RURAL HEALTH OUTREACH GRANT PROGRAM

PROGRAM GUIDE AND APPLICATION INSTRUCTIONS
FY 2002

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
HEALTH RESOURCES AND SERVICES ADMINISTRATION

Office of Rural Health Policy

The Program Guide and the Application Instructions have changed from previous years. The Program Guide (Part I of this document) contains some important new information for applicants and also reflects changes in the grant review criteria. In the Application Instructions (Part II of this document) we are now providing a detailed "Application Template" that you must follow in the preparation of your Outreach Grant application. This Application Template will serve as the table of contents for your application. It specifies the order in which application materials are to be assembled and includes a detailed outline that you must follow in preparing the narrative portions of your application. Applicants who do not follow this template will lose scoring points in the review process. Please read this entire document before beginning to prepare your grant application.

TABLE OF CONTENTS

APPLICATION SUBMISSION INFORMATION

DUE DATE

ADDRESS

1. INTRODUCTION

2. BACKGROUND

A. Rural Health Outreach Grants

B. Rural Health Network Development Grants

3. GENERAL PROGRAM INFORMATION ON OUTREACH GRANTS

4. NOTICE OF INTENT TO APPLY

5. ELIGIBILITY RULES

A. Networks

B. Geographic and Ownership

6. OBTAINING ASSISTANCE

A. Programmatic Information

B. Financial Information

7. NOTIFYING YOUR STATE OFFICE OF RURAL HEALTH

8. GRANT AWARDS AND FISCAL ISSUES

A. Size of Projects

B. Duration of Funding

C. Projected Number of New Awards

D. Limitations on the Use of Grant Funds

9. COST PARTICIPATION

10. COST PRINCIPLES

11. GRANTEES MEETING

12. FUNDING PREFERENCES

13. GEOGRAPHIC CONSIDERATIONS IN FUNDING

14. REVIEW PROCESS AND CRITERIA

A. PROCESS

B. REVIEW CRITERIA

15. PAGE LIMITATION FOR APPLICATIONS

16. ASSURANCES AND PUBLIC POLICY REQUIREMENTS

17. REPORTS

A. AUDIT

B. ANNUAL PERFORMANCE REPORT

C. PAYMENT MANAGEMENT SYSTEM QUARTERLY REPORT (PMS 272)

D. FINANCIAL STATUS REPORT

E. FINAL PROGRAM PERFORMANCE REPORT

18. DEFINITIONS

19. PUBLIC HEALTH IMPACT STATEMENT

20. WHERE TO SEND YOUR APPLICATION

21. DATA SOURCES

22. SOME KEY ADVICE FOR APPLICANTS

INTRODUCTION

FORMATTING YOUR APPLICATION

APPLICATION TEMPLATE

1. FACE PAGE (STANDARD FORM 424)

2. TABLE OF CONTENTS: TEMPLATE WITH PAGE NUMBERS

3. PROJECT ABSTRACT

4. BUDGET ABSTRACT and BUDGET FORM 424A

Sample Budget Abstract

Grand Total

5. PROJECT/POPULATION FOCUS SUMMARY

6. PROJECT NARRATIVE AND BUDGET

A. Need for the Proposed Project and the Network - 25 Points

l. Description of Need

2. Description of Network Capability

B. Description of the Program to Meet the Needs - 25 Points

1. Description of the Planning Process

2. Project Plan

C. Project Management and Network and Community Involvement - 20 Points

1. Responsibilities of the Applicant and Network Members

2. Community Support and Involvement in Project

D. Budget - 10 Points

1. Budget Information and Instructions for Completing the SF424A

2. Budget Justification Narrative

E. Personnel - 5 Points

1. Biographical and Position Information on Key Personnel

F. Evaluation and Dissemination Plan - 10 Points

1. Measuring Progress and Results

2. Utilizing Results

G. Sustainability Plan - 5 Points

1. Continuing the Program After the Grant Ends

7. FUNDING PREFERENCE STATEMENT

8. PROOF OF NON-PROFIT OR PUBLIC STATUS

9. ASSURANCES (STANDARD FORM 424B)

10. CERTIFICATION FORMS

11. DISCLOSURE OF LOBBYING ACTIVITIES FORM

12. CHECKLIST FORM

13. APPENDICES

Applications are due on September 28, 2001. To be considered submitted on time applications must be OFFICIALLY POSTMARKED BY 11:59 P.M. September 28, 2001. Postmarked means Official Post Office cancellation mark, Federal Express Shipping Receipt Form, United States Parcel Company receipt or other carrier that Officially records the pick-up or drop-off time of a package. PRIVATE POSTAGE METER CANCELLED PACKAGES WILL NOT BE ACCEPTED UNLESS THE PACKAGE ARRIVES ON OR BEFORE THE DUE DATE.

Submit the signed original and at least two copies (submission of an original and 5 copies will assist in the review process) of the application to

This Program Guide provides general information about the Outreach Grant Program including legislative authorities, eligibility criteria, funding limitations and preferences, and other important information. Please read the material before you begin writing your application. In addition, you should read the first four pages of Form PHS-5161-1 for additional information.

The Rural Health Outreach Grant Program is authorized by Section 330A of the Public Health Service Act as amended by the Health Centers Consolidation Act of 1996, Public Law 104-299.

The law States that the purpose of the Rural Health Outreach Grant Program is "to expand access to, coordinate, restrain the cost of, and improve the quality of essential health care services, including preventive and emergency services, through the development of integrated health care delivery systems or networks in rural areas and regions."

The same law also authorizes the Rural Health Network Development Grant Program. This program is similar to the Outreach Grants in several respects and uses many of the same application materials.

Applicants need to decide whether their project is best suited for the Outreach Grant Program or the Network Development Program. The following information is provided to help you make this determination.

These grants are available to applicants who propose to use the funds for the delivery of health care and related services to defined population groups in rural areas. These may be new services in the community or an expansion of existing services. A primary purpose of the program is to foster the development of new collaborative networks for the delivery of health care in rural areas. Consequently, grant projects must be undertaken by three or more separately owned organizations working together. The participating organizations may be similar (e.g., all hospitals) or diversified providers (e.g., hospital, home health agency, nursing homes). All entities participating in the project must have clearly defined roles and responsibilities. The grant application must include a letter of commitment or other formal agreement signed by each network organization’s CEO that documents its intent to participate in the project and the scope of its commitment to the project.

These grants are designed for organizations that propose to establish more formally integrated systems of care in rural communities. The grants support the integration of administrative, clinical, financial and information system functions across network members. Unlike the Outreach Grants, the funds provided are not used for the direct delivery of services. The ultimate goal of a grant is to strengthen the rural health care delivery system by improving the viability of the individual providers in the network. Projects must involve at least three separate health care providers or other entities that provide or support the delivery of health care services. Each member of the network must sign a memorandum of agreement, contract, or other formal collaborative agreement.

Applicants may not apply for both the Rural Health Outreach Grant Program and the Rural Health Network Development Grant Program in the same year. If you are uncertain about the program that best applies to you, please contact the Office of Rural Health Policy (ORHP) at 301/443-0835 or visit our web site at www.hrsa.gov. Please click on the Office of Rural Health Policy. You can also find us at: www.nal.usda.gov/orhp.

The rest of this Program Guide and the Application Instructions apply only to the Rural Health Outreach Grant Program.

The Rural Health Outreach Program supports projects that demonstrate creative or effective models of outreach and service delivery in rural communities. Applicants may propose projects to address the needs of a wide range of population groups including, but not limited to, low-income populations, the elderly, pregnant women, infants, adolescents, rural minority populations, and rural populations with special health care needs. Projects should be responsive to the unique cultural and linguistic needs of the target population.

Applicants may propose to deliver many different types of services. These include primary care, dental care, mental health services, home care, emergency care, health education programs, outpatient day care, and other services not requiring inpatient care. The program will not support services provided in inpatient settings such as hospital inpatient units and nursing care facilities.

In order to allow the Office of Rural Health Policy to plan for the objective review process, applicants are encouraged to notify the Office in writing of their intent to apply and the program they are applying for. This notification serves to inform the Office of anticipated numbers of applications, which may be submitted. The address is Lilly Smetana, Office of Rural Health Policy, Health Resources and Services Administration, Parklawn Building, Room 9A-55, Rockville, Md., 20857, or Fax # 301/443-2803. If notification is offered, it should be received no later that September 7, 2001.

Management Criteria: In addition to meeting one of the criteria stated above, applicants must have financial management systems in place and must have the capability to manage the project. The applicant organization must be able to: 1) exercise administrative and programmatic direction over the grant project; 2) must be responsible for hiring and managing the grant project staff; 3) must have the administrative and accounting capabilities to manage the grant funds; and 4) must have permanent staff at the time a grant award is made. Further, the applicant organization must have an Employer Identification Number from the Internal Revenue Service and an Internal Revenue Service letter or a letter from an appropriate State agency of non-profit status. Proof of organizational viability must be included with the grant application. A management review form included in the application kit is used to demonstrate organizational viability. (See Page 23 for information.)

Applicants Outside the 50 States: In addition to the 50 States, applicants can be located in the District of Columbia, the Commonwealth of Puerto Rico, the Commonwealth of the Northern Mariana Islands, the Territories of the Virgin Islands, Guam, American Samoa, the Compact Free Association Jurisdictions of the Republic of the Marshall Islands, the Republic of Palau, and the Federated States of Micronesia.

Current and former Rural Health Outreach Grantees may not apply for FY 2002 funds regardless of the type of project or services proposed. However, they may be included as network members in projects developed by other applicant organizations. The new project must have at least two network members who are different from any previous grant. Also, the project must differ significantly from any previous grants. All current or former grantees involved in a new project must identify the dates of any prior funding, the grant number assigned to the previous project, and include a copy of the abstract or project summary that was submitted with the earlier grant application.

You are required to notify your State Office of Rural Health early in the application process to advise them of your intent to apply. The State Offices are often a useful source of information on statewide activities that may be important to your project. Also, they can often provide technical assistance to applicants. A list of the State Offices of Rural Health is enclosed.

Cost participation serves as one important indicator of community and organization commitment to the project. It also increases the likelihood that the project will continue after Federal grant support has ended. Cost participation may be in the form of cash or in-kind contributions (e.g., equipment, personnel, building space, indirect costs). Cash and in-kind contributions must be addressed in the budget forms and in the narrative budget justification. Instructions for preparing a budget are found later in this document. (See page of 26 Application Instructions.)

If a grant award is made, all funds identified as dedicated to the project (including cost participation) will be subject to the applicable Federal cost principles, audit, and reporting requirements. The Cost Principles governing non-profit organizations are found in OMB Circular A-122 (non-profits), OMB Circular A-102 (State and Local Governments), or OMB Circular A-110 (Institutions of Higher Education, Hospitals and Other Non-Profit Organizations). These documents can be found on the Internet at: http://www.whitehouse.gov/omb/circulars/

Grantees are required to allocate funds for sending at least one representative to an annual 2-3 day meeting of all grantees in the Washington, D.C. area. (Grant funds may be used to send a maximum of 2 persons to the meeting).

As provided in the law a funding preference will be awarded to any qualified organization that can demonstrate substantial inclusion of any one of the following:

1. The project includes a majority of the health care providers serving in the area or region to b e served by the network participants. (The applicant must document the number of health care providers in the service area or region and the percentage of those providers that will be involved in the project.)
2. The project includes any Federally qualified health centers, rural health clinics, and local public health departments serving the area or region. The involvement must be more than a referral relationship with other providers in the area. The entity must be a full and active member of the network. A letter of commitment must demonstrate the organization’s roles, responsibilities, and contribution of resources to the project.
3. The project includes outpatient mental health providers serving in the area or region. (The applicant must identify the mental health providers in the area and demonstrate their level of participation in the project.)
4. Appropriate social service providers, such as agencies on aging, school systems, and providers under the Women, Infants and Children (WIC) program that are working to improve access to care and the coordination of health care services in the service area or region. (The applicant must identify the social service providers in the area and demonstrate their level of participation in the project.)

Applicants receiving the preference will be placed in a more competitive position among the applications that can be funded. Applications that do not receive a funding preference will be given full and equitable consideration during the review process. However, all applications that request and are eligible to receive a funding preference will be funded before applications in the funding line that do not have a funding preference.

The Office of Rural Health Policy seeks to expand the outreach program into geographic areas not currently served by the program. Consequently, the Office will consider geographic location when deciding which approved applications to fund.

The entire application may not exceed 70 pages in length, including the abstract, project and budget narratives, face page, forms, attachments, letters of commitment and support, and any appendices. Pages must be numbered consecutively. Applications that exceed the 70-page limit will be returned.

Applicants are required to sign certain certifications and assurances as part of the application process. These materials and instruction on their use are found in the Application Instructions.

We are providing definitions for some of the terms commonly used in conjunction with the Outreach Grant Program.

1. Budget Period: One calendar year, which usually begins on the date of the grant award.
2. Central Administrative Headquarters of Applicant: The location where all decision making, personnel, fiscal, and administrative processes are conducted.
3. Equipment: Durable items that cost over $5,000 per unit and have a life expectancy of at least one year.
4. Funding Preference: Placing an application in a more advantageous position among all the applications that qualify for funding.
5. Grantee: A public or nonprofit private entity that receives a grant award and that is responsible for the use of the funds provided through the grant.
6. Letter of Commitment: A document submitted by a network member that delineates the role, responsibilities and resources committed to the project by that member.
7. Letter of Support: A letter submitted by a community-based organization that is not a member of the network, but wishes to express support for the project.
8. Network: Three or more organizations that are separately owned and that come together to accomplish the goals of the grant project.
9. Nonprofit: Any entity that is a corporation or organization where no part of the net earnings may benefit shareholders or individuals, and is identified as nonprofit by the IRS, State taxing authority, State Attorney General, or other appropriate State official.
10. Notice of Grant Award: The legally binding document that serves as a notification to the recipient and others that a grant has been made. It contains or references all terms of the grant award and documents the obligation of Federal funds in the Department of Health and Human Services accounting system.
11. Program Director: Sometimes used synonymously with Project Director as defined below.

12. Program Income: All income that is generated as a direct result of receiving these grant funds. Program income must be used for purposes that will enhance the grant project and can be spent only for purposes that are legally eligible expenditures under the Outreach Program.

13. Project: Refers to all proposed activities specified in a grant application approved for funding by the program.

14. Project Director: An individual designated by the grantee institution to direct the project supported by the grant. The Project Director is responsible and accountable to the recipient organization for the proper conduct of the project. In turn, the grantee organization is legally responsible and accountable to the Office of Rural Health Policy and the Department of Health and Human Services for the performance and financial aspects of the grant. The Project Director must be employed by or under contract to the grantee organization and be located in the rural area to be served by the grant. If the Project Director is under contract to the grantee organization, the contractual agreement must be explained in the application. (See page 29 for justification of project personnel.)
15. Project Period: The total time for which grant support has been approved. A project period may consist of one or more budget periods up to a maximum of three budget periods. The total project period comprises the original period approved for the grant plus any extensions that have been approved.
16. Rural County/ZIP Code: All counties that are not Metropolitan Statistical Areas as defined by the Office of Management and Budget are eligible for this program. Also included are certain ZIP Codes in large urban counties that are designated as rural for the purposes of this grant program. A list of rural counties and qualified ZIP Codes in urban counties is included with the application kit.
17. Rural Ownership: The central administrative headquarters of a grantee organization must be located in a rural county or in a rural census tract of an urban county. Only organizations that meet this test are eligible for the program (See eligibility rules on page 7.)

    19. PUBLIC HEALTH IMPACT STATEMENT

    The Rural Health Outreach Grant Program is subject to Public Health System Reporting Requirements. Under these requirements, community-based, non-government applicants (that is, where no local government or State run health organization is the applicant), must prepare and submit a Public Health Impact Statement. The statement is intended to provide timely information to State and local health officials. Community-based and non-government applicants are required to submit the following information to the head of the local health department or the appropriate State health agencies that provide health care in the areas affected by the project – no later than the Federal application receipt deadline date.

    1. A copy of the face page of the application (Standard Form 424)
    2. A summary of the project, not to exceed one page, which provides:
    • A description of the project
    • A summary of the services to be provided
    • A description of the coordination planned with appropriate State and local health agencies

    20. WHERE TO SEND YOUR APPLICATION

    Please submit the signed original application and at least two copies (submission of an original and five copies will help us manage the review process) of the application to the following address:

    HRSA GRANTS APPLICATION CENTER
    1815 NORTH FORT MYER DRIVE, SUITE 300
    ARLINGTON, VA 22209

    21. DATA SOURCES

    Several data sources established by the Health Resources and Services Administration may have information that will help you in preparing the application. These sources are listed below.

    Health Resources and Services Administration: http://www.hrsa.dhhs.gov/

    Maternal and Child Health Data System: http://www.mchdata.net/ This system contains data by State on services to women and children.

    State Profiles: http://www.hrsa.gov/ Provides selected demographic data by State, health status indicators, health care provider resources, and HRSA resources in the States.

    Community Health: http://www.communityhealth.hrsa.gov/ Provides health status indicators at the county level.

    Health Workforce: http://www.bhpr.hrsa.gov/healthworkforce/profiles/ Provides profiles on the health workforce by State.

    22. SOME KEY ADVICE FOR APPLICANTS

    A. Experience has shown that successful applicants have engaged in an effective pre-application planning process involving all parties having a stake in the project. We urge significant community involvement in the project from the very beginning. Applicant organizations should work closely with community representatives and organizations that will be affected by the projects or involved with its implementation. Community involvement can be accomplished through the use of town meetings, focus groups, surveys and other appropriate techniques. A primary objective is to identify and reach consensus on community needs to be addressed by the project. Community representatives and participating organizations should also be involved in setting the specific goals for the grant program and in decisions on the allocation of grant resources. Some applicants have conducted a formal needs assessment in their communities or can rely on assessments conducted by others. If a formal needs assessment has not been conducted, applicants can demonstrate community needs through the use of demographic data for their community or region, State and national data, and other appropriate information. The data sources shown in item #18 above may be helpful in completing your application.

    B. Projects that bring together multiple sources of support are encouraged. If other funding sources are available or anticipated (e.g. Federal, State, philanthropic, etc), it will strengthen the grant application. Also, we are interested in developing strategies to address the health care needs of underserved populations that can be exported to other rural communities around the country. Therefore, applicants should note in their application materials if the project they are proposing is modeled after a program that was successful in another community.

    C. Please follow the Table of Contents and the Outline for the narrative portion of the application closely. Failure to address all items can result in fewer points awarded during the review process. If an item in the outline is not relevant to your project, or the information required is not available, do not leave the item blank. Instead, you should explain why the information is not relevant or cannot be provided. (See Appendix I.)

    D. Outreach Grants require substantive participation by at least three different organizations. Many applicants fail to establish a meaningful and substantive role for each member of the outreach network that results in the application receiving an unacceptable rating. All Network members must be fully involved in the proposed project and all must work together to achieve the project goals. (See page 22 - 26 of Application Instructions.)

    E. Applicants that put off planning, consensus building and sign-off by appropriate network members until close to the application deadline may risk the appearance, in the final application, that the project does not have sufficient commitment by all network members. This weakness could jeopardize a positive review of the application. Please make sure the community and network members are involved from the start and final signatures are secured well before the application deadline. Signatures on letters of commitment included in the application must be original. Any copied or mechanically reproduced signatures or letters of commitment signed by someone other than the senior executive will put your application in jeopardy as not containing sufficient evidence of network commitment.

    F. Make sure to prepare a budget for the full duration of your grant proposal – usually three years. The required budget forms (Standard Form 424A) are specifically designed to capture data for three budget years or less. (See page 26 of application instructions.)

    G. Be certain to include all required forms and certification. Omissions can mean that your application will not receive a favorable review.

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    PART TWO: APPLICATION INSTRUCTIONS

    A. INTRODUCTION

    This section provides detailed instructions for completing the forms and other materials required by the Grant Application Form: PHS-5161-1. As noted in Part One, it includes a template for the application. This template specifies the order in which materials are to be presented in the application and a detailed outline for you to follow in preparing the narrative description of your project. The outline for your project narrative corresponds to the criteria that will be used for scoring your application. Please follow the template and the specific instructions for each part of the application. Failure to do so may result in an incomplete application or loss of points in the review process.

    B. FORMATTING YOUR APPLICATION

    Applications must be legible with no less than a one-inch margin at the top and no less than ½ inch margins on the sides and bottom. The print for all narrative materials must be no smaller than Courier 12-point or a 12-pitch font. The narrative material can be single-spaced. Charts must be prepared in no smaller than 10-pitch fonts.

    The entire application must be no more than 70 pages, including all forms, budget and program narratives, supporting documents and appendices. (Note: If a cover letter is submitted, it will be counted against the70 page limit, even if it is not numbered.)

    Pages must be numbered consecutively from the beginning of the Template to the end.

    A completed application should be signed in blue ink. The original copy should be identified using an "ORIGINAL" stamp or some other means of notation. Use binder clips or rubber bands to secure the application pages, do not staple or bind the original application or the copies. Please send at least two copies (five copies would be better).

    C. APPLICATION TEMPLATE

    A Template of how your information should be formatted, written and assembled is included as Appendix I. Page numbers may be entered by hand in the Table of Contents and on each page if necessary.

    1. FACE PAGE (STANDARD FORM 424)

    The first numbered page of your application is the Face Page or Standard Form 424. Here are instructions for completing the form.

    Address (Block 5):
    The address in Block 5 will be used to verify that the applicant is located in a rural area. This address will also be used for all correspondence and must be the applicant’s "corporate office." All applicants must include their entire address, including city, county, State and ZIP Code in this block. Further, if eligibility is based on the applicant’s location in a rural ZIP Code of a metropolitan county, the ZIP Code must be included in this block. Zip Codes will be verified for all applicants located in metropolitan counties. (See Appendix II)

    Applications that do not include the county name and the ZIP Code, will be returned.

    In the right hand portion of Block 5, please include the organizational unit that will manage the project, name of contact person, telephone, E-mail address and fax numbers. If the Project Director named in the application has a different address, please report it in this Block.

    Employer Identification Number (Block 6):
    Enter your Employer Identification Number as assigned by the Internal Revenue Service.

    Type of Applicant (Block 7):
    Insert the appropriate letter in the box provided. Non-profit organizations should check N for "Other" and identify themselves as non-profit.

    Name of Federal Agency (Block 9):
    Insert Health Resources and Services Administration, Office of Rural Health Policy.

    Catalog Of Federal Domestic Assistance Number (Block 10):
    Insert 93.912A in the boxes provided and enter "Rural Health Outreach Grant Program" as the title.

    Proposed Project (Block 13):
    This Block is for showing the total number of years (not to exceed three) for which funding is requested. Enter May 1, 2002 as the start date. The ending date for a three-year project would be April 30, 2005. If you intend to request a three-year project you must include information on the second and third years in this application.

    Congressional Districts (Block 14):
    Insert the Congressional District in which the applicant is located and any other Congressional Districts affected by the project.

    Estimated Funding (Block 15):
    (Line a) Insert the total amount of Federal funds requested for the first twelve months of support. (This figure should be the same as shown in Section B, Column 1, Line 6 k on Form 424A)

    (Lines b – e) Insert the amount of cash or in-kind contributions for the first twelve-month period from the sources shown. These figures will correspond to amounts shown on Form 424A, Page 2, Section C, Line 12, columns b, c, and d.

    (Line f) Insert the amount of anticipated program income to be earned by the project during the first twelve months, if any. This figure should be the same amount as shown on Form 424A, Section B, Page 1, Line 7, Column 1. (Note: Your budget justification should include an explanation of how any program income will be spent.)

    (Line g) Insert the total of lines 15a through 15f.

    Executive Order 12372 (Block 16):
    This grant program is subject to Executive Order 12372 which requires applicants to seek comments on the application from their State Single Point of Contact (SPOC) unless the applicant is a Federally recognized Indian Tribal Government or the State does not participate in this process. A list of State SPOCs and the non-participating States is included with the application kit. In general, SPOCs are State agents that review grant applications to determine if they are in accordance with State policy. Further, applicants in participating States must submit a copy of the application to the SPOC no later than the Federal application receipt deadline.

    Note: If required by your State, you must make the application available for State review and must advise the State to submit comments to the Federal Grants Management Officer within 60 days of the Federal application receipt date. The address is: Grants Management Officer, Office of Grants Management, Bureau of Primary Health Care, Health Resources and Services Administration, 11^th Floor, East-West Towers, 4350 East-West Highway, Bethesda, MD. 20814.

    Authorization: The application must be signed by a representative of the applicant organization who has the legal authority to sign for the organization. The applicant must have in its files a copy of the authority for this individual to sign the application. The authorized representative is an individual with the legal authority to obligate the applicant organization financially and programmatically. He or she is not necessarily the Project Director.

    2. TABLE OF CONTENTS: TEMPLATE WITH PAGE NUMBERS

    Follow the template form shown in Appendix II. The page numbers for the application and the Table of Contents may be hand written if necessary. Your Table of Contents will list items 1 (Face Page) through 13 (Appendices) and show the page number where each item is found in your application. A page number must be given for each item. Under Item 6, "Project Narrative and Budget," there are sub-headings for various components of the narrative. These sub-headings must also be a part of your Table of Contents. They must appear under Item #6 with page numbers shown for each sub-heading. This will allow reviewers to refer quickly to specific parts of the Project Narrative and Budget. (See Appendix I)

    3. PROJECT ABSTRACT

    The Project Abstract must be single-spaced and must not exceed one page. It should include a brief description of the proposed grant project including the needs to be addressed, the proposed services, the population group(s) to be served and the organizations comprising the network. The abstracts of funded projects are widely shared and should effectively communicate the project’s purpose and goals.

    4. BUDGET ABSTRACT and BUDGET FORM 424A

    The Budget Abstract that must appear at this point in your application is a one-page dollar summary of the budget that you are proposing for the grant project. The Abstract will give reviewers an overview of the cost of the project. We have provided a Sample Budget Abstract that will be helpful to you. Please note that your Abstract must include all years of requested support, up to the maximum of three. You may find that some of the budget categories in the sample do not apply to your project or you can add other categories as needed. The budget numbers should represent only the Federal share of the project per budget year. While the instructions for filling out the budget forms (SF 424A) and creating the budget narrative will be discussed later under Section Six (6), Project and Budget Narrative of the template, Criterion D, Budget, please include the budget forms (SF 424A) at this point in the assembly of your application. The budget narrative should remain under Section Six (6), Criterion D, Budget.

    Sample Budget Abstract

    	Year 1	Year 2	Year 3
    Personnel:
    Project Director	$30,000	$30,000	$30,000
    Secretary	$9,000	$18,000	$18,000
    Counselor	$25,000	$25,000	$25,000
    Fringe Benefits	$15,360	$18, 250	$18,250
    Travel	$1,560	$1,560	$1,560
    Equipment	$32,900	$26,910	$26,910
    Supplies	$1,000	$500	$500
    Contractual Costs:
    Therapist	$50,000	$50,000	$50,000
    Program Evaluation	$4,900	$3,000	$3,000
    Training	$29,050	$24,000	$24,000
    Other Costs	$198,770 $1,200	$197,220 $1,200	$197,220 $1,200
    Grand Total	$199,970	$198,420	$198,420

    Note: In the above sample we have not provided any cost-of-living increments in the out-years for salaries or other expenses. Most applicants will want to allow for cost-of-living increases in salaries and possibly in other budget categories as well.

    5. PROJECT/POPULATION FOCUS SUMMARY

    The Project/Population Focus Summary is included in the application forms packet. In Column 1, Section A of the form, please identify the top three (3) services or activities that will be offered through the project. Estimate the percentage of time that will be spent providing each of these services. Next, please answer the question in Column 1, Section B. In Column 2, Section A, specify the percentage ethnic mix of the population(s) to be served. In Column 2, Section B, estimate the total number of unduplicated visits or encounters that will be provided to the clients of the project during each year of the grant. The numbers of persons in each category is likely to be more than the total number of unduplicated visits or encounters because of overlap in the categories.

    6. PROJECT NARRATIVE AND BUDGET

    The following Project Narrative and Budget Sections are used to explain the problems that your proposed project seeks to resolve, the plan for the project you hope to undertake, the support for your proposal, your credentials and those of your network partners, and the costs of your proposal. The maximum review points that can be earned for each item are shown. Please thoroughly explain your project in relation to all points under each criterion. If you find an item that is not relevant to your project or where the information needed is not available, please explain the circumstances. Please include all information that is relevant to your project but keep in mind the 70 page limitation and decide what is and is not necessary in the description of your area and its needs.

    A. Need for the Proposed Project and the Network - 25 Points

    Federal funds are available only for the most capable networks able to address the most significant health needs of rural communities. It is up to each applicant to accurately describe the problems it wishes to address and its capabilities to deal with them.

    l. Description of Need - 15 Points (Applicant response required to each point below)

    1. Unmet Health Needs of the Target Population: The target population and its unmet health needs must be described and documented in this section. Demographic data should be used whenever possible to document the unmet needs. (Refer to page 21 for some data sources.) Local data is particularly important, but often needs to be complimented by State data, and sometimes by national information. The population to be served needs to be identified. The population description may include information about the incidence and prevalence of specific conditions, such as chronic diseases, or about the age or socioeconomic status of the target population. Health status indicators may be relevant to some applications, as may be the ethnicity and occupational status of the population. Statistics regarding crime, drug abuse, illegitimacy and other social problems may be relevant. Information about health insurance may be important to many projects.

    2. Access Barriers to Needed Services: Please discuss the relevant barriers to health care in the service area that the project hopes to overcome. In some instances there is a general problem of access to particular health services in the community. In other cases needed services may be available in the community, but not to all who need them. In many rural communities shortages of health care personnel are important access issues. Any geographic, financial, cultural, linguistic, workforce, or other barriers to access should be discussed in this section.
    3. Description and Map of the Service Area: Every project will be offered in an area that is geographically bounded in some way There may be important physical features to the landscape that are important for reviewers to understand. This section describes the area to be served and must include a map of the area to be used as a reference by reviewers. The map does not have to be "tailor made" for this application. It can be simply a copy or portion of an existing map, altered by hand if necessary.
    4. Relevant Services Available in or Near the Service Area: It is important for reviewers to understand the number and type of relevant health and social service providers that are located in and near the service area of the project and how they relate to the project. Applicants should also describe the potential impact of the project on existing providers (e.g., changes in referral patterns, practice patterns, etc.) who are not part of the project. Any potential adverse effects are particularly important, as well as estimates of how the project might augment and enhance any existing capabilities in the service area.

    2. Description of Network Capability - 10 Points (Applicant response required to each point below)

    1. Applicant Management Information: Applicants must document their capabilities to address the problems described above. The applicant organization should be described in this section, with an emphasis on its ability to manage the project network, to administer grant funds, and deliver the services proposed for the project. The applicant’s history in providing and managing the relevant services should be discussed. Evidence of success with other similar projects, particularly collaborative endeavors, should be provided when applicable. Information about key staff may be briefly introduced in this section, but should not be dealt with in any detail here. Instead, it should be covered in Section E below.

    2. Management Review Form: The Management Review form included in the application kit must be completed and inserted here. The purpose of this form is to document some of the applicant’s financial and management systems. It is used as one tool to evaluate organizational capability to manage Federal funds.
    3. Identification and Credentials of Network Members: Evidence of the ability to deliver services and otherwise meet the needs of the project should be presented here for each organization participating in the project network. Remember that each participating Network member must have a substantive and vital role in achieving the goals of the project.
    4. History of Network Development and Collaborative Activities: The history of how the proposed network has developed should be presented in this section. How did the network come together and decide to make and support this application? Does this application represent the network’s first collaboration, or does the network have a history of working together in the past?
    5. Letters of Commitment from Network Members: Each letter should commit that particular network member explicitly to the role assigned to it. The ability of each network member to fulfill its role should have been established in section A.2.c..

    B. Description of the Program to Meet the Needs - 25 Points

    Now that the applicant has described the need for the proposed project and the network’s capability to meet the need, this section describes the program to meet the need, how it was developed, and how it will be implemented if the application is approved.

    1. Description of the Planning Process - 10 Points (Applicant response required to each point below)

    1. Role of the Network in Planning: The beginning of the planning process that led to the development of the application should be described in this section. The point at which the other members of the network became involved, and the nature and extent of their contributions, up to the submission of the application, should be described.
    2. Role of the Community in Planning: If representatives of local, sub-State regional and/or State government were involved in the planning process, their involvement should be described, as well as the involvement of local non-governmental organizations.
    3. Models that Work: If the application proposal is based upon another program that has worked in another community, please describe that program, why you think it will succeed in your community, and how it was funded. There is particular interest in programs that may have received funding from the Department of Health and Human Services.

    2. Project Plan - 15 Points(Applicant response required to each point below)

    1. Goals, Strategies, Activities, Responsible Agents and Completion Milestones:
    
    These are the components of a project plan. A goal is something that is to be accomplished by the proposed project. If the grant is received and if its implementation is successful, the result may be thought of as the goal fulfilled. Applicants may state a single goal or multiple goals. Applicants should indicate, if accomplished, how significant the realization of the goal(s) will be for the target population and for others in the community. For example, will there be an increase in access to health care? A strategy is a plan to accomplish a goal, or a portion of a goal. An activity is an action step toward completion of a strategy. Responsible agents are persons or organizations that are responsible for completing activities. Completion dates are deadlines by which goals, strategies and activities are to be completed by responsible agents. Outcomes and/or process measures are used to determine whether a goal, a strategy or an activity has been achieved. Using these measures, the applicant should identify a process for periodic feedback and program modification as necessary. (They are discussed below in the Evaluation Plan, Section F. Put together, these components will describe how the project plan will be accomplished, by whom, fueled by what resources, and on what schedule.)

    It might be helpful to develop a chart that identifies the responsible agent, and network member that is responsible for accomplishing each goal, strategy and activity, and by what date. The chart should be explained in this section and in agreement with the Budget Narrative. Any information included in this type of chart must also be explained or referenced in the narrative part of this section. (The chart below is illustrative. Some applicants may develop a different but equally effective format. For example, some applicants have included sub-goals, or objectives. Only charts may be generated in 10 pitch fonts.)

    Goals	Strategies	Activities	Responsible Agency/Person	Outcomes and/or Process Measures	Completion Date
    A. Reduce Teen Drinking and driving by 75%	1. Educate Teens and Parents	a) Hold Parent/teen meetings on the effects of alcohol b)Display cars that have been involved in drinking and driving accidents	1. County Substance Abuse Counselors 2. School District 1. County Impound Lot and 2. Sheriff’s Department	Numbers of teens involved in drunk driving arrests/accidents compared with baseline data	Every 3 months
    B. Reduce number of teens buying alcohol	2. Educate Liquor Store Owners	a) Class on how to Say No to teens carrying Fake IDs	1. County Mental Health Counseling Clinic 2. Sheriff’s Department	Numbers of teens caught using Fake IDs	Every 3 months

    C. Project Management and Network and Community Involvement - 20 Points

    For a project to be successful there must be a sound plan for its accomplishment, as described above. Such a plan will not succeed without strong management and direction from a well-coordinated network, and solid community support for the plan.

    1. Responsibilities of the Applicant and Network Members - 10 Points(Applicant response required to each point below)

    1. Plans for Network Governance: The first element of the management plan is the identification of the paid staff who will be available at the time of award and will be able to initiate the activities described in the Project Plan section above. Having at least one such staff person available is a requirement of the grant. Next, the applicant should describe how other project resources will be assembled and how the project will be managed. If some of the capabilities of the project staff or other resources are described below in Section E (Personnel), it is not necessary to repeat it here in any detail, but it may be referenced in this section. Measures should be included to assess the effectiveness of the plan for network guidance and its timely implementation. The applicant should identify a process for periodic feedback and program modification as necessary.

    2. Plans for Network Communication and Coordination: Will there be weekly network conference calls or monthly meetings? Will project status information be available to network members on a frequent basis? Will important decisions be reserved for the participation of the entire network? What authority, if any, will the Project Director have to act without full network participation in an emergency? Answers to these specific questions are not required here, but the applicant should show that they have a clear workable communication and coordination plan. Measures should be included to assess the effectiveness of the plan for network coordination and its timely implementation. The applicant should identify a process for periodic feedback and program modification as necessary.

    3. Description and Chart of Organization and Lines of Authority: How will authority flow from the applicant that receives the Federal grant funds, both within the applicant organization and within the network? Charts can be particularly helpful in complimenting a narrative description of organization and lines of authority.

    2. Community Support and Involvement in Project - 10 Points (Applicant response required to each point below)

    Financial (Including Documentation): Indicate only actual commitments from the network members and other community members, including amounts, when to be received, and any conditions that apply. The letters of commitment should be included.

    1. In-Kind (Including Documentation): Only actual commitments should be referenced, including what assistance is to be received (For example, personnel or supplies), when it is to be received and any conditions that apply.
    2. Letters from Community Leaders: Include letters of advice, approval and encouragement that do not include any offers of tangible support. Annotations should be used when a reviewer will not be able to identify the community position of a letter’s writer. (For example, a letter from a town’s mayor, written on personal stationary, in which his/her office is not identified in the text either).

    D. Budget - 10 Points (Applicant response required)

    This section is the location for the narrative justification of your budget. The completed Budget Forms, which are described below, will be placed under Section Four (4) Budget Abstract and Budget Forms.

    1. Budget Information and Instructions for Completing the SF424A - 5 Points

    1. Budget Information (Standard Form 424A): This form has been provided in single-sided format for Rural Health Outreach Grant applicants. It is a separate item in the application kit (Do not use the double-sided format found with Form PHS-5161-1). Also, please follow the instructions found here rather than the information in Form PHS 5161-1.

    SF 424A: Section A – Budget Summary

    Line 1, Column a: Enter Outreach Program.
    Line 1, Column b: Enter 93.912A.
    Line 1, Columns c and d: Leave blank (not applicable for new applications).
    Line 1, Columns e and f: Enter the Project Costs from Federal and non-Federal Sources.
    Line 1. Column g: Enter the total for Columns e and f.
    Line 2-4: Leave Blank.
    Line 5, Columns e, f, and g: Enter totals for these columns.

    SF 424A: Section B – Budget Categories

    Line 6, Column 1: Enter the amount of Federal support requested for each Object Class Category. The amount on Line 6, Column k, should be the same as the amount in Section A, Line 5, Column e, and Block 15 a of the Face Page.

    Note: Funds requested for equipment and Vehicles must not exceed 40 percent of the total Federal award each year.
    Line 6, Item j. (Indirect Costs): These are the costs incurred that are not readily identifiable with a particular project or program, but are essential to the operations of the organization. Indirect costs will be allowed only if the applicant organization has a negotiated indirect cost rate approved by a Federal Agency. The applicant must submit a copy of its most current rate agreement to substantiate the request. Indirect costs are included in the total amount requested and count against the upper dollar limit of $200,000 per year.
    Line 6, Column 3: (Non-Federal Contributions): Distribute the amount shown in Section A, Line, 5, Column f, among the Object Class Categories (this includes both cash and in-kind contributions from all non-Federal sources). Insert the total for this column on Line k.
    Line 6, Column 5: Enter the totals for Columns 1 and 3 for each Object Class category. The amount on Line k, Column 5 should be the same as the amount on Line 15, Column g on the Face Page Form (SF 424).
    Line 7, Column 1: Enter the amount of estimated program income for the first twelve-month period. This is the same amount that appears on the Face Page, Block 15f.

    SF 424A: Section C – Non-Federal Resources

    Line 8, Column a: Enter Outreach Program.
    Line 8, Columns b, c, and d: Enter the value of cash and in-kind contributions commited by the applicant, State and other sources and insert the total(s) on Line 12. These figures correspond with those on the Face Page, Blocks 15 b, c, d, and e.
    Line 12, Column e: Enter the total of Columns b, c, and d. This amount should be the same as that shown in Section A, Line 5, Column f.

    SF 424A: Section D – Forecasted Cash Needs

    This section does not apply. Leave this section blank.

    SF 424A: Section E – Budget Estimates of Federal Funds Needed For Balance of the Project

    Line 16, Column a: Insert Outreach Program
    Line 16, Column b: Insert the dollars requested for the second budget period, including Indirect Costs, if appropriate.
    Line 16, Column c: Insert the dollars requested for the third and final budget period, including appropriate Indirect Costs.
    Line 20, Column b: Insert the figure on line 16 for the second budget period.
    Line 20, Column c: Insert the amount on line 16 for the third budget period.
    Note: Columns d and e are blank since the maximum length of a grant is three years.

    SF 424A: Section F – Other Budget Information

    Line 21 (Direct Charges): Leave this item blank. The information will be provided in your detailed budget justification as described below.
    

    Line 22 (Indirect Charges): Specify the type of Indirect Cost Rate that has been negotiated with a Federal Agency, if applicable. Indirect Costs are only allowed if a rate has been approved by a Federal Agency.
    

    Line 23 (Remarks): Leave blank. Remarks should be included in the Budget Justification Narrative section.

    2. Budget Justification Narrative – 5 Points (Applicant response required to each point below)

    1. Applicants must provide justification for all items in the budget and explain the relevance of each cost to the overall goals of the project. All items in the budget must be addressed. The details and justifications must be presented for each year of the proposed project.
    1. Personnel: Each position (Project Director, Secretary, etc.) should be itemized and compensation shown for each position. (The qualifications of key personnel are discussed in the next Section (E).

    2. Fringe Benefits: Describe how the fringe benefits are calculated for the proposed personnel.

    3. Equipment: Equipment is defined as durable items that cost over $5,000 per unit and have a life expectancy of at least 1 year. List every item of equipment and describe its purpose in relation to the project. Please remember that the cost of equipment/vehicles may not exceed 40 percent of the total Federal funds requested for each year of the project. Also, applicants are advised that they must get at least three price quotations.

    4. Supplies: Please itemize and explain the expendable items required for the project. These would include, among other items, computer equipment and peripheral supplies costing less than $5,000 per unit.

    5. Travel: Explain the need for all requested travel, including numbers of people involved, duration of trips, destinations, importance to project, etc. Remember to include funds for at least one person (2 are permitted) to attend one grantee meeting per year in Washington, D.C.

    6. Contractual Costs: Explain the need for all proposed contractual arrangements and how they relate to the project.

    7. Program Income: Describe income that is generated as a direct result of receiving these grant funds and how they are utilized to enhance the project.

    8. Other: Itemize and explain any other expenses not captured in any other budget category.

    E. Personnel - 5 Points

    A strong management plan to direct the grant activities requires an equally strong staff to be successful. In the following section the applicant provides the information necessary to defend both the capabilities of key staff already identified, and the requirements that the applicant has established to fill other key positions if the grant is received.

    1. Biographical and Position Information on Key Personnel - 5 Points (Applicant response required)

    This section of the application should include biographical sketches (Short overviews of past education and experience that suggest the qualifications necessary to perform assigned work). Resumes may be used for key staff that will be involved in the implementation of the project. This includes staff of the network members, staff of the grantee organization, and staff to be hired that have a key role in the day-to-day management of the program. Information on the staff of the network members should only be included for the staff that will have a major role in the implementation and success of the project.

    If new positions are to be developed specifically for key personnel of this project, a position description for each must be included in the application. Each position description should be short (One page is suggested.) and include only major duties to be performed and the experience required for the person to be hired.

    F. Evaluation and Dissemination Plan - 10 Points

    1. Measuring Progress and Results - 6 Points (Applicant response required)

    The Evaluation Plan: Important evaluation components already are included in Sections A.2.a. and both C.1.a and b. These sections measure progress toward completion of the project. The plan referenced here is to be developed now to measure the success of the project at its completion. It is based on the goals of the project. Both outcome and process measures may be used in the plan. For example, an outcome measure would be one that assesses the lowering of the rate of a particular disease, or finds higher satisfaction in the population’s access to health care. By contrast, a process measure could demonstrate that 2000 patients were screened by the project. The purpose of the plan is to try and determine if, and to what extent, the project made a difference to the lives of those it touched. The evaluation plan should account for between one (1) and five (5) percent of the project budget.

    2. Utilizing Results - 4 Points (Applicant response required)

    1. The Dissemination Plan: If successful, it is important that information about the project be available to other communities facing similar problems so that replication may be considered. The applicant should include a brief strategy to make information about the project as widely available as possible, locally, statewide and nationally. Information may be disseminated as the project progresses, toward the end of the Federal grant, or even afterwards as well. Use of the Internet should be considered, as well as the publications of organizations interested in the problem and potential approaches to deal with it.

    G. Sustainability Plan - 5 Points

    Many Outreach grants throughout the years have provided the seed money to enable a community to start programs that have continued to grow and develop long after the Federal grant ended. The chances of this happening are increased if planning for sustainability is accomplished at the beginning.

    1. Continuing the Program After the Grant Ends - 5 Points (Applicant response required)

    The applicant should include a plan for sustaining the project that is realistic and feasible. Sustainability strategies must include options that do not depend solely on other grant funding. The plan should indicate how such funds will be phased in during the project period. This is important. If the plan assumes no phased in funding until the grant ends, the chances of the project continuing are greatly diminished.

    As you analyze options for sustainability, it is suggested that you consider a range of possible options. For example, in projects targeting any kind of children's health services, applicants are encouraged to consider using grant funds to identify and enroll children who are eligible for Medicaid or the respective State Children's Health Insurance Program. Past experience with outreach and network grantees has demonstrated that effective enrollment programs can help reduce uncompensated or charity care in rural populations. This helps produce revenue that can help sustain a project directly or lessen the financial burden on participating providers such as private practitioners, hospitals or clinics so that they can assume more costs for continuation of the project.

    Similarly, if the proposed project is to provide services to Medicare eligible individuals, applicants may want to consider encouraging seniors who are dually eligible for both Medicare and Medicaid to enroll in two special programs entitled the Qualified Medicare Beneficiary (QBM) and the Select Low-Income Medicare Beneficiary (SLMB). These are medical assistance programs for certain people who are entitled to Medicare and have a low income. These programs may pay some or all of Medicare's premiums and may also pay Medicare's deductibles and coinsurance. To qualify, one must have Medicare Part A, a limited income, and assets, such as bank accounts, stocks, and bonds must be less than $4,000 for a single person, or $6,000 for a couple. These programs can help seniors defray costs associated with Medicare-covered services and encourage Medicare eligible individuals to seek services that can then be billed for by the Outreach grant to generate program income. Applicants should contact their State office that handles Medicaid billing for more information.

    7. FUNDING PREFERENCE STATEMENT (Applicant response required)

    Please refer to Part I, Section 12 (page 11) to see if you qualify for a funding preference. If your project does quality for one or more of the preferences described in that section, you must provide supporting information and documentation in this section. Please discuss and support the specific preference(s) that apply to your project. Being in one or more categories does not increase the level of preference the application will receive. You will not receive a funding preference unless it is specifically requested and justified in this section.

    8. PROOF OF NON-PROFIT OR PUBLIC STATUS (Applicant response required)

    In this section applicants must include documents from the United States Internal Revenue Service or appropriate agencies in their States to prove their status as either a non-profit or public organization. Applicants who fail to establish their status will have their applications returned without review.

    9. ASSURANCES (STANDARD FORM 424B) (Applicant response required)

    The application kit includes Standard Form 424B, which applies to all applicants for Non-Construction Programs. The form can be found in the Form PHS-5161-1. Please sign the Assurance and include it under this section of your application.

    10. CERTIFICATION FORMS (Applicant response required)

    The application kit includes certain certifications involving workplace requirement, disbarment, fraud, and other issues. Applicants are required to read and sign these certifications. They are found beginning on page 17 of Form PHS-5161-1.

    11. DISCLOSURE OF LOBBYING ACTIVITIES FORM (Applicant response required)

    A form titled DISCLOSURE OF LOBBYING ACTIVITIES is also included with the application kit and may be found in For PHS-5161-1. Please review and sign this form and include it here in your application package. Do not submit this form if your organization does not lobby.

    12. CHECKLIST FORM

    The application kit includes a Checklist Form that will help you make sure that all of the required application materials have been completed. Please use this form and insert it here in your application. On the Checklist Form in Part A., Section 4 there is reference made to HHS Form 690. This form is no longer used, you must enclose your original, signed copies of all the Certifications and Assurances for a non-construction program that are contained in the application materials.

    13. APPENDICES

    This last section is discretionary. It may be used if applicants want to include additional information that is not required by this document. Applicants are reminded that any appendices they use will count against the page limitation (70 pages including appendices).