. CHP funding will be based on not allowable general and administrative expenses (section 1, line 24)

c. In Section 11, Part A, indicate the basis for the distribution of the general and administrative expenses, for example, accumulated costs, number of personnel, percentage of total payroll.

d. In Section 11, Part 8, record in box (1) the total base units for the entire agency. Of that total indicate in box (2) the amount of units assigned to this program and (3) the amount of units assigned to all other programs operated by the parent agency. Box (4) will always be 100%. Determine in box (5) the percentage of the total base units assigned to this program and in box (6) determine the percentage of base units assigned to all other programs operated by the parent agency.

e. In Section II, Part C, determine the Program's share of the general and administrative expenses by multiplying the Balance of Administrative Expenses Shared Among Programs (Section 1, Line 24) by the Program's Percentage of Base Units (Section II, Part 8, Subsection 5). This figure should appear on Your Program Expense (CHPF-004) in the general and administrative line item.

COMMUNITY HEALTH PROGRAM

GENERAL AND ADMINISTRATIVE EXPENSES

(CHPF-008)

PERSONNEL EXPENSES	Section I(1) Total Agency Expenses	(2) Exclusions & Unallowables	(3) General Admin Expenses
1. Salaries & Wages
2. Fringe Benefits
3. Consultant Fee
4. Providers' Fee
5. Total Pers. Exp
EQUIPMENT
6. Purchases
7. Rental
8. Total Equip Exp
SUBCONTRACTS
9. Total Sub-contracts
ALL OTHER
10. Occupancy Expense
11. Depreciation
12. Utilities
13. Heat
14. Maintenance
15. Telephone
16. Materials & Supplies
17. Travel
18. Insurance
19. Postage
20. Other (attach detail)
21. Total All Other
(lines 5, 8, 9, & 21) 22. TOTAL EXPENSES
Less G & A Credits applied to General & 23. admin expenses
Balance of Admin Exp 24. Shared Among Prog.
SECTION II
A. BASIS OF DISTRIBUTION OF GENERAL & ADMINISTRATIVE EXPENSES:	b. TOTAL BASE UNITS (1)	THIS PROGRAM (2)	ALL OTHER PROGRAMS (3)
% Direct Salaries	(4)	(5)	(6)
C. PROGRAM SHARE OF GENERAL AND ADMINISTRATIVE EXPENSES $

DETERMINATION OF CHP PERCENTAGE OF EXPENSE REPORT (CHPF-010)

It is important to complete this form correctly.

In Section A: Complete the income and expense entries based upon anticipated budget.

In Section B: List adjustments (eliminations and unallowables) to the income and expense columns. Determine the Balance by subtracting the Expenses column from the Income column. Total the Income, Expenses and Balance columns.

In Section C: Determine total available for cost-sharing by subtracting the total adjustments 'B' from Total-per Reports in 'A'.

In Section D: Bring totals from 'C' to respective Total columns in "D", (Available Income, Allocated Expense and Balance columns.

(1) List all funding sources, including client fees.

(2) List % of total income budget (from CHPF-003)

(3) List available (actual) income from each funding source under 'Available Income'

(4) Determine % of Available Income for each funding source. List % under % of Total Available Income" column.

(5) Apply % of each funding source to Total available for cost sharing, to determine the Allocated Expense for each source.

(6) Subtract Allocated Expense column from Available Income column for each funding source to determine balance due each funding source.

IN-KIND CONTRIBUTIONS

For all In-kind contributions, list on a separate page the sources and the value of all anticipated In-Kind contributions and attach to the grant.

COMMUNITY HEALTH PROGRAM

DETERMINATION OF CHP PERCENTAGE OF EXPENSE REPORT

(CHPF-010)

AGENCY NAME		PROG TITLE
PERIOD OF PERFORMANCE:		TO
Income	Expense	Balance
A.	TOTAL -Per Reports to DPAD
B.	ADJUSTMENTS
C.	TOTAL ADJUSTMENTS
D.	COST SHARING

Funding Sources	% of total Income Bud.	% of total Avail Income	Available Income	Allocated Bal Expense
TOTALS

C.M.R. 10, 144, ch. 502, app 144-502-A