Positive Alternatives Grant Program Application

June 20, 2016 –June 30, 2019:

Information and MaterialsDecember 4, 2015

Community and Family Health DivisionMaternal and Child Health Section

Positive Alternatives ProgramP. O. Box 64882

St. Paul, MN 55164-0882

Phone: 651-201-3581Fax: 651-201-3590

http://www.health.state.mn.us/divs/cfh/program/paa/

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Table of Contents

Introduction................................................................................................................3Program Description...................................................................................................4Evaluation and Report Requirements.........................................................................5Eligibility Requirements..............................................................................................5Available Funding.......................................................................................................6Application Requirements..........................................................................................7Grant Application Checklist.........................................................................................8Disposition of Responses............................................................................................9What happens after application is received?..............................................................9Program Summary....................................................................................................11Application Instructions and Forms..........................................................................13Form A: Application Face Sheet................................................................................14Form B: Due Diligence Review Form.........................................................................15Form C: Assurance and Agreements Form................................................................18Project Narrative.......................................................................................................20Organizational Capacity............................................................................................20Grant Proposal..........................................................................................................21Logic Model and Evaluation......................................................................................23Form D: Logic Model and Evaluation........................................................................25Budget Section..........................................................................................................28Instructions...............................................................................................................28Salary and Fringe......................................................................................................28Contractual Services.................................................................................................29Travel........................................................................................................................29Supplies and Expenses..............................................................................................30Other Expenses.........................................................................................................31Evaluation.................................................................................................................33Indirect Costs............................................................................................................31Form E: Budget Justification Sheet...........................................................................33Form F: Budget Summary Sheet...............................................................................35Budget Summary Instructions...................................................................................36Form G: Indirect Cost Questionnaire........................................................................37Appendices...............................................................................................................38Appendix A: Criteria for Grant Review......................................................................39Appendix B: Sample Logic Model..............................................................................41Appendix C: Positive Alternatives Statute.................................................................44Appendix D: Sample of MDH Grant Agreement........................................................47

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Program Overview

IntroductionThis document provides the forms and instructions needed to complete the Positive Alternatives Grant Program application. It is suggested that your organization review this document, including Appendix A, which includes a copy of the Criteria for Grant Review, before beginning to write your application. Also included in Appendix C is a copy of the Positive Alternatives Act, M.S. 145.4235. Other resources to assist in completing this application are available in the “For Organizations with Positive Alternatives Grants” section of the Positive Alternative website .

The Minnesota Department of Health (MDH) will be available to answer questions during the application process. If you have questions contact:

Mary OttmanPositive Alternatives Program Coordinator651-201-3581 mary.ottman@state.mn.us

Please note that MDH staff will not be able to help with the actual writing of the application or critique drafts.

MDH will maintain an “Answers to Grant Application Questions” link on the Positive Alternatives web site, under the “For Organizations with Positive Alternatives Grants” section.

MDH will host two optional Web-Ex seminars (Webinars) to review the application materials and answer questions. Attendance at a workshop is not necessary in order to submit an application. Organizations are encouraged to participate especially if your organization is new to the Positive Alternatives grant application process or your organization has questions regarding the application. The seminars will be held on:

1) Tuesday, December 15, 2015, 9:30-11:30 a.m.2) Thursday, December 17, 2015, 1:00-3:00 p.m.

Applicants are welcome to attend either event. Registration is required. Please send your name, your organization’s name and contact phone number, the date of the event you will attend, and your email address to mary.ottman@state.mn.us. Technical instructions will be provided upon registration.

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Program DescriptionThe Positive Alternatives Program supports, encourages and assists women to carry their pregnancies to term by providing information on, referral to, and assistance with securing necessary services that enable women to carry their pregnancies to term and care for their babies after birth. Positive Alternatives grants provide funds to non-profit organizations promoting healthy pregnancy outcomes and assisting pregnant and parenting women in developing and maintaining family stability and self-sufficiency. Caring for her baby after birth could also include making an adoption plan for her child, if requested.

All grant-funded programs must offer all participants accurate information on, referral to, and assistance with securing specified necessary services that enable women to carry their pregnancies to term, support improved pregnancy outcomes, and care for their babies after birth. Babies are defined as infants up to 12 months old. In addition, the program may elect to also provide some or all of these services directly.

Necessary Services include, but are not limited to: Medical Care Nutrition Services Housing Assistance Adoption Services Education and Employment Assistance, including services that support the continuation and

completion of high school Childcare Assistance Parenting Education and Support Services

Examples of how organizations may expand availability of their current services include: Expanding hours of operation Hiring staff so more women can be served Establishing satellite offices targeting certain neighborhoods Expanding outreach activities Partnering with other community organizations to coordinate and integrate the delivery of

services to jointly served women

Examples of how organizations may add to their current services include: Provide some of the “necessary services” listed above directly Add components to existing programs, such as adding a crib or car seat safety component

to a parenting program Provide ongoing support to women who are facing significant challenges Services could range from periodic phone contact to one-on-one mentoring Services could be provided by hired personnel (a client services advocate) or community

agencies under contract

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Provide women with the resources needed to access necessary services. These could include providing vouchers for childcare or access to computer work stations for job searches or educational planning

These are only some examples. Refer to the Positive Alternatives web site for additional information on what past grantees have done, and for additional resources. Refer to Appendix B, Sample Logic Model, for a list of suggested activities.

Evaluation and Report RequirementsThe following evaluation and report activities will be required of funded programs.

MDH will require grantees to report on the status of their programs based on their Work Plans. The Work Plan is derived from the grantee’s application and describes its contractually-agreed upon goals, duties and responsibilities.

MDH will require grantees to send a financial report (invoice) monthly or quarterly. Grantees will be paid for actual expenses on a reimbursement basis. This means your organization will pay for the grant activity expenditures, and report the expenditures to MDH on an invoice form. When the invoice is approved your organization will be reimbursed.

MDH requires grantees to report only non-identifying demographic information and responses obtained from program participants to questions asking about the Organization’s offered Necessary Services.

Grantees will be required to evaluate at least one of their funded activities. The evaluation will be based on a measurable intermediate outcome linked to the grantee’s activity in the Logic Model (refer to page 24 for more information). Grantees will be required to develop and submit an evaluation plan for approval by December 31, 2016. A minimum of 5% of grant funds must be budgeted for evaluation purposes. MDH assistance will be provided to grantees in formalizing program evaluations.

Eligibility Requirements to Apply To be eligible to apply for a Positive Alternatives Grant, an agency or organization must:

Be a private, 501(c) 3 nonprofit organization, and maintain this status throughout the grant period.

Have had an alternatives-to-abortion program in place for at least one year as of July 1, 2011, or incorporated an alternatives-to-abortion program that has been in existence for at least one year as of July 1, 2011.

Ensure that its alternatives-to-abortion program’s purpose is to assist and encourage women in carrying their pregnancies to term and maximizing their potential thereafter.

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If awarded a Positive Alternatives Grant an agency or organization must: Conduct the grant program under appropriate supervision. Not charge women for services provided under the program. Provide pregnant women who receive counseling with accurate information on the

developmental characteristics of babies and unborn children, including offering the booklet, If You Are Pregnant: Information on Fetal Development, Abortion and Alternatives.

Ensure that health information is medically accurate and that medical services meet standards defined by the appropriate professional organization, or are broadly recognized within the medical community.

Ensure that no funds provided by Positive Alternatives Grant are used to encourage or affirmatively counsel a woman to have an abortion that is not necessary to prevent her death, or to provide her an abortion, or to directly refer her to an abortion provider. The agency may provide a woman who requests it a list of health care providers that provide abortion services.

Have written privacy policies and procedures in place to ensure that any information that might identify any woman seeking services is not made public or shared with any other agency or organization without the written consent of the woman.

Adhere to the requirements in Minnesota Statute 144.291 - 298 [Access to Health Records]. These statutes are available on the Positive Alternatives web site under “Grant Resources.”Ensure that only MDH Commissioner of Health approved information on the health risks associated with abortion be provided to women in grant-funded programs. Commissioner of Health approved information can be found in the booklet “ If You Are Pregnant: Information on Fetal Development, Abortion and Alternatives” . (You can find this booklet at: http://www.health.state.mn.us/wrtk/index.html or you can call 651-201-3580 or toll free 888-234-1137 to receive a free copy.)

An organization that provides abortions, promotes abortions, or directly refers to an abortion provider for an abortion is not eligible to receive a grant under this program. An affiliate of an organization that provides abortions, promotes abortions, or directly refers to an abortion provider for an abortion is ineligible to receive a grant under this section unless the organizations are separately incorporated and independent from each other.

Available FundingGrant awards will be made for a three year time period (6/20/2016 to 6/30/2019), with the ability to extend awards to December 31, 2020. Grant renewal is contingent upon the grantee's satisfactory performance, including execution and fulfillment of work plan, achievement of objectives, evaluation efforts, and appropriate and expeditious use of the awarded funds. Funding available for the three year grant cycle is approximately $11,071,000, contingent on continued state legislative appropriations.

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MDH expects to award: Approximately 21 - 26 grants for up to $75,000 per year; Approximately 5 – 6 grants between $75,001 and $135,000 per year; Approximately 3 – 5 grants between $135,001 and $200,000 per year; 1 - 2 grants between $200,001 and $300,000 per year to an organization(s) whose

service area includes the entire state.

Application Requirements Application should be written in at least 12-point font with one-inch margins. All pages should be numbered consecutively. One signed unbound original and 6 unbound copies of the complete application should

be submitted. Submissions may be fastened with metal binder clips or large paper clips. Applications should meet application deadline requirements. Late applications will not

be reviewed. Applications should be complete and signed where noted. Incomplete applications will

not be reviewed. Faxed or e-mailed applications will not be accepted.

Late applications, incomplete applications, applications lost in transit, faxed applications, or e-mailed applications will not be considered for review.

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Grant Application ChecklistUse this checklist to ensure that you have included all the required items for your grant application. Any application that does not contain all required items will be considered incomplete and will not be reviewed.

Have you included the following required items? Grant Application Face Sheet (Form A) Due Diligence and accompanying financial documents (Form B) Assurances and Agreements Form (Form C) Logic Model (Form D) Budget Justification Sheet (Form E) Budget Summary Sheet (Form F) Indirect Cost Questionnaire (Form G) Project Narrative Copy of your 501 (c)3 form

APPLICATION DEADLINE: Your application must be received by MDH no later than 4:00 p.m. on Thursday, January 21, 2016, or have a legible postmark from the U.S. Post Office, or a private courier, date on or before January 21, 2016.

Delivery Address:Mary Ottman, MPHMinnesota Department of HealthDivision of Community and Family Health85 East 7th Place, Suite 220Golden Rule Building, 5th floorSt. Paul, MN 55101

Mailing Address:Mary Ottman, MPHMinnesota Department of HealthDivision of Community and Family HealthP.O. Box 64882St. Paul, MN 55164-0882

Late applications, incomplete applications, applications lost in transit, faxed, or emailed applications will not be considered for review.

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Disposition of ResponsesAll 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 Minnesota Department of Health (MDH) has completed negotiating the grant agreement with the selected grantee. If the Responder 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 Responder must:

Clearly mark all trade secrets 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 indemnify and hold harmless the State, its agents and employees, from any judgments or damages awarded against the State in favor of the party requesting the materials, and any and all costs connected with that defense. This indemnification survives the State’s award of a grant contract. In submitting a response to this RFP, the Responder agrees that this indemnification survives as long as the trade secret materials are in possession of the State.

Applications 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.

Sending in a Positive Alternatives Program Grant application does not guarantee funding. Applications must meet all requirements listed in this packet. Organizations must meet all eligibility requirements and proposals must meet the criteria and requirements listed in this application. Awards for Positive Alternatives Grant funding will be based on formal review of the application and the funding available.

What happens after the application is received?Only complete applications received on or before January 21, 2016, or postmarked on or before January 21, 2016, will be reviewed by a grant review committee according to the Criteria for Grant Review (Appendix A). Reviewers will score applications based on the criteria outlined and document strengths and weaknesses of each proposal. Applicants with current or past Positive Alternatives grant awards may have past performance taken into consideration.

Reviewers may include staff from MDH and other state agencies with grants management expertise; individuals from other organizations that represent a broad range of professionals

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with experience in program planning and project management; individuals with experience working with women with unplanned or challenging pregnancies, or with individuals seeking to establish self-sufficiency; and individuals with experience writing and/or reviewing grants. Reviewers will be required to identify any conflicts of interest and will not review a proposal if they have a potential conflict of interest relationship with the applicant.

Staff from the Community and Family Health (CFH) Division of MDH will review the applications, scores from the reviewers, and reviewers’ recommendations for funding. In addition to reviewer scores and recommendations, staff from the CFH Division will consider:

diversity in activities funded diversity in populations receiving services that grants are distributed to organizations to provide access to services throughout the

state that grants are distributed to organizations of various sizes

CFH Division staff will recommend to the Commissioner of Health which applications should be funded. The decisions on grant awards made by the Commissioner will be final; there will be no appeal process.

It is anticipated that grant award decisions will be made by May 1, 2016. Applicants will be notified whether or not their grant proposal was funded. MDH reserves the right to negotiate changes to budgets or work plans submitted.

MDH will enter into grant agreements with those organizations that are awarded grant funds. The effective date of the grant contract will be June 20, 2016, or date upon which all signatures to the grant contract are obtained, whichever is later. Grant agreements will be made for a three year time period, and may be extended for another one and one-half years until December 31, 2020, subject to satisfactory grantee performance and availability of funding. No work on grant activities can begin until a fully executed grant agreement is in place.

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Program Summary

Eligibility for Grant Funds

Private non-profit organizations with a 501 (c) 3 Organizations with an alternatives-to-abortion program in place (or

incorporated with an alternatives-to-abortion program) for at least one year as of July 1, 2011

Organizations that do not provide abortions, promote abortions, or directly refer to an abortion provider

Total Funds Available

Approximately $11,071,000 is available for the three year grant cycle, contingent on continued state legislative appropriations.

Grant Cycle Three years period from 6/20/16 to 6/30/19 with the possibility of a one and one-half year extension contingent upon satisfactory performance.

Maximum Grant Amount

Approximately 21 to 26 grants awarded for up to $75,000 per year. Approximately five to six grants awarded for amounts between $75,001 and

$135,000 per year. Three to five grants awarded for amounts between $135,001 and $200,000

per year. One to two grants to a statewide organization whose service area includes

the entire state between $200,001 and $300,000 per year. The number of agencies awarded in each funding category amount may

vary depending upon applications received.Grant Purpose To support, encourage, and assist women in carrying their pregnancies to term

and caring for their babies after birth.Application Requirements

Application should be in at least 12-point font with one-inch margins.Submit one signed unbound original and six (6) unbound copies.All pages should be numbered consecutively.

Complete Application

Application Face Sheet (Form A) - submit by mail with the application and include a signed original with application

Copy of 501(c) 3 status Due Diligence and accompanying financial documents (Form B) Signed Assurance and Agreements (Form C) Project Narrative Logic Model (Form D) Budget Justification Sheets (Form E) Budget Summary Form (Form F) Indirect Cost Questionnaire (Form G)

Late applications, incomplete applications, applications lost in transit, faxed, or emailed applications will not be considered for review.

Application Deadline

All applications must be received by MDH no later than 4:00 p.m. on Thursday, January 21, 2016, or have a legible postmark from the U.S. Post Office or a private courier dated on or before January 21, 2016.

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Late applications, incomplete applications, applications lost in transit, faxed, or emailed applications will not be considered for review.

Applications sent: Mailing Address: Mary Ottman, MPHMinnesota Department of HealthDivision of Community and Family HealthP.O. Box 64882St. Paul, MN 55164-0882

Delivery Address:Mary Ottman, MPHMinnesota Department of HealthDivision of Community and Family Health85 East 7th Place, Suite 220Golden Rule Building, 5th floorSt. Paul, MN 55101

Award Decision Approximately May 1, 2016Beginning Grant Agreement Date

June 20, 2016 or when all required signatures to execute the grant/contract are obtained.

Statutory Authority

M.S. 145.4235 (Appendix C)

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Application Instructions and Forms

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Form A: Application Face SheetGeneral Applicant Information

Applicant’s Legal Name (do not use a “doing business as” name):     

Applicant’s Business Address:      

Applicant’s Minnesota Tax Identification Number:      

Applicant’s Federal Tax Identification Number:      

Director of Applicant AgencyName:     

Business Address:      

Phone Number:      

Email:      

Financial Contact, or Fiscal Agent, for this grantName of Financial Contact for this grant:      

Name of Fiscal Agent for this grant, if applicable:      

Phone Number:      

Email:      

Contact Person for this grantName:      

Business Address:      

Phone Number:      

Email:      

Requested FundingTotal Amount on Proposed Budget: $     

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 agency.

Signature of Authorized Agent for Applicant

Date of signature

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Form B: Due Diligence Review FormThe Minnesota Department of Health (MDH) must conduct due diligence reviews for non-governmental organizations (NGOs) applying for grants, according to MDH Policy 240.

Due diligence refers to the process through which MDH researches an organization’s financial and organizational health and capacity (MDH Policy 240). The due diligence process is not an audit or a guarantee of an organization’s financial health or capacity. It is a review of information provided by a NGO and other sources to make an informed funding decision.

As 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.

1. How long has your organization been doing business?      

2. How many employees does your organization have, both part time and full time?      

3. What was your organizations total revenue in the most recent 12 month accounting period?

     

4. How many different funding sources does the total revenue listed in question #3 come

from?      

5. Does your organization have a current 501(c) 3 status from the Internal Revenue Service?

Yes No

6. Has your organization done business under any other name or names within the last five

years? Yes No

a. If you answered yes to questions #6, list the names previously used.      

7. Is your organization affiliated with or managed by any other organizations, such as a

regional or national office? Yes No

8. Does your organization receive management or financial assistance from other

organizations? Yes No

a. If yes, provide details.      

9. Have you been a grantee of the Minnesota Department of Health within the last five years?

Yes No

a. If yes, from which divisions did you receive grants from?      

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10. Does your organization have written policies and procedures for accounting processes? Yes

No

If yes, please attach a copy of the table of contents of the written policies and procedures.

11. Does your organization have written policies and procedures for purchasing processes? Yes

No

If yes, please attach a copy of the table of contents of the written policies and procedures.

12. Does your organization have written policies and procedures for payroll process? Yes No

If yes, please attach a copy of the table of contents of the written policies and procedures.

13. Which of the following best describes your organization’s accounting system?

Manual Automated Both

14. Does the accounting system identify the deposits and expenditures of program funds for

each and every grant separately? Yes No Not Sure

15. If your organization has multiple programs within a grant, does the accounting system

record the expenditures for each and every program separately by budget line items? Yes

No Not sure Not Applicable

16. Are time studies conducted for employees who receive funding from multiple sources? Yes

No Not sure Not Applicable

17. Does the accounting system have a way to identify over-spending of grant funds? Yes No

Not sure

18. If grant funds are mixed with other funds, can the grant expenses be easily identified? Yes

No Not sure

19. Are the officials of the organization bonded? Yes No Not sure

20. Did an independent certified public accountant ever examine the organization’s financial

statements? Yes No Not sure

21. Has any debt been incurred in the last six months? Yes No

a. If yes, what was the reason for the new debt?      

b. What is the funding source for paying back the new debt?      

22. What is the current amount of unrestricted funds compared to total revenues?      17

23. Are there any current or pending lawsuits against the organization? Yes No

24. If yes, could there be an impact on the organization’s financial position? Yes No or Not

Applicable

25. Has the organization lost any funding due to accountability issues, misuse, or fraud? Yes

No

If yes, please describe the situation, including when it occurred and whether issues have

been corrected.      

The following documentation is required in addition to the due diligence form.

If you’re an Non-Governmental Organization with an annual income of

Then submit your most recent

Under $25,000 Board-reviewed financial statementBetween $25,000 and $750,000 IRS Form 990Over $750,000 Certified financial audit

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Form C: Assurance and Agreements FormBy signature, the authorized official agrees and assures that the agency is a private nonprofit 501(c) 3 organization and that:

The agency has had an alternatives-to-abortion program in existence for at least one year as of July 1, 2011; or incorporated an alternatives-to-abortion program that has been in existence for at least one year as of July 1, 2011.

Their alternatives-to-abortion program’s purpose is to assist and encourage women in carrying their pregnancies to term and in maximizing their potentials thereafter. Encourage means to affirmatively counsel a woman on carrying her pregnancy to term unless her life is in danger.

Only accurate information on the developmental characteristics of babies and of unborn children will be provided to women.

Medical information provided by the agency will be medically accurate, and that medical services meet standards defined by the appropriate professional organization or are broadly recognized within the medical community.

The agency does not provide abortions, promote abortions, or directly refer to an abortion provider.

The agency is not an affiliate of an agency that provides abortions, promotes abortions, or directly refers to an abortion provider unless the organizations are separately incorporated and independent from each other.

None of the grant funds will be used to encourage or affirmatively counsel a woman to have an abortion not necessary to prevent her death, to provide her an abortion, or to directly refer her to an abortion provider for an abortion. An agency may provide “nondirective counseling” as defined in Minnesota Statute 145.4235 (Appendix C)

Only Commissioner of Health approved information on the health risks associated with abortions will be provided to women in grant-funded programs. (Commissioner of Health approved information can be found in the booklet IF YOU ARE PREGNANT: Information on Fetal Development, Abortion and Alternatives.)

The agency will not charge women for services provided using grant funds.

The agency has a privacy policy and procedures in place to ensure that the name, address, telephone number, and any other information that might identify any woman seeking the 19

services of the program are not made public or shared with any other agency or organization without the written consent of the woman.

Medical care provided by the agency, including, but not limited to, pregnancy tests or ultrasonic scanning, adheres to the requirement in Minnesota Statutes 144.291 – 144.298 that apply to providers releasing information relating to the medical care provided.

Adoption agencies referred to or adoption services provided are from a Minnesota licensed adoption agency.

No grant funds will be used to fund religious worship, instruction, or proselytization and that individuals who receive grant related services will not be required or encouraged to participate in any religious activities.

If the agency is funded, this agreement will become part of the Grant Agreement the agency will enter into with the Minnesota Department of Health.

Name of Agency

Address of Agency

Signature of authorized official

Title of authorized official

Date of signature

Telephone number of authorized official

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Project NarrativeThe project narrative provides an overall description of your organization, the related issues your organization would like to address in the community and the proposed activity or activities for which grant funds will be used. The Project Narrative is broken into four sections:

Organizational Capacity Grant Proposal Logic Model and Evaluation Budget

Your organization will need to provide specific information in each of these sections. To assist with completing the application, we have provided detailed instructions on what information should be included and what grant reviewers will be looking for as they review your organization’s proposal. Please remember proposals submitted should use at least 12-point font with one-inch margins. The Project Narrative should be submitted in the same sequence as listed above. Please review all of the information in the Project Narrative before you begin.

Organizational Capacity In this section, briefly tell us about your organization.

Describe your organization, its administrative structure and history Describe who your organization serves Describe the services your organization provides Describe how your organization works with other community organizations and/or

services to support pregnant women

Include information that is important for grant reviewers to understand about your organization, including your capacity to administer grant funds. If you have a Positive Alternatives grant now, include information about its successes and/or challenges. Please limit this section to a maximum of four pages.

The following are examples of items your organization might want to include in this section. Provide background information on your organization. How long has your organization

been in existence and what is its mission? How is it funded? Does your organization have paid staff? How many volunteer hours support your organization’s efforts and in what ways?

Describe your facilities and location. How does the space your organization has lend itself to providing the programming its proposing? Describe your location in relation to the population you serve.

Describe the Board of Directors that guides the organization’s work: How do they represent the community served?

Describe the services your organization provides. Be sure to include a description of the alternatives-to-abortion program that has been in existence since 2011. How does this

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program support, encourage and assist women in carrying their pregnancies to term and caring for their babies after birth? What services are provided by this program?

Describe your organization’s clientele (ages; Race/Ethnic groups). How many individuals do you serve per year?

Does your organization work with other community agencies or groups to provide services to pregnant women and infants? If so, which ones and in what way?

Criteria for Grant Review: The Organizational Capacity section of the application will be reviewed according to the following criteria (25 Points):Does the description provide clear and concise information of the history and structure of the organization?

Is it clear how the organization is funded? How and by whom is it supported?

Does the organization have the capacity (administration, facilities, staff, etc.) to deliver the proposed activity?

Does the organization adequately describe their alternatives-to-abortion program, that is, a program that supports, encourages and assists women in carrying their pregnancies to term and caring for their babies after birth?

Does the organization partner or work with others to serve pregnant women and their infants?

Grant Proposal (How will the Grant Funds be used?)As stated in the Positive Alternatives statute, to be eligible for a grant, “an organization must… ensure that its alternatives-to-abortion program’s purpose is to assist and encourage women in carrying their pregnancies to term and to maximize their potentials thereafter”. It further states that grants will be awarded “for the reasonable expenses of alternatives-to-abortion programs to support, encourage and assist women in carrying their pregnancies to term and caring for their babies after birth”.

In this section, your organization needs to describe each activity for which funds are being requested, and demonstrate how it will provide assistance and encouragement to pregnant and/or parenting women, and what it will do to maximize their potentials after the births of their babies. Give details of each activity for which your organization is requesting funding, including the following items:

Describe your organization’s proposed activity, how it will support pregnant women or women caring for infants, how it will improve pregnancy outcomes or care for babies after birth, or improve family stability and self- sufficiency.

Describe the women your organization plans to serve including basic demographic information.

Describe how your organization’s proposal will address unmet needs in your community.

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Describe how the grant-funded activity will fit into the programs your organization currently provides. Include information about the needs, strengths, and resources of your community as they relate to pregnant women or women with infants.

Your narrative should include information your organization thinks is important for grant reviewers to know in order to understand what it’s planning to do with the grant funds. Please keep this section to a maximum of ten pages. The following are examples of information your organization might want to include in this section:

Describe the goals and objectives your organization aims to achieve. Describe each activity your organization plans to implement and why it is important.

Describe how the activity supports, encourages and assists women in carrying their pregnancies to term and/or caring for their babies after birth.

Describe how your organization’s activity will help women carry their pregnancies to term, improve pregnancy outcomes, improve and/or support their parenting, and/or improve family stability and self-sufficiency.

Describe what effect or impact your organization thinks the activity will have on pregnant or parenting women and why it thinks the effect will be what is described. Give evidence from research to support the reasoning, your organization’s own experience, and/or the experience of similar organizations.

Describe the needs of pregnant women and women with infants in your community. Cite statistics or other data. In what way will your organization’s activity help to meet their needs?

Describe how your organization’s current activities and resources (staff, facilities) will support the activities being proposed.

Describe the geographic area your organization will serve; the women it expects to serve by age, Race/Ethnic group (if targeted) and other characteristics; the number expected to be served and the frequency of contacts with them for each proposed activity.

If other agencies or community services will be involved in your organization’s proposal, describe who they are and what will be their roles and responsibilities.

Describe how your organization will use existing staff, if additional training will be sought, and if additional staff members will be hired.

Describe how your organization plans to let your target population know about the services that will be provided.

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Criteria for Grant Review: The Grant Proposal section of the application will be reviewed according to the following criteria (50 points):Is the proposal clear and understandable? Is it clear what activity or activities the grant would fund?

Are the goals and objectives of each activity clearly explained?

Does the proposed activity support, encourage and assist women in carrying their pregnancies to term or in caring for their babies after birth?

Does the proposed activity help women carry their pregnancies to term, improve pregnancy outcomes, improve or support their parenting, infant care, family stability or self-sufficiency?

Does the proposal include the geographic area to be served, a description of the targeted population, and information on the number and frequency of women to be served? Are these numbers realistic?

Does the proposal identify sufficient resources (staff, facilities, etc.) to be successful when current and proposed resources are combined?

Is the need for the services documented or identified? Does the proposed activity address the need?

Is the proposed activity feasible? Is it likely to be effective? Is evidence given to support this?

Does the proposal have a reasonable plan to reach (contact, attract) the women to be served?

Does the proposal include partnerships or collaborate with others in the community?

Logic Model and Evaluation: (Please complete Form D for this section)The purpose of the Logic Model is to visually display the connections between the activities your organization plans to provide and the outcomes or affects your organization plans to achieve.

The Logic Model contains short-term and intermediate outcomes that correspond to the activities that will be funded. Other related short and intermediate outcomes will be considered for funding. No long-term outcomes will be considered for funding.

The Logic Model will also aid in evaluating your program’s effectiveness. In the logic model an intermediate outcome associated with an activity will be linked to a measure to help determine if the activity is achieving the intended outcome.

Your organization’s program evaluation will consist of the measurement of the intermediate outcome that corresponds to the activity described in your organization’s grant proposal and 24

entered on the Logic Model. (Your organization may have several grant-funded activities, but will only be required to evaluate one or two, depending on the funding level.) As part of the Evaluation Plan, your organization will be required to submit an indicator for the intermediate outcome associated with the activity entered on the Logic Model. An indicator is specific measurable data collected to document that an outcome has occurred. Indicators are measurements of the outcomes that report on the activities impact and helps answer the question, “did the activity achieve the intended outcome.” After funding has been awarded, Minnesota Department of Health will provide assistance in formalizing evaluation plans.

Do not submit an evaluation plan with your application. Your organization must submit a Logic Model.

Instructions for completing the Logic Model: There are two Logic Models beginning on page 26, one for the Goal “Support, encourage and assist women in carrying their pregnancies to term” and one for the Goal “Support, encourage and assist women in caring for their babies after birth”. Under each Goal is an “Activity Category” column related to that goal. Decide which “Goal” and “Activity Category” best fits the activity for which your organization is seeking grant funding. Enter the activity for which your organization is requesting funding under the “Activity Category” column and row in the Logic Model where it best fits. It will best fit where it corresponds to the short and intermediate outcomes listed on the same row in the Logic Model. If your proposal receives funding, your organization will have an opportunity to further develop your Logic Model. The short-term and intermediate outcomes are suggested outcomes for the types of activities that will be funded. If your organization’s proposed activity does not fit into one of the categories, develop and enter your own category and short and intermediate outcomes. Do not add a long-term outcome. The long-term outcomes will be the same for all funded proposals. If your organization is asking for more than one activity to be funded, enter each activity in which funding is sought onto the Logic Model. Refer to Appendix B, for a sample completed Logic Model.

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Form D: Logic Model and EvaluationGOAL 1: Support, encourage and assist women in carrying their pregnancies to term

Activity Category

Number of individuals

served/year

Short-Term Outcomes Intermediate Outcomes Long-Term Outcomes

Medical Services

Women are aware of their pregnancy status

Women are aware of their weight, blood pressure and other medical indicators related to pregnancy

Women schedule and attend prenatal appointments

Women make healthy changes to benefit their own and their babies health during pregnancy

Women have healthy pregnancy outcomes

Services to Support Healthy Pregnancy Behavior

Women have increased knowledge of the benefits of: Early prenatal care Use of folic acid Good nutrition Exercise Smoking cessation Reducing/eliminating

Alcohol/drug use

Women schedule and attend prenatal appointments

Women take prenatal vitamins Women have healthy meals Women exercise appropriately Women quit smoking or reduce

amount or exposure to tobacco products

Women quit drinking alcohol Women quit drug use or enter

appropriate treatment

Women have healthy pregnancy outcomes

Support in Carrying Baby to Term

Women have increased knowledge of and access to: Resources and referrals for

support services Financial resources Material resources Prenatal development Adequate housing

Women: Make appointments with local

agencies to access services to meet identified needs

Contact resources for rental assistance Contact resources for maternity and

baby items Move into or maintain safe, supportive

housing

Women have healthy pregnancy outcomes

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GOAL 2: Support, encourage and assist women in caring for their babies after birth (caring for a baby after birth could also include making an adoption plan)

Activity Categories

Number of individuals served/year

Short-Term Outcomes Intermediate Outcomes Long-Term Outcomes

Support to Women to Increase their Knowledge and Skills as Parents

Women have increased knowledge regarding Sleep safety Car seat safety Infant nutrition Age-appropriate developmental

expectations and activities Violence prevention Engaging fathers of babies

Women Use cribs and car seats appropriately Use safe sleep techniques Breastfeed their babies Demonstrate age-appropriate

parenting expectations and activities Involve the fathers’ of their babies

when the relationship is safe and supportive

Women demonstrate appropriate care for their babies

Support to Women to Increase their Ability to Become Self-sufficient

Women have increased access to and/or knowledge of and/or resources on Adoption Accessing child care Affordable housing Education opportunities Supportive employment Family stability

Women plan and Explore parenting options Make informed child care choices Make informed housing choices Graduate from high school/continue

higher education Maintain/gain further employment

Women increase family stability and self-sufficiency

Criteria for Grant Review: The logic model section of the application will be reviewed according to the following criteria (10 points):

Is there a complete Logic Model included in the application?

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Criteria for Grant Review: The logic model section of the application will be reviewed according to the following criteria (10 points):

Does the Activity Category column of the Logic Model contain each of the major activities described in the Project Narrative?

Will the activity achieve the short and intermediate outcomes?

Does the activity match the organization’s goal, capacity and budget that is submitted?

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Budget Section

InstructionsBefore you begin writing your organization’s budget, consider the specific activity planned and the resources needed to do it. Which resources does your organization already have and what needs to be purchased? Which items will need to be replaced during the program (grant time period)? When considering the skills needed to carry out the activity, remember to include any training that will be needed for paid staff or volunteer members.

The Budget Section of the application is composed of two forms: Budget Justification Sheet (Form E) Budget Summary Sheet (Form F).

Your organization will need to complete three Budget Justification Sheets, one for each year of your grant program:

6/20/16 – 6/30/17 7/1/17 - 6/30/18 7/1/18 – 6/30/19

Each Budget Justification Sheet will provide the details of your organization’s expenses and a brief description of how they support your proposed grant activity for that year. (The full description of the purpose of each grant-funded position and the necessity of budgeted items should appear in the Project Narrative.)

The Budget Summary Sheet (Form F) is where your organization will provide the total expenses for the first three years of your proposal by adding the expenses from the three Budget Justification Forms together.

The categories below, salary and fringe benefits, contractual services, travel, supplies and expenses, other costs, evaluation, and indirect costs correspond to the sections in both the Budget Justification Sheet and the Budget Summary Sheet. The description of costs that may be included in each category are listed below.

Salary and Fringe BenefitsFor each proposed funded position, indicate the title, the full time equivalent (FTE) on this grant (see box below for a definition), the expected rate of pay, and the total amount you expect to pay the position for the year. Grant funds can be used for salary and fringe benefits for staff members directly involved in your organization’s proposed activities. It is strongly suggested that grantees incorporate into their budget the costs of appropriate financial staff to provide

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oversight to the grant. This could be through contracting with an individual or organization or a direct hire.

NOTE: “Full time equivalent” (FTE) is defined as the percentage of time a person will work on the Positive Alternatives project. To calculate the FTE, divide the hours the person will work by the standard number of work hours, which is 40 hours per week, 174 hours per month, or 2,088 hours per year. For example, a person who works 20 hours per week is a 0.5 FTE (20/40 = 0.5)

Contractual ServicesGrant funds can be used for small contracts with speakers or trainers, and for large contracts if other organizations will be providing some of the services included in your grant proposal. Rented or leased equipment for the project should be included in this category. Supplies and travel expenses for contractors should be included here, if applicable.

Applicants 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 your 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 for; 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 contractor.

TravelList your staff’s expected travel costs, including mileage, hotel and meals. At a minimum, your organization must include the cost for at least one staff member to attend two MDH-sponsored statewide or regional meetings during each year. If project staff will travel during the course of their jobs or for attendance at educational events, 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.

Any applicant that is awarded a grant agreement will not be reimbursed for travel and subsistence expenses incurred outside Minnesota unless it has received the State's prior written approval for out of state travel. Minnesota will be considered the home state for determining whether travel is out of state.

Non-tribal applicants:Budget for travel costs using the rates listed in the State of Minnesota’s Commissioner’s Plan. Please reference the meal allowances rates listed there.

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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.

Tribal applicants:Budget for travel costs using the rates provided by the General Services Administration (GSA).

Current lodging amounts and meal reimbursement rates vary depending on where in Minnesota the travel occurs. Please reference the per diem rates listed there.

A breakdown of the meals and incidental expenses can be found here.

Mileage will be reimbursed at the current IRS rate.

Supplies and ExpensesBriefly explain the expected costs for items and services your organization will purchase to run your program. These might include additional telephone equipment; postage; printing and photocopying; office supplies, training materials, pregnancy tests; baby items; and equipment. Include the costs expected to be incurred to ensure that community representatives, partners or clients who are included in your organization’s process or program can participate fully. Examples of these costs are fees paid to translators, interpreters, or childcare providers, or for transportation. Include items such as rent for space that is being added for the project. 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.

If you plan on purchasing gift cards to use as incentives or rewards, they must be listed separately by purpose (food, gas, etc.) and denomination.

We will rely on electronic means to communicate with funded programs (grantees). If your organization does not have a reliable computer and Internet access, include the cost of these items in your budget.

Grantees may include reasonable costs to reach women intended to be served by their programs in their budgets. These outreach expenses may include, but are not limited to, print ads in newspapers, directories and broadcast ads like internet, radio or theater ads. Outreach expenses may not exceed $7,000 per year or 7% of the annual budget, whichever is higher. Print and promotional items like brochures, business cards and logo pens or cups are not included in outreach expenses.

Food expenses such as meals and/or refreshments can only be considered if residential housing is being requested as part of the grant program. Funds from Positive Alternatives grant cannot be used for field trips.

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Other ExpensesInclude in this section any expenses you expect to have for other items that do not fit in any other category. An example is staff training, which can be charged to the grant at a rate not to exceed $250 per year per grant-funded person. The cost of membership dues for state or national affiliated organizations cannot be charged to the grant.

EvaluationEach applicant’s budget must include evaluation costs. Five percent of all of the program expenses is the minimum required budget line item amount on an applicant’s Budget Justification Sheet (Form E). Applicants should total all expenses listed on the Budget Justification Sheet (Form E) except indirect expenses. Multiply that total by 5% and enter the amount on the line item category “evaluation”. An organization may apply for more than 5% of the total grant amount requested for evaluation activities. If an organization requests more than 5% the rationale for the increased amount must be included on the Budget Justification Sheet (Form E). Indirect CostsIndirect Costs are defined as: 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: executive and/or supervisory salaries and fringe, rent, facilities maintenance, insurance premiums, etc. It is these costs that could be included in the 10% maximum but could also be charged directly to the grant. See Form G.

For grantees receiving federal funds: Any salaries from the administrative, accounting, human resources, or IT support MUST be supported by time studies, or some type of time tracking, in order to be included as a direct line expense. If these salary expenses are not supported by time reporting documentation, then those costs must be included in the Indirect line.

If you have a Federally Negotiated rate, MDH will use that rate. Please submit documentation of your most current Federally Negotiated Rate to MDH with your application to this RFP.

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. Grant funds may not be used to purchase any individual piece of equipment that costs more than $5,000.

The scoring of the Budget Section will be done using the Budget Justification Sheets and the Budget Summary Sheet. If supplementary information is included, it will not be taken into consideration for scoring purposes.

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Criteria for Grant Review: The Budget Section of the application will be reviewed and scored for accuracy according to the following criteria (15 points):

Are there three complete Budget Justification Sheets (Form E), one for each year of the grant? Does the sum of the section totals equal the Grand Total on each Budget Justification Sheets (Form E)?

Is the Budget Summary Sheet (Form F) complete and do the amounts in each category add up to the total grant amount being requested?

Is line 9 (Indirect Costs) less than or equal to 10% of line 8 (Subtotal of Direct Expenses)?

Is the information contained in the Budget Justification Sheets consistent with the proposed activity?

Is the budget sufficient to accomplish the proposed activity and provides the appropriate accounting support?

Are the projected costs reasonable? Is the cost per participant reasonable?

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Form E: Budget Justification Sheet(See instructions starting on page 29)

Complete one form for each of the following years:6/20/16 – 6/30/177/1/17 – 6/30/187/1/18 – 6/30/19Applicant Agency:Contact Person:Phone Number:Email Address:Budget Period: July 1, 20__ to June 30, 20__

Revision # (MDH use only):

1. Salary and Fringe BenefitsFor each proposed funded position, list the title, the full time equivalent, the expected rate of pay, and the total amount you expect to pay the position.

REQUESTEDDOLLARS

Budget Justification:

Total Salary and Fringe $

2. Contractual ServicesList the services your organization expects to contract out, the contractor’s or consultant’s name, whether the contractor is non-profit or for-profit, the length of time the services will be provided and the total amount expected to be paid. Supplies and travel of contractor should be included, if applicable. Itemize equipment rented or leased for the project.

REQUESTEDDOLLARS

Budget Justification:

Total Contractual Services $

3. TravelExplain your expected instate travel costs, including mileage, hotel and meals. At a minimum, your organization must include the cost for at least one staff member to attend two MDH-sponsored statewide or regional meetings. If program staff will travel, itemize the costs, frequency and the nature of the travel.

REQUESTEDDOLLARS

Budget Justification:

Total Travel $

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4. Supplies and ExpensesExplain the expected costs for items and services your organization will purchase to run your 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 additional rent for program space, participant transportation, participant training and other direct costs as needed.

REQUESTEDDOLLARS

Budget Justification:

Total Supplies and Expenses $

5. Other ExpensesBriefly describe any expenses that do not fit in any other category. An example is staff training, which can be charged to the grant at a rate not to exceed $250 per year per person.

REQUESTEDDOLLARS

Budget Justification:

Total Other Expenses $

6. SUBTOTAL (Enter sum of lines 1 through 5): $

7. Evaluation5% of grant expenses must be included in the budget for evaluation costs. Multiply the amount of line 6, Subtotal, by 5% and enter here. It is not necessary to include any information on evaluation procedures.

REQUESTEDDOLLARS

Total Evaluation $

8. SUBTOTAL OF DIRECT EXPENSES (Sum of lines 6 and 7) $

9. Indirect CostsIf applicable, enter the indirect cost rate below. In the box to the right, enter the amount of indirect costs being requested. Maximum indirect rate is 10% of line 8, Subtotal of Direct Expenses.

Indirect cost rate: _____%

REQUESTEDDOLLARS

Indirect Total $

10. TOTAL (sum of line 8 + line 9) $

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Form F: Budget Summary Sheet6/20/16 – 6/30/19

Minnesota Department of Health, Positive Alternatives Grant ProgramName of Applicant Agency:

Name of Contact Person for Budget:

Phone: Fax:

E-mail:

Line Item Total Proposed Amount1) Salary and Fringe Benefits

2) Contractual Services

3) Travel

4) Supplies and Expenses

5) Other Expenses

6) Subtotal (sum of line 1 through line 5)

7) Evaluation (5% of line 6)

8) Subtotal of Direct Expenses (line 6 + line 7)

9) Indirect Costs (maximum of 10% of Line 8)

10) TOTAL (line 8 + Line 9)

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Budget Summary InstructionsThis form should be used to show the total requested budget for your organization’s proposed grant-funded activities from 6/20/16 – 6/30/19. The budget should include funding necessary in each category for three years of the grant. The total in each category should reflect the total of that category from the three Budget Justification Sheets: 6/20/16 – 6/30/17, 7/1/17 - 6/30/18 and 7/1/18 – 6/30/19. The Subtotal (line 11) should reflect the total of all the expenses listed on the three Budget Justification Sheets. Please enter zero (0) in the Total Proposed Amount column if you do not propose to expend grant funds in a line item.

Please type all items on the Budget Summary Sheet (Form F).Name of Applicant Agency – Legal name of the agency applying for grant funds.Name of Contact Person for Budget – Person who may be contacted for questions related to the budget proposal.Phone – Telephone number of the person listed.Fax – Fax number of the person listed.E-Mail – E-mail address of the person listed.1. Salary and Fringe Benefits – The total amount of grant funds that will be used during the

three year grant period to cover salary/fringe benefits (add the figures from the “Total Salary and Fringe” box in all of the Budget Justification Sheets).

2. Contractual Services – The total amount of grant funds that your organization plans to spend on contractual services (add the figures from the “Total Contractual Services” box in all of the Budget Justification Sheets).

3. Travel – The total amount of grant funds that your organization plans to spend on travel (add the figures from the “Total Travel” box in all of the Budget Justification Sheets).

4. Supplies and Expenses – The total amount of grant funds that your organization plans to spend on supplies and expenses (add the figures from the “Total Supplies and Expenses” box in all of the Budget Justification Sheets).

5. Other Expenses – The total amount of grant funds that your organization plans to spend on items that are not listed above (add the figures from the “Other Total” box in all of the Budget Justification Sheets).

6. Subtotal – The total from adding line 1, line 2, line 3, line 4, and line 5. This figure should match the sum of the subtotals on your Budget Justification Sheets.

7. Evaluation – Include 5% of the cost of your proposal for evaluation purposes. Multiply the figure on line 6 by 5% and enter it on line 7. This figure should match the sum of the evaluation costs on your Budget Justification Sheets.

8. Subtotal of Direct Expenses – Add line 6 and line 7 to calculate the subtotal of direct expenses and enter in line 8.

9. Indirect Costs - The total amount of grant funds that your organization plans to spend for indirect costs. The indirect costs cannot exceed 10% of Line 8 .This figure should match the sum of the indirect costs on your Budget Justification Sheets.

10. Total – The total in adding lines 8 and 9.

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Form G: Indirect Cost Questionnaire

Applicant’s Legal Name: _________________________________________

Program: Positive Alternatives Grant Program

Please check one of the three options below:

1. Not applicable

No charges to the grant program listed above are for indirect costs.

2. Federally Approved Indirect Cost Rate Agreement

A federally negotiated fixed rate is to be charged against all grant programs.

A copy of the federally approved Indirect Cost Rate Agreement covering the current federal fiscal year is attached.

3. No federally approved indirect cost rate – requesting up to 10% maximum

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.

The applicant agency is requesting a rate of      % for the grant program listed above.

Per MDH Policy, the applicant must inform MDH of the types of costs included in the applicant’s indirect costs. Please list below.

     

     

     

     

     

     

     

Appendices

Appendix A: Criteria for Grant Review

Appendix B: Sample Logic Model with Suggested Activities

Appendix C: Positive Alternatives Act, M.S. 145.4235

Appendix D: Sample of MDH Grant Agreement

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Appendix A: Criteria for Grant Review

Section of Application

Total Points Available

Review Criteria

Organizational Capacity

25 Does the description provide clear and concise information of the history and structure of the organization?

Is it clear how the organization is funded? How and by whom is it supported? Does the organization have the capacity (administration,

facilities, staff, etc.) to deliver the proposed activity? Does the organization have a history of providing a grant-eligible

alternatives-to-abortion program, that is, a program that supports, encourages and assists women in carrying their pregnancies to term and caring for their babies after birth?

How successful has your program been? Does the organization partner or work with others to serve

pregnant women and their infants?

Grant Proposal 50 Is the proposal clear and understandable? Is it clear what activity or activities the grant would fund? Are the goals and objectives of each activity clearly explained? Does the proposed activity support, encourage and assist

women in carrying their pregnancies to term or in caring for their babies after birth?

Does the proposed activity help women carry their pregnancies to term, improve pregnancy outcomes, improve or support their parenting, infant care, family stability or self-sufficiency?

Does the proposal include the geographic area to be served, a description of the targeted population, and information on the number and frequency of women to be served?

Are these numbers realistic? Does the proposal identify sufficient resources (staff, facilities,

etc.) to be successful when current and proposed resources are combined?

Is the need for the services documented or identified? Does the proposed activity address the need? Is the proposed activity feasible? Is it likely to be effective? Is evidence given to support this? Does the proposal have a reasonable plan to reach (contact,

attract) the women to be served? Does the proposal include partnerships or collaborate with

others in the community?

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Section of Application

Total Points Available

Review Criteria

Logic Model 10 Is there a complete Logic Model included in the application? Does the Activity Category column of the Logic Model contain

each of the major activities described in the Project Narrative? Will the activity achieve the short and intermediate outcomes? Does the activity match the organization’s goal, capacity

and budget that is submitted?

Budget Justification Sheets

15 Are there three complete Budget Justification Sheets (Form E), one for each year of the grant?

Does the sum of the section totals equal the Grand Total on each Budget Justification form E?

Is the Budget Summary Sheet (Form F) complete and do the amounts in each category add up to the total grant amount being requested?

Is line 9 (Indirect Costs) less than or equal to 10% of line 8 (Subtotal of Direct Costs)?

Is the information contained in the Budget Justification Sheets consistent with the proposed activity?

Is the budget sufficient to accomplish the proposed activity? Are the projected costs reasonable? Is the cost per participant reasonable?

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Appendix B: Sample Logic Model

Below is a sample of what a completed Logic Model might look like. An applicant would provide the information written here underlined in bold font. The applicant must insert at least one of the short-term and one of the intermediate outcomes listed for the goal and category activity. If more than one short-term and/or intermediate outcome applies the applicant can list all that apply for the proposed grant activity. Do not change the long-term outcome listed.

GOAL 1: Support, encourage and assist women in carrying their pregnancies to termActivity Number of

individuals served/year

Short-term Outcome Intermediate Outcome Long-term Outcome

Medical Services

Provide pregnancy tests

150

Women are aware of their pregnancy status.

Women plan for their own and their babies’ care during pregnancy.Women make positive changes to benefit themselves and their babies during pregnancy.Women are aware of their weight, blood pressure and other medical indicators related to pregnancyWomen bond with their babies

Women have healthy pregnancy outcomes.

Services to Support Healthy Pregnancy Behavior

Provide necessary services resources and referrals

200

Women have increased knowledge of and access to pregnancy support resources and referrals.

Women make appointments with local agencies to access services to meet identified needs.

Women have healthy pregnancy outcomes.

Support in Carrying Baby to Term

Provide maternity clothes, baby clothes and diapers

300

Women have necessary material resources (to assist them in pregnancy and parenting infants).

Women utilize available resources to meet their material needs.

Women have healthy pregnancy outcomes.

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GOAL 2: Support, encourage and assist women in caring for their babies after birth Activity Number of

individuals served/year

Short-term Outcome Intermediate Outcome Long-term Outcome

Support to Women to Increase their Knowledge and Skills as Parents

Provide parenting education program where cribs are distributed and safe sleep instruction is provided

200

Women have increased knowledge regardingsleep safety.

Women use cribs safely. Women demonstrate appropriate care for their babies.

SUGGESTED ACTIVITIESThe chart below lists suggested activities that can be funded under each Activity Category on the Logic Model. Some programs or services have required components associated with them. These are identified with an asterisk (*). The required components are listed under the chart.

Activity Category Possible Funded Programs or Services

Required Services for the Activity Category

Provide medical services Pregnancy testing*Prenatal obstetrical or midwife care*Ultrasound services*

Pregnancy testing*Prenatal obstetrical or midwife care*Ultrasound services*

Provide education and services to support health pregnancy behavior

Pregnancy education programCase management or client advocate servicesHome visiting assessment and support servicesProvide cribs and safe sleep education*Childbirth education classesPrenatal nutrition classes

Provide cribs and safe sleep education*

Provide support in carrying a baby to term

Provide Positive Alternatives Necessary Services intake and referral Provide financial assistance directly or through referralsProvide material assistance directly or through referrals

Provide referrals to local resources for identified needs that applicant cannot meet.

It would be helpful to require a referral to a clinic/medical provider for prenatal care.

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Activity Category Possible Funded Programs or Services

Required Services for the Activity Category

Provide housing to pregnant and/or parenting womenStaff a 24-hour Information hotline providing referrals and information

Provide support to women to increase their knowledge and skills as parents

Parenting education programProvide car seats and education*Provide infant care classes Mentoring programChild careProvide scholarships to ECFE or other community education classes

Provide car seats and education*

Provide support to women to increase their ability to become self-sufficient

Provide licensed adoption services*Provide or subsidize literacy or ESL classesAssist women in employment and/or education training and/or searches

Provide licensed adoption services*

These activities may be funded in any category without entering them on the Logic Model

Transportation, Interpreters, Food, Incentives

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Appendix C: Positive Alternatives Statute

145.4235 POSITIVE ABORTION ALTERNATIVES.Subdivision 1. Definitions.

For purposes of this section, the following terms have the meanings given:

(1) "abortion" means the use of any means to terminate the pregnancy of a woman known to be pregnant with knowledge that the termination with those means will, with reasonable likelihood, cause the death of the unborn child. For purposes of this section, abortion does not include an abortion necessary to prevent the death of the mother;

(2) "nondirective counseling" means providing clients with:

(i) a list of health care providers and social service providers that provide prenatal care, childbirth care, infant care, foster care, adoption services, alternatives to abortion, or abortion services; and

(ii) nondirective, nonmarketing information regarding such providers; and

(3) "unborn child" means a member of the species Homo sapiens from fertilization until birth.

Subd. 2.Eligibility for grants.(a) The commissioner shall award grants to eligible applicants under paragraph (c) for the

reasonable expenses of alternatives to abortion programs to support, encourage, and assist women in carrying their pregnancies to term and caring for their babies after birth by providing information on, referral to, and assistance with securing necessary services that enable women to carry their pregnancies to term and care for their babies after birth. Necessary services must include, but are not limited to:

(1) medical care;

(2) nutritional services;

(3) housing assistance;

(4) adoption services;

(5) education and employment assistance, including services that support the continuation and completion of high school;

(6) child care assistance; and

(7) parenting education and support services.

An applicant may not provide or assist a woman to obtain adoption services from a provider of adoption services that is not licensed.

(b) In addition to providing information and referral under paragraph (a), an eligible program may provide one or more of the necessary services under paragraph (a) that assists

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women in carrying their pregnancies to term. To avoid duplication of efforts, grantees may refer to other public or private programs, rather than provide the care directly, if a woman meets eligibility criteria for the other programs.

(c) To be eligible for a grant, an agency or organization must:

(1) be a private, nonprofit organization;

(2) demonstrate that the program is conducted under appropriate supervision;

(3) not charge women for services provided under the program;

(4) provide each pregnant woman counseled with accurate information on the developmental characteristics of babies and of unborn children, including offering the printed information described in section 145.4243;

(5) ensure that its alternatives-to-abortion program's purpose is to assist and encourage women in carrying their pregnancies to term and to maximize their potentials thereafter;

(6) ensure that none of the money provided is used to encourage or affirmatively counsel a woman to have an abortion not necessary to prevent her death, to provide her an abortion, or to directly refer her to an abortion provider for an abortion. The agency or organization may provide nondirective counseling; and

(7) have had the alternatives to abortion program in existence for at least one year as of July 1, 2011; or incorporated an alternative to abortion program that has been in existence for at least one year as of July 1, 2011.

(d) The provisions, words, phrases, and clauses of paragraph (c) are inseverable from this subdivision, and if any provision, word, phrase, or clause of paragraph (c) or its application to any person or circumstance is held invalid, the invalidity applies to all of this subdivision.

(e) An organization that provides abortions, promotes abortions, or directly refers to an abortion provider for an abortion is ineligible to receive a grant under this program. An affiliate of an organization that provides abortions, promotes abortions, or directly refers to an abortion provider for an abortion is ineligible to receive a grant under this section unless the organizations are separately incorporated and independent from each other. To be independent, the organizations may not share any of the following:

(1) the same or a similar name;

(2) medical facilities or nonmedical facilities, including but not limited to, business offices, treatment rooms, consultation rooms, examination rooms, and waiting rooms;

(3) expenses;

(4) employee wages or salaries; or

(5) equipment or supplies, including but not limited to, computers, telephone systems, telecommunications equipment, and office supplies.

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(f) An organization that receives a grant under this section and that is affiliated with an organization that provides abortion services must maintain financial records that demonstrate strict compliance with this subdivision and that demonstrate that its independent affiliate that provides abortion services receives no direct or indirect economic or marketing benefit from the grant under this section.

(g) The commissioner shall approve any information provided by a grantee on the health risks associated with abortions to ensure that the information is medically accurate.

Subd. 3.Privacy protection.(a) Any program receiving a grant under this section must have a privacy policy and

procedures in place to ensure that the name, address, telephone number, or any other information that might identify any woman seeking the services of the program is not made public or shared with any other agency or organization without the written consent of the woman. All communications between the program and the woman must remain confidential. For purposes of any medical care provided by the program, including, but not limited to, pregnancy tests or ultrasonic scanning, the program must adhere to the requirements in sections 144.291 to 144.298 that apply to providers before releasing any information relating to the medical care provided.

(b) Notwithstanding paragraph (a), the commissioner has access to any information necessary to monitor and review a grantee's program as required under subdivision 4.

Subd. 4.Duties of commissioner.The commissioner shall make grants under subdivision 2 beginning no later than July 1,

2006. In awarding grants, the commissioner shall consider the program's demonstrated capacity in providing services to assist a pregnant woman in carrying her pregnancy to term. The commissioner shall monitor and review the programs of each grantee to ensure that the grantee carefully adheres to the purposes and requirements of subdivision 2 and shall cease funding a grantee that fails to do so.

Subd. 5.Severability.Except as provided in subdivision 2, paragraph (d), if any provision, word, phrase, or clause

of this section or its application to any person or circumstance is held invalid, such invalidity shall not affect the provisions, words, phrases, clauses, or applications of this section that can be given effect without the invalid provision, word, phrase, clause, or application and to this end, the provisions, words, phrases, and clauses of this section are severable.

Subd. 6.Supreme Court jurisdiction.The Minnesota Supreme Court has original jurisdiction over an action challenging the

constitutionality of this section and shall expedite the resolution of the action.

History:

2005 c 124 s 2; 2007 c 147 art 10 s 15; 2012 c 152 s 1

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Appendix D: MDH Grant Agreement Template

See hyperlink to pdf of MDH Grant Agreement Template on the Positive Alternatives website.

December 2015

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