State of Louisiana by 053Dhw

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									                                                                                                State of Louisiana
                                                                   DHH/Office of Public Health/STD/HIV Program
                                                                       2012 STD Prevention Proposal Guidelines



                                      State of Louisiana
                              Department of Health and Hospitals
                           Office of Public Health/STD/HIV Program

                                2012 SYPHILIS ELIMINATION
                                   FOR MSM IN REGION 1
                                  PROPOSAL GUIDELINES

                                      Released: May 9, 2012


INTRODUCTION

        The Louisiana Office of Public Health STD/HIV Program (SHP) announces the expected
availability of 2012 federal funding to provide targeted Syphilis testing and enhanced linkage to
medical treatment for men who have sex with men (MSM) who are infected with Syphilis.
Contractors will be expected to focus screening and testing efforts for MSM in community
settings. This focus should be reflected in proposals for this solicitation of offers. Activities will
be consistent with the Centers for Disease Control and Prevention’s Syphilis Elimination Effort
(SEE). This announcement will fund one fee for service contract in New Orleans, LA (Region
1).

       This Solicitation of Offers (SO) contains the requirements that all proposals shall meet to
be considered for funding. Failure to conform to these requirements will result in
disqualification of the proposal without further consideration. Each applicant is solely
responsible for the preparation and submission of a proposal in accordance with instructions
contained in this SO.

PLEASE READ ALL MATERIALS BEFORE PREPARING YOUR APPLICATION

This proposal packet contains the following sections:
A.     Purpose (page 1)
B.     Available Funding (page 3)
C.     Timeline (page 4)
D.     Background (page 4
E.     Overview of Fundable Activities (page 6)
F.     Recipient and SHP Activities (page 9)
G.     Proposal Review Process (Page 9)
H.     Proposal Requirements and Content (Page 10)
I.     Proposal Format (Page 11)
J.     Additional Information (Page 12
K.     Appendices List (Page 18)
L.     Proposal Format with Appendices & Forms (Page 19-29)
M.     Reviewers’ Score sheet (Page 30)




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                                                                                                State of Louisiana
                                                                   DHH/Office of Public Health/STD/HIV Program
                                                                       2012 STD Prevention Proposal Guidelines


A.       PURPOSE

       The Office of Public Health STD/HIV Program (SHP) will provide funds to conduct
Syphilis Elimination activities targeting MSM in COMMUNITY SETTINGS.

            1. Respondents must be established as an appropriate legal entity.

            2.    Respondents must be in good standing with the Louisiana Secretary of State
                 office and compliant with the Louisiana Legislative Auditor’s office in order to do
                 business in Louisiana and to conduct the activities described in the SO.
                      Louisiana Secretary of State website: www.sos.la.gov
                      Louisiana Legislative Auditor website: www.lla.state.la.us

            3. Respondents must be in good standing with the U.S. Internal Revenue Service.

            4. Respondents must have a Louisiana address and must have an existing office
               (physical address) in the designated service area (Region 1). A post office box
               may be used when the proposal is submitted, but the respondent must conduct
               business at a physical location in the Region 1 area of Louisiana prior to the date
               that the contract is awarded.

            5. Respondents’ staff members, including the executive director, must not serve as
               voting members on their employer’s governing board.

Eligible Applicants:

        Federally recognized Indian tribes
        Non-profit community based organizations
        Faith-Based Organizations

Ineligible Applicants:

        For-profit agencies
        Governmental organizations such as, local health departments and publicly funded
         universities and colleges
        Individuals

        The Office of Public Health disburses funds to organizations through a competitive
solicitation of offers process which results in State contracts to organizations that compete
successfully.




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                                                                                              State of Louisiana
                                                                 DHH/Office of Public Health/STD/HIV Program
                                                                     2012 STD Prevention Proposal Guidelines


B.     AVAILABLE FUNDING

        It is expected that the initial contract period will begin on or about October 1, 2012, and
will be made for a 12-month budget period.
        This contract may be renewed up to two (2) additional one year periods, with renewal
initiated at the sole discretion of SHP. Continued funding of the contract in future years is
contingent upon the availability of funds and the satisfactory performance of the contractor
during the prior contract period. Funding levels may vary and is subject to change each renewal
period.
        Contracts awarded under this SO and any anticipated contract renewals are contingent
upon the continued availability of funding. SHP reserves the right to alter, amend or withdraw
this SO announcement at any time prior to the execution of a contract if funds become
unavailable through lack of appropriations, budget cuts, transfer of funds between programs or
agencies, or any other disruption of current appropriations.

         The contract period beginning October 1, 2012 will be for a three-year period, with the
option of early termination of any poorly performing contracts or if CDC or State priorities
change. The contract period will be from October 1, 2012 through September 30, 2015. It is
expected that awards will range from $30,000 - $60,000. The maximum and total amount of
funding available for this SO is $60,000. Applicants should not submit proposals with budgets
requesting funding in excess of the total funding available.

   Applicants should not assume that they will receive funds solely because they have received
funding in previous years. Applicants will be selected based on the consistency of each proposal
with the following:
    Proposal Guidelines
    Applicant’s capacity to carry out its proposal
            o Merit of the proposed approach
            o Strength of collaborations

        The grant process is competitive. SHP anticipates selecting one applicant through this
solicitation of offers but more than one applicant may be selected based on the
comprehensiveness of applications received and the requested funding amounts (within the
maximum funding amount).

Three-year Funding Cycle

        All contracts funded through this SO will be for a three-year period. Quarterly progress
reports are required from each grantee. Due dates for the reporting periods for the first year are
as follows:

1st quarter (October 1- December 31)         Due January 14, 2013
2nd quarter (January 1 – March 31            Due April 14, 2013
3rd quarter April 1 –June 30                 Due July 14, 2013
4th quarter July 1 – September 31)           Due October 14, 2013



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                                                                                               State of Louisiana
                                                                  DHH/Office of Public Health/STD/HIV Program
                                                                      2012 STD Prevention Proposal Guidelines


       All reports are due in the format provided by SHP no later than 14 days after the end of
each reporting period. The progress toward meeting the project objectives shall be reported for
the quarter as well as year-to-date. All required data, including referral information must be
submitted to SHP. The fourth quarter will serve as the final program report for the funding year.
Subsequent year’s schedules will be the same and budgets and objectives will be reviewed every
year.

C.     TIMELINE

May 9, 2012                           Solicitation of Offers (SO) Posted
May 18, 2012                          Applicant Technical Assistance Conference Call
                                           1-866-339-1399 Pass code:*1082670; 10:00AM
                                              CST.
May 31                                Deadline for Questions from Applicants
June 1                                Compilation of questions with answers posted on website
June 29                               Proposals due by 4:00 PM Central Standard Time
July 13                               Award notification
July 17                               Contract negotiations
July 19                               Contract finalized
October 1                             Date Contract Begins

       Questions regarding the guidelines of this SO may be submitted in writing, either by fax
(504) 568-7044, e-mail: jacky.bickham@la.gov, or by mail to, Jacky Bickham, SHP Regional
Coordinator Supervisor, SHP, 1450 Poydras Street, Suite 2136, New Orleans, LA 70112. The
deadline for questions is May 31, 2012. Upon issuance of this SO, employees and
representatives of SHP will not answer questions or otherwise discuss the contents of the SO
with any potential applicants or their representatives. To ensure that all applicants have access to
the same information, SHP will provide written answers to applicant questions by June 1, 2012.

Deadline

       Applicants must submit an original and five (5) copies of their proposal by June 29, 2012
to the OPH STD/AIDS Program, 1450 Poydras Street, Suite 2136, New Orleans, LA 70112.
Proposals must be received no later than 4:00 PM on June 29, 2012. Faxed applications or
applications post marked before, but received after the deadline will not be considered.

D.     BACKGROUND

       The Syphilis Elimination Effort (SEE) is a national initiative that brings together health care
providers, community leaders and state and local public health agencies to reduce syphilis rates in the
United States.

      Louisiana consistently experiences some of the highest rates of sexually transmitted diseases
(STDs) in the United States. In the most recent CDC report, Sexually Transmitted Disease Surveillance,




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                                                                                                      State of Louisiana
                                                                         DHH/Office of Public Health/STD/HIV Program
                                                                             2012 STD Prevention Proposal Guidelines


2010, Louisiana ranked 1st in the nation for rates of primary and secondary (P&S) syphilis, 2nd for rates
of gonorrhea, and 3rd for rates of Chlamydia.


P&S Syphilis
   From January to May 2011, 171 Primary and Secondary (P&S) syphilis cases were reported in
Louisiana. This represents a 29% decrease in the number of reported cases as compared to January to
May 2010 (242 cases).

  Monthly distribution of Syphilis cases in Louisiana, January-May 2010 & 2011

                                              Stage of Syphilis
   Month       Primary &                           Early          Unknown
                              Early Latent                                              Late Latent
               Secondary                         Syphilis**        Latent
             2010   2011      2010   2011      2010    2011       2010   2011          2010       2011
   January    49     29        58     40       107      69         15     21            38         48
  February    40     40        57     36        97      76         21     21            40         38
    March     63     32        89     36       152      68         35     20            97         40
     April    37     41        72     28       109      69         37     26            70         45
     May      53     29        59     26       112      55         37     14            81         34
    Total     242   171       335    166       577     337        145    102           326        205

       The New Orleans region has the second largest proportion of P & S syphilis in the state.

       According to the STD/HIV Program, of the cases with known gender, the percentage of male
cases increased from 48% in 2010 to 57% in 2011, and the percentage of female cases decreased
from 52% in 2010 to 43% in 2011. The percentage of cases with unknown gender decreased from 1%
in 2010 to 0% in 2011.

        Race/Ethnicity: In 2011, of the cases with reported race, 79% were black, 14% were white, and
2% were Hispanic. In 2010, the proportion of black cases was much higher (91%) while only 7% of
cases were white and 2% were Hispanic. Race is missing from a small portion of Primary and Secondary
syphilis (P&S) syphilis cases. In 2011, 6% of all P&S syphilis cases were missing race.

        Age: Persons age 20-29 made up 50% of all P&S syphilis cases in both time periods. In 2010
and 2011, 15-19 year olds made up an additional 16% of new cases. Age was missing from two P&S
syphilis cases in 2010 and zero cases in 2011.

       Geography: For a number of years, the Shreveport Region has had the greatest proportion of
reported P&S syphilis cases in the State and a significant increase was observed from 2010 to 2011
(36% and 46%, respectively). Meanwhile, the New Orleans Region had the second largest proportion
(15%) in 2011, For both time periods, five of the nine designated public health regions in the State (New
Orleans, Baton Rouge, Lafayette, Shreveport, and Monroe) comprised approximately 83% of all P&S


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                                                                                                      State of Louisiana
                                                                         DHH/Office of Public Health/STD/HIV Program
                                                                             2012 STD Prevention Proposal Guidelines


syphilis cases in Louisiana. Only one P&S syphilis case was missing geographic information in 2010
and zero cases were missing geographic information in 2011.

        Syphilis among MSM: In FY 2011, MSM accounted for a disproportionately high percentage of
syphilis cases in the Region 1 area. Specifically, 42% of primary, 30% of secondary and 15% of early
latent syphilis cases were diagnosed among MSM in the Region 1 area.

                     Table 1: MSM syphilis cases in Region 1 among MSM, FY2011

Parish               Primary Syphilis           Secondary Syphilis          Early Latent Syphilis

                 Reported cases    MSM      Reported cases     MSM       Reported cases            MSM
Jefferson             5             4               7           5                 33                  4
Orleans               14            4               63          16               143                 21
Plaquemines           0             0               0           0                 1                   0
St. Bernard           0             0               0           0                 0                   1
Region 1 Total        19            8               70          21               177                 26


E.       OVERVIEW OF FUNDABLE ACTIVITIES

The following is a brief description of the fundable activities under this SO. Once funded, grantees will
be provided a more thorough description of each activity and intervention with evaluation plans outlined
in the SHP CBO Manual. Additional technical assistance will also be provided to each grantee.
Applicants are encouraged to use these brief descriptions as guides in developing their proposals. These
descriptions are not meant to limit the creativity of applicants in developing innovative programs that
will address the Syphilis Elimination needs of the MSM community, but rather identify key elements
necessary to create a fundable program.

Syphilis Elimination Testing, integrated with HIV testing, recruitment, and enhanced linkage to
care targeting men who have sex with men (MSM)

This strategy must:
    Conduct syphilis screening and testing, integrated with HIV testing, targeting men who have sex
        with men (MSM) in high morbidity areas to identify individuals who are infected with syphilis.
    Establish enhanced linkage to syphilis treatment for MSM who are infected with syphilis or
        provide treatment for syphilis on site.
    Establish enhanced linkage to medical care for MSM who are infected with HIV.
    Reduce the incidence of new syphilis and HIV cases among MSM and their partners by
        providing (or making referrals to) related medical, social, and prevention services.

These services are to be fully accessible, well suited to the behaviors and other life situations of MSM
and fully integrated into a comprehensive system of related health services.

Respondents should use multiple strategies (social networking, social marketing, traditional and non
traditional online and face to face recruitment/outreach, referrals, etc., to recruit MSM for syphilis and
HIV screenings.


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                                                                                                        State of Louisiana
                                                                           DHH/Office of Public Health/STD/HIV Program
                                                                               2012 STD Prevention Proposal Guidelines


Respondents will be required to conduct risk screenings to determine the services most appropriate for
individual clients. Risk screenings must include, but are not limited to, the following:
     Basic demographic information;
     Sexual behaviors and injection drug use behaviors the client has been and is currently engaged in
       that may increase his risk of syphilis and HIV;
     The last date of the client’s last syphilis and HIV tests and the results;
     The reason(s) the client chose to get a syphilis or HIV test;
     If the client has recently been diagnosed with and treated for a sexually transmitted infection
       (STI).

Risk screenings can be conducted using face to face interviews, written questionnaires, or computer-
based tools. Based on the risk screening information, clients must be provided appropriate and tailored
health education that addresses their risk level and prevention needs. Contractors may include
additional information in the risk screening with advance written SHP approval.

Information about syphilis testing should be provided to clients, including but not limited to:
     Benefits of testing;
     Potential adverse consequences of being tested;
     Ways that syphilis can be transmitted and how it can be prevented;
     “Window” period for syphilis;
     When and how syphilis test results will be provided;
     Requirements for name reporting of syphilis infection to public health authorities;
     Requirements for partner elicitation/notification by public health authorities;
     Procedure if client tests positive;
     Procedure if client tests negative; and.
     Where to obtain further information, counseling, and additional support and services.
Information can be provided verbally, through the use of videos, computers or in writing.
Specific arrangements should be made to ensure all clients receive their syphilis results. Contractors
may consider delivering negative syphilis test results by telephone. A reliable process for verifying the
client’s identity before providing the result must be established prior to providing the test result.
Additionally, policy and procedures must be in place describing under what circumstances results will
be made by telephone and outlining the protocol for giving results by telephone. Syphilis positive test
results may only be given in person.
All clients who receive a positive syphilis result should be provided emotional support and counseling at
the time that result is provided to assist the client in understanding the meaning of the test result and the
benefit of being treated. Risk reduction messages should also be provided during the session to deliver
positive syphilis test results.

Linkage to medical care for persons who test positive will be an essential component of contracts
awarded under this SO. Contractors must establish enhanced linkage to medical care programs for
people who are positive, for both syphilis and HIV.

Collaboration



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                                                                                                                    State of Louisiana
                                                                                       DHH/Office of Public Health/STD/HIV Program
                                                                                           2012 STD Prevention Proposal Guidelines


           The contractor will conduct screening tests for syphilis and HIV targeting MSM and must collaborate
           with recruitment/outreach efforts in the New Orleans area (the Region 1 Collaborative) and be able to
           provide screenings (a phlebotomists is needed for drawing blood for syphilis screening) in field settings,
           including gay bars, popular clubs, and other venues MSM congregate.

           Fee for Service Schedule Including Recruitment Encounters
           This contract will be paid utilizing a performance-based reimbursement methodology (fee for service)
           for tests conducted and recruitment/ outreach efforts needed to reach MSM.

                      Service Category               Unit of Service Description      Unit cost

                      Recruitment             Encounters with MSM                                     $5.00
                      Syphilis Testing        Blood Draws                                            $25.00
                                              Risk Screenings                                        $10.00
                                              Linkage to or Provision of Treatment1                  $30.00
                                              Providing Test Results                                 $10.00
                      Total                                                                          $80.00

           Recruitment encounters are defined as an episode in which a worker has an extensive dialogue with the
           client, including but not limited to, talking with the individual, learning about their life and possible
           issues that may impact their ability to make healthy decisions and have a healthy life, providing a
           prevention material demonstration, a risk-reduction discussion, documented referrals, following up on a
           referral or risk-reduction plan, and/or HIV/STD education.


           F.        RECIPIENT AND SHP ACTIVITIES

           Required Recipient Activities

           1.        Involve the target populations in the planning, implementation and evaluation of
                     intervention(s).
           2.        Assist persons positive for syphilis and HIV in gaining access to appropriate
                     services/care;
           3.        Assist persons positive for syphilis and HIV with practicing safer sex and clean needle
                     techniques;
           4.        Assist high-risk persons who test negative for syphilis and HIV in gaining access to
                     appropriate services;
           5.        Incorporate cultural competency, sensitivity to issues of sexual and gender identity and
                     linguistic and developmental appropriateness into all program activities and prevention
                     messages;
           6.        Ensure adequate protection of client confidentiality;
           7.        Participate in all local Collaborative Planning Group meetings;
           8.        Establish and maintain ongoing collaborations and referral networks;


1
    Only applies to clients with positive syphilis results.

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                                                                                             State of Louisiana
                                                                DHH/Office of Public Health/STD/HIV Program
                                                                    2012 STD Prevention Proposal Guidelines


9.     Acknowledge SHP as the funding source in any materials and events funded by these
       prevention monies during the award period. NOTE: All written materials, pictorials,
       audio-visuals, questionnaires, survey instruments, and educational sessions must be
       submitted to the SHP’s program materials review panel for approval before purchase;
10.    Work with SHP to develop appropriate evaluation plans;
11.    Maintain monitoring logs and schedules of intervention activities;
12.    Conduct standardized surveys with a sample of intervention participants;
13.    Submit Quarterly and Annual Progress Reports to SHP and any other reports as required
       by SHP and CDC;
14.    Develop internal evaluation systems, which include staff performance appraisals, direct
       observation of specific interventions by the CBO supervisor, regular staff meetings, and
       internal monitoring of contract objectives;
15.    Submit an annual audit at the end of the contract year;
16.    Follow SHP protocols for interventions; and
17.    Document and follow-up on all referrals made, regardless of originating intervention.

SHP Activities

1.     Provide technical assistance in administrative and programmatic activities;
2.     Provide protocols for interventions;
3.     Provide training in order for recipients to conduct prioritized intervention strategies;
4.     Provide up-to-date information on HIV/AIDS and STDs in Louisiana;
5.     Coordinate the Community Planning Process;
6.     Provide Syphilis and HIV testing laboratory services & supplies
7.     Provide literature and posters, based on available funding;
8.     Provide technical assistance in the design and implementation of program evaluation
       activities; and
9.     Monitor recipients’ performances of program and fiscal activities.

H.     PROPOSAL REVIEW PROCESS

PHASE ONE: Pass/Fail Evaluation

        SHP will screen each proposal to verify that it contains all required components.
Required documents are listed in Appendix B – (page 20). Failure to include the required
components is grounds to disqualify the proposal from further review, which shall be at the sole
discretion of SHP. Proposal deadline is 4:00 P.M. June 29, 2012. Proposals post marked
before June 29, 2012, but received after the deadline will not be considered. During this phase,
SHP will verify to ensure that the respondent is in good standing to do business in Louisiana and
to conduct the activities described in the proposal.

PHASE TWO: Review Panel

       An internal panel, consisting of subject matter experts from SHP staff will evaluate the
proposals using the standard evaluation criteria as outlined in Appendix H. Reviewers will



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                                                                                                State of Louisiana
                                                                   DHH/Office of Public Health/STD/HIV Program
                                                                       2012 STD Prevention Proposal Guidelines


individually rate each proposal        based    on     the   criteria   found       in     Appendix           H.
Reviewer Score Sheet - Page 30.

PHASE THREE: Review

       Average scores and comments will be reviewed and awards will be recommended.

***NOTE: Inevitably, there will be more funds requested than are available. SHP’s goal is
to allocate funds among proposals most likely to provide services to those most in need in
the most efficient and successful manner.

        Proposals will be reviewed according to the criteria below. To maximize fairness for all
proposals during review, SHP staff will only confirm receipt of a proposal and are not permitted
to discuss the proposal or its review during the review process. All proposals remain with SHP
and are not returned to the applicant.

NOTE: Agencies with the top scoring proposals may receive a Pre-decisional site visit from a
     member of SHP before a final decision is made concerning award. The results of this
     visit will be considered when making final decisions.


PROPOSAL COMPONENTS & Pre-Decisional           VALUE
Site Visit
FORM K: Background                             12
FORM L: Assessment Narrative                   15
FORM N: Work plan                              21
Total proposal Points                          48
Pre-Decisional Site Visit                      52
MAXIMUM TOTAL                                  100



I.     PROPOSAL REQUIREMENTS AND CONTENT

        Proposals should conform to the following instructions and format. Failure to follow
these instructions will negatively impact a proposal’s score and could affect funding:

1.     Applicants are to submit an original and five (5) copies of the proposal.

2.     The original and each copy of the proposal set must be submitted unstapled and
       unbound.
        Use a binder clip to hold the pages together.

3.     All material must be typewritten into the forms provided:
            Form K: Respondent Background
            Form L: Assessment Narrative
            Form M: Performance Measures



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                                                                                                  State of Louisiana
                                                                     DHH/Office of Public Health/STD/HIV Program
                                                                         2012 STD Prevention Proposal Guidelines



               Form N: Work Plan

         Documents should be single spaced, in Times New Roman with a font of 12 point,
         printed on one side. Please follow the page limits listed at the bottom of each form.
         Proposals exceeding the narrative page limits will not be reviewed.

4.       Number each page sequentially, in the proposal, and the attachments, and provide a
         complete Table of Contents for the proposal and its attachments.
5.       Label each section using the title indicated.

6.       If a section is not applicable, use the designation N/A by the title.

       Applicants must submit an original and five (5) copies of the proposal, due June 29,
2012, to the OPH STD/HIV Program, 1450 Poydras Street, Suite 1450, New Orleans, LA 70112.
Proposals must be received not later than 4:00 PM on June 29, 2012. Faxed applications or
applications post marked before, but received after the deadline will not be considered.

J.       PROPOSAL

       In developing your proposal, use the following format and instructions that begin on page
26. Your proposal will be scored according to the quality of the responses to the following
questions listed in this SO on forms K, L, M & N. Please follow the format and answer all of the
questions. Unanswered questions will result in a reduction of points.

Appendix A: Proposal Cover Sheet – Page 19

        Please complete all sections except the section marked for SHP Office Use Only.

Appendix B: Proposal Checklist – Page 20

        Please make sure to check all applicable sections of your proposal.

Appendix C: Summary of Funding Sources and Current Contracts – Page 21

        Please include all sources of funding from current contractors.

Appendix D: Collaboration Agreement Forms – Page 22

        Collaborative agreements are formal statements of commitment between
organizations/businesses to collaborate or cooperate on a program. The agreement describes
specific roles and responsibilities of both organizations involved. Please use the form in
Appendix D

        Please fill out one collaborative agreement form for each strategic partner for this project.




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                                                                                                State of Louisiana
                                                                   DHH/Office of Public Health/STD/HIV Program
                                                                       2012 STD Prevention Proposal Guidelines


Appendix E: Fee for Service Budget – Page 23

      Please complete a budget for this project using the formula provided in Appendix E.

Appendix F: Minority CBO Determination Survey – Page 24

      Please complete this survey.

        This form is for information only and will not affect your score or the likelihood of being
funded. This information is provided to the Centers for Disease Control and Prevention and
other entities to help plan for and provide technical assistance and for statistical purposes. Please
review the criteria as outlined on the form. If your organization meets the criteria, please fill the
form out and submit it with your proposal.

Appendix G: Income Statement Form – Page 25

      Please include all STD/HIV related contracts/programs NOT included in Appendix C.
       A current organizational income statement is required. The statement of income should
       list all sources of financial support (i.e. foundations, government agencies, fund-raising
       events, individual contributions, in-kind support, etc.) Foundations and government
       bodies are to be listed by name.

Form K: Respondent Background – Page 26

      Number each response to the items requested in Form K with the information requested.
      Note page limitations.

Form L: Assessment Narrative – Page 27

      Number each response to the items requested in Form K with the information requested.
      Identify any additional resources used in completing this form.
      Note page limitations.

Form M: Performance Measures – Page 28

      Include the listed performance measures in the proposal along with proposed target levels
       of performance for each measure.
      Proposed target levels of performance may be negotiated and agreed upon by respondent
       and SHP if respondent is selected to negotiate a contract.

Form N: Work Plan – Page 29

      Number each response to the items requested in Form N with the information requested.
      Note page limitations.


ADDITIONAL INFORMATION
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                                                                                               State of Louisiana
                                                                  DHH/Office of Public Health/STD/HIV Program
                                                                      2012 STD Prevention Proposal Guidelines




Non-Profit Status

       Proof of the organization’s non-profit status i.e., federal tax exemption under Internal
Revenue Code 501 (c) (3), Articles of Incorporation certified by the Secretary of State, etc. is
required. Any entity applying under this SO must have been certified by the Federal Internal
Revenue Service as a 501(c) (3) organization prior to February 11, 2008.

Board Resolution Requirements

       CBOs are required to submit a notarized, current (less than 2 years old) board resolution,
which designates an agency representative responsible for signing an official state contract.

List of Current Board Members

A current list of board members and their affiliations must be submitted.

D.H.H. Audit Requirements

               POLICY NUMBER:                3105-96

               SUBJECT:                      DHH AUDIT REQUIREMENTS

               CONTENT:                      Defines DHH policy for compliance with federal
                                             and state audit requirements

               EFFECTIVE DATE:               Issued:        March 20, 1996
                                             Revised:       February 25, 2000
                                             Revised:       May 17, 2000 (Form Only)

               INQUIRIES TO:                 Office of Management and Finance
                                             Division of Fiscal Management
                                             P.O. Box 3797
                                             Baton Rouge, LA 70821-3797
                                             (225) 342-1483

I.     Statement of Policy

       It is the policy of the Department of Health and Hospitals (DHH) to fully adhere to Public
       Law 98-502 (Single Audit Act of 1984), Public Law 104-156 (Single Audit Act
       Amendments of 1996) and the Louisiana Administrative Code 34:V.134. The Single
       Audit Act of 1984 requires DHH to ensure that each sub-recipient of federal pass-through
       funds totaling $300,000 or more has an annual audit done in accordance OMB Circular
       A-133 (Audits of States, Local Governments and Non-Profit Organizations).

II.    Applicability

       This policy applies to all offices and employees of DHH.
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                                                                                               State of Louisiana
                                                                  DHH/Office of Public Health/STD/HIV Program
                                                                      2012 STD Prevention Proposal Guidelines




III.   Implementation

       The effective date of this revised policy shall be February 25, 2000.

IV.    Federal Audit Requirements

       The Single Audit Act of 1984 (PL 98-502) requires DHH to ensure that each sub-
       recipient of federal pass-through funds totaling $300,000 or more has a yearly audit done
       in accordance with OMB Circular A-133 (Audits of States, Local Governments and
       Non-Profit Organizations).

V.     DHH's Audit Requirements

       State/local governments and corporations (profit/non-profit) which have social services
       contracts with DHH and receive $100,000 or more in funds from one or more state
       contracts must have Financial and Compliance Audits performed in accordance with
       Government Auditing Standards (Yellow Book).

       A. Program Offices Audit Requirements

           Program offices within DHH may set higher standards than those contained in this
           policy, but may not set less restrictive standards.

       B. Type of Audit DHH Requires

           The type of audit required under DHH policy is one in accordance with the
           Government Auditing Standards. Government Auditing Standards are established by
           the Comptroller General of the United States and published by the U.S. General
           Accounting Office (GAO) in a book entitled Government Auditing Standards.
           Because of its bright yellow cover, this publication is often called the Yellow Book,
           even in fairly formal literature. Also, the standards it contains are frequently referred
           to by the acronym GAS, for Government Auditing Standards, or GAGAS for
           Generally Accepted Governmental Auditing Standards. All four of these terms,
           Government Auditing Standards, Yellow Book, GAS and GAGAS are synonyms for
           the same set of standards.

VI.    Responsibilities

       The Secretary or designee, the Undersecretary and each assistant secretary are responsible
       for assuring that managers and supervisors within their organizational authority comply
       with the provisions and the intent of this policy. Each employee will be advised of this
       policy. Each office is responsible for assuring that the language in its contracts
       complies with this policy.

       A. DHH Contract Negotiator


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           The following items are the responsibility of the DHH employee who negotiates a
           contract, and must be completed before the contract is signed:

                     1.      Inform the contractor of all audit requirements associated with the
                             contract.

       B. DHH Contract Management

           Input the information into the Contract Financial Management System (CFMS).

           1. Indicate in CFMS whether or not an audit is required.

           2. If an audit is required, indicate on the KAUD (Contract Audit Table) screen the
              type of audit, the audit due date, the audit monitor, and the audit monitor’s address.

       C. Division of Fiscal Management

           1. Provide technical assistance to all DHH offices in interpreting the federal and state
              audit laws and DHH audit requirements.

           2. If requested, provide copies of the Government Auditing Standards (Yellow Book),
              and OMB Circular A-133 to DHH employees and DHH contractors.

           3. Maintain an audit tracking system to track the type of audit due, the audit's due
              date, and the audit findings and if the findings have been resolved. The Division of
              Fiscal Management will maintain the audit report records for DHH. This function
              is described in DHH Policy #3175-95, Audit Report Monitoring.

           4. Run a report to identify the contractors with multiple contracts with DHH who
              have a cumulative total in excess of $100,000.

       D. Contractor

           It is the responsibility of the contractor to hire and pay an independent certified public
           accountant to perform the audit. The contractor may contact the Society of Louisiana
           Certified Public Accountants at 1-(800)288-5272 to request a list of CPAs who
           perform GAS or A-133 Audits.

VII.   Definitions

       For the purpose of this policy the following words or phrases shall have the following
       meanings:

       A. Audit - a term used to describe not only work done by auditors in examining financial
          statements, but also work done by auditors in reviewing compliance with laws and
          regulations, economy and efficiency of operations, and effectiveness in achieving
          program results.

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B. Audit Report - the medium through which an auditor communicates the results of
   the audit. The report should contain the following information:

        1.   The audit's objectives, scope and methodology.

        2.   Significant audit findings and, where applicable, an auditor's conclusion.

        3.   Recommendations for action to correct problem areas and to improve
             operations.

        4.   Statement assuring the audit was made in accordance with generally accepted
             government auditing standards and, if applicable, OMB Circular A-133.

        5.   Significant instances of non-compliance and all significant instances of abuse
             that were found during or in connection with the audit. In some
             circumstances, auditors should report illegal acts directly to parties external to
             the audited entity.

        6.   Scope of their work on management controls and any significant weaknesses
             found during the audit.

        7.   Views of responsible officials of the audited program concerning auditors'
             findings, conclusions, and recommendations, as well as corrections planned.

        8.   Report noteworthy accomplishments, particularly when                       management
             improvements in one area may be applicable elsewhere.

        9.   Report on the governmental financial assistance received.

C.      Audit Standards - general measures of the quality and adequacy of the work
        performance by the auditor, which should relate to the auditor's competency and
        proficiency in the performance of assigned duties.

     F. Central Offices - the DHH offices which do not fall under the authority of a DHH
        Regional Administrative Office. They include the Office of the Secretary, Office
        of Management and Finance and the Program Offices.

     G. Generally Accepted Accounting Principles (GAAP) - is defined as conventions,
        rules, and procedures necessary to describe accepted accounting practice at a
        particular time. The Financial Accounting Standards Board (FASB) is the body
        that establishes accounting principles.

     H. Government Auditing Standards (Yellow Book) - are standards for audits of
        government organizations, programs, activities, and functions and of government
        assistance received by contractors, non-profit organizations, and other non-
        governmental organizations. These standards are to be followed by auditors and
        audit organizations when required by law, regulation, agreement, contract or
        policy. The standards pertain to auditors' professional qualifications, the quality of
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         audit effort, and the characteristics of professional and meaningful audit reports.
         The standards are issued by the United States General Accounting Office.

      I. OMB Circular A-133 (Audits of States, Local Governments and Non-Profit
         Organizations) - provides policy guidance to federal agencies for establishing
         uniform requirements for audits of awards provided to institutions of higher
         education and other nonprofit organizations. It promotes the efficient and effective
         use of audit services. The circular is issued by the United States Office of
         Management and Budget.

      J. Program Offices - the following offices within the DHH: Office for Citizens with
         Developmental Disabilities; and the Bureau of Health Services Financing.

      K. Provider/Contractor - a state agency, any subdivision of the State or any private
         business person(s) or entity that enters into a contract with any office of DHH or
         the federal government to provide goods or services under any public welfare,
         health or social program which DHH has responsibility to control, monitor or
         audit.

J.       Regional Program Offices - the regional offices within the Office for Citizens
         with Developmental Disabilities, Office of Public Health, and the Office of
         Medicaid Eligibility and Health Standards within the Bureau of Health Services
         Financing.

K.       Social Services Contract - work rendered by any person, firm, corporation,
         governmental body or governmental entity in furtherance of the general welfare of
         the citizens of Louisiana, including but not limited to:

         1. Rehabilitation and Health Support

         2. Habilitation and Socialization

         3. Protection for Adults and Children

         4. Improvement of Living Conditions and Health

         5. Evaluation, Testing and Remedial Educational Services for Exceptional,
            Handicapped or Learning Disabled Nonpublic School Students

 L.      Sub-recipients - any person or governmental department, agency, establishment,
         or non-profit organization that receives federal assistance to carry out a program
         through a primary recipient or other sub-recipient, but does not include an
         individual that is a beneficiary of such program. A sub-recipient may also be a
         direct recipient of federal financial assistance or awards under other agreements.
         Characteristics of a Sub-recipient

         1. Determines eligibility for assistance

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         2. Performance is measured against meeting the objectives of the program

         3. Responsible for programmatic decision-making

         4. Responsible for applicable program compliance requirements

         5. Uses the funds passed through to carry out a program of the sub-entity, not to
         provide goods or services for a program of the prime recipient

    M.   Federal Pass-Through Funds - federal financial assistance received indirectly
         through other units of state or local governments. Medicaid (Title XIX) funds are
         an exception to this definition. The State of Louisiana has determined that Title
         XIX funds received by interagency transfer will be considered as state general
         funds by the receiving agency.

    N.   DHH Regional Administrative Offices - the offices established within the Office
         of the Secretary to provide administrative support services to regional program
         offices and bureaus within a specific geographic territory.


    APPENDICES

   Appendix A: Proposal Cover Sheet - Page 19
   Appendix B: Proposal Checklist - Page 20
   Appendix C: Summary of Funding Sources and Current Contracts - Page 21
   Appendix D: Community Support/Collaboration Agreements      - Page 22
   Appendix E: Fee for Service Budget – Page 23
   Appendix F: Minority CBO Determination Survey - Page 24
   Appendix G: Income Statement Form - Page 25
   Form K: Respondent Background - Page 26
   Form L: Assessment Narrative      - Page 27
   Form M: Performance Measures      - Page 28
   Form N: Work Plan                 - Page 29
   Appendix H: Reviewer’s Score Sheet - Page 30




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Appendix A

PROPOSAL COVER SHEET


Organization Name: ______________________________________________________

Address: ________________________________________________________________

Phone:______________ Fax:_____________________ Email: _________________________

Contact Person and Title: _________________________________________________

Region: ______________________________




---------------------------------------------------------------------------------------------------------------------
OPH/HAP OFFICE USE ONLY

DATE RECEIVED: ___________________________ TIME RECEIVED: _________________

LOGGED IN BY: ____________________________________________________________
                         SHP STAFF MEMBER NAME

POSTMARKED DATE: _______________


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Appendix B

STD/HIV Program (SHP)
Syphilis Elimination Proposal Checklist


      Appendix A: Proposal Cover Sheet

      Appendix B: Proposal Checklist

      Appendix C: Summary of Funding Sources and Current Contracts


      Appendix D: Community Support/Collaboration Agreements

      Appendix E: Fee for Service Budget

      Appendix F: Minority CBO Determination Survey

      Appendix G: Income Statement Form


      Appendix H: Reviewer’s Score Sheet




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Appendix C SUMMARY OF FUNDING SOURCES & CURRENT CONTRACTS

Include all HIV/AIDS related contracts/programs & programs to proposed target populations
     Source of Funds Amount of Contract Target Population Intervention/Service Geographic Area         Funding Period




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Appendix D
COLLABORATION AGREEMENT FORM

TO:                ________________________________
                   Name of applicant
                   ___________________________
                   ___________________________
                   ___________________________
                   Address of applicant
FROM:              ___________________________
                   Name of cooperating agency/business
                   ___________________________
                   ___________________________
                   ___________________________
                   Address of cooperating agency/business

In the event that the above applicant agency receives funding for Syphilis Elimination activities,
we agree to coordinate and collaborate and/or provide the following services:

Applicant Agency will:




Collaborating Agency will:




I understand that personnel from Louisiana Office of Public Health, STD/AIDS Program (SHP),
may verify this information.

________________________________ _____________________ ____________________
Authorized signatory of Proposing Agency     Title                     Date

________________________________ _____________________ ____________________
Authorized signatory of Cooperating Agency   Title                     Date




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Appendix E: Fee for Service SAMPLE                       BUDGET
Service                      Unit of Service Description          Number of          Unit cost           Total
Category                                                         Unduplicated                           Funding
                                                                   Clients                             Requested
Recruitment             Encounters with MSM                         2,000                   $5.00        $10,000.00
Syphilis Testing        Blood Draws                                  700                   $25.00        $17,500.00
                        Risk Screenings/Assessments                  600                   $10.00         $6,000.00
                                                             2
                        Linkage to or Provision of Treatment          35                   $30.00         $1,050.00
                        Providing Test Results                       700                   $10.00         $7.000.00

                                         TOTAL BUDGET                                                    $51,550.00




Appendix E: Fee for Service Budget


Please complete this budget based on your numbers from FORM M


Service                      Unit of Service Description          Number of          Unit cost           Total
Category                                                         Unduplicated                           Funding
                                                                   Clients                             Requested
Recruitment             Encounters with MSM                                                 $5.00
Syphilis Testing        Blood Draws                                                        $25.00
                        Risk Screenings/Assessments                                        $10.00
                        Linkage to or Provision of Treatment                               $30.00
                        Providing Test Results                                             $10.00

                                         TOTAL BUDGET




2
    Applies to clients with positive test results only


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Appendix F
Minority Community Based Organization Determination Survey

Name of CBO: _________________________________________________________

Name of Agency Contact Person: __________________________________________

Title: _________________________________________________________________

Agencies must meet all three of the criteria presented below in order to be classified as a
minority community-based organization, in accordance with the Centers for Disease Control and
Prevention (CDC) definition.

CRITERIA 1: Racial and Ethnic Composition of Governing Board
(CDC definition of minority CBO requires agencies to have a governing board composed of
more than 50% racial or ethnic minority members.)

Number of Agency Board Members: _________________
Number Identified as Racial or Ethnic Minorities: _____________

CRITERIA 2: Key Agency Positions Held by Racial and Ethnic Minorities
(CDC definition requires agencies to have a significant number of minority individuals holding
key program positions (including management, administrative, and service provision that reflect
the racial and ethnic demographics and other characteristics of the populations to be served.)

Number of Key Agency Positions held by racial or ethnic minorities: ___________
Individually list the job titles and the names of the persons in those positions:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

CRITERIA 3: Established Record of Service to Racial or Ethnic Minorities
(CDC definition for minority CBO requires agencies to have an established record of service to
racial or ethnic minority communities.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

*To be classified as a minority CBO in accordance with CDC guidelines, if an organization is a local affiliate of a
larger organization with a national board, the larger organization must meet the same criteria described above.



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Appendix G
INCOME STATEMENT (Include all STD/AIDS related contracts/programs NOT included in Appendix E)
    Source of Funds Amount of Contract Target Population      Intervention/Service Geographic Area        Funding Period




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                         FORM K: RESPONDENT BACKGROUND

Instructions: Number each response to the items below with the information requested.

1. Provide a narrative description of the respondent’s overall purpose or mission statement, a
   brief history of accomplishments, and the organizational structure such as board of directors,
   officers, advisory councils, or committees. Attach an organization chart as part of response.

2. Provide a narrative description of any experience (including number of years) that
   demonstrates qualifications for the proposed services and working with the MSM population
   to be served. Include a description of relationships, collaborations, or partnerships with other
   entities related to syphilis and HIV testing and enhanced linkage to medical care systems.
   Experience and success of such efforts should be supported with quantitative and qualitative
   data.

3. Describe the respondent’s history and experience conducting recruitment and syphilis and
   HIV testing. Experience and success of such efforts should be supported with quantitative
   and qualitative data including: syphilis and HIV positivity rates (new positives), total number
   of syphilis and HIV tests conducted, MSM tested, proportions of positive test results
   delivered, and proportion of syphilis and HIV positive clients successfully linked to medical
   care in 2010/2011. Describe experience with all proposed test technologies.

4. Describe the respondent’s history and experience integrating STD services with other
   services – especially HIV screening if applicable.

    A maximum of 3 additional pages may be attached, if needed.




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                          FORM L: ASSESSMENT NARRATIVE

Instructions: Number each response to the items below with the information requested. Identify
    any additional resources used in completing this form.

1. Provide a brief synopsis of:
   a. Geographic boundaries;
   b. Characteristics of target population (MSM), including demographic (age range,
      conditions/disabilities, language, culture, etc.);
   c. Agency’s current population(s) served (characteristics, population data, numbers of
      clients served, types and numbers of services provided.

2. Describe the existing resources available in the community for syphilis and HIV testing
   efforts, health and human service systems, networks, and pertinent health-related resources
   and services that provide linkage to care for people who are infected with syphilis and HIV.

3. Describe any gaps in resources and the potential barriers to accessing needed services and
   improving health status.

4. Summarize the needs identified by the community and target population assessments and
   describe the proposed project’s priorities that are designed to address these needs.

5. Describe your agency’s ability to provide services to the MSM population.

An additional 5 pages may be attached, if needed.




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                           FORM M: PERFORMANCE MEASURES

  Respondent must include the following performance measures in the proposal along with the
  proposed target levels of performance for each measure. The proposed target levels of
  performance and reporting frequency may be negotiated and agreed upon by respondent and
  SHP if respondent is selected to negotiate a contract.


                           Performance Measures for All Contractors

  OBJECTIVE A          At least 95% of clients testing for syphilis will receive results.

  OBJECTIVE B          At least 100% of clients testing positive for syphilis will receive results.
                       At least 100% of clients who are syphilis positive (all positives) and received
  OBJECTIVE C          results will be successfully linked to medical care or provided treatment for
                       syphilis.
  OBJECTIVE D          Contractor will maintain a minimum of 1.5% positivity rate.


                                 Projected Numbers to be Served

                                          OBJECTIVE E
Projected Number of syphilis tests to be performed by the end of each
quarter to MSM:

                Projected MSM (Numbers) to be Reached During Recruitment

                                          OBJECTIVE G

Projected Number of encounters made targeting MSM.




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                                  FORM N: WORK PLAN

Instructions: Number each response to the items below with the information requested.

1. Describe recruitment strategies that will be used to reach MSM and specific venues and/or
   locations where recruitment will be conducted. Provide evidence of support for access to
   such venues/locations (i.e. letters of support, memoranda of agreement, etc.)
2. Describe how respondent will establish enhanced linkage to medical care systems for people
   who are infected with syphilis and or HIV, and identify staff person (s) responsible for
   tracking linkage activities.
3. Describe respondent’s plan to use multiple strategies to recruit high-risk individuals for
   testing. Detail efforts on recruiting men who have sex with men.
4. Describe brief risk screening process to determine the services most appropriate for
   individual clients. Include the format for how the risk screening assessment will be
   conducted. List elements of the risk screening assessment tool.
5. Describe testing process to be utilized.
6. Describe how syphilis test results will be provided to both syphilis positive and syphilis
   negative clients.
7. Describe Respondent’s plan to overcome any barriers that may prevent linkage to appropriate
   medical care.
8. Describe quality assurance activities that will be used to ensure that the proposed activities
   are implemented as intended. List any positions involved in the quality assurance process
   and frequency of activities.

A maximum of 8 additional pages may be attached if needed.




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       Appendix H
       Reviewer Score Sheet

                                        FORM K: RESPONDENT BACKGROUND

                                                                                                     Point        Evaluator
                                                          Review Criteria
                                                                                                     Range         Score
Respondent provided a narrative
description of the overall               0   Not addressed or not enough information to
purpose/mission statement, brief             ascertain this requirement.
history of accomplishments, and          1   Limited or inadequate information is provided.
organizational structure (i.e. board         Organizational chart not included.
of directors, officers, advisory                                                                        0-3
councils, committees, etc.) Copy         2   Requested information is provided but may be
                                             incomplete or insufficient.
of Organizational Chart was
included.                                3   A thorough description of all requested information
                                             is provided. Organizational chart included.


                                         0   Not addressed or not enough information to
Respondent described type and                ascertain this requirement.
length of experience that
                                         1   Limited or inadequate information is provided.
demonstrates qualifications for the          Respondent documents little to no experience.
proposed services and working
with MSM. Description(s) included        2   Respondent documents two to three years
relationships etc. with other                experience with proposed services. Relationships
                                             with other testing entities and enhanced linkage to
Syphilis and HIV testing entities            HIV medical care systems are described but not             0-3
and enhanced linkage to medical              supported with quantitative and qualitative data.
care systems. Experience and
success were supported with              3   Respondent documents over three years
                                             experience with a thorough description of
quantitative and qualitative data.           relationships with other HIV testing entities and
                                             enhanced linkage to HIV medical care systems.
                                             Experience and success are supported with
                                             quantitative and qualitative data.

Respondent provided quantitative
                                         0   Not addressed or not enough information to
and qualitative data supporting              ascertain this requirement.
experience and success with
recruitment and syphilis and HIV         1   Limited or inadequate information is provided.
testing including: total number of           Respondent documents little to no experience.
syphilis tests conducted, proportion     2   Respondent documents moderate experience by
of MSM and HIV tested,                       providing at a minimum 3 of the 5 data points
proportions of positive test results         requested.
                                                                                                        0-3
delivered, and proportion of syphilis
                                         3   Respondent documents considerable experience
and HIV positive clients                     by providing quantitative and qualitative data
successfully linked to medical care          demonstrating success with recruitment and HIV
in 2010/2011. Respondent                     testing including: HIV positivity rates, total number
described experience with all                of HIV tests conducted, proportion of MSM tested,
                                             proportion of positive test results delivered, and
proposed test technologies.                  proportion of HIV positive clients successfully
                                             linked to HIV medical care.




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                                             FORM K: RESPONDENT BACKGROUND

                                                                                                          Point        Evaluator
                                                                Review Criteria
                                                                                                          Range         Score
                                              0    Not addressed or not enough information to
Respondent described history and                   ascertain this requirement.
experience integrating targeted
                                              1    Limited or inadequate information is provided.
MSM recruitment into syphilis and                  Respondent documents little to no experience.
HIV testing programs. Respondent
provided quantitative and                     2    Respondent documents two to three years
                                                   experience. Limited data is provided to support           0-3
qualitative data supporting their
                                                   agency experience.
experience and success with such
efforts.                                      3    Respondent documents over three years
                                                   experience by providing a thorough description of
                                                   condom distribution activities. Data supporting
                                                   experience is provided.


Total Points for FORM K: RESPONDENT BACKGROUND                                                               0-3



                                                  FORM L: ASSESSMENT NARRATIVE

                                                                                                          Point        Evaluator
                                                                Review Criteria
                                                                                                          Range         Score
Respondent provided a brief
synopsis of :                                 0    Not addressed or not enough information to
a. Geographic boundaries;                          ascertain this requirement.
b. Characteristics of target population,
   including demographic (age range,          1    Limited or inadequate information is provided.
   conditions/disabilities, language,              Respondent poorly documents required
   culture, etc.);                                 components.
c. Current population served
   (characteristics, population data,         2    Respondent provided detailed information on at            0-3
   numbers of clients served, types and            least two of the following: geographic boundaries,
   numbers of services provided) –                 characteristics of target population or current
   identifying any differences between the         population served... Additional clarification may be
   current population served and the               needed
   proposed target population and
   rationale for changes in target.           3    A thorough description of all requested information
                                                   is provided.


                                              0    Not addressed or not enough information to
Respondent described the existing                  ascertain this requirement.
resources available in the
community for syphilis and HIV                1    Limited or inadequate information is provided.
                                                   Respondent poorly describes existing resources.
testing efforts, health and human
service systems, networks, and                2    Respondent provides a description of existing
pertinent health-related resources                 resources. Additional information regarding the           0-3
and services that provide linkage to               availability of HIV testing and linkage to HIV
                                                   medical care services may be needed.
medical care for people who are
infected with syphilis and HIV.               3    A thorough description of existing resources is
                                                   provided. Information on the availability of HIV
                                                   testing and linkage to HIV medical care services is
                                                   included.




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                                     FORM L: ASSESSMENT NARRATIVE

                                                                                               Point       Evaluator
                                                   Review Criteria
                                                                                               Range        Score
                                 0    Not addressed or not enough information to
                                      ascertain this requirement.
Respondent described any
gaps in resources and the        1    Limited or inadequate information is provided.
                                      Respondent poorly describes gaps and barriers to
potential barriers to                 accessing services and improving health status.
accessing needed services        2    Respondent adequately describes gaps and                   0-3
and improving health                  barriers to accessing services and improving
status.                               health status. Additional information or clarification
                                      may be needed.

                                 3    A thorough description of gaps and barriers to
                                      accessing services and improving health status is
                                      provided.
Respondent summarized            0    Not addressed or not enough information to
the needs identified by the           ascertain this requirement.
community and target             1    Limited or inadequate information is provided.
population assessments                Respondent poorly describes identified needs.
and described the                2    Respondent provides an adequate description of             0-3
proposed project’s priorities         the needs identified. Additional information or
                                      clarification may be needed.
that are designed to
address these needs.             3    A thorough description of all requested information
                                      is provided. Project priorities are clearly described
                                      and are designed to address identified needs.

                                 0    Not addressed or not enough information to
Respondent described the              ascertain this requirement.
agency’s ability to provide
                                 1    Limited or inadequate description is provided.
services to culturally
diverse populations              2    Respondent adequately describes ability to serve           0-3
                                      culturally diverse populations. Additional
especially, MSM                       information or clarification may be needed.

                                 3    Respondent thoroughly describes the agency’s
                                      ability to provide services to culturally diverse
                                      populations.

Total Points for FORM L: ASSESSMENT NARRATIVE




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                                               FORM N: WORK PLAN

                                                                                                  Point       Evaluator
                                                       Review Criteria
                                                                                                  Range        Score
Respondent described recruitment
                                      0   Not addressed or not enough information to
strategies that will be used to           ascertain this requirement.
reach MSM and specific venues
and/or locations where recruitment    1   Limited or inadequate information is provided.
will be conducted. Respondent             Respondent poorly describes recruitment
                                          strategies.
provided evidence of support for                                                                     0-3
access to such venues/locations       2   Respondent provides a description of recruitment
(i.e. letters of support, memoranda       strategies and venues. Evidence of support from
of agreement, etc.)                       identified venues may be missing.

                                      3   A thorough description of recruitment strategies is
                                          provided. Evidence of support included.


                                      0   Not addressed or not enough information to
                                          ascertain this requirement.

Respondent described how              1   Limited or inadequate information is provided.
respondent will establish enhanced        Respondent poorly describes how an enhanced
                                          linkage to HIV medical care system will be
linkage to medical care systems for       established.
people who are infected with
syphilis and or HIV, and identified   2   Respondent provides an adequate description of             0-3
staff person(s) responsible for           how an enhanced linkage to HIV medical care
                                          system will be established. Additional clarification
tracking linkage activities.              may be needed

                                      3   A thorough description of all requested information
                                          is provided. Respondent clearly demonstrates
                                          how an enhanced linkage to HIV medical care
                                          system will be established. Staff responsible for
                                          tracking linkage activities identified.


                                      0   Not addressed or not enough information to
Respondent describe risk
                                          ascertain this requirement.
screening process to determine the
services most appropriate for         1   Limited or inadequate information is provided.
individual clients, including the         Respondent poorly describes risk-screening
                                          process.
format for how the risk screening
                                                                                                     0-3
assessment will be conducted.         2   Respondent adequately describes risk-screening
Respondent listed elements of the         process. Additional information or clarification may
risk screen assessment tool.              be needed

                                      3   A thorough description of risk-screening process is
                                          provided. Elements of risk screen assessment tool
                                          provided.




                                                                33
                                                                                                                       State of Louisiana
                                                                                          DHH/Office of Public Health/STD/HIV Program
                                                                                              2012 STD Prevention Proposal Guidelines



                                                  FORM N: WORK PLAN

                                                                                                     Point      Evaluator
                                                          Review Criteria
                                                                                                     Range       Score
                                         0   Not addressed or not enough information to
                                             ascertain this requirement.

                                         1   Limited or inadequate information is provided.
Respondent     described       testing       Respondent poorly describes testing process.
process to be utilized.
                                         2   Respondent adequately describes the testing               0-3
                                             process. Additional information or clarification may
                                             be needed

                                         3   A thorough description of the testing process is
                                             provided.


                                         0   Not addressed or not enough information to
                                             ascertain this requirement.

Respondent described how                 1   Limited or inadequate information is provided.
syphilis test results will be provided       Respondent poorly describes the results process.
to both those clients that test          2   Respondent provides adequate description of               0-3
positive and negative.                       results process. Additional information or
                                             clarification may be needed

                                         3   A thorough description of the results process for
                                             both HIV positive and HIV negative clients is
                                             provided.

                                         0   Not addressed or not enough information to
                                             ascertain this requirement.

                                         1   Limited or inadequate information is provided.
                                             Respondent poorly describes the plan to overcome
Respondent described plan to
                                             barriers to linkage to HIV medical care for
overcome any barriers that may               positives.
prevent linkage to appropriate
                                         2   Respondent provides an adequate description of            0-3
medical care.
                                             the plan to overcome barriers to linkage to HIV
                                             medical care for positives. Additional information
                                             or clarification may be needed

                                         3   A thorough description of the plan to overcome
                                             barriers to linkage to HIV medical care for positives
                                             is provided.
                                         0   Not addressed or not enough information to
                                             ascertain this requirement.
Respondent described quality             1   Limited or inadequate information is provided.
assurance activities that will be            Respondent poorly describes quality assurance
used to ensure that the proposed             activities.
activities are implemented as
                                         2   Respondent describes quality assurance activities
intended. Respondent listed                  to be used. Additional information or clarification       0-3
positions involved in the quality            may be needed. Positions involved in quality
assurance process and frequency              assurance activities may not be listed.
of activities.
                                         3   A thorough description of all quality assurance
                                             activities is provided. Positions involved in this
                                             process and the frequency of activities have been
                                             identified




                                                                  34
                                                                                       State of Louisiana
                                                          DHH/Office of Public Health/STD/HIV Program
                                                              2012 STD Prevention Proposal Guidelines



                                     FORM N: WORK PLAN

                                                                    Point       Evaluator
                                        Review Criteria
                                                                    Range        Score
Total Points for FORM N: WORK PLAN




                                             35

								
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