Attachment 4
NDDoH DIVISION OF FAMILY HEALTH - TITLE V/MCH BUDGET EXAMPLE
Budget & Budget Justification MCH BLOCK GRANT PROGRAM $
July 1, 2011 – June 30, 2012
COMPONENT A MATCH COMPONENT B MATCH
PERSONNEL $23,340.00 $14,590.00 $21,060.00 $12,870.00
Name and title of each staff person
Salary rate (i.e. hourly rate x hours/month x 12 months or % time x # months based on annual salary) for each staff person.
1. Sue Johnson, Public Health Nurse: 50% Component A - 50% Component B x 12 months. Yearly salary $43,860. 12,500.00 9,430.00 12,500.00 9,430.00
2. Peg Anderson, Public Health Dietitian: 30% Component A - 20% Component B x 12 months. Yearly salary $40,000. 6,840.00 5,160.00 4,560.00 3,440.00
3. Betty Hanson, DON: 5% Component A - 5% Component B x 12 months. Yearly salary $48,000. 2,400.00 0.00 2,400.00 0.00
4. Toni Jackson, Administrative Assistant: 5% Component A - 5% Component B x 12 months. Yearly salary $32,000 1,600.00 0.00 1,600.00 0.00
Justification: (Provide brief description of each staff person's scope of service to the program)
1. Public Health Nurse (Component A) provides breastfeeding support through home visits, networks with local lactation counselors and participates in state and local Coalitions.
Public Health Nurse (Component B) provides school screenings, immunizations and educational programs.
2. Public Health Dietitian (Component A) provides healthy lifestyle classes and promotes various physical activity programs.
Public Health Dietitian (Component B) provides nutritional assessments, medical nutrition therapy, teacher trainings and educational services to various groups/organizations.
3. DON provides administrative oversight to the MCH grant programs/activities (Component A & B).
4. Administrative Assistant provides support to the MCH programs (Component A & B).
FRINGE BENEFITS $4,642.00 $4,461.00 $4,094.00 $4,049.00
Provide amount and type of benefits offered to each staff person listed in Personnel above.
1. Public Health Nurse: $21,930 x 24% = $5,263 - Component A, $21,930 x 24% = $5,263 - Component B 3,000.00 2,263.00 3,000.00 2,263.00
2. Public Health Dietitian: $12,000 x 24% = $2,880 - Component A, $8,000 x 24% = $1,920 - Component B 1,642.00 1,238.00 1,094.00 826.00
3. DON: $2,400 x 24% = $576 - Component A, $2,400 x 24% = $576 - Component B 0.00 576.00 0.00 576.00
4. Administrative Assistant: $1,600 x 24% = $384 - Component A, $1,600 x 24% = $384 - Component B 0.00 384.00 0.00 384.00
Justification:
1., 2., 3. & 4. Fringe benefits are prorated for each position and include FICA Social Security, FICA Medicare, health,
disability and life insurance, pension and worker's compensation. Total fringe benefits are 24% of salaries.
Budget Example Page 1 of 4
Budget & Budget Justification MCH BLOCK GRANT PROGRAM $ Attachment 4
July 1, 2011 – June 30, 2012
TRAVEL, FOOD & LODGING $825.00 $635.00 $0.00 $1,230.00
In-State Travel, Food & Lodging COMPONENT A MATCH COMPONENT B MATCH
1. Public Health Nurse to make home visits (Component A), attend two Regional Public Health Nurses meetings
and two ND State School Nurse Organization meetings (Component B).
Mileage: Home visits - 50 miles/month x 12 months x .375/mile = $225 - Component A 225.00 0.00
Meetings - 200 miles x 4 meetings x .375/mile = $300 - Component B 0.00 300.00
Per Diem: $25/day x 8 days = $200 - Component B 0.00 200.00
Lodging: $55/night x 4 nights = $220 - Component B 0.00 220.00
2. Public Health Dietitian to attend two MCH Nutrition meetings in Bismarck (Component B)
Mileage: 400 miles x 2 meetings x .375/mile = $300 0.00 300.00
Per Diem: $25/day x 4 days = $100 0.00 100.00
Lodging: $55/night x 2 nights = $110 0.00 110.00
Justification: (Provide brief justification for each in-state travel request)
1. & 2. Home visits are necessary for preventative health services. Attending continuing educational opportunities is critical to stay informed of new or emerging issues and a good peer
networking opportunity.
Out-of-State Travel, Food & Lodging
1. Public Health Dietitian to attend a National Breastfeeding Conference (Component A)
Airfare: $600 600.00 0.00
Per Diem: 3 days x $40/day = $120 0.00 120.00
Lodging: 2 nights x $120/night = $240 0.00 240.00
Registration Fee: $200 0.00 200.00
Transportation/Taxi Fees: $75 0.00 75.00
Justification: (Provide brief justification for each out-of-state travel request)
1. The Public Health Dietitian will attend the National Breastfeeding conference to acquire additional knowledge and skills needed to provide breastfeeding support.
SUPPLIES $0.00 $648.00 $0.00 $576.00
Supplies (Medical/Laboratory, Office, Educational)
1. Office supplies
$60/month x 12 months x 90% time = $648 - Component A [PHN 50%, PHD 30%, DON 5%, Admin Assist 5%] 0.00 648.00
$60/month x 12 months x 80% time = $576 - Component B [PHN 50%, PHD, 20%, DON 5%, Admin Assist 5%] 0.00 576.00
D:\Docstoc\Working\pdf\[bb930709-2baf-403c-96b3-36e01776204a.xlsx]Budget
Justification: (Provide brief justification for each supply request)
1. General office supplies are used by staff members to carry out daily activities of the program. Office supplies include paper, printer cartridges, binders, charting supplies,
letterhead paper, and envelopes.
Budget Example Page 2 of 4
Budget & Budget Justification MCH BLOCK GRANT PROGRAM $ Attachment 4
July 1, 2011 – June 30, 2012
RENT / UTILITIES $0.00 $900.00 $0.00 $800.00
Office Rent/Utilities/Facility Expenses (List office rent/utilities/facility expense for each office location) COMPONENT A MATCH COMPONENT B MATCH
1. Public Health Nurse Office
120 s.f. x $10. 00 s.f. x 100% time = $1,200 - Component A 50%, Component B 50% 0.00 600.00 0.00 600.00
2. Public Health Dietitian
100 s.f. x $10.00 s.f. x 50% time = $500 - 30% Component A, 20 % Component B 0.00 300.00 0.00 200.00
Justification: (Provide brief justification for each office rent/utilities/facility expense)
1. & 2. Office space for Public Health Nurse and Public Health Dietitian.
D:\Docstoc\Working\pdf\[bb930709-2baf-403c-96b3-36e01776204a.xlsx]Budget
COMMUNICATIONS (TELEPHONE / POSTAGE) $0.00 $1,026.00 $336.00 $576.00
Telephone
1. Public Health Nurse, Public Health Dietitian, DON, Administrative Assistant
$35/month x 12 months x 90% time - Component A [PHN 50%, PHD 30%, DON 5%, Admin Assist 5%] 0.00 378.00
$35/month x 12 months x 80% time - Component B [PHN 50%, PHD, 20%, DON 5%, Admin Assist 5%] 336.00 0.00
Justification: (Provide brief justification for telephone expense)
1. Necessary for communication.
Postage
1. Public Health Nurse, Public Health Dietitian, DON, Administrative Assistant
$60/month x 12 months x 90% time - Component A [PHN 50%, PHD 30%, DON 5%, Admin Assist 5%] 0.00 648.00
$60/month x 12 months x 80% time - Component B [PHN 50%, PHD, 20%, DON 5%, Admin Assist 5%] 0.00 576.00
Justification: (Provide brief justification for postage expense)
1. Necessary for communication.
EQUIPMENT (>$5,000 PER ITEM) $0.00 $0.00 $0.00 $0.00
Note: Equipment $5,000 and under (i.e., computers, chairs) must be listed under Supplies.
Justification: (Provide brief justification for each equipment item requested)
CONSULTANT / CONTRACTUAL $0.00 $0.00 $960.00 $0.00
List each consultant/contractual contract and salary rate (i.e., hourly rate x hrs/month x number of months).
1. Interpreter (Component B)
$20/hr x 4 hrs/month x 12 months = $960 960.00 0.00
Justification: (Provide a brief justification of the scope of work the consultant/contractor will be providing.)
Interpreter will be utilized during educational sessions to parents/caregivers whom have limited English understanding.
Budget Example Page 3 of 4
Budget & Budget Justification MCH BLOCK GRANT PROGRAM $ Attachment 4
July 1, 2011 – June 30, 2012
OTHER (SPECIFY) $250.00 $0.00 $100.00 $0.00
List each "Other" requested item COMPONENT A MATCH COMPONENT B MATCH
1. Printing of nutritional educational materials for pregnant women. (Component A)
1,000 copies x .25/copy = $250 250.00 0.00
2. Professional Publication - School Nursing Journal (Component B) 100.00 0.00
$100/year
Justification: (Provide brief justification for each "Other" requested item)
1. Print materials necessary for educational purposes.
2. Professional publications are imperative for staff educational and training purposes.
COMPONENT A MATCH COMPONENT B MATCH
TOTAL BUDGET $29,057.00 $22,260.00 $26,550.00 $20,101.00
MCH BLOCK GRANT PROGRAM $
BUDGET SUMMARY
COMPONENT A MATCH COMPONENT B MATCH
PERSONNEL $23,340.00 $14,590.00 $21,060.00 $12,870.00
FRINGE BENEFITS $4,642.00 $4,461.00 $4,094.00 $4,049.00
TRAVEL, FOOD & LODGING $825.00 $635.00 $0.00 $1,230.00
SUPPLIES $0.00 $648.00 $0.00 $576.00
RENT / UTILITIES $0.00 $900.00 $0.00 $800.00
COMMUNICATIONS (TELEPHONE / POSTAGE) $0.00 $1,026.00 $336.00 $576.00
EQUIPMENT (>$5,000 PER ITEM) $0.00 $0.00 $0.00 $0.00
CONSULTANT / CONTRACTUAL $0.00 $0.00 $960.00 $0.00
OTHER $250.00 $0.00 $100.00 $0.00
TOTAL BUDGET $29,057.00 $22,260.00 $26,550.00 $20,101.00
TOTAL PROGRAM COSTS $51,317.00 $46,651.00
Note: This budget represents an overmatch of the minimum required ($21,793 for Component A and $19,913 for Component B)
and more than the required 30% of federal funds in Component B ($16,682).
Budget Example Page 4 of 4