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Minnesota Evidence-Based Fam-ily Home Visiting Grant ProgramREQUEST FOR PROPOSAL MATERIALSLetter of Intent Deadline: December 7, 2017
Proposal Deadline: February 1, 2018
Minnesota Evidence-Based Family Home Visiting Grant Program Request for Proposal Materials
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Community and Family Health DivisionMinnesota Department of HealthFamily Home Visiting SectionPO Box 64882St. Paul, MN 55164-0882651-201-4090www.health.state.mn.us/fhv/
November 14, 2017
Revised on December 7, 2017: Revisions are noted on pages 20 and 42.
Revised on December 13, 2017: Revisions made throughout the RFP to the application deadline and grant start date.
Upon request, this material will be made available in an alternative format such as large print, Braille or audio recording. Printed on recycled paper.
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ContentsMinnesota Evidence-Based Family Home Visiting Grant Program.................................................0
Program Overview.....................................................................................................................4
Introduction...........................................................................................................................4
Program Description..............................................................................................................6
Project Narrative and Work Plan for Implementation Grant Applicants..................................12
Budget Section.........................................................................................................................19
Introduction.........................................................................................................................19
Incentives.............................................................................................................................19
Required Budget Forms.......................................................................................................20
Budget Scoring.....................................................................................................................20
Program Requirements........................................................................................................21
Forms....................................................................................................................................... 22
Form A: Application Face Sheet...........................................................................................23
Form B: Work Plan...............................................................................................................24
Form C: Budget Justification - Instructions..........................................................................25
Form E: Budget Summary....................................................................................................32
Form F: Due Diligence Review..............................................................................................33
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Purpose................................................................................................................................... 33
Definition.................................................................................................................................33
Instructions..............................................................................................................................33
Organization Information Questionnaire...............................................................................33
Additional Documentation Required......................................................................................36
Form G: Indirect Cost Questionnaire...................................................................................38
Appendices.............................................................................................................................. 39
Appendix A: Criteria for Scoring Applications......................................................................40
Appendix B: Definitions........................................................................................................42
Appendix C: Home Visitor Staffing Plan...............................................................................45
Appendix D: Minnesota Family Home Visiting Evaluation Measures...................................46
Appendix E: Grant Agreement Sample.................................................................................48
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Program OverviewIntroductionThis Request for Proposal (RFP) document provides the instructions, forms and information needed to complete the Evidence-Based Family Home Visiting (EBHV) grant application. It is suggested that these instructions and a copy of the Criteria for Grant Review Score Sheet (Appendix A), be examined prior to writing the application.
Minnesota Department of Health (MDH) staff will be available to provide limited consultation and guidance during the application process. All questions or requests for assistance must be submitted to [email protected]. MDH Family Home Visiting staff should not be directly contacted with questions or requests for assistance related to the application. In addition, MDH will maintain Frequently Asked Questions on the MDH Family Home Visiting Grant s website , which will be updated as needed. Please note that MDH staff will not be able to help with writing the application.
Application Review, Scoring, and Funding RecommendationsThis is a competitive grant application. Eligible applications will be reviewed and scored according to the Criteria for Scoring the Evidence-Based Home Visiting Grant applications (Appendix A).
Reviewers may include MDH staff, staff from state agencies with experience related to family home visiting, maternal and child health, and early childhood, or individuals who are familiar with or who have provided services to pregnant and parenting families. Reviewers will be required to identify any conflicts of interest and will not review an application if a conflict is identified.
Final funding recommendations will be based on the scores and comments from reviewers. Consideration will be given to distributing funding throughout the state and meeting the funding priorities identified in the Minnesota Statutes Minnesota Session Laws 2017, First Special Session, Chapter 6, Article 18, Section 3, Subdivision 2. It is anticipated that grant award decisions will be made in March 2018. Applicants will be notified whether or not their grant application is selected for funding.
Awarded applicants that are not current vendors in the State’s SWIFT system will need to get set up as vendors before a grant agreement can be created. Instructions on how to do that will be sent out to awarded applicants after the awards are announced.
The grant agreement will then be executed with the applicant agency being awarded the funds. The effective date of the agreement will be May 1, 2018, or the date upon which all signatures to the agreement are obtained, whichever is later. The grant agreement will be in effect until December 31, 2022. There may be negotiations to finalize the work plan, grantee’s duties, and/or budgets before a grant agreement can be fully executed.
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The grantee will be legally responsible for assuring the implementation of the work plan, compliance with all state and federal requirements, including worker’s compensation, nondiscrimination, data privacy, budget compliance, and reporting requirements.
Applications and Data PrivacyApplications are nonpublic until opened. Once opened, the name of the applicant, the address of the applicant, and the amount the applicant requested is public. All other data in an application is nonpublic data until completion of the evaluation process. After the evaluation process has been completed, all data submitted by the applicant is public.
All materials submitted in response to this RFP will become property of the State and will become public record in accordance with Minnesota Statutes, section §13.599 after the evaluation process is completed. Pursuant to the statute, completion of the evaluation process occurs when the government entity has completed negotiating the grant agreement with the selected grantee. This is defined as when a grant agreement is fully executed (signed by all parties). If the applicant submits information in response to this RFP that it believes to be trade secret materials, as defined by the Minnesota Government Data Practices Act, Minnesota Statute §13.37, the applicant must:
Clearly mark all trade secret materials in its response at the time the response is submitted; Include a statement with its response justifying the trade secret designation for each item;
and, Defend any action seeking release of the materials it believes to be trade secret, and indem-
nify and hold harmless the State, its agents and employees, from any judgements or dam-ages awarded against the State in favor of the party requesting the materials, and any costs connected with that defense. This indemnification survives the State’s award of a grant con-tract. In submitting a response to this RFP, the applicant agrees that this indemnification survives as long as the trade secret materials are in possession of the State.
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Program Description
BackgroundIn 2017, the Minnesota state legislature awarded the Minnesota Department of Health $12 million in funding over state fiscal years 2018 and 2019 and $16.5 million per year starting in state fiscal year 2020 to start up or expand evidence-based home visiting programs.
Purpose of the FundingThe purpose of this Request for Proposals (RFP) is to identify organizations interested in starting-up or expanding selected evidence-based home visiting models to serve families in need. These models are intended to be implemented at the community level as part of a coordinated, integrated system of early childhood services.
The Minnesota EBHV Grant program has an estimated total amount of $3.2 million per year for grantee funding under this RFP for the period of May 1, 2018 – December 31, 2022. Continued funding may be available and is contingent upon continued state funding. MDH anticipates funding up to 12 applicants under this RFP to provide evidence-based home visiting services to families in Minnesota.
Applicants may include community health boards, non-profits, and tribal nations. Interested applicants may propose the implementation of new or expanded services or propose a planning or implementation grant.
Definitions, a list of defined terms used throughout this RFP, can be found in Appendix B.
Grant awards are for planning or implementation of a new or expanded evidence-based home visiting model:
Planning Grants (anticipate 2-3 awards): New or existing home visiting programs, proposing an evidence-based home visiting model, may apply for up to 14 months (5/1/18 through 06/30/19) to collaboratively implement an evidence-based home visiting model. During the planning grant period, grantees will work with community partners, model developers, and MDH staff to determine which evidence-based home visiting model(s) best serves their community. They will also develop and implement a workplan of collaboration and next steps that will allow them to submit an implementation proposal for the next round of EBHV grant funding. MDH anticipates releasing an additional $10 million for EBHV funding in summer/fall 2019.
Implementation Grants (anticipate 8-10 awards): New or existing evidence-based home visiting programs may apply for an implementation grant. This funding is available to sites ready to implement a new or expand an existing evidence-based home visiting model. Implementation grants support start-up and expansion needs including training, staff, and reflective practice.
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Program Goals and ComponentsThe goal of the Minnesota Evidence Based Home Visiting (EBHV) program is to equip parents and other caregivers with the knowledge, skills, and tools to assist their children in being healthy, safe, and ready to succeed in school. The overall goal of the Minnesota EBHV is to:
Expand services provided through evidence-based home visiting models in Minnesota by coordinating with and building on federally and locally funded programs;
Improve coordination of services for families; and, Identify and provide comprehensive services to improve outcomes for families.
The Minnesota EBHV program will support the development of evidence-based home visiting models in communities that serve families such as parents with high risk or high needs, parents with a history of mental illness, domestic abuse, or substance abuse, or first-time mothers prenatally until the child is four years of age, who are eligible for medical assistance under Minnesota Statutes, chapter 256B, or the federal Special Supplemental Nutrition Program for Women, Infants, and Children.
The initiative also contributes to the development of an integrated system of early childhood services to meet the complex and diverse needs of at-risk families and communities across Minnesota. Expected outcomes include improvements in maternal and prenatal health, infant health, and child health and development; reduced child maltreatment; improved parenting practices related to child development outcomes; improved school readiness; improved family socio-economic status; improved coordination of referrals to community resources and supports; and reduced incidence of injuries, crime, and intimate partner violence.
Funded applicants will be required to provide data and reports on participating families and services provided; participate in state evaluation efforts; coordinate services to ensure the complex and diverse needs of the identified at-risk communities are being met; and fulfill the grant requirements outlined in the grant agreement. Funding needed for collecting and submitting required evaluation data, including modifications to computer systems, should be included in the proposal submitted.
Priority will be given to applicants who propose to serve: Low-income families Families with pregnant women Families with women who have not attained age 21 Families that have a history of child abuse or neglect or have had interactions with child
welfare services Families that have a history of substance abuse or need substance abuse treatment Families that have users of tobacco products in the home Families that are or have children with low student achievement Families with children with developmental delays or disabilities
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Families that include individuals who are serving or formerly served in the Armed Forces, including such families that have members of the Armed Forces who have had multiple deployments outside of the United States
Eligibility CriteriaEligible applicants include community health boards, nonprofits, and tribal nations.
All applicants submitting an application for funding are advised that in accepting state dollars under this RFP, as a sub-recipient, they will be required to comply with all state laws, executive orders, regulations, and policies governing these funds.
All applicants must meet the following criteria in order to be considered eligible:
Serve, or plan to serve, families such as parents with high risk or high needs, parents with a history of mental illness, intimate partner violence, or substance abuse, or first-time mothers prenatally or until the child is four years of age, as prescribed by model developers, who are eligible for medical assistance under Minnesota Statutes, chapter 256B, or the federal Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).
Implement an evidence-based home visiting model. Refer to this list of 17 evidence-based home visiting models eligible under this RFP. Applicants planning to start-up or expand implementation for the following evidence-based models will be given priority consideration: Healthy Families America, Nurse Family Partnership, Family Spirit, Early Head Start, Family Connects or Parents as Teachers.
Submit one application that includes all applicants who are applying as a multi-partner or regional collaboration. The application must describe the home visiting approach and program. Applicants may not submit more than one application requesting funding for the same population.
Select a defined community for which they will provide services. Applicants need to justify how the selected community is a viable and feasible area in which to provide services.
Implementation grant applicants must provide documentation that demonstrates the capability and capacity for implementing (start-up or expansion), and sustaining a successful evidence-based home visiting model. In addition to the criteria listed above: implementation grant applicants must meet the following criteria:
If starting a new evidence-based home visiting model: Applicants may apply to establish a new evidence-based home visiting model based on
community needs. Applicants must meet an identified gap in the exisitng continuum of early childhood
services and complement, rather than duplicate, existing home visiting services.
Applicants must be able to demonstrate an ability to reach their projected target caseload within one year of funding.
Applicants must be able to demonstrate that they are supplementing not replacing existing funds being used for evidence-based home visiting services as of June 30, 2017.
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If expanding an evidence-based home visiting model:
Applicants must demonstrate sufficient additional need in an identified high-risk area, and the ability to expand the current home visiting program to meet those needs.
Applicants for expansion must have had an average enrollment of 85% or more of their target caseload for the period of July 1, 2017 – December 31, 2017.
Applicants must be able to demonstrate an ability to reach their projected target caseload within one year of funding.
Applicants for expansion must maintain their current level of funding for existing evidence-based home visiting programs.
Applicants must be able to demonstrate that they are supplementing not replacing existing funds being used for evidence-based home visiting services as of June 30, 2017.
Questions and Information SessionsThere will be a technical assistance webinar to assist in writing the application. Applicants do not need to attend the webinar to submit an application. The technical assistance webinar will include a review of the main components of the grant application. Questions about the grant application will not be addressed during the webinar, but will be gathered, answered and posted on the Family Home Visiting web site.
The webinar will be held using WebEx technology so that applicants can participate at their desk using a computer with an internet connection and a phone line. The technical assistance webinar will be held on Thursday, November 30, 2018, from 12:00 – 1:00 pm. To participate in the webinar, click here.
All questions must be submitted by December 4, 2017 to [email protected]. MDH will post “Answers to Grant Application Questions” by December 11, 2017 on the Family Home Visiting web site.
Letter of IntentApplicants are strongly encouraged to submit a Letter of Intent (LOI) to apply for funding under this RFP. Letters should include:
The name of the primary applicant and any entities partnering with the primary applicant, if known, for this RFP;
Contact information for the primary applicant and any partnering entities, including phone number(s) and e-mail address(es);
Type of grant application: planning or implementation. If implementation, indicate whether this is for start-up or expansion;
The proposed community or population and geographic area to be served; The anticipated evidence-based model(s) that will be funded under this request; and, The anticipated target caseload that would be funded, if awarded, through this RFP
once the program is at full capacity (typically 2nd year).
A list of applicants that submit an LOI will be shared amongst all the applicants to allow for and encourage coordination where possible. Letters of Intent must be submitted electronically by
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4:00 pm (CST) on December 7, 2017 to: [email protected] with EBHV LOI included in the subject line.
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Project Narrative and Work Plan for Planning Grant Appli-cantsThe project narrative and work plan describes the applicant’s organization and what is intended to be accomplished. To assist applicants, MDH has provided detailed instructions on what information should be included and what grant reviewers will be reviewing in each application. Planning grant applicants must complete the project narrative components described below.
The Project Narrative is divided into distinct sections and should be submitted in the sequence stated below:
A. Abstract (two pages or less)Provide a summary of your application. The summary should be clear, accurate, concise, and without reference to other parts of the application. The abstract must be single-spaced, limited to two pages in length, and include the following sections:
Annotation: Provide a three-to-five-sentence description of your project that identifies the project’s goal(s) and the population and/or community needs that are addressed.
Primary applicant’s name and the name(s) of all partnering entities Community(ies) served by the proposed activities in this application Type of grant: Planning Problem: Describe the principal needs and problems addressed by the project. Purpose: State the purpose of the project. Goal(s) And Objectives: Identify the major goal(s) and objectives for the project.
Typically, the goal(s) are stated in a sentence, and the objectives are presented in a numbered list.
Methodology: Briefly list the major activities used to attain the goal(s) and objectives.
B. Statement of Need (one page or less)Please describe the need that you are addressing in the community as you plan for start-up or expansion of an evidence-based home visiting model. Include information about target population (if known); any needs assessment that was completed by the applicant separately, or in collaboration with other community partners; any gaps or overlaps in the continuum of home visiting services (if known), etc.
C. Organizational Capacity (one page or less) Summarize your history and experience related to home visiting. Describe any support you have received for this grant application, including
agency or governing body support. Describe your history and capacity to fund home visiting services, including third
party billing.
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Identify the evidence-based home visiting model to be implemented, or those models being considered.
D. Linkages and Collaboration (one page or less) Describe your collaboration with community partners related to planning or
implementation of the evidence-based home visiting model. Describe any proposed or current regional partnerships, including discussions
that have occurred.
E. Purpose, Goals and Objectives (one page or less) State the purpose of the project. Identify the goal(s) and objectives for the project. Typically, the goal(s) are stated
in a sentence, and the objectives are presented in a numbered list. Objectives should support progress toward goals.
Utilize the SMART objective framework: specific, measurable, achievable, realistic, and time bound are characteristics of SMART objectives.
F. Challenges and Plan for Resolution (one page or less)Please describe any challenges or barriers to planning for start-up or expansion of an evidence-based home visiting model. Include any potential staffing, logistical, outreach or family engagement, and community partnership challenges. Describe potential solutions to the identified challenges.
G. Work Plan (no page limit)All planning grant applicants shall submit a completed Work Plan that includes a description of the goals/objectives, planned activities, responsible staff, and timeframes. The Work Plan must include the goals, objectives, and activities that the applicant has included in the project narrative. Your objectives and activities should address topics such as, but not limited to:
Developing a referral network Continuous quality improvement, including team and participation Community Advisory Board Program funding, budgeting and sustainability Reflective practice Required MDH reporting, including quarterly reports and monthly data
submission Model fidelity and accreditation Integrating into the early childhood system Meeting target caseload
Additionally, the planning grant applicant must include as an activity in the Work Plan to develop a comprehensive summary of the applicant’s overall home visiting budget, including all major home visiting funding sources. Complete the Work Plan Form B. Note: If the application is approved and funded at the level requested, the Work Plan will be incorporated into the grant agreement between the State and the grantee
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applicant as Grantee’s duties. A Work Plan must be completed according to directions so it can be separated easily from the rest of the application.
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Project Narrative and Work Plan for Implementation Grant ApplicantsAll implementation grant applicants shall submit a comprehensive narrative description of community needs and resources and clearly justify why the selected evidence-based home visiting model is appropriate for addressing the identified gap in services for at-risk families. The capacity of the proposed program to enroll and maintain the projected target caseload must be clearly demonstrated. The applicant must describe its capacity and capability for meeting all programmatic data and reporting requirements. The applicant must also detail planned activities and a timeline necessary to achieve program goals and objectives.
For applicants providing new home visiting services, but not expanding existing services, the description should follow the points as written below. For those expanding existing home visiting services, the project narrative should be worded as it relates to the expanded service focus, justifying the need for such an expansion, and describing the capacity to provide additional services. The narrative should include:
The Project Narrative is divided into distinct sections and should be submitted in the sequence below:
A. Abstract (two pages or less)Provide a summary of your application. The summary should be clear, accurate, concise, and without reference to other parts of the application. The abstract must be single-spaced, limited to two pages in length, and include the following sections:
Annotation: Provide a three-to-five-sentence description of your project that identifies the project’s goal(s) and the population and/or community needs that are addressed.
Primary applicant’s name and the name(s) of all partnering entities Community (ies) served by the proposed activities in this application Type of grant: Implementation Start-up or Implementation Expansion Problem: Describe the principal needs and problems addressed by the project. Purpose: State the purpose of the project Goal(s) And Objectives: Identify the major goal(s) and objectives for the project.
Typically, the goal(s) are stated in a sentence, and the objectives are presented in a numbered list.
Methodology: Briefly list the major activities used to attain the goal(s) and objectives.
B. Purpose, Goals and Objectives (one page or less) State the purpose of the project.
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Identify the goal(s) and objectives for the project. Typically, the goal(s) are stated in a sentence, and the objectives are presented in a numbered list. Objectives should support progress toward goals.
Utilize the SMART objective framework: Specific, measurable, achievable, realistic, and time bound are characteristics of SMART objectives.
C. Description of Proposed Community, Population and Geographic Area to Be Served (two pages or less)
Identify the geographic area or community selected for implementation of the home visiting model. Provide a clear rationale for why the community(ies), regional collaboration or other geographic area has been selected and why it constitutes a reasonable area for service delivery. Priority shall be given to applicants that develop or expand services through a regional partnership.
Discuss specific needs and risk factors of the geographic area or community. Please include data that supports the description of risk factors and needs.
Discuss the capacity of the selected geographic area or community to generate the projected target caseload to participate in the proposed program. Examples may include number of births, number of teen pregnancies, and referral systems currently in place.
Identify community assets available to support families served by the proposed home visiting program. Describe how the assets will support the families.
Identify and describe the families in greatest need of home visiting services, especially those identified as priority populations.
D. Selection of Proposed Evidence-Based Home Visiting Model (two pages or less, not including attachments)For the purposes of this RFP, applicants must select an evidence-based home visiting model. Priority will be given to applicants implementing the following evidence-based home visiting models: Healthy Families America, Nurse-Family Partnership, Family Connects, Family Spirit, Early Head Start and Parents as Teachers.
Identify the evidence-based home visiting model selected for implementation and provide documentation of contact with the model developer. If the applicant already has the official approval from the model developers to start-up or expand the model, provide documentation (documentation includes the approved affiliate or implementation plan or an e-mail or letter from the model developers stating that the agency is approved). Official approval to implement the model from the model developers is not required at the time of application submission, but should be reflected in your workplan.
Provide documentation of agency support for initiation or expansion of program. Identify how the specific needs of the community and at-risk families will be met
by the selected evidence-based home visiting model. Clearly link the selected evidence-based home visiting model to documented
gaps in the service area. Describe how the program will identify and refer eligible families for enrollment
in the proposed evidence-based home visiting program.
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Describe any anticipated challenges and/or risks associated with the implementation of the selected evidence-based home visiting model and possible strategies for addressing these challenges.
Describe any anticipated challenges and/or risks to maintaining quality and fidelity to the model and possible strategies for addressing these challenges.
E. Organizational Capacity (two pages or less) Describe any current and/or prior experience with implementing the selected
home visiting models and/or any other models, as well as the current capacity of your agency to support the model.
For start-up proposals, provide information on building capacity and infrastructure, such as plans for recruiting, hiring and training staff.
For start-up and expansion proposals, provide information on capacity and ability to reach and maintain 85% of target caseload. Address such things such as recruitment and engagement, retention, and waitlists.
Demonstrate and document the infrastructure in place to budget and manage funds, submit invoices and reports on time, and provide or be able to hire and/or contract, for the provision of services. For previous or current home visiting grantees, describe your level of timeliness with invoicing and reporting submissions. Describe how you will address any current challenges with timely reporting and invoicing. Indicate how often your program and budget staff meet to discuss programs costs and billing.
F. Linkages and Collaboration (two pages or less) Describe the existing continuum of home visiting services in the community.
This includes home visiting programs and services not included on this proposal. Please provide information on the following:
o The number and types of home visiting programs and their respective providers in the community;
o The models that are used by the identified home visiting programs;o The eligibility requirements and number of clients currently being
served; and,o Identified gaps and overlaps in the existing continuum of home visiting
services and how they will be addressed.
List your community and multi-disciplinary partners and describe how you currently or plan to collaborate with them to enhance the local early childhood system. Partners could include primary care providers, social workers, school districts, child care providers.
Discuss how start-up or expansion of the evidence-based home visiting model(s) will enhance and be integrated into the local early childhood system.
G. Implementation Plan for the Proposed Evidence-Based Home Visiting Model (three pages or less)
Describe how you will recruit, hire, and retain well-trained and competent staff for all positions and provide high-quality supervision.
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Describe the training requirements for the selected model, training needs, timeline and plan for obtaining training from the national model developer. Grantees should plan on securing the required trainings for each model without the assistance of MDH.
Describe specific activities for how you will implement the evidence-based home visiting model with fidelity and how fidelity will be maintained throughout the length of the grant.
Describe the plan for providing high quality reflective practice for all home visitors and supervisors including infant mental health consultation, challenges, and resolutions that may be encountered in providing high quality reflective practice for all home visitors and supervisors.
Describe how you will reach, engage, recruit, enroll, and retain the families in need of home visiting services in the identified service provision areas. Specifically address community-wide screening processes in identifying and referring eligible families to the proposed program.
Describe specific activities that you will carry out to assure culturally and linguistically appropriate services. Include a description of how these activities support your identified priority population.
Provide a calculated estimate of the number of staff required to maintain the projected target caseload of families in the proposed program. Consider historical caseload and retention data for your program, if available. Complete the Home Visitor Staffing Plan table using the template provided in Appendix C. Include a summary of staffing ratios of supervisors to home visitors to clients and how they meet the guidance specific to your chosen model.
A referral system involves regular communication with the partners who do or should provide referrals to your program, so that they understand the services, are encouraged to refer clients to your program, are familiar with the process for providing referrals, and can provide feedback on their experience with referrals to your program. Describe how you will expand, implement, and maintain a referral process to the home visiting program. Referral resources shall include, at a minimum, WIC, public health, family planning, prenatal care (OB/GYNs, Family Practice, NPs, etc.), hospitals, clinics. Include other referral sources if identified (such as Child Protective Services, mental health services, child care, school nurses, social workers, etc.).
A referral system also involves communication with the programs that you refer your home visiting clients to. This aspect of the system also requires regular communication among partners and is more active than providing clients with a referral slip or a phone number to call. Describe your plan for providing referrals from your program to other community resources and how you will follow-up on referrals made.
Describe the community’s plans for sustainability of the home visiting program on an ongoing basis, and/or how the community will address the sustainability of the project during the project period.
Describe the applicant’s history related to third party billing and reimbursement.
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Discuss your plans for establishing, or to continue utilizing, an existing, local advisory council to provide input on proposed home visiting services. List current and potential partners to serve on the advisory council.
H. Data Collection and Reporting (three pages or less)Awarded applicants will have three options for reporting of evaluation data:
Program enters evaluation data directly into state-provided data system (REDCap).
Program enters evaluation data into a local data system with the capability of creating an export file that conforms to state specifications. MDH will provide a list of local data systems that demonstrate that they meet export file criteria. Program is responsible for securely transmitting or uploading the evaluation data export file to the state FHV data collection system, as described in the current FHV Reporting Requirements document.
Program designates or subcontracts with another organization or government entity that will report evaluation data to the state on the applicant’s behalf. Awarded applicants are responsible for ensuring that the designee or subcontractor submits evaluation data according to state requirements and timelines.
Applicants should allocate sufficient funds in their budget to support the collection and reporting of evaluation data, including staff time and computer systems. MDH will update the FHV Reporting Requirements document (available on the MDH FHV website) at least annually, as well as provide guidance and technical assistance to awarded applicants to establish and improve data collection and submission processes. The planned State FHV Evaluation Measures are listed in Appendix D.
Describe the methods and systems you will use to collect and report required evaluation data. Specifically include:
o Name of software or data system(s) that will be used to capture data on home visiting clients;
o Planned data collection method (for example, paper forms completed by home visitors during/after visits, followed by data entry into electronic system; tablets or mobile devices used by home visitors and/or families);
o Roles of home visiting and administrative staff in data collection, data entry, and data submission to the state;
o Any local infrastructure, partnerships, or data linkages you plan to leverage (for example, shared data system with another program); and,
o Whether you will designate or subcontract with another entity to collect or report evaluation data. Identify the organization or subcontractor. Describe how you will ensure the outside entity will comply with state requirements for evaluation data.
Describe how you will monitor and improve evaluation data quality and integrity, including the accuracy, completeness, and timeliness of data collection and submission.
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Describe your data safety and security policies and procedures, including protection of private data, limits to data access by staff, data system backups, and compliance with applicable state and federal laws such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99), and the Minnesota Government Data Practices Act.
Describe any anticipated barriers or challenges in the process of collecting and/or reporting evaluation data, and possible strategies for addressing these challenges. Include anticipated needs for resources or technical assistance to establish, update, or improve data collection and reporting processes.
I. Continuous Quality Improvement (two pages or less) Describe your program’s experience with quality improvement. Describe your experience with quality improvement activities required by the
proposed evidence-based home visiting model. Describe how staff will be supported in conducting quality improvement
activities. Describe the data systems will you use for quality improvement purposes, and
how you will use those data systems to track progress, measure whether change ideas resulted in improvement, identify the need for course corrections, and how data will be used to drive decision-making.
J. Work Plan (no page limit)All implementation grant applicants shall submit a completed Work Plan that includes a description of the goals/objectives, planned activities, responsible staff, and timeframes. The Work Plan must include the goals, objectives, and activities that the applicant has included in the project narrative. The Work Plan must include the goals, objectives, and activities that the applicant has included in the project narrative. Your objectives and activities should address topics such as, but not limited to:
Developing a referral network Continuous quality improvement, including team and participation Community Advisory Board Program funding, budgeting and sustainability Reflective practice Required MDH reporting, including quarterly reports and monthly data
submission Model fidelity and accreditation Integrating into the early childhood system Meeting target caseload
Additionally, the applicant must include in the Work Plan an activity to develop a comprehensive summary of the applicant’s overall home visiting budget, including all major home visiting funding sources. Complete the Work Plan Form B. Note: If the application is approved and funded at the level requested, the Work Plan will be incorporated into the grant agreement between the State and the grantee applicant as
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contractor’s duties. A Work Plan must be completed according to directions so they can be separated easily from the rest of the application.
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Budget SectionIntroductionBefore writing the budget, consider the specific activities planned and the resources (staffing, supplies, equipment, etc.) needed to conduct those activities. Are there resources already available? Are there resources that need to be purchased? Which items will need to be replaced during the grant period? Give consideration to the skills needed to carry out the grant activity and comply with any requirements, particularly the financial aspect of the grant. Budgeting for a financial staff person is allowable. Remember to include any training that will be needed for paid staff or volunteers.
Costs of entertainment, including amusement, diversion and social activities where no grant program information is disseminated, and any costs directly associated with such costs (tickets to shows/movies/sporting events, meals, lodging, rentals, transportation, and gratuities) are unallowable.
IncentivesApplicants proposing activities that involve the distribution use of incentives for program participation must include the costs for purchasing incentives in the “Other” line of the budget and follow the guidelines stated below.
Incentives may include gift cards or specific items and may only be given to eligible participants. This includes:
Gift cards and infant supplies may be used as incentives for participating mothers and caregivers receiving evidence-based home visiting services.
Applicants must adhere to the following rules regarding incentives: A participant may not receive more than $50 worth of incentives per year. If using gift
cards as incentives, multiple cards can make up the $50 maximum as long as the $50 is not surpassed.
Incentives must be kept in a secure locked location at all times (ex: locked drawer, locked cabinet).
The applicant/grantee must track which client/participant received the incentive and the dollar value of that incentive. Applicants/grantees must ensure data privacy when tracking the distribution of incentives.
Incentives must be distributed in the funding year in which they are purchased. In order for the expense of incentives to be reimbursable, the applicant must:
o address the use of incentives in the text of the RFP applicationo account for the incentives in the “Other” line of the budget justificationo obtain MDH’s approval of the budget justification that includes the incentives
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Required Budget FormsThe applicant will need to complete and submit the following budget forms. Detailed instructions are on each form. These budget forms are in addition to the programmatic forms required in this RFP listed on page 22.
Budget Justification (Form D) Budget Periods 1-4 (see page 25 for more information) Budget Summary (Form E) Budget Periods 1-4 (see page 25 for more information) Due Diligence Form (Form F) Must be completed by non-profit applicants Indirect Cost Questionnaire (Form G)
Grantees with strong accounting and Excel skills are encouraged to submit equivalent budget justification and summary forms in an Excel format. If using Excel, the same detail that is asked for on the Budget Summary and Justification must be provided.
The Budget Periods listed above were previously listed incorrectly as Budget Periods 1-6. They have been changed to reflect the correct number of Budget Periods.
Budget ScoringThe Budget Justification Form and the Budget Summary Form will be used for scoring the budget portion of the application. If supplementary information is included, it will not be taken into consideration for scoring purposes. Be sure to double check the calculations and use whole dollar amounts, no decimals.
Proposals seeking to expand an existing evidence-based home visiting model must clearly demonstrate that requested funding will not be used to supplant current resources.
No more than 10 percent of the grant amount, or up to your federally approved indirect rate, may be spent on costs associated with administering the grant (indirect).
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Program Requirements
Submission Requirements All potential applicants are strongly encouraged to submit a Letter of Intent to MDH by
the due date listed below. A letter of intent does not bind an applicant to submit an application. Letters of Intent must be submitted electronically by 4:00 pm (CST) on Thursday, December 7, 2017 to [email protected]
All applicants must complete this short survey (https://survey.vovici.com/se/56206EE324308B63) as part of the application process.
Program Narrative must be 12-point font, single spaced, with one inch margins. The Work Plan (Form B) can be in 11-point font. All pages are numbered consecutively. The entire application should be submitted via email to [email protected]
The application must be limited to Word, Excel or PDF files. Submission deadline is 4:00 pm (CST) on Thursday, February 1, 2018. No late or
incomplete applications will be accepted or reviewed. If applicant is using a fiscal agent, it must be stated on the Face Sheet. A fiscal agent is
an organization that assumes full legal and contractual responsibility for the fiscal management and award conditions of the grant funds and that has authority to sign the grant agreement. A fiscal agent is a different entity than the entity that will actually perform the work/grantee’s duties.
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FormsApplication Face Sheet (Form A)
Work Plan (Form B)
Budget Justification Instructions (Form C)
Budget Justification (Form D)
Budget Summary (Form E)
Due Diligence (Form F)
Indirect Cost Questionnaire (Form G)
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Form A: Application Face SheetGeneral Applicant Information
Applicant Legal Name (do not use a doing business as” name):
Business Address (street, city, state, zip):
Minnesota Tax Identification Number:
Federal Tax Identification Number:
SWIFT Vendor ID Numbers (if you have one):
Director of Applicant Agency Information
Name:
Business Address (street, city, state, zip):
Phone Numbers:
Email:
Financial Contact for this Application
Name:
Phone Numbers:
Email:
Contact Person for this Application
Name:
Business Address (street, city, state, zip):
Email:
Requested Funding
Total Amount Requested $
I certify that the information contained above is true and accurate to the best of my knowledge; that I have informed this agency’s governing board of the agency’s intent to apply for this grant; and, that I have received approval from the governing board to submit this application on behalf of the applicant.
Signature of Authorized Agent for Applicant:
Date of Signature:
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Form B: Work Plan Complete the information in the fields below.
Name of Community Health Board, Non-Profit or Tribal Nation (Primary Applicant):
Name(s) of partner applicants:
Contact person for Work Plan, including name, e-mail and phone number:
Proposed target caseload (start-up) or number of new family slots (expansion) if funded (implementation grant applicants only):
Date submitted:
Develop and complete a table that includes SMART Objectives, activities for each objective, and target completion dates. Include goals, objectives and activities described in your project narrative. Refer to the Work Plan description in the project narrative section for more information. A sample table format is listed below:
Goals/SMART Objectives
Activities Person Responsible Time Period
Example: By July 2018, expand the referral network for incoming referrals to the program.
Complete annual outreach, education, and training to local providers working at XYZ clinic.
Educate social services staff in community on program eligibility criteria.
Name, Program Outreach Worker
May 2018 – July 2018
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Form C: Budget Justification - Instructions
IntroductionYou will need to account for all of your grant program costs under six different line items. The following paragraphs provide detailed information on what costs are allowable and associated with each of the six lines. You will be required to show detailed calculations to support your costs. Failure to include the required detail could result in a delayed grant agreement if your application is selected for funding.
All costs under this grant must be prorated to reflect fair share of the expense to this program. For example, if a computer is purchased for one staff person who works .5 FTE on this grant and .5 FTE on another program, the cost for that computer should be split 50 – 50 by this grant and the other program.
It is strongly suggested that applicants incorporate into their budgets the costs of appropriate financial staff to provide financial oversight to the grant. This could be through contracting with an individual or organization or a direct hire.
Each partner providing evidence-based home visiting services is required to complete a Budget Justification form for each period listed below. The lead partner/fiscal host should include the total budgets of partner agencies under “Other”:
Period 1: May 1, 2018 to June 30, 2019
Period 2: July 1, 2019 to June 30, 2020
Period 3: July 1, 2020 to June 30, 2021
Period 4: July 1, 2021 to December 31, 2022
Salary and FringeFor each proposed funded position, indicate the title, the full time equivalent (FTE) on this grant (see example below), the expected rate of pay, and the total amount the applicant expects to pay the position for the year. Grant funds can be used for salary and fringe benefits for staff members directly involved in applicant’s proposed activities.
Any salaries from the administrative support, accounting, human resources, or IT support, MUST be supported by some type of time tracking in order to be included in the Salary and Fringe line. Salary and fringe expenses not supported by time reporting documentation may be included in the indirect line if these unsupported salaries and fringe were included on the Indirect Cost Questionnaire form and approved by MDH. Any salary and fringe expenses not supported, not included on the Indirect Cost Questionnaire, and not approved by MDH are unallowable and may not be charged to this grant.
A brief description of the key duties that each staff will perform MUST be included. Staffing ratios must conform to model guidance.
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Full time equivalent (FTE): The percentage of time a person will work on this grant project. Each position that will work on this grant should show the following information:
EXAMPLE:Public Health Nurse: $30.40/hourly rate
x2,080/annual hours (or whatever your agency annual standard is)$63,232 annual salary
Multiply annual salary by your agency’s fringe rate:$63,232 annual salaryx 23% fringe rate (use your agency fringe rate, 23% is just an example)$14,543 fringe amount
Provide the breakdown of what your fringe rate includes: 6.20% FICA1.45% Medicare3.00% Retirement
12.35% Insurance 23.00% Total Fringe Rate
Now add the annual salary and the fringe amount together:$63,232 annual salary
+$14,543 fringe$77,775/annual salary and fringe total
Multiply the annual salary and fringe total by the FTE being charged to this grant:$77,775 annual salary and fringe totalX .50 FTE assigned to grant$38,888 total to be charged to grant for this position
All staff must be prorated to the anticipated time that they will work on the grant. If a position needs to be hired, grantees must prorate the final salary to account for delays in posting, recruiting and hiring the position based on their typical agency hiring practices and history. For the above example in Budget Period 1, the position would be prorated for fourteen months as follows:
($38,888/12months) X 14 months = $45,369 charged to grant for this position
Contractual ServicesApplicants must identify any subcontracts that will occur as part of carrying out the duties of this grant program as part of the Contractual Services budget line item in the proposed budget. The use of contractual services is subject to State review and may change based on final work plan and budget negotiations with selected grantees.
Applicant responses must include: Description of services to be contracted;
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Anticipated contractor/consultant’s name (if known) or selection process to be used; Length of time the services will be provided; and, Total amount to be paid to the contractor.
TravelBriefly explain and list the expected travel costs for staff working on the grant, including mileage, parking, hotel, and meals. Applicants must budget for home visitors and supervisors to attend:
Required essential trainings for their chosen home visiting model. (Could be out of state)
Annual two-day MN Home Visiting Conference (Metro location; Budget Periods 1-4) CQI Learning collaborative: two in-person meetings (Metro location; Budget Periods 1-4) Mileage for travel to home visits and reflective practice (or indicate if covered by
another funding source)
If project staff will travel during the course of their jobs or for attendance at educational events, describe the purpose of the event, how it supports the chosen home visiting model, and itemize the costs, frequency, and the nature of the travel. Grant funds cannot be used for out-of-state travel without prior written approval from MDH. Minnesota will be considered the home state for determining whether travel is out of state.
Examples of Mileage and Out of State Travel Justifications are below:
Mileage: 5,000 miles for home visits each year: 5000 x .535 per mile= $2,675
Out of State Travel for 5 day Family Spirit Training (2 HVs and 1 Supervisor) (Albuquerque, NM)
Airfare R/T $600 * 3 Staff = $1,800.00 Mileage 208 R/T *.535 = $111.28 * 3 Staff = $333.84 Hotel $174 a night * 5 nights = $870 * 3 Staff = $2,610 Meals (calculate according to applicable policy):
o Tribal Nations would include: Per Diem (first and last days calculated at 75%) 1st- $44.25 * 2 + 59 *4= $265.50 * 3 Staff = $796.50
o CHBs/Non-Profits would include Commissioner’s Plan rates: 5 full days of meals for 3 staff: $36 x 5 days x 3 staff=$540
Baggage Fees $50 R/T * 3 Staff = $150 Taxi/Shuttle Fees $68 R/T * 3 Staff = $204
Non-tribal applicants:
Budget for travel costs (mileage, lodging, and meals) using the rates listed in the State of Minnesota’s Commissioner’s Plan (http://www.health.state.mn.us/divs/opi/gov/lphact/docs/travelexpenses.pdf ) .
Hotel and motel expenses should be reasonable and consistent with the facilities available. Grantees are expected to exercise good judgement when incurring lodging expenses.
Mileage will be reimbursed at the current IRS rate at the time of travel.
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Tribal Nation applicants:
Budget for travel costs (mileage, lodging, and meals) using the rates provided by the General Services Administration (GSA) (http://www.gsa.gov/portal/category/100120) . Current lodging amounts and meal reimbursement rates vary depending on where the travel occurs in Minnesota.
Consult the breakdown of the GSA meal and incidental expenses reimbursements (http://www.gsa.gov/portal/content/101518) for current rates for Tribal Nations.
Mileage will be reimbursed at the current IRS rate at the time of travel.
Supplies and ExpensesBriefly explain the expected costs for items and services the applicant will purchase to run the program. These might include additional telephone equipment, postage, printing, photocopying, office supplies, training materials, and equipment. Include the costs expected to be incurred to ensure that community representatives, partners, or clients who are included in the applicant’s process or program can participate fully. Examples of these costs are fees paid to translators or interpreters. Grant funds may not be used to purchase any individual piece of equipment that costs more than $5,000, or for major capital improvements to property.
The following are examples of supply and expense descriptions that should be provided:
25 Family Spirit workbooks for families x $125 per workbook = $3,125
FHV program & Growing Great Kids Curriculum supplies = 25 families x $20 per family= $500 (Scale covers, antiseptic cleaners, hand sanitizer, brochures, fact sheets, plug in covers, cupboard latches, safety alarms, safety gates, other FHV and safety supplies. Glue, markers, paints and brushes, Ziploc bags, shoelaces, ribbon, yarn, bells, stickers, pom-poms, fabric, felt squares, athletic socks, 3-ring binders, copy paper, laminating paper, and other GGK activity supplies, GGK books with disks, postage).
Cell phones for 3.0 FTE home visitors: 3 X $50/phone x 12 months= $1,800
OtherInclude in this section any expenses the applicant expects to have for other items that do not fit in any other category. Some examples include but are not limited to: staff training, and, incentives. Grant funds cannot be used for capital purchases, permanent improvements; cash assistance paid directly to individuals; or any cost not directly related to the grant. Expenses in the “Other” line should represent the appropriate fair share to the grant.
The primary applicant should clearly label and include the budget period totals for each partner under this section.
Example of Other Costs and Justifications:
Partner Costs:Home Visiting Agency Partner 1: $225,000
Home Visiting Agency Partner 2: $179,000
Electronic Health Record License (PHDoc): 3 staff x $1,200/staff = $3,600
Family Spirit Registration Fee:
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2 Home Visitors x $3,000 = $6,000 1 supervisor x $4,000 = $4,000
Indirect CostsIndirect costs are expenses of doing business that cannot be directly attributed to a specific grant program or budget line item. These costs are often allocated across an entire agency and may include administrative, executive and/or supervisory salaries and fringe, rent, facilities maintenance, insurance premiums, etc.
The following are examples that could be included in indirect costs: Your department pays a general percentage to the city/county attorney’s office or the
sheriff’s department and these costs cannot be specifically attributed to an individual grant.
Your CHB or department pays a fee or percentage to the county/city human resources department and these costs are not tied to a specific grant.
The CHBs accounting system does not allow community health services (CHS) adminis-trator’s time to be directly attributed to specific grant activities.
In contrast, administrative costs are expenses not directly related to delivering grant objectives, but necessary to support a particular grant program. These are items that, while general expenses, can be attributed and appropriately tracked to specific awards. These items should be included in the grantee budget as direct expenses in the appropriate lines of Salaries and Fringe, Supplies, Contractual Services, or Other. They should not be included in the Indirect line.
The following are examples of administrative costs that should be included in direct lines of the budget and/or invoice:
The CHS administrator’s time that can be tracked through time studies to a specific grant (include in the Salary/Fringe line).
A portion of secretarial/administrative support, accounting, human resources or IT sup-port staff expenses that can be tracked through time studies to a specific grant (include in the Salary/Fringe line).
Printing and supplies that your accounting system is able to track (for example through copy codes) to a specific grant (include in the Supply line).
Any salary costs included in the Salary and Fringe line of the budget and/or invoice must be supported by proper time documentation. The total allowed for indirect costs can be charges up to your federally approved indirect rate, or up to a maximum of 10%.
If the applicant will be using a Federally Negotiated Indirect Cost Rate, you will need to submit with your application your most current federally approved indirect rate.
Please go to the next page to start completing the Budget Justification Form.
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Form D: Budget JustificationComplete this form for each budget period listed on page 25.
Use whole dollar amounts, no decimals.
Applicant information
Applicant Agency:
Contact Person for Budgets:
Phone number:
Email address:
Budget Period: to
1. Salary and FringeFor each proposed funded position, list the title, the full time equivalent based on 2,080 hour/year, or whatever your agency’s annual standard is, the expected rate of pay, fringe rate (%), total annual salary and fringe, and the percent of each position being charged to the grant. Failure to provide the requested detail for each position may result in a delayed grant agreement. Please refer back to page 26 for an example of how to show the salary/fringe expenses. Be sure to include a breakdown of your FICA costs in the specified area below.
Justification:
FICA Breakdown:
Total Salary and Fringe Requested $
2. ContractualList the services that are expected to be contracted out, the contractor’s name, whether the contractor is a non-profit or for-profit entity, the length of time the services will be provided and the total amount expected to be paid. Supplies and travel of the contractor should be included here, if applicable. Itemize equipment rented or leased for the project.
Justification:
Total Contractual Requested $
3. TravelExplain the expected in-state travel costs, including mileage, parking, lodging, and meals. If program staff will travel, itemize the costs, frequency and nature of the travel. Be sure to use the current IRS mileage rate and the appropriate meal amounts referenced on pages 27-28.
Justification:
Total Travel Requested $
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4. Supplies and ExpensesExplain the expected costs for items and services that will be purchased to run the grant program. Include telephone expenses that are part of this proposal; cell phones and new telephone equipment to be purchased, if applicable. Estimate postage if part of the project. List printing and copying costs necessary for the project (other than occasional copying on an office copy machine). List office and program supplies and expendable equipment such as training materials, curriculum and software. Generally, supplies include items that are consumed during the course of the project, equipment under $5,000 and items such as rent for program space, participant transportation, participant training and other direct costs as needed.
Justification:
Total Supplies and Expenses Requested $
5. OtherBriefly describe any expenses that do not fit in any other category. Examples include applicant staff training, incentives, gift cards, and emergency need cards.
Justification:
Total Other Requested $
6. SubtotalAdd up the totals for lines 1 through 5.
Subtotal $
7. IndirectIf applicable, enter the indirect cost rate being requested. The maximum that can be used is 10% unless using a federally approved indirect rate. %
Multiply the indirect percentage by the Subtotal and enter the dollar amount here. Be sure to use whole dollar amounts, no decimals. $
8. TotalThis is the sum of line 6 (subtotal) and line 7 (indirect). Be sure to double check your calculations as errors could result in a delay in executing a grant agreement. Use whole dollar amounts, no decimals.
Total $
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Form E: Budget SummaryComplete this form for each time period listed on page 25.
Use whole dollar amounts, no decimals.
Applicant information
Primary/Partner Applicant Agency:
Contact Person for Budgets:
Phone number:
Email address:
Budget Period: to
This form is used to capture the summarized information from the Budget Justification Form(s). Please enter zero (0) in the Total Proposed Amount column if no grant funds will be expended in a line item.
Be sure to double check your calculations as errors could result in a delay in executing a grant agreement.
Line Item Amount
1. Salary and Fringe $
2. Contractual $
3. Travel $
4. Supplies and Expenses $
5. Other $
6. Subtotal $
7. Indirect $
8. Total $
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Form F: Due Diligence ReviewThis form is only required from non-profit applicants.
PurposeThe Minnesota Department of Health (MDH) must conduct due diligence reviews for non-governmental organizations (NGOs) applying for grants, according to MDH Policy 240.
DefinitionDue diligence refers to the process through which MDH researches an organization’s financial and organizational health and capacity (MDH Policy 240). The due diligence process is not an audit or a guarantee of an organization’s financial health or capacity. It is a review of information provided by a NGO and other sources to make an informed funding decision.
InstructionsAs an applicant for MDH funds you must answer the following questions about your organization, and return the form (along with any required additional documentation) to the grant manager.
Organization Information QuestionnaireQuestion Response
1. How long has your organization been doing busi-ness?
2. How many employees does your organization have (both part time and full time)?
3. What was your organization's total revenue in the most recent 12-month accounting period?
4. How many different funding sources does the to-tal revenue come from?
5. Does your organization have a current 501(c)3 status from the IRS? Circle Yes or No.
Yes No
6. Has your organization done business under any other name(s) within the last five years? Circle
Yes No
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Question Response
Yes or No.
If yes, list name(s) used.7. Is your organization affiliated with or managed by
any other organizations, such as a regional or na-tional office? Circle Yes or No.
If yes, provide details.
Yes No
8. Does your organization receive management or financial assistance from any other organiza-tions? Circle Yes or No.
If yes, provide details.
Yes No
9. Have you been a grantee of the Minnesota De-partment of Health within the last five years? Cir-cle Yes or No.
If yes, from which division(s)?
Yes No
10. Does your organization have written policies and procedures for accounting processes? Circle Yes or No.
If yes, please attach a copy of the table of con-tents.
Yes No
11. Does your organization have written policies and procedures for purchasing processes? Circle Yes or No.
If yes, please attach a copy of the table of con-tents.
Yes No
12. Does your organization have written policies and procedures for payroll processes? Circle Yes or No.
If yes, please attach a copy of the table of con-tents.
Yes No
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Question Response
13. Which of the following best describes your orga-nization's accounting system? Circle one re-sponse.
Manual Automated Both
14. Does the accounting system identify the deposits and expenditures of program funds for each grant separately? Circle one response.
Yes No Not sure
15. If your organization has multiple programs within a grant, does the accounting system record the expenditures for each program separately by budget line items? Circle one response.
Yes or Not applicable
No Not sure
16. Are time studies conducted for employees who receive funding from multiple sources? Circle one response.
Yes or Not applicable
No Not sure
17. Does the accounting system have a way to iden-tify over-spending of grant funds? Circle one re-sponse.
Yes No Not sure
18. If grant funds are mixed with other funds, can the grant expenses be easily identified? Circle one re-sponse.
Yes No Not sure
19. Are the officials of the organization bonded? Cir-cle one response.
Yes No Not sure
20. Did an independent certified public accountant (CPA) ever examine the organization's financial statements? Circle one response.
Yes No Not sure
21. Has any debt been incurred in the last six months? Circle Yes or No.
If yes:
What is the reason for the new debt?
What is the funding source for paying back the new debt?
Yes No
22. What is the current amount of unrestricted funds compared to total revenues?
23. Are there any current or pending lawsuits against the organization? Circle Yes or No.
Yes No
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Question Response
24. If yes, could there be an impact on the organiza-tion's financial position? Circle one response.
Yes No or Not applicable
25. Has the organization lost any funding due to ac-countability issues, misuse, or fraud? Circle Yes or No.
If yes, please describe the situation, including when it occurred and whether issues have been corrected.
Yes No
Additional Documentation RequiredThe following documentation is required in addition to the due diligence form.
IF you’re an NGO with annual income: THEN submit your most recent:
under $50,000
OR have not been in existence long enough to have a completed IRS Form 990 or audit
board-reviewed financial statements
examples: Statement of Activities; Statement of Financial Position
$50,000 – $750,000 IRS Form 990
over $750,000 certified financial audit
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Form G: Indirect Cost Questionnaire
BackgroundApplicants applying may request an indirect rate to cover costs that cannot be directly attributed to a specific grant program or budget line item. This allowance for indirect costs is a portion of any grant awarded, not in addition to the grant award. Please refer to page 29 for more detailed information on indirect costs.
InstructionsPlease complete the information below and return this form as part of the application.
1. Name of applicant agency:
2. Are you requesting an indirect rate? Yes No
3. Do you have an approved Indirect Cost Rate Agreement with a Federal agency? Yes – Please submit a copy of your current rate with this completed form. No – Please continue completing the rest of this form.
4. Non-federal indirect rate being requested: Up to 10% of the direct expenses in the budget for the grant program listed above can be used for indirect costs per CFR Part 200 - Uniform Administrative Requirements, Costs Principles, and Audit Requirements for Federal Awards, and per MDH policy for State funds.
5. Please list the expenses included in your indirect cost pool below, or attach a copy of your current indirect cost allocation plan to this form.
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AppendicesAppendix A Criteria for Scoring Applications
Appendix B Definitions
Appendix C Home Visitor Staffing Plan
Appendix D Minnesota Family Home Visiting Evaluation Measures
Appendix E Link to MDH Grant Agreement Sample
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Appendix A: Criteria for Scoring Applications
Each application will be evaluated and scored by members of a Review Panel (RP) established by MDH for this RFP. Internal and external reviewers will be selected based on their background, knowledge and experience in maternal and child health and early childhood development.
Each question must be answered within the section where it is asked. Information that pertains to a question in another section will not be counted towards the response. Reviewers will be instructed to only give credit for the response to each individual question within its designated section. Applicants are strongly encouraged to provide clear, succinct, and direct responses to each question in the space provided for that question.
Planning grant applicants will be scored on a total of 200 possible points as follows:
Project Narrative and Work Plan (170 points maximum) Clear statement of need (30 point maximum) Organizational capacity (40 points maximum). Five of these points will be awarded
based on selection of one of the following evidence-based home visiting models: Healthy Families America, Nurse-Family Partnership, Family Connects, Family Spirit, Early Head Start or Parents as Teachers.
Linkages and collaboration (20 points maximum) Clear statement of purpose, goals and objectives (30 points maximum) Challenges and plan for resolution (20 points maximum) Work Plan (30 points maximum)
Budget and Budget Justification (30 points maximum)
Implementation grant applicants will be scored on a total of 450 possible points as follows:
Project Narrative and Work Plan (400 points maximum) Clear statement of purpose, goals and objectives (15 points maximum) Identification of population, community and geographic area to be served (50 points
maximum) Appropriateness of selected evidence-based home visiting model (50 points maximum).
Ten of these points will be awarded based on selection of one of the following evidence-based home visiting models: Healthy Families America, Nurse-Family Partnership, Family Connects, Family Spirit, Early Head Start or Parents as Teachers.
Organizational capacity (50 points maximum) Linkages and collaboration (30 points maximum) Implementation plan for the proposed evidence-based home visiting model (75 points
maximum) Data collection and reporting (50 points maximum) Continuous quality improvement (30 points maximum) Work Plan (50 points maximum)
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Budget and Budget Justification (50 points maximum) Budget narrative description supports the activities described in the proposal (15 points
maximum) Assurances that proposed funding will not supplant existing funds (5 points maximum) A reasonable budget to implement is proposed. The average yearly cost per family once
target caseload is reached will be taken into consideration (30 points maximum)
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Appendix B: Definitions
Adaptations to Evidence-Based Home Visiting Models –Acceptable adaptations to an evidence-based home visiting model include changes to the model that have not been tested with rigorous impact research but are determined by the Model Developer not to alter the core components related to program impacts. The Model Developer or its designee must approve any proposed adaptations.
At-Risk Family – High-risk priority families residing in identified communities and eligible to receive home visiting services.
Community – A community is a geographically distinct area that is defined by the applicant. Communities should be areas that hold local salience and may be defined as a neighborhood, town, city, county or other geographic area. Services provided within a particular community should be distinguishable from services provided in other communities.
Community Health Board (CHB) – The community health board as defined by Minnesota Statute 145A.02 is the legal governing authority for local public health in Minnesota. Community health boards work with MDH in partnership to prevent diseases, protect against environmental hazards, promote healthy behaviors and healthy communities, respond to disasters, ensure access to health services, and assure an adequate local public health infrastructure.
Continuous Quality Improvement (CQI) – A systematic approach to specifying the processes and outcomes of a program or set of practices through regular data collection and the application of changes that may lead to improvements in performance.
Evaluation Data – Individual-level data collected on families served by the evidence-based home visiting model and reported to the State for evaluation purposes. All awarded applicants will be required to collect evaluation data on participating families, and enter or upload the data into a system designated by MDH. Evaluation data will include demographic and service data, as well as data needed to calculate process and outcome evaluation measures. A list of the planned state FHV evaluation measures is provided in Appendix D. The list of FHV evaluation measures was previously listed incorrectly as Appendix A. It has been changed to reflect the name of the correct Appendix.
Evidence-based Home Visiting Model – A home visitation model that has been in existence for at least three years and is research-based, grounded in relevant empirically-based knowledge, linked to program-determined outcomes, and associated with a national organization or institution of higher education that has comprehensive home visitation program standards that ensure high quality services delivery and continuous program improvement, and has demonstrated significant, positive outcomes on indicators described in federal legislation, when evaluated using a well-designed and rigorous randomized controlled research design and/or
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quasi-experimental research design, and the results of which have been published in a peer-reviewed journal.
Expansion – For the purposes of this RFP, expansion includes using the evidence-based model currently being implemented by the local agency to serve 1) additional participants within the current service area; or 2) additional participants within an expanded service area (high need county(ies), zip codes).
High Need Area or Community – A community for which the following indicators demonstrate greater risk than Minnesota as a whole: premature birth, low-birth weight infants, and infant mortality, including infant death due to neglect, or other indicators of at-risk prenatal, maternal, newborn, or child health; poverty; crime; intimate partner violence; high rates of high school dropouts; substance abuse; unemployment; or child maltreatment.
Home Visiting Models– Programs or initiatives in which home visiting is a primary service delivery strategy and in which services are offered on a voluntary basis to clients including, but not limited to, pregnant women, expectant fathers, and parents and caregivers of children ages birth to kindergarten entry, targeting specific participant outcomes. For the purposes of this RFP, the following evicence-based home visiting models are eligible for priority funding: Healthy Families America, Nurse-Family Partnership, Family Spirit, Family Connects, Early Head Start and Parents as Teachers. Information on these models and the model developers is available here.
Informed Consent – Written permission from an individual to allow a government entity to release the individual’s private data to another government or non-government entity or person, or to use the individual’s private data within the entity in a different way (Minnesota Statutes, section 13.05, subdivision 4). A valid informed consent must be voluntary and not coerced, be in writing, and explain why the use or release of data is necessary. Awarded applicants must have a process that asks clients for their written informed consent to provide the State with their identifiable individual level data for the purpose of evaluating the evidence-based home visiting model. Awarded applicants must inform their clients that the client’s decision regarding informed consent will not in any way impact that family’s access to services.
Maintaining Fidelity of a Model – Providing services which meet the specified criteria and components of the identified evidence-based home visiting model on an on-going basis.
Multi-partner – An partnerhsip that includes two or more counties, tribal nations, or non-profits.
National model developer – Entity responsible for the development of an identified evidence-based home visiting model.
Non-Profit Organization – An entity granted tax-exempt status by the Internal Revenue Services and that does not seek or produce a profit.
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Primary Applicant – Entity that, if awarded, serves as the named grantee and fiscal agent for the grant award.
Reflective Supervision – Reflective supervision is a distinctive form of competency-based professional development that is provided to multidisciplinary early childhood home visitors who are working to support very young children’s primary caregiving relationships. Reflective supervision is a practice which acknowledges that very young children have unique developmental and relational needs and that all early learning occurs in the context of relationships. Reflective supervision is distinct from administrative supervision and clinical supervision due to the shared exploration of the parallel process, that is, attention to all of the relationships is important, including the relationships between home visitor and supervisor, between home visitor and parent, and between parent and infant/toddler. Reflective supervision supports professional and personal development of home visitors by attending to the emotional content of their work and how reactions to the content affect their work. In reflective supervision, there is often greater emphasis on the supervisor’s ability to listen and wait, allowing the supervisee to discover solutions, concepts and perceptions on his/her own without interruption from the supervisor.
Review Panel (RP) – A group of reviewers with backgrounds, knowledge and experience in maternal and child health and early childhood development selected by MDH to evaluate and score applications submitted in response to this RFP.
Target Caseload – The target caseload is the total number of family slots that will be added as a result of this funding. Only active cases as defined by the evidence-based home visiting model may be counted toward the target caseload when reporting. Awarded applicants will identify a target caseload that will be achieved and maintained throughout the grant agreement.
Tribal Nation – A federally recognized American Indian tribe considered a sovereign nation.
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Appendix C: Home Visitor Staffing Plan
Home Visitor, Supervisor, Other Staff Position
Home Visiting Model
FTE amount funded from EBHV grant (proposed)
Number of Family Slots (caseload) added if EBHV grant is funded
Total number of family slots to be served by this HV position
Existing Staff (Y/N)
Staff planning to hire (Y/N)
Sally Example NFP 0.5 12 24 Y N
Mary Supervisor NFP 0.2 0 0 Y N
Vacant Home Visitor
NFP 0.5 12 24 N Y
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Appendix D: Minnesota Family Home Visiting Evaluation Measures
Measure Name Measure Description
Preterm BirthPercentage of infants born to mothers enrolled in home
visiting prenatally who are born before 37 weeks 0 days of gestation
Low Birth Weight Percentage of mothers enrolled in home visiting during pregnancy who deliver a low birth weight (LBW) child.
BreastfeedingPercent of infants (among mothers who enrolled in home visiting prenatally) who were breastfed any amount at 6
months of age
Initiation of Breastfeeding Percent of mothers enrolled in home visiting during pregnancy who initiate and continue breastfeeding for at least 3 months.
Depression ScreeningPercent of primary caregivers enrolled in home visiting who are screened for depression using a validated tool within 3 months of enrollment (for those not enrolled prenatally) or within 3 months of delivery (for those enrolled prenatally)
ImmunizationsPercent of children enrolled in home visiting who are up-to-
date on immunizations per CDC recommendations at 3 months, 6 months, and 12 months
Postpartum CarePercent of mothers enrolled in home visiting prenatally or
within 30 days after delivery who received a postpartum visit with a healthcare provider within 8 weeks (56 days) of delivery
Inter-Birth IntervalPercentage of mothers participating in home visiting before
the target child is 3 months old and who stay in home visiting until the child is 18 months old, who have an inter-birth
interval of at least 18 months.
Developmental ScreeningPercent of children enrolled in home visiting with a timely screen for developmental delays using a validated parent-
completed tool
Social-Emotional Screening Percent of children enrolled in home visiting who receive social-emotional screening at 12 months of age.
Intimate Partner Violence Screening
Percent of primary caregivers enrolled in home visiting who are screened for intimate partner violence (IPV) using a
validated tool
Primary Caregiver Education
Percent of primary caregivers who enrolled in home visiting without a high school degree or equivalent who subsequently
enrolled in, maintained continuous enrollment in, or completed high school or equivalent during their participation
in home visiting
Completed Depression ReferralsPercent of primary caregivers referred to services for a positive screen for depression who receive one or more
service contacts Completed Developmental Referrals
Percent of children enrolled in home visiting with positive screens for developmental delays (measured using a validated
tool) who receive services in a timely manner. This measure needs to be reported on for all target children, including those
from subsequent pregnancies after enrollment in the home
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Measure Name Measure Description
visiting program.
Completed Social Emotional Referrals
Percent of children enrolled in home visiting with positive screens for social-emotional well-being concerns (measured
using a validated tool) who receive services in a timely manner
Intimate Partner Violence ReferralsPercent of primary caregivers enrolled in home visiting with
positive screens for IPV (measured using a validated tool) who receive referral information to IPV resources
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Appendix E: Grant Agreement SampleMinnesota Department of Health (http://www.health.state.mn.us/divs/cfh/program/paa/content/document/pdf/app1sga.pdf). This is sample language only. If awarded a grant your actual language may vary.
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