Renewal Grant Application School Tobacco Program Grant by sW9S27


									                  Wisconsin Department of Public Instruction                       INSTRUCTIONS: Submit original and 4 copies. Application must be
                  RENEWAL GRANT APPLICATION                                        received at DPI no later than October 12, 2007. Late applications will
                                                                                   not be accepted. Return to:
                  PI-2392-A (Rev. 08-07)                                               WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION
                                                                                       ATTN: ELIZABETH PEASE
                                                                                       AODA Program
For questions regarding this grant, contact:
                                                                                       P.O. BOX 7841
Pam Kanikula, Student Services, Prevention, and Wellness (608) 266-7051
                                                                                       MADISON, WI 53707-7841

                                                                 I. GENERAL INFORMATION

1. Applicant of Agency Legal Name of Agency               2. Grant Type              3. Mailing Address Street, City, State, ZIP
                                                                 Single District
4. District/Agency Administrator                                                                5. CESA Region           6. Telephone Area/No.

                                                                                                  Select from List
7. Project Coordinator                                           8. Title                                                9. Telephone Area/No.

10. Project Coordinator’s Address Street, City, State, ZIP

11. E-mail Address                                                          12. Grant Period Beginning Mo./Day/Year        13. Ending Mo./Day/Year

                                                                                           June 1, 2007                            June 30, 2008
14. Total Grant Funds Requested for            15. Local Match                     16. Project Title
    2007-2008 School Year

                                                                       II. ASSURANCES
Assurance is hereby given:
 1. That the local educational agency will administer each program                   8. The local educational agency will participate in statewide
    covered by the application in accordance with all applicable statutes,              monitoring and evaluation activities such as the Youth Risk
    re-evaluation, program plans, and applications;                                     Behavior Survey and Youth Tobacco Survey.
 2. That the control of funds provided to the local educational agency               9. The district assures it will contribute a minimum of 20 percent of
    under each program and title to property acquired with those funds,                 the costs of the project as “in-kind match” in accordance with the
    will be in a public agency and that a public agency will administer                 requirements of the funding authority. Records of match
    those funds and property;                                                           calculations will be maintained in local records.
 3. That the local educational agency will use fiscal control and fund              10. The school district assures that it will not accept funding from nor
    accounting procedures that will ensure proper disbursement of, and                  have an affiliation or contractual relationship with a tobacco
    accounting for, funds paid to that agency under each program;                       company, any of its subsidiaries, or parent company during the
 4. That any application, evaluation, periodic program plan or report                   term of this grant. Acceptance of such funds during the term of
    relating to each program will be made readily available to parents and              this grant is grounds for withdrawal of the funds.
    other members of the general public;                                            11. The programs and services provided under this grant will be used
 5. That the local educational agency will make reports to the state                    to address the needs set forth in the application and fiscal related
    educational agency as may be reasonably necessary to enable the                     information will be provided within the fiscal year timelines
    state educational agency to perform their duties and that the local                 established for new, reapplying, and/or continuing programs.
    educational agency will maintain such records and provide access to             12. The activities and programs that will be performed under this
    those records as the state educational agency deem necessary to                     grant will be used to supplement services and not supplant funds
    perform their duties;                                                               from non-federal sources.
 6. The local educational agency will provide reasonable opportunity for            13. The school district will comply with civil rights and nondiscrimina-
    the participation by teachers, parents, and other interested agencies,              tion requirement provisions and equal opportunities to participate
    organizations, and individuals in the planning for and operation of                 for all eligible students, teachers, and other program
    each program.                                                                       beneficiaries.
 7. That the local educational agency will ensure compliance with civil             14. The applicant will file financial reports and claims for
    rights and nondiscrimination requirement provisions and equal                       reimbursement in accordance with procedures prescribed by the
    opportunities to participate for all eligible students, teachers, and other         Department of Public Instruction
    program beneficiaries.

                                                             III. CERTIFICATION/SIGNATURES
WE, THE UNDERSIGNED, CERTIFY that the information contained in this application is complete and accurate to the best of our knowledge; that
the necessary assurances of compliance with applicable state and federal statutes, rules, and regulations will be met; and, that the indicated agency
designated in this application is authorized to administer this grant.
WE FURTHER CERTIFY that the assurances listed above have been satisfied and that all facts, figures, and representation in this application are
correct to the best of our knowledge.
Signature of Applicant Agency Administrator             Date Signed                Signature of School Board Clerk If applicable      Date Signed
                                                        Mo./Day/Yr.                                                                   Mo./Day/Yr.
                                                                                  
Page 2                                                                                                                                            PI-2392-A
                                                                        IV. ABSTRACT
 Summarize the key elements of the proposal.
   Outline how at least one of the two priority areas (Youth leadership and advocacy and Access to cessation and education for tobacco users) will
 be targeted.

   Identify which objective from the tobacco free coalition multi-year action this project will support. (In communities or counties with no funded
 coalition, indicate which objective from the local public health department community health improvement plan will be supported by the grant.

    Identify, using quantitative and qualitative data, at least one population disproportionately impacted by tobacco that will be targeted by this project
 [racial/ethnic groups, sexual minorities, 18-21 year olds, alternative school students, pregnant teens, students living in homes with smokers, low
 socio-economic status students/families, rural districts (where spit tobacco is more prevalent), urban districts (where there is heavy marketing
 targeting these populations)].

                                                                   V. COLLABORATION

 Describe how the enhanced project was built by a partnership between school staff and the tobacco free coalition (along with other community
 agencies, as appropriate, and families). Include number of meetings held and list of attendees. Also describe the involvement of these same partners
 in implementing the project and a plan for sustaining involvement of school personnel in the tobacco free coalition.
PI-2392-A                                                                                                                                               Page 3

                                                 VI. LOCAL PLAN FOR USE OF DISCRETIONARY FUNDS
 For each objective identified in the narrative, develop a chronological list of activities, the completion date(s), and person(s)/position(s) responsible for
 only this first year of the grant cycle. Attach as many pages as necessary for this section ONLY. To add additional rows, tab out of the last cell in the
                                                                                                                Date to be            Person/Position
               Measurable Objectives                                       Activity                           Accomplished               Responsible
Page 4                                                                                                                                          PI-2392-A

                                                   XIII. LOCAL TOBACCO FREE COALITION VERIFICATION
                                                   This form must be submitted along with the grant application.
 School District Name                                                                                                         Telephone Area/No.


 Contact Person for Local Tobacco Coalition                                     Contact Person’s Title

                                                    TO BE COMPLETED BY SCHOOL REPRESENTATIVE

 Major objectives of grant application

 Plan for continued collaboration with coalition

                                            TO BE COMPLETED BY COALITION CHAIR OR THEIR DESIGNEE

 Recommendations or comments related to this application, including how it is tied to the coalition multi-year action plan.


I, THE UNDERSIGNED, agree to share this plan with the Tobacco Coalition as a whole at the next general meeting.
 Signature Tobacco Coalition Representative                      Position with Coalition                                        Date Signed Mo./Day/Yr.

Page 5                                                                                                                                                                                                     PI-2392-A

                                                                                            VIII. BUDGET DETAIL
 Date of Request Mo./Day/Yr.                             Applicant Agency                                                                          Project No. For revisions only

                                                                                     1. Personnel Summary (100s-200s)
                                                                                   All staff must hold the appropriate license.
          List all employees to be paid from this project. Do not include contracted personnel employed by other agencies in this section. If a vacancy exists which will be filled, indicate “vacant”.

          a.                                 b.                                                      c.                                   d.                   e.                                  f.
  Function Code
 (Indicate for each                                                                                                                    Project       Date(s) Service to be                   Total Cost
   position listed)                        Name                                                Position/Title                           FTE                Provided                 Salary                Fringe

                                                                                                                                                     Total Salary & Fringe**                  $0                   $0
** All project totals must equal salary and fringe totals on budget summary page.
Page 6                                                                                                                                       PI-2392-A

                        `                                    VIII. BUDGET DETAIL (cont.)
Date of Request Mo./Day/Yr.       Applicant Agency                                                   Project No. For revisions only

                                                     2. Purchased Services Summary (300s)
     a.                          b.                             c.                                  d.                                 e.
  Function                    Type of                Date(s) Service to be         Specify Agency/Vendor or Supplier
   Code                 Service Purchased                  Provided                            If Known                               *Cost

                                                               Must agree with Purchase Services Total on Budget Summary                     $0

           * Note: Per day contract rate for consultants and speakers is limited to $1,000 per day out of these funds.

                                                     3. Non-Capital Objects Summary (400s)
                         a.                             b.                                     c.                                       d.
                  WUFAR Code
                    Function                                                               Item Name                                   Total
   (Indicate for each item listed in column c.)      Quantity                      Include all items budgeted.                         Costs

                                                                Must agree with Non-Capital Objects Total on Budget Summary                  $0
PI-2392-A                                                                                                                                        Page 7

                                                                    IX. BUDGET SUMMARY

 School District                             Grant Period                                              Date Submitted
                                             Beg.                      Initial Request           First Revision              Second Revision
                                                July 1, 2007
 Project Number For DPI Use Only             End
                                               June 30, 2008
Budget Revisions: Submit a copy of the Budget Change Request form (PI-1824) for State Alcohol and Tobacco Grant Programs located at with appropriate revisions included. Note: Submit request at least 30 days prior to expenditure of grant
monies. The final two columns are for district recording purposes only. After submitting any budget change request on form PI-1824, district may record
additional budget detail on this page.
     WUFAR Function                      WUFAR Object                    Amount Requested              First Revision           Second Revision

                               a. Salaries (100s)
 Instruction (100 000
 Series) Activities dealing    b. Fringe Benefits (200s)
 directly with the
 interaction between
                               c. Purchased Services (300s)
 instructional staff and
                               d. Non-Capital Objects (400s)

                               TOTAL Instruction                                         $0                    $0                          $0
 Support Services—             a. Salaries (100s)
 Pupil and Instructional
 Staff Services (in 210
 000 and 220 000 Series)       b. Fringe Benefits (200s)
 Support services are
 those which facilitate and    c. Purchased Services (300s)
 enhance instructional or
 other components of the
                               d. Non-Capital Objects (400s)
 grant. This category
 includes staff
 development,                  TOTAL Support Services—                                   $0                    $0                          $0
 supervision, and              Pupil/Instructional Staff Services
 coordination of grant

                               a. Salaries (100s)
 Support Services—
                               b. Fringe Benefits (200s)
 (Associated with
 functions in 230 000
 series and above.)            c. Purchased Services (300s)
 Includes general;
 building; business; central   d. Non-Capital Objects (400s)
 service administration,
 and insurances.
                               TOTAL Support Services—Admin.                             $0                    $0                          $0
                                                    TOTAL BUDGET                         $0                    $0                          $0

 DPI Approval                  DPI Reviewer Signature/Date

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