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Wellness Strategies for HealthSubaward Application Toolkit

Contents

Introduction.............................................................................................................2Strategy 1: Implement evidenced-informed and culturally adapted policy, systems, and environmental changes (PSE) to prevent obesity..............................3Strategy 2: Implement evidenced-informed and culturally adapted policy, systems, and environmental changes (PSE) to prevent and control commercial tobacco use.............................................................................................................5Strategy 3: Implement evidence-informed and culturally adapted community-clinical linkages (CCL) to support type 2 diabetes prevention.................................6Strategy 4: Implement evidence-informed and culturally adapted community-clinical linkages (CCL) to support heart disease and stroke prevention..................8

Resource List.........................................................................................................10Application Template...........................................................................................13

Part 1: Tribal Health Organization Information......................................................13Part 2: Community Information.............................................................................13Part 3: Project Narrative........................................................................................14Part 4: Project Readiness.......................................................................................20Part 5: Signatures and Approvals..........................................................................21

Strategy Selection Guide.....................................................................................22Budget Template...................................................................................................23

WSH Application Toolkit, 1

Introduction

The materials in this toolkit may prove useful to you as you prepare your application for a Wellness Strategies for Health (WSH) subaward. These awards are being made available through the Centers for Disease Control and Prevention (CDC) Good Health and Wellness in Indian Country (GHWIC) Notice of Funding Opportunity CDC-RFA-DP19-1903, available here.

This toolkit contains a description of the grant strategies and objectives, a resource list for more information about the topics addressed by this grant, an application template, a strategy selection guide, and a sample budget template. The templates can be used as subaward application documents.

StrategiesThe CDC has set out four main strategies in the GHWIC Notice of Funding Opportunity. Those strategies are:

1. Obesity prevention 2. Commercial tobacco use prevention and control 3. Type 2 diabetes prevention 4. Heart attack and stroke prevention

Each applicant must propose work in at least one, but not more than two strategies for the first year of the grant.

ObjectivesFor each strategy, the CDC has also identified specific objectives to pursue. Applicants do not have to address every objective under their chosen strategies. Information on how many objectives should be selected for each strategy is included in the strategy summaries below.

The summaries provided also include examples of possible activities for each objective. Applicants may choose from the activities listed or propose activities that are not listed that will lead to achievement of the objectives.


https://foa.grantsolutions.gov/files/pa/cdc/1046159/1158266.htm

Strategy 1: Implement evidenced-informed and culturally adapted policy, systems, and environmental changes (PSE) to prevent obesity.

This strategy focuses on making sustainable changes that will increase access to healthy food, increase opportunities for physical activity, and increase community support for breastfeeding.

Application Requirement: Applicants proposing to work in this strategy must propose activities under at least two of the three objectives.

Objective 1.1: Increase the number of places offering healthy foods and beverages by making sustainable changes to food and beverage systems or programs.

This objective focuses on making sustainable changes to places where food is served or sold that will increase access to healthy foods (e.g., fresh produce, low-sodium options) and beverages.

Examples of possible activities for this objective: Implement a healthy food policy at a Tribal organization. Work with local grocery stores to increase and promote healthy

food options. Partner with local schools to strengthen healthy food policies and

practices. Pursue administering agency status under the Food Distribution

Program on Indian Reservations (FDPIR).

Objective 1.2: Increase the number of places for safe and accessible physical activity by collaborating with partners on community design.

This objective focuses on increasing access to safe places for physical activity so that it is easier for community members to incorporate physical activity into their daily routines.

Examples of possible activities for this objective: Build partnerships to pursue improvements/expansions to trails,

boardwalks, playgrounds, etc. (Note: funds cannot be used to pay for construction).

Partner with local schools to strengthen physical activity policies and practices.


Establish or expand community access to a gym or exercise facility.


Objective 1.3: Increase the number of places that implement culturally-adapted community support services that support breastfeeding.

This objective focuses on increasing the use of community services that support breastfeeding by building breastfeeding support into community programs, establishing culturally appropriate and accessible lactation services, and providing training to health care providers or other community members who work with mothers and babies. Examples of possible activities for this objective:

Incorporate breastfeeding support into WIC, Early Head Start, or other existing public health programs that serve new families (Note: funds cannot be used to duplicate work being done by existing programs).

Implement breastfeeding support policies at early care and education centers.

Establish one-on-one or group peer support breastfeeding programs in communities.

Assist a hospital in pursuing Baby-Friendly Hospital (see Resource List) designation.


Strategy 2: Implement evidenced-informed and culturally adapted policy, systems, and environmental changes (PSE) to prevent and control commercial tobacco use.

This strategy focuses on work to reduce exposure to secondhand smoke and on supporting tobacco cessation for current tobacco users.

Application Requirement: Applicants proposing to work on this strategy should propose activities under at least one of the two objectives below.

Objective 2.1: Increase the number of commercial tobacco-free policies within workplaces, restaurants, bars, casinos, schools, multi-unit housing, indoor and outdoor events, celebrations, and gatherings.

This objective focuses on implementing or enhancing tobacco-free policies in community settings.

Examples of possible activities for this objective: Expand existing tobacco-free policies to include e-cigarettes,

outdoor spaces, and organization-sponsored events. Implement comprehensive tobacco-free policies in multi-housing

units owned and operated by a THO. Support schools in implementing “gold star” tobacco prevention

and control policies.

Objective 2.2: Increase referrals to evidence-based commercial tobacco cessation treatment, including counseling and FDA-approved medications.

This objective focuses on connecting patients who use tobacco with services and resources to help them quit.

Examples of possible activities for this objective: Implement prompts in electronic health records (EHR) systems

that require tobacco use status to be entered before moving to the next screen.

Establish standard practices for providers that include advice to quit and referral to a cessation resource.

Utilize EHRs to pull lists of tobacco users and do proactive outreach.


Strategy 3: Implement evidence-informed and culturally adapted community-clinical linkages (CCL) to support type 2 diabetes prevention.

This strategy focuses on improving community support for patients with prediabetes and diabetes by expanding access to the National Diabetes Prevention Program (National DPP) in Tribal communities.

Application Requirement: Applicants proposing to work on this strategy should choose at least two of the four objectives listed below.

Objective 3.1: Increase awareness of prediabetes among Tribal members and health care providers/health professionals through efforts such as community-wide events, educational campaigns, or health care provider/health professionals training.

This objective focuses on raising awareness of prediabetes and its prevalence among both community members and health care providers.

Examples of possible activities for this objective: Use existing community events to raise awareness of

prediabetes as a serious health condition. Conduct a local media campaign to share information with the

public on diabetes prevention, screening, or treatment. Provide information or training for health care providers on the

importance of prediabetes screening and testing.

Objective 3.2: Increase prediabetes screening, testing, and referrals to CDC-recognized type 2 diabetes prevention programs (DPPs) by health care teams, community partners, health paraprofessionals.

This objective focuses on improving the number of patients with prediabetes who are identified and referred to a CDC-recognized DPP.

Examples of possible activities for this objective: Coordinate A1C testing at health fairs or other community events

and provide appropriate referrals to patients whose values indicate they are at risk for prediabetes.

Implement prompts in EHR systems to refer patients with prediabetes to an existing DPP.


Objective 3.3: Increase the reach and sustainability of CDC-recognized type 2 diabetes prevention programs (DPP) in Tribal communities. Establishing or expanding the reach of CDC-recognized type 2 diabetes in AI/AN communities and promoting sustainability (for example, by assessing existing resources, CDC-recognized programs offered by other organizations in the AI/AN community, and various methods of program delivery).

This objective focuses on making CDC-recognized DPPs more widely available and accessible to patients with prediabetes in Tribal communities.

Examples of possible activities for this objective: Assess existing DPPs or lifestyle change programs in the

community. Work to establish a DPP or pursue CDC recognition of an existing

DPP. Work to ensure that existing DPPs are sustainable by pursuing

insurance reimbursement or other long-term funding solutions.

Objective 3.4: Increase the number of culturally relevant approaches to increase DPP participation and retention among AI/AN people.

This objective focuses on tailoring DPPs to better suit Tribal communities so that patients with prediabetes are aware of and more likely to engage with these programs.

Examples of possible activities for this objective: Create culturally appropriate communication and training

materials for DPPs to increase participation by AN individuals. Pursue lifestyle coach training for community members. Develop and test innovative program retention strategies.


Strategy 4: Implement evidence-informed and culturally adapted community-clinical linkages (CCL) to support heart disease and stroke prevention.This strategy focuses on detecting heart disease through screening for high blood pressure and high cholesterol in both community and clinical settings and supporting individuals who have high blood pressure or cholesterol in managing those health conditions.

Application Requirement: Applicants proposing to work in this strategy should propose activities under at least two of the three objectives below.

Objective 4.1: Increase the number of community health representatives and other health paraprofessionals who are equipped to deliver evidence-informed, locally available community health programs that support the prevention, detection, and control of high blood pressure and high cholesterol.

This objective focuses on providing training and resources to health professionals to support their work to screen individuals for high blood pressure and high cholesterol and to support patients with high blood pressure or high cholesterol in managing those health conditions.

Examples of possible activities for this objective: Provide training and resources on screening, detection, and

management of high blood pressure and high cholesterol to health care providers.

Perform blood pressure checks at health fairs or other community events and provide appropriate referrals to patients with high blood pressure.

Establish partnerships with local organizations to support community members with high blood pressure or high cholesterol (e.g., offer free or low cost opportunities for physical activity, offer discounts for healthy foods)

Objective 4.2: Increase the number of patients with or at risk for high blood pressure or high blood cholesterol who receive team-based care.

This objective focuses on engaging teams of professionals, including physicians and non-physician members (e.g., nurses, pharmacists, patient navigators), to work together to manage patients with or at risk for high blood pressure or high blood cholesterol.

Examples of possible activities for this objective:


Establish and support blood pressure self-monitoring programs with care team members adjusting care in accordance with the patient’s blood pressure measurements.

Establish clinical systems to refer patients with high blood pressure to health care extenders (e.g., patient navigators or health educators) for assistance with home blood pressure monitoring.

Pursue the use or expansion of web-based tools for health management, such as secure messaging between patients and providers.

Objective 4.3: Increase the number of culturally relevant materials and approaches to link Tribal/village resources and clinical services to support prevention, detection, and control of high blood pressure and high blood cholesterol.

This objective focuses on tailoring health communication strategies and approaches so that patients with or at risk for high blood pressure or high blood cholesterol are aware of and engage with available services to help them manage these health conditions.

Examples of possible activities for this objective: Use existing community events to share information on heart

health and the importance of screening and treatment of high blood pressure and high cholesterol.

Conduct a local media campaign to share information with the public on prevention, screening, or treatment for high blood pressure and high cholesterol.

Connect patients with high blood pressure or high cholesterol with community events or resources that support heart health (e.g., physical activity or lifestyle programs).


Resource List

Resource Description Strategies/Objectives

Baby Café USA Baby Cafés are free resources for breastfeeding mothers, offering support from specifically trained staff, opportunities to share experiences and make friends, and open-forum discussions. This website for Baby Café USA offers information on the organization’s Baby Café model and how to establish a café.

Breastfeeding

Community-Clinical Linkages

The Agency for Healthcare Research and Quality’s page on community-clinical linkages. Page includes a link to AHRQ’s Innovations Exchange, which features examples of successful clinical-community collaborations and more resources for linking clinical practices and community organizations.

CCLs

Community-Clinical Linkages for the Prevention and Control of Chronic Diseases

This document guides public health practitioners on key strategies to implement community-clinical linkages that focus on adults 18 years or older.

CCLsDiabetesHeart Disease

Community-Clinical Linkages to Improve Hypertension Identification, Management, and Control

This issue brief discusses how public health agencies can work with clinical and community partners to improve high blood pressure control, and highlights examples of successful partnerships from the Association of State and Territorial Health Officials (ASTHO) Million Hearts Learning Collaborative.

CCLsHeart Disease

Dietary Guidelines for Americans 2015-2020

The 2015-2020 Dietary Guidelines translates science into succinct, food-based guidance that can be relied upon to help Americans choose foods that provide a healthy and enjoyable diet.

Nutrition

Division of Nutrition, Physical Activity, and Obesity

The DNPAO is a division of the CDC. Look for Proven Strategies on the left-hand

side for links to strategies on nutrition, physical activity, and breastfeeding.

NutritionPhysical ActivityBreastfeeding


https://www.cdc.gov/nccdphp/dnpao/state-local-programs/index.html



https://health.gov/dietaryguidelines/2015/guidelines/



http://www.astho.org/Prevention/Community-Clinical-Linkages-Issue-Brief/



https://www.cdc.gov/dhdsp/pubs/docs/ccl-practitioners-guide.pdf



https://www.ahrq.gov/ncepcr/tools/community/index.html



http://www.babycafeusa.org/


Guide to Strategies to Support Breastfeeding Mothers and Babies

This CDC document provides guidance for public health professionals and others on how to select strategies to support breastfeeding mothers and increase breastfeeding rates. It offers the most relevant information on each type of strategy, including action steps and program examples.

Breastfeeding

Healthy Food Service Guidelines

A set of standards and best practices that make healthier choices more available in food service facilities

Nutrition

IHS Health Promotion/Disease Prevention

The IHS Health Promotion and Disease Prevention (HPDP) program aims to improve health by enhancing preventive efforts at local, regional, and national levels.

Physical ActivityTobacco

Million Hearts Initiative

Million Hearts 2022 is a national initiative co-led by the CDC and the Centers for Medicare & Medicaid Services to prevent 1 million heart attacks and strokes in 5 years. The initiative focuses partner actions on a small set of priorities selected for their impact on heart disease, stroke, and related conditions.

Heart Disease

National Collaboration on Childhood Obesity Research

The mission of the National Collaborative on Childhood Obesity Research (NCCOR) is to accelerate progress in reducing childhood obesity for all children, with particular attention to high-risk populations and communities.

Obesity

National Diabetes Prevention Program (NDPP)

The National DPP provides a framework for diabetes prevention efforts. It brings together partners from the public and private sectors to prevent or delay type 2 diabetes in the United States. A key part of the National DPP is the

lifestyle change program to prevent or delay type 2 diabetes.

Diabetes

Physical Activity and Nutrition Reports and Publications

This page provides links to various Department of Health and Human Services physical activity and nutrition resources.

NutritionPhysical Activity

Physical Activity Guidelines for

The Physical Activity Guidelines for Americans provides evidence-based guidance to help Americans maintain or improve their health

Physical Activity


https://health.gov/paguidelines/second-edition/


https://www.hhs.gov/surgeongeneral/reports-and-publications/physical-activity-nutrition/index.html



https://www.cdc.gov/diabetes/prevention/index.html



https://www.nccor.org/



https://millionhearts.hhs.gov/

https://millionhearts.hhs.gov/

https://www.ihs.gov/hpdp/



https://www.cdc.gov/obesity/strategies/food-serv-guide.html#Guidelines



https://www.cdc.gov/breastfeeding/pdf/BF-Guide-508.PDF




Americans through physical activity.Promising Practices for Commercial Tobacco Prevention and Control in Indian Country

Public health workers in tribes, Tribal organizations, and the CDC funded Tribal Support Center initiative have integrated evidence-based practices and cultural appropriateness in efforts to reduce tobacco prevalence rates and exposure to second hand smoke in Tribal populations. This document provides summaries of some of these promising practices, grouped by the MPOWER model components.

Tobacco

Recommended Community Strategies and Measurements to Prevent Obesity in the United States

This report presents the first set of comprehensive recommendations published by CDC to promote healthy eating and active living and reduce the prevalence of obesity in the United States. This report describes each of the recommended strategies, summarizes available evidence regarding their effectiveness, and presents a suggested measurement for each strategy that communities can use to assess implementation and track progress over time.


Roadmap to Comprehensive Food Service Guidelines

This roadmap is a resource for public health advocates, policymakers, and others who seek to advance, adopt, and implement more effective and equitable food service guideline policies. It includes key considerations, best practices, and resources for improving the food environment in diverse settings, venues, and programs.

Nutrition

Robert Wood Johnson Foundation What Works for Health

Page provides link to evidence-based strategies for a wide variety of public health topics, including chronic disease prevention. Strategies include clinical interventions

(e.g., text messaged-based health interventions).

Tobacco Physical ActivityNutrition Breastfeeding

School Health Guidelines to Promote Healthy Eating and Physical

The guidelines establish a foundation for developing, implementing, and evaluating school-based healthy eating and physical activity policies and practices for students. Each of the nine guidelines is accompanied by



https://www.cdc.gov/mmwr/pdf/rr/rr6005.pdf


https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health



https://cspinet.org/resource/roadmap-comprehensive-food-service-guidelines



https://www.cdc.gov/obesity/downloads/community_strategies_guide.pdf



https://keepitsacred.itcmi.org/wp-content/uploads/2015/06/PromisingPractices-for-Commercial-Tobacco.pdf





Activity a series of strategies for schools to implement.

State of Alaska Tobacco-Free Policies

State of Alaska Tobacco Prevention and Control Program page with model tobacco-free policies and resources for implementing the policies in a variety of settings.

Tobacco

Surgeon General’s Call to Action to Support Breastfeeding

These documents summarize what the Surgeon General is doing to give mothers the support they need to make breastfeeding their first choice for infant nutrition.

Breastfeeding

Ten Steps to Successful Breastfeeding

The Ten Steps to Successful Breastfeeding are the broad framework that guide the Baby-Friendly Hospital Initiative. They were developed by a team of global experts and consist of evidence-based practices that have been shown to increase breastfeeding initiation and duration. Baby-Friendly hospitals and birthing facilities must adhere to the Ten Steps to receive, and retain, a Baby-Friendly designation.

Breastfeeding

Tobacco Reports and Publications

Page provides links to various Department of Health and Human Services tobacco resources.

Tobacco

WSH (Round 1) The Alaska Native Epidemiology Center’s website for the first five-year WSH program with information on partner sites and strategies pursued by each site.

Note: The CDC has modified the strategies for the new GHWIC grant.


http://anthctoday.org/epicenter/wsh.html

https://www.hhs.gov/surgeongeneral/reports-and-publications/tobacco/index.html



https://www.babyfriendlyusa.org/for-facilities/practice-guidelines/10-steps-and-international-code/



https://www.hhs.gov/surgeongeneral/reports-and-publications/breastfeeding/index.html



http://dhss.alaska.gov/dph/Chronic/Pages/Tobacco/TobaccoFreeAlaska/modelpolicies.aspx#schools




Application TemplateThis template is formatted as a single table that can be copied and pasted into a new document and completed.

Part 1: Tribal Health Organization Informationa. THO Name:

b. THO DUNS Number:

c. THO Tax ID Number:

d. Contact Name:

e. Contact Position:

f. Contact Phone Number:

g. Contact Email Address:

Part 2: Community Informationa. Service area population:

b. Number and names of communities that will be served through this project:

c. Estimated number of people served through this project:

Part 3: Project Narrativea. Strategies


Year 1: Select up to two strategies that you will work on in the first year of the project, and indicate why you chose each strategy. If selecting two strategies, you are encouraged to choose one non-clinical strategy (obesity or tobacco use) and one clinical strategy (diabetes prevention or heart disease and stroke prevention).

☐ Strategy 1: Policy, systems, and environmental (PSE) changes to prevent obesity☐ Strategy 2: PSE changes to prevent and control tobacco use☐ Strategy 3: Community-clinical linkages (CCL) to support type 2 diabetes prevention☐ Strategy 4: CCL to support heart disease and stroke prevention

Reasons for choosing first strategy:

Reasons for choosing second strategy (required only if two strategies are selected):

Years 2-4: Select each strategy that you may be interested in working on in years 2-4. Include the strategy or strategies you selected in year 1 if you anticipate working on those strategies for more than one year. ☐ Strategy 1: Policy, systems, and environmental (PSE) changes to prevent obesity☐ Strategy 2: PSE changes to prevent and control tobacco use☐ Strategy 3: Community-clinical linkages (CCL) to support type 2 diabetes prevention☐ Strategy 4: CCL to support heart disease and stroke prevention

Strategy 1: Policy, systems, and environmental (PSE) changes to prevent obesity


Complete this section if you are proposing to work on the obesity strategy. If you are not planning to work on obesity, leave this section blank.

If you are proposing to work on this strategy, you must select at least two of the three objectives. You may select all three objectives.

Obesity Objective: Choose an item.

Activities: List the activity/activities related to this objective that you plan to work on, and describe why you selected the activity/activities.

Obesity Objective: Choose an item.


Obesity Objective: Choose an item.Activities: List the activity/activities related to this objective that you plan to work on, and describe why you selected the activity/activities.

Strategy 2: PSE changes to prevent and control tobacco use Complete this section if you are proposing to work on the tobacco prevention

and control strategy. If you are not planning to work on tobacco prevention and control, leave this section blank.

If you are proposing to work on this strategy, you must select at least one of


the two objectives. You may select both objectives.

Tobacco Objective: Choose an item.


Tobacco Objective: Choose an item.


Strategy 3: Community-clinical linkages (CCL) to support type 2 diabetes prevention.

Complete this section if you are proposing to work on the diabetes prevention strategy. If you are not planning to work on diabetes prevention, leave this section blank.

If you are proposing to work on this strategy, you must select at least two of the four objectives. You may select up to four objectives.

Diabetes Objective: Choose an item.









Strategy 4: Community-clinical linkages (CCL) to support heart disease and stroke prevention.

Complete this section if you are proposing to work on the heart disease and stroke prevention strategy. If you are not planning to work on heart disease and stroke prevention, leave this section blank.

If you are proposing to work on this strategy you must select at least two of the three objectives. You may select all three objectives.

Heart Disease Objective: Choose an item.







ii. Describe the steps you will take to finalize a detailed action plan within three months of grant award.

iii. Describe how you will ensure that your annual action plan is completed. Include information on who at your organization will be involved in completing the action plan.


Part 4: Project Readinessa. Describe any previous policy, systems, or environmental change activities your

organization has worked on for each strategy you are applying for.

b. Staffing Plan i. Which department at your THO will oversee the program?

ii. Name of Department Manager:

iii. Who will serve as the Project Coordinator? Indicate whether this role will be filled by an existing staff member or whether someone new will be hired to coordinate the project.

iv. Describe any other staff who will be involved in coordinating the project and ensuring that the annual action plan is completed.

c. Organizational Support and Project Team i. Please provide a Letter of Commitment signed by the Tribal Health Director.ii. Please provide a Letter/Letters of Support from your Project Champion(s).


iii. List the key people/positions who will participate in your internal project stakeholder team and describe the role of each person/position in the project. Include Letters of Commitment from each potential team member.

d. Reporting and Management i. Describe your organization’s plan for completing quarterly and annual

progress and financial reports.

ii. Describe your organization’s ability to participate in regular (monthly or bi-monthly) project-related meetings with ANTHC EpiCenter staff, other THO partner sites, and the funding agency (CDC). Include information on staff who will participate in meetings and describe your capacity to participate in meetings via teleconference and videoconference.

Part 5: Signatures and ApprovalsTribal Health Organization Name:

Signature: Date Signed:

Print Name and Title:


Strategy Selection Guide

As you are considering which strategy or strategies to work on, you may find it helpful to consider the factors listed below.

Factor Questions to ConsiderImportance How important is it to work on this strategy in your

community or region?Support Are staff in your organization interested in doing this

work? Do your organization’s leaders support working on this

strategy?Capacity Do you have staff who are knowledgeable about this

issue and able to dedicate time to working on it?Impact How many communities or people can you reach by

working on this strategy?Cost Do you have the funding you need to work on this

strategy?Existing Efforts

Is your organization already doing work related to this strategy that you could build on?

Champion Do you have someone in your organization who can be a champion for this strategy?

Enthusiasm Are you excited about working on this strategy? Are others in your organization enthusiastic about it?


Budget TemplateThis template is formatted as a single table that can be copied and pasted into a new document and completed.Category Amount

Requested

Salaries and Wages

Position Name Time % Months

Salary Subtotal $ Fringe Benefits __% of Salaries and

Wages

$

Personnel Subtotal

$ -

Consultant Costs

Nature of Service Name of Consultant# of Days

Expected Rate of

Compensation

Consultant Costs Subtotal $

Equipment $

Equipment Subtotal $ Supplies

Item Requested Type NumberEstimated Unit Cost


Supplies Subtotal $

Travel

TripExpense Category Number of Trips

Number of People

Number of Units

(days)Estimated

Unit Cost

NAME OF TRIP Airfare $

Lodging $ Per Diem-M&IE $ Other (Ground

Transport, Internet, etc.)

$ Trip Subtotal $

Travel Subtotal $

Other

Item Type NumberEstimatedUnit Cost

Other Subtotal $

Contractual Costs

Scope of Work Name of Contractor

Period of Performan

ce

Expected Rate of

Compensation

Contractual Services Subtotal $

Total Direct Costs $ Indirect Costs $ Grand Total $


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