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Nebraska Departments of Health and Human ServicesDivision of Public HealthHealth Promotion Unit

Preventive Health and Health Services Block Grant

CHRONIC DISEASE, INFECTIOUS DISEASE AND INJURY PREVENTION AND CONTROL PROJECTS

Request for ApplicationsFY 2015

Phone: 402-471-3485Email: [email protected]

Website: http://dhhs.ne.gov/publichealth/Pages/hpe_phhsbg.aspx

Date of Issuance: Nov 7, 2014

Applications Due: Dec 8, 2014

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http://dhhs.ne.gov/publichealth/Pages/hpe_phhsbg.aspx

mailto:[email protected]

Table of Contents

Application Summary..............................................................................................................................3

Application Overview.............................................................................................................................4

Purpose of Funding....................................................................................................................4

Project Priorities.........................................................................................................................5

Eligible Organizations..............................................................................................................10

Available Funding................................................................................................................... 10

Audit Responsibilities..............................................................................................................10

Project Period...........................................................................................................................11

Potential Continuation Funding................................................................................................11

Use of Funds.............................................................................................................................11

Reporting Requirements...........................................................................................................12

Application Deadline................................................................................................................12

Technical Assistance................................................................................................................13

RFA Timeline...........................................................................................................................13

DHHS Authority.......................................................................................................................13

DHHS Expectations for Grantee Agencies and Organizations................................................14

Application Review Process.....................................................................................................15

Application Instructions........................................................................................................................15

Application Format................................................................................................................................16

FORM A................................................................................................................................................19

FORM B................................................................................................................................................20

FORM C.......................................................................................................................................21 & 22

FORM D.......................................................................................................................................23 & 24

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APPLICATION SUMMARY

Grantor: Nebraska Department of Health and Human Services (DHHS)Division: Public HealthUnit: Health Promotion UnitContact: Barbara Pearson: barbara.pearson@nebraska,gov ; 402-471-3485

The information contained in this summary highlights items of immediate importance to all applicants. Applicants are reminded that this summary is not intended as a substitute for reading all of the materials contained in this document in their entirety.

Funds to Be Awarded: A total of $300,000.00 has been set aside from the Preventive Health and Health Services (PHHS) Block Grant, awarded to the Nebraska Department of Health and Human Services for the period that ends September 30, 2015, will be available to fund Chronic Disease Infectious Disease and Injury Prevention and Control Projects. We anticipate 6 to 10 projects will be funded, ranging from $10,000 to $50,000.

Project Period: January 1, 2015 – August 31, 2015

Funding Purpose: To allow local health agencies and organizations to carry out proven (evidence-based) primary prevention and secondary prevention interventions addressing chronic disease, infectious disease and injury among highly selected populations AND/OR to increase the capacity or competency of agency/organization staff to deliver effective primary or secondary prevention public health interventions.

Funding Restrictions: Funds may only be used to support approved work. These funds must not supplant state, local or private funds that would otherwise be made available for the project.

Reporting Requirements: Narrative describing progress on work plan, data, and expenditure reports are due at mid-term and end of term.

Eligible Applicants: Local/District Health Departments, Tribal Health Departments, other Community-Based Non-Profit Health Agencies.

Application Due Date: 5:00 p.m. Central Time, Dec 8, 2014.

Tentative Award Notification: 5:00 p.m. Central Time, Dec 17, 2014. Response to any contingencies are due Dec 29, 2014.

Review Criteria: Each Application will be reviewed for responsiveness to this guidance: description of the proposed objectives, activities and collaborations, appropriateness proposed budget, budget justification, and project evaluation; previously perceived capacity of applicant to perform the work.

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mailto:barbara.pearson@nebraska,gov

APPLICATION OVERVIEW:

Purpose of Funding

The two related purposes of this RFA are: (1) to increase application of evidence-based primary and secondary prevention strategies in the areas of chronic disease, infectious disease and injury and (2) improve the capacity or competency of local agencies/organizations to carry out effective public health interventions aimed at primary and secondary prevention.

It is intended that all funded projects will carry out careful adaptation of selected interventions to reduce or delay the development of chronic diseases, mitigate the health consequences of infectious disease, prevent or decrease severity of injury, or increase the capacity or competency of local health agencies to carry out effective public health interventions in the areas of chronic disease, infectious disease and injury.

All proposed projects must:1. Help DHHS to achieve a specific Healthy People 2020 Objective. 2. Describe the capacity of the applicant agency/organization and competence of staff.3. Cite an evidence-based intervention that will be adapted with close fidelity to the model.4. Provide clear explanation or evidence of need for the selected intervention.5. Name specific target population, geographic location(s), justifying the selection.6. Show how the proposed work will improve or expand existing prevention interventions

being carried out by the applicant AND/OR 7. Show how the proposed project will increase the capacity or competency of staff to carry

out prevention and control activities following proposed training. Training/education must be well-established as effective. Training/education must be completed during the term of the project.

8. Clearly state how the requested PHHS Block Grant funds complement and supplement any other public health funding currently available to the agency/organization.

9. Maintain and grow partnerships with other community agencies10. Have a budget that’s reasonable for the proposed quantity and quality of activities

described in the work plan.11. Be well-designed in order to show results at the end of the project term on Aug 31, 2015. 12. Be submitted using the forms and format provided in this RFA and meet stated deadlines

for submission.

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Project Priorities

Healthy People 2020 Objectives: (listed in alphabetical order by category, not priority ranking)

All proposed projects must help Nebraska and the nation to achieve Healthy People 2020 objectives, preferably from a list of DHHS-selected priority topics. Applicants should select ONE Healthy People 2020 Objective and ONE strategy to help achieve that objective. If selecting an objective other than those selected as DHHS priorities, the applicant must carefully explain and adequately justify their choice.

Cancer – HP2020

C-20 Increase the proportion of persons who participate in behaviors that reduce their exposure to harmful ultraviolet (UV) irradiation and avoid sunburn

C-20.3 Reduce the proportion of adolescents in grades 9 through 12 who report using artificial sources of ultraviolet light for tanning.

C-20.5 Reduce the proportion of adults aged 18 and older who report using artificial sources of ultraviolet light for tanning.

Recommended Skin Cancer Prevention Strategies and Activitieso Implement the Pool Cool program, a multi-component sun-safety education

program especially designed for use at swimming pools. Main objective: increase awareness, motivation, and sun protection practices among children aged 5-10 who take swimming lessons, parents of children, pool staff, and other pool users. National Cancer Institute link -- http://rtips.cancer.gov/rtips/programDetails.do?programId=288737

EH-14 Increase the proportion of homes with an operating radon mitigation system for persons living in homes at risk of radon exposure.

Recommended Lung Cancer Prevention Strategies and Activitieso Continue or expand interventions designed to increase the number of Nebraska

home owners who test their homes for radon. o Radon is a cancer-causing natural radioactive gas that cannot be seen, smelled or

tasted. Radon is the leading cause of lung cancer among non-smokers and claims about 20,000 lives annually. Nebraska has a very high prevalence of radon in homes. One out of every two homes tested in the state is elevated, however, many Nebraskans have never tested their home for radon.

o Link to EPA’s radon page -- http://www.epa.gov/radon/

Immunization and Infectious Disease Hepatitis C – HP2020

IID-27 Increase the proportion of persons aware they have a hepatitis C infection

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http://www.epa.gov/radon/

http://rtips.cancer.gov/rtips/programDetails.do?programId=288737

http://rtips.cancer.gov/rtips/programDetails.do?programId=288737

Recommended Strategy: Implementation of hepatitis c virus (HCV) prevention education, screening and linkage to care activities in a project that target high-risk individuals, including those in homeless shelters, treatment centers and programs for persons who inject drugs (PWID), and correctional programs serving inmates, work release participants, parolees or those newly released and reentering the community.

Goal: Increase the proportion of persons who are aware of their hepatitis C virus (HCV) infection from 45 percent to 66 percent

Recommended Activities: o Identify and seek to engage new partners and stakeholders (i.e., agencies,

organizations, payers, and providers) in responding to viral hepatitis, particularly allies with the ability to reach vulnerable populations most impacted by HCV to initial a pilot project that includes viral hepatitis prevention education, screening and linkage to care services.

o Collaborate with the Nebraska Hepatitis Program to implement the pilot project for HCV prevention education, screening and linkage to care utilizing a limited amount of rapid HCV tests and RNA confirmatory tests available for this project.

o Determine the prevalence of HCV in the targeted high-risk individuals screened with the pilot project and collect detailed epidemiology data, including specific health disparity information and characteristics to assist in understanding the emerging hepatitis C epidemic in young adults.

o Improve rates of confirmatory testing for persons who screen positive for HCV antibodies by providing onsite testing or linkage to care with providers that will follow the CDC recommendations regarding screening for HCV.

o Link to CDC Hepatitis page -- http://www.cdc.gov/hepatitis/c/cfaq.htm

Injury and Violence Prevention – HP2020

IVP-2 Reduce fatal and nonfatal traumatic brain injuries IVP-2.2 Reduce hospitalizations for nonfatal brain injuries Recommended Brain Injury Prevention Strategies and Activities

o Develop and deliver training for community organizations and agencies for best practices implementation and policy development of the Nebraska Concussion Awareness Act.

o Link to CDC’s Traumatic Brain Injury page -- http://www.cdc.gov/traumaticbraininjury/

IVP-16 Increase age-appropriate vehicle restraint use in children IVP-16.1 Increase age-appropriate vehicle restraint use in children 0 to 12 months IVP-16.2 Increase age-appropriate vehicle restraint use in children aged 1 to 3 years IVP-16.3 Increase age-appropriate vehicle restraint use in children aged 4 to 7 years IVP-16.4 Increase age-appropriate vehicle restraint use in children aged 8 to 12 years Recommended Vehicle Restraint Use Strategies and Activities

o Conduct Safe Kids approved community seat check events

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http://www.cdc.gov/traumaticbraininjury/

http://www.cdc.gov/hepatitis/c/cfaq.htm

o Establish or maintain a Safe Kids approved car seat inspection stationso CDC’s web page link --

http://www.sciencedirect.com/science/article/pii/S0749379701003774

Maternal, Infant and Child Health – HP2020

MICH 21.5 – Increase proportion of infants who are breastfed exclusively through 6 months

MICH 21.2 – Increase proportion of infants who are breastfed at 12 months Recommended Breastfeeding Support Strategies and Activities

o Coordinate professional education opportunities for an array health care providers working in maternity care and/or increase access to professional breastfeeding support either in person, online over the phone, in a group or individually.

Suggested activities as outlined in the CDC Guide to Breastfeedingo Establish a community breastfeeding coalition o Conduct as assessment of professional lactation support in the communityo Address gaps to create a comprehensive, network to provide home-based, clinic-

based, and/or group support as follow-up care to newborns in the community. o Plan and execute training for health care providers which may include, professionals

from primary care, hospital maternity care, or community-based settings. o Coordinate with the local birthing hospitals to develop and disseminate a resource

directory of local lactation support services available to new mothers.o Ensure that WIC participants have professional services for breastfeeding support in

place before they are discharged from the hospital.o Distribute clinical protocols developed by experts such as the Academy of

Breastfeeding Medicine, to local doctors. o Offer training/support for professionals in the community to become an

Internationally Board Certified Lactation Consultant. Link to CDC’s Guide -- o http://www.cdc.gov/breastfeeding/pdf/breastfeeding_interventions.pdf o Recognized Trainings:

Certified Lactation Counselor Training (40 hour certificate program) Milk Mob Training (16 hour program for Primary Care Providers)

Physical Activity – HP2020

PA-3 Increase the proportion of adolescents who meet current Federal physical activity guidelines for aerobic physical activity and for muscle-strengthening activity

PA-13 Increase the proportion of trips made by walking PA-14 Increase the proportion of trips made by bicycling Recommended Physical Activity Strategies and Activities

Build local capacity through community and school wellness teams to increase walking and biking among students and staff.

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http://www.cdc.gov/breastfeeding/pdf/breastfeeding_interventions.pdf

http://www.sciencedirect.com/science/article/pii/S0749379701003774

Recommended activities include assessment, education/training, programming and messaging for a Safe Routes to School initiative.

o Enhance school wellness teams, implement local assessment to identify safe routes to school, education and training (re: Bicycle Safety- helmet use), and programs like a Walking School Bus or Bike Trains.

o More information can be found here at Safe Routes Nebraska: http://www.saferoutes.nebraska.gov/

o Link to CDC Guideline -- http://www.cdc.gov/obesity/downloads/pa_2011_web.pdf

Public Health Infrastructure – HP2020

PH-17 Increase the proportion of Tribal, State and local public health agencies that are accredited

Recommended Strategies and Activities o Launch or continue organizing to meet steps of accreditation process o Link to Public Health Accreditation Board --- http://www.phaboard.org/

Community Health Assessment: Recommended for a group that has never done a health assessment.

PHAB Measure 1.1.1 T – Tribal/local partnership that develops a comprehensive community health assessment of the population served by the health department.

o Establish a partnership (including partners outside the health department) that meets on a regular basis to consider data sources, review data, consider assets and resources, and conduct data analysis.

o The partnership eventually needs to use a collaborative process to identify and collect data and information, identify health issues, and existing Tribal assets and resources to address health issues. For example, the Mobilizing for Action through Planning and Partnerships process would work.

PHAB Measure 1.1.2 T – A Tribal community health assessment that includes:o Data and information from various sources (must include qualitative and

quantitative data)o Demographics of the populationo Description of health issues and health disparitieso Description of factors that contribute to specific populations’ health challengeso Description of existing Tribal or community assessment or resources to address

health issues

Community Health Improvement Plan: Recommended for a group that has already completed a Community Health Assessment within the past year or two.

PHAB Measure 5.2.1 T – A process to develop a Tribal community health improvement plan that includes:

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http://www.phaboard.org/

http://www.cdc.gov/obesity/downloads/pa_2011_web.pdf

http://www.saferoutes.nebraska.gov/

o Broad participation of public health system partnerso Information from Tribal health assessmentso Issues and themes identified by the stakeholderso Identification of Tribal assets and resourceso A process to set Tribal health priorities

PHAB Measure 5.2.2 T – Tribal community health improvement plan adopted as a result of the health improvement planning process

o Tribal community health improvement plan that includes: Desired outcomes of health improvement and priorities for action Policy changes needed to accomplish health objectives Individuals and organizations that have accepted responsibility for

implementing strategies Consideration of local, state, and national priorities

Respiratory Diseases – HP2020

RD-2 Reduced hospitalizations for asthma RD-2.1 Reduce hospitalizations for asthma among children under age 5 years RD-2.2 Reduce hospitalizations for asthma among children and adults aged 5 to 64 years RD-2.3 Reduce hospitalizations for asthma among adults aged 65 and older RD-3 Reduce emergency department (ED) visits for asthma RD-3.1 Reduce emergency department (ED) visits for asthma among children under age

5 years RD-3.2 Reduce emergency department (ED) visits for asthma among children and adults

aged 5 to 64 years RD-3.3 Reduce emergency department (ED) visits for asthma among adults aged 65 and

older RD-6 Increase the proportion of persons with current asthma who receive patient

education. RD-7 Increase the proportion of persons with current asthma who receive appropriate

asthma care according to National Asthma Education and Prevention Program (NAEPP) guidelines.

Recommended Asthma Strategies and Activitieso Maintain or expand recruitment and training of health professionals to offer in-

person educational services to reduce emergency department visits and hospitalizations due to asthma.

o Carry out additional home visitation activities, serving previously identified children and families

o Enhance educational opportunities for health professionals to increase use of current guidelines and establishment of appropriate care for persons with asthma.

o Link to CDC Asthma page-- http://www.cdc.gov/asthma/interventions.htm

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http://www.cdc.gov/asthma/interventions.htm

Tobacco Use – HP2020

TU-11 Reduce the proportion of nonsmokers exposed to secondhand smoke. TU-14 Increase the proportion of smoke-free homes. Recommended Strategy and Activity: Promote Smoke-Free Housing at the local level. Recommended Activities:

o Develop or expand efforts at the local level to increase the number of market-based or public multiunit housing buildings that have a 100% smoke-free indoor policy.

o Assure local property owners and managers are aware of the process for establishing smoke-free policies in multiunit housing facilities.

o Resources available at DHHS Tobacco Free Nebraska website www.smokefree.ne.gov/housing

o http://www.cdc.gov/tobacco/stateandcommunity/best_practices/

Eligible Organizations

Local health departments, tribal health departments and other not-for profit community organizations are eligible to apply for funds.

Only one application per agency/organization will be considered.

Available Funding: Preventive Health and Health Services Block Grant (PHHSBG)

A total of $300,000 has been set aside for competitive subgrants to local entities. We anticipate funding from 6 to 10 projects, ranging from a minimum of $10,000 to a maximum of $50,000.

Audit Responsibilities

1. All Grantee books, records, and documents regardless of physical form, including data maintained in computer files or on magnetic, optical or other media, relating to work performed or monies received under this subgrant shall be subject to audit at any reasonable time upon the provision of reasonable notice by DHHS. Grantee shall maintain all records for five (5) years from the date of final payment, except that records that fall under the provisions of the Health Insurance Portability and Accountability Act (HIPAA) shall be maintained for six (6) full years from the date of final payment. In addition to the foregoing retention periods, all records shall be maintained until all issues related to an audit, litigation or other action are resolved to the satisfaction of DHHS. All records shall be maintained in accordance with generally accepted business practices.

2. The Grantee shall provide DHHS any and all written communications received by the Grantee from an auditor related to Grantee’s internal control over financial reporting requirements and communication with those charged with governance including those in compliance with or related to Statement of Auditing Standards (SAS) 112 Communicating Internal Control related Matters Identified in an Audit and SAS 114 The Auditor’s Communication with Those Charged With Governance. The Grantee agrees to provide DHHS with a copy of all such written

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http://www.cdc.gov/tobacco/stateandcommunity/best_practices/

http://www.smokefree.ne.gov/housing

communications immediately upon receipt or instruct any auditor it employs to deliver copies of such written communications to DHHS at the same time copies are delivered to the Grantee, in which case the Grantee agrees to verify that DHHS has received a copy.

3. The Grantee shall immediately correct any material weakness or condition reported to DHHS in the course of an audit and notify DHHS that the corrections have been made.

4. In addition to, and in no way in limitation of any obligation in this subgrant, the Grantee shall be liable for audit exceptions, and shall return to DHHS all payments made under this subgrant for which an exception has been taken or which has been disallowed because of such an exception, upon demand from DHHS.

Project Period

The project period for this competitive RFA will be for nine months, beginning January 1, 2015 and concluding on August 31, 2015.

The need to align this RFA with work being done or planned under other funding has resulted in a delay in the start date.

The expiration date of the funds dictates a shortened subaward period in order to allow for proper reporting and sufficient time to process final payments. The Final Report due date will be strictly enforced.

Potential Continuation Funding

The DHHS anticipates continued award of PHHS Block Grant funds to Nebraska by CDC. However, the amount of the award is contingent upon the level established in the FY2015 Federal Budget, which is likely to occur late as April, 2015. If the funding is sufficient, it is our hope to continue the best performing projects for another full year.

Use of Funds

Funds may be used only to carry out activities described in their approved work plan.

Permitted Use: Funds may be used to support salaries for project staff, fringe benefits, travel and training costs for project staff (mileages, meals and lodging, registration fees/tuition), project operating expenses (rental of facilities or equipment, printing/duplication, postage, materials and supplies, supplies, office supplies, contractual costs and indirect costs. All budget items must in accordance with Federal guidelines. (See Line Item Budget form provided.) All funded agencies and organizations must be good stewards of federal funds awarded and keep required program and financial records.

Match is not required for projects supported by PHHS Block Grant Funds. Applicants should not show matching funds or in-kind contributions of any kind in their application, Applicants are advised to reserve such resources for applications which require match.

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Funds cannot be used to directly subsidize individuals for the cost of health care, for lobbying, for the purchase of major medical equipment, or to supplant other state, local, or private funds that would otherwise be made available for the project. Funds awarded may not be used for purchase, construction or renovation of real property, e.g., buildings, land, etc. Expenses associated with preparing and submitting a proposal will not be reimbursed. Expenses associated with preparing and submitting an application may not be included in the application budget.

Indirect cost may be included in the proposed budget so long as the amount requested does not exceed the 10% of the amount requested in the project budget.

Reporting Requirements

Grantees will be required to submit a narrative mid-term progress report and expenditure report and a final narrative progress report and expenditure report. Both expenditure report must include scanned copies of all receipts, bills, employee time records, and other appropriate documentation. The reporting schedule is below.

Report Title Period Covered Due DateFirst Half of Term January 1 to April 30, 2015 May 7, 2015Second Half of Term May 1 to August 31, 2015 September 11, 2015

Please note the start date for the project has been delayed to January 1, 2015 to allow for adequate planning time to align this external competitive PHHSBG RFA with (1) the Nebraska State Health Improvement Plan, (2) Nebraska Strategic Plan and (3) selected strategies being developed by the DHHS under on-going and new funding. The DHHS has recently received additional Federal funding to support wide-ranging chronic disease interventions. To avoid duplication of effort, the DHHS has decided to direct the PHHS Block Grant Competitive RFA to topics remaining under-funded.

The end date for the project has been set as August 31, 2015 and the due date for the final progress and expenditure report is September 11, 2015 to accommodate the payment process at DHHS. Final reports must be received on or before that deadline because these funds expire at the end of September 2015.

Application Deadline

A complete application with scanned signature page must be emailed to: [email protected], by 5:00 p.m. Central Time on December 8, 2014.

No extension of the deadline date will be granted. Late, incomplete, or noncompliant applications will not be reviewed or scored. Additions or corrections will not be accepted after the closing date.

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mailto:[email protected]

An original signed application (hard copy) must also be submitted, postmarked no later than midnight December 9, 2014. The hard copy should be mailed to:

Barbara PearsonPHHS Block Grant Health Promotion Unit NE Dept. of Health & Human Services301 Centennial Mall SouthPO BOX 95026Lincoln, NE 68509-5026

All versions of the application, including attachments, become the property of the NebraskaDepartment of Health and Human Services upon receipt and will not be returned to the applicant.

Technical Assistance

During the period following release of this RFA and during the review of applications, all questions must be submitted in writing by December 4, 2014 to: www.dhhs.ne.gov/PHHSBlockGrant. All questions and their respective answers will be posted in writing for viewing on that page. In no case shall verbal communications override written communications. Only written communications will be considered binding.

In the event it becomes necessary to revise any part of this RFA prior to the scheduled submission date, an addendum will be issued to all qualified applicants.

RFA Timeline

Issuance of RFA November 7, 2014Applications Due – email version December 8, 2014Approximate Date of Award Notification with Contingency Definitions December 17, 2014Contingency Responses Due December 29, 2014Anticipated Date of Final Award Notifications January 1, 2015Project Start Date January 1, 2015

DHHS Authority

1. The Department of Health and Human Services reserves the right to withdraw any award if a satisfactory response to contingencies has not been received within 10 calendar days of notice to the applicant by DHHS.

2. DHHS reserves the right to withdraw an award, and/or negotiate the work plan, budget or component of a proposed project. If project deliverables, including progress and expenditure reports are not completed satisfactorily, DHHS has the authority to withhold and/or recover payment of funds.

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http://www.dhhs.ne.gov/PHHSBlockGrant

3. DHHS reserves the right to make all decisions regarding selection among applications to fund or not fund any and all proposed projects

DHHS Expectations of Grantee Agencies and Organizations

1. Grantees are to expend funds in accordance with the approved line item budget. If budget changes are needed that exceed 10% of the total award amount, the grantee must request in writing a budget revision or a work plan amendment. It is up to the discretion of the DHHS whether or not to approve the requested budget revision or work plan amendment.

2. Grantees are reimbursed for actual expenses incurred by the grantee. Grantees must submit mid-term and final reports for expenses incurred during the term. On average it takes 30-45 days for the state to issue payments to grantees. Advance payments for services are not allowed by DHHS. Grantees are encouraged to submit reports to the DHHS in a timely manner to ensure prompt payment of expenses and cash flow maintenance.

3. Grantees are expected to contact the DHHS if they or any community partner or collaborator have difficulties implementing the work plan or need to make changes in the approved activities. DHHS staff members have expertise in many of the topic area listed as priorities for this RFA. To the extent possible, each funded project will be assigned a DHHS staff person to provide Technical Assistance. Requests for such technical assistance must be made in writing by the awardees directly to the PHHSBG Coordinator.

The grantee must be aware that it is legally bound to deliver the services as stated in the work plan. The DHHS will work with the grantee to determine possible solutions or best outcomes. If changes need to be made in the work plan, the grantee must contact the DHHS in writing to request a revision or amendment, including changes in Project Director.

4. Grantees are to maintain accurate records regarding program implementation and evaluation which document the persons and organizations involved, activities carried out, and any materials or information developed. It is expected that these documentation records may include but will not be limited to logs, sign-in sheets, meeting minutes, survey and evaluation data, etc. Copies of the above documents as wells as all receipts, bills, employee records of time, and other appropriate documents are required to be submitted as scanned (electronic) documents with the both the mid-term and final reports.

5. Grantees must submit to the DHHS timely, accurate, and complete progress reports at mid-term and at the end of the subgrant period using the forms, format, and time line provided by the DHHS. All projects will be overseen by the Coordinator of the Preventive Health and Health Services (PHHS) Block Grant, housed within the Health Promotion Unit. Division of Public Health, Nebraska Department of Health and Human Services.

6. Grantees are to be aware that the DHHS may withhold payment for claimed expenses due to lack of documented and/or timely progress, as well as any apparent non-compliance with grant

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requirements. Continued lack of documented and/or timely progress and/or noncompliance with grant requirements may result in funds being redirected.

Application Review Process

All applications will be subject to a technical review to assure that all required documentation has been included. Only those applications successfully clearing technical review will advance to the content review phase of the review process. Applications are judged nonresponsive if they are incomplete, improperly formatted, inadequately developed, or otherwise unsuitable for peer review and funding consideration. Non-responsive applications will not be reviewed further.

During the second phase, experienced reviewers will assess all required parts of the application including the project work plan and narrative, the target population and setting, and budget and budget justification.

Final decisions regarding funding will be based on funds available and the application’s responsiveness to the previously identified priorities.

APPLICATION INSTRUCTIONS

Applications should be typed or word-processed, single-spaced in 12-point typeface, leaving one inch margins. The completed full application must be submitted to:www.dhhs.ne.gov/PHHSBlockGrant as Microsoft Word or Excel or Adobe documents. The email with which the application is submitted serves as the applicant’s signature until the original signature is received in the mail.

An original signed application must be mailed to:Nebraska Dept. of Health & Human ServicesHealth Promotion Unit301 Centennial Mall SouthPO Box 95026Lincoln, NE 68509

All applications must use the following format in describing the proposed project. The Application Package is intended to help assure that all required elements are included in the application. Limit application length to no more than 15 pages, not including attachments. Lengthy applications and unnecessary attachments or supporting materials are discouraged.

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http://www.dhhs.ne.gov/PHHSBlockGrant

Application Format

I. Cover Sheet (FORM A)

Complete all sections of the Cover Sheet.

Project Director - This is the person directly responsible for the oversight of the proposed project. This individual will serve as the liaison between the Preventive Health and Health Services (PHHS) Block Grant and other project staff and will be responsible for the completion and submission of all required documentation.

II. Project Narrative (FORM B) -- Limit to two pages

Proposed project narrative should contain the following:

1. The mission and vision statements of the applicant agency/organization.

2. A description of the applicant’s agency/organization experience over the past few years with projects addressing the selected topic or similar projects. Describe need/gaps in service or capacity that would be addressed by the proposed project. Describe the target population and geographic area. Include baseline data on population(s) served, when applicable.

List the key partner(s) who will actively participate and contribute resources to enhance efforts and describe the contributions of each. Name the local stakeholders who with an interest in project success and describe the process by which the applicant has or will solicit feedback on meeting project objectives.

Identify any barriers or challenges applicant agency/organization and/or partners may encounter in preforming any aspect of this subgrant.

3. A description of the expertise and/or credentials of the Project Director and the Project Coordinator. Indicate what role each will play in the performance of the work plan. Should a new Project Director be assigned during the term of the project, a description of that person’s expertise and/or credentials must be submitted to the PHHS Block Grant Coordinator in writing.

4. A description of what, how and by whom the extent of accomplishment or progress toward the stated goals and objectives will be tracked (examples: numbers of activities carried out, numbers of persons served, or the method by which an estimate of number reached will be calculated). Include a description of how the results of the evaluation and final progress report will be disseminated and communicated.

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III. Project Work Plan (FORM C)

The following statements have been selected as the Goals for all external competitive projects: All applications must work toward achievement of one or both Goals.

Project Goal 1: Continue and expand current primary and secondary preventive services, incorporating evidence-based strategies and well-established models shown to be effective in similar settings.

Project Goal 2: Improve staff capacity or competency through participation in training and/or education in order to improve the effectiveness of future delivery of public health interventions, both primary and secondary prevention.

Objectives and activities should be written to directly relate to the identified needs and strategies proposed. The work plan should describe:

1. Specific tasks to be accomplished, who will be responsible for them, and when they will be accomplished.2. The products that will result from the tasks completed.3. Definitions: An objective is a statement, expressed in terms of time and measures, of a defined health problem or health issue. It should describe specific action(s) designed to promote desired changes in risk factors or risk conditions.

An activity is a statement of the detailed steps that will be taken to achieve the objective.

Objectives must be SMART:Specific: Is there a description of a precise or specific behavior/outcome which is linked to a rate, number, percentage, or frequency?Measurable: Is there a reliable system in place to measure progress towards the achievement of the objective?Achievable: With a reasonable amount of effort and application, can the objective be achieved?Relevant: Can the people with whom the objective is set make an impact on the situation? Do they have the necessary knowledge, authority, and skill?Time-Based: Is there a finish and/or a start date clearly stated or defined?

IV. Line Item Budget (FORM D)

Proposed budget must be reasonable for the proposed quantity and quality of activities in the work plan. The budget should be detailed outlining all costs associated with the project for the term of the subaward.

Budgeted items may include:

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1. Personnel – Personnel costs must be budgeted for separately on the line item budget. The justification should include title, percent full time equivalent (FTE), and dollar amount requested for each position.

2. Fringe Benefits – The justification for this line item should specify which expenses are included in the figure (including but not limited to retirement, FICA, insurance, Workers’ Compensation, etc.)

3. Travel & Training – Funding may be requested to support travel. Mileage should be computed at the State rate, currently $0.56 per mile. The justification should describe how the travel relates to the accomplishment of project objectives. For all travel, indicate who will be traveling and the number of days per trip.

4. Project Operating Expenses – Rental of space and needed equipment, printing and duplication, office supplies and materials, communications/computer and data costs, evaluation costs.

5. Indirect Costs - Indirect costs may not exceed 10% of the requested award amount

6. Contractual – Grantees may contract with another agency or individual for purposes of performing grant activities. The budget must specify the amount to be contracted, and the budget narrative must describe the work to be done. A signed copy of the contract must be submitted to the PHHS Block Grant Coordinator following award of funds.

V. Budget Justification (FORM D – continued)

1. Applicants must provide a justification for the proposed budget in detail noting how estimated expenditures will support the work plan and project goals. An explanation for the calculation of estimated amounts for grant funds must be given for each item listed. Be sure that the budget categories and the line items directly agrees with the descriptions in the budget justification. Applications lacking specificity may delay approval of the proposed budget.

2. Explain the relationship between the proposed project and any current efforts supported by other funding previously acquired by the applicant agency/organization.

3. No In-Kind Contribution or Match is required by the PHHS Block Grant. Do not include in-kind or match in the Line-Item Budget or Budget Justification portions of the application.

VI. Attachments

Attachments should include letters of support from partners and stakeholders. These documents will not count toward the page limit.

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FORM APHHS Block Grant

PREVENTION AND CONTROL PROJECT FY2015 Cover Sheet

Project Title: __________________________________________________________________

Applicant Agency/ Organization: __________________________________________________

Federal Tax Identification Number: __________________________________________

Address: __________________________________________________________________

City/Zip Code: ____________________________________________________________

Project Director

Name: _____________________________

Title: ______________________________

Address: ___________________________

City/State/Zip: ______________________

Phone: ____________________________

Fax: ______________________________

Email: _____________________________

Financial Officer

Name: _____________________________

Title: _____________________________

Address: __________________________

City/State/Zip: _____________________

Phone: ____________________________

Fax: ______________________________

Email: _____________________________

By submitting and signing this application, the applicant agrees to operate the project as described in the application and in accordance with the grant Terms and Assurances.

Authorized official: _____________________________________________________________(Printed name) (Title)

Signature: _______________________________________ Date: ________________________

Healthy People Objective: _______________________________________________________-

Amount of funding requested: $___________________

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FORM BPHHS Block Grant

PREVENTION AND CONTROL PROJECT FY2015 Project Narrative

Project Title: _________________________________________________________

Applicant: _________________________________________________________

1. Mission and Vision Statements.

2. Agency/organization experience, partner and stakeholders list, anticipated barriers or challenges

3. Expertise and/or credentials and role of the Project Director and the Project Coordinator.

4. Description of need and gaps, target population

5. Documentation of results and evaluation strategy

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FORM C

PHHS Block Grant PREVENTION AND CONTROL PROJECT FY2015

Project Work Plan

Project Title: _________________________________________________________

Applicant: _________________________________________________________

Project Goal 1: Continue and expand current primary and secondary preventive services, incorporating evidence-based strategies and well-established models shown to be effective in similar settings.

Objective: Outputs (Activities) Responsible Party

Expected Results

Performance Measures

1.0 1.11.2

2.0 2.12.2

3.0 3.13.2

Project Goal 2: Improve staff capacity or competency through participation in training and/or education in order to improve the effectiveness of future delivery of public health interventions, both primary and secondary prevention.

Objective: Outputs (Activities) Responsible Party

Expected Results

Performance Measures

1.0 1.1

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2.0 2.1

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FORM D

PHHS BLOCK GRANT PREVENTION AND CONTROL PROJECT FY2015

Line Item Budget

Project Title: _________________________________________________________

Applicant: _________________________________________________________

This form can be used in the portrait or landscape page layout.

Line Items Amount RequestedPersonnel (include % FTE for each position)Fringe BenefitsTravel

MileageMeals and LodgingOther (Specify)

Project Operating ExpensesTraining Cost/Tuition/RegistrationRental of facilities, equipmentPrintingPostageMaterials and SuppliesCommunicationsEvaluation Cost

Contractual Indirect Costs (limited to 10% of total project budget)

TOTAL

(Match/Indirect Cost should NOT be shown in the budget.)

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FORM D - continued

PHHS Block Grant Prevention and Control Project 2014-2015Budget Justification

Project Title: _________________________________________________________

Applicant: _________________________________________________________

In the space below, provided a narrative description justifying and accurately reflecting each of the line items of the budget. Describe why the item is needed, how it will be used, how it supports the goal and objectives of the proposed project.

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