School Nurse Application Competitive- FY2010

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					COMPETITIVE GRANT APPLICATION Mississippi Department of Education School Nurse Intervention Program

Application deadline is 5:00pm Wednesday, September 30, 2009. Completed applications should be mailed to: Lea Ann McElroy, Director Bureau of Coordinated School Health Office of Healthy Schools Mississippi Department of Education P.O. Box 771 Jackson, MS 39205-0771 Or hand-delivered to: Lea Ann McElroy, Director Bureau of Coordinated School Health Office of Healthy Schools 239 North Lamar Street, Suite 601 Jackson, MS 39201 For questions about the grant or grant application, please contact: Lea Ann McElroy 601-359-3189 lmcelroy@mde.k12.ms.us or Estelle Watts 601-359-1725 ewatts@mde.k12.ms.us

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COMPETITIVE GRANT APPLICATION Mississippi Department of Education School Nurse Intervention Program PART A APPLICATION COVER PAGE School District:_________________________ ___ _____________________

Address:_________________________________________________________________________ City:_________________________________________ Zip Code:___________________________ Phone Number: _______________________________ Fax Number:________________________

Contact Person:____________________________________________________________________ Address of Contact Person:__________________________________________________________ City:________________________________________ Zip Code:____________________________ Phone Number:_______________________________ Fax Number:_________________________ Email Address of Contact Person:_____________________________________________________ School Site Name:____________________________ School Grade Levels:___________________ No. of Students:___________ On-Site Grant Coordinator:__________________________________ Email Address of On-site Grant Coordinator: _____________________________________________ Phone Number:____________________ Business Manager:_______________________________ Email Address of Business Manager:___________________________________________________

The applicant certifies that to the best of his/her knowledge, the information in this application is correct and that the filing of this application is duly authorized by the governing body of this institution.

_____________ Original Signature of Superintendent __________________________________________________ Typed or Printed Name of Superintendent Date

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PART B STATEMENT OF STANDARD TERMS AND CONDITIONS, ASSURANCES AND CERTIFICATIONS
By signing this statement, the Grantee hereby certifies and assures that the school district and school site submitting this application shall comply with the following Standard Terms and Conditions, Assurances and Certifications in accordance with state regulations, MDE policy and requirements pertaining to this program. The applicant certifies further that the information submitted on this application is true and correct. Standard Terms and Conditions Changes This agreement shall not be modified, altered, or changed except by mutual agreement by an authorized representative(s) of each party to this agreement, and must be confirmed in writing through the Mississippi Department of Education grant modification procedures. Independent Grantee The grantee shall perform all services as an independent grantee and shall discharge all of its liabilities as such. No act performed or representation made, whether oral or written, by grantee with respect to third parties shall be binding on the Mississippi Department of Education. Termination The Mississippi Department of Education, by written notice, may terminate this grant, in whole or in part, if funds supporting this grant are reduced or withdrawn. To the extent that this grant is for services, and if so terminated, the Mississippi Department of Education shall be liable only for payment in accordance with payment provisions of this grant for services rendered prior to the effective date of termination. The Mississippi Department of Education, in whole or in part, may terminate this grant for cause by written notification. Furthermore, the Mississippi Department of Education and the grantee may terminate this grant, in whole or in part, upon mutual agreement. Either the Mississippi Department of Education or the grantee may terminate this agreement at any time by giving written notice to the other party of such termination and specifying the effective date thereof. The grantee shall be paid an amount which bears the same ratio to the total compensation as the services actually performed bear to the total services of the grantee covered by the agreement, less payments of compensation previously made. Access to Records The grantee agrees that the Mississippi Department of Education, or any of its duly authorized representatives, at any time during the term of this agreement, shall have access to, and the right to audit and examine any pertinent books, documents, papers, and records of grantee related to grantee's charges and performance under this agreement. Such records shall be kept by grantee for a period of five (5) years after final payment under this agreement, unless the Mississippi Department of Education authorized their earlier disposition. Grantee agrees to refund to the Mississippi Department or Education any overpayments disclosed by any such audit. However, if any litigation, claim, negotiation, audit or other action involving the records has been started before the expiration of the five year period, the records shall be retained until completion of the action and resolution of all issues which arise from it. Laws This agreement, and all matters or issues collateral to it, shall be governed by, and construed in accordance with, the laws of the State of Mississippi. Legal Authority The grantee assures that it possesses legal authority to apply for and receive funds under this agreement.

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Equal Opportunity Employer The grantee shall be an equal opportunity employer and shall perform to all affirmative action and other applicable requirements; accordingly, grantee shall neither discriminate nor permit discrimination in its operations or employment practices against any person or group of persons on the grounds of race, color, religion, national origin, handicap or sex in any manner prohibited by law. Copyrights MDE grants to the Grantee the right to copyright materials and articles that may result from research carried out under this grant. MDE shall have unlimited royalty free license to use, reproduce, translate or publish all product(s) produced under this agreement for and on behalf of the MDE and the public school districts of the State of Mississippi. Personnel Grantee agrees that, at all times, the employees of grantee furnishing or performing any of the services specified under this agreement shall do so in a proper, workmanlike, and dignified manner. Assignment Grantee shall not assign or subcontract in whole or in part, its rights of obligations under this agreement without prior written consent of the Mississippi Department of Education. Any attempted assignment without said consent will be void and of no effect. Property, Equipment and Supplies Property, equipment and supplies purchased, in whole or in part, with funds provided under this agreement shall be procured, accounted for and disposed of in accordance with applicable State and Federal laws and regulations. Title to any equipment and supplies purchased under this agreement shall be vested in the grantee. Mississippi Ethics It is the responsibility of the grantee to ensure that subcontractors comply with the Mississippi Ethics Law in regard to conflict of interest. A statement attesting to said compliance shall be on file by the grantee. Mississippi Department of Education (MDE) Assurances and Certifications 1. The applicant shall be an equal opportunity employee and shall perform to all other applicable requirements; accordingly, the applicant shall neither discriminate nor permit discrimination in its operation or employment practices against any person or group of persons on the grounds of race, color, religion, national origin, handicap, or sex in any manner prohibited by law. Further, the applicant agrees to comply with the Civil Rights Acts of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act of 1990, and the No Child Left Behind Act of 2001; 2. The applicant agrees that the MDE, or any of its duly authorized representatives, at any time during the term of this agreement, shall have access to, and the right to audit examine any pertinent books, documents, papers, and records of applicant related to applicant’s charges and performance under this agreement. Applicant shall keep such records for a period of five years after final payment under this agreement, unless the MDE authorizes their earlier disposition. Applicant agrees to refund to the MDE any overpayments disclosed by any such audit. However, if any litigation, claim, negotiation, audit, or other action involving the records has been started before the expiration of the five-year period, the records shall be retained until completion of the action and resolution of all issues which arise from it; 3. The applicant assures that it possesses legal authority to apply for and to receive funds under this agreement; 4. The grantee certifies they have not been barred from contracting or otherwise doing business with the State or Federal Governments; 5. This agreement shall not be modified, altered, or changed except by mutual agreement by representative(s) of each party to this agreement, and must be confirmed in writing through MDE grant modification procedures;

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6. The applicant shall perform all services as an independent applicant and shall discharge all of its liabilities as such. No act performed or representation made, whether oral or written, by the applicant with respect to third parties shall be binding on the MDE; 7. The MDE, by written notice, may terminate the grant, in whole or in part, if funds supporting the grant are reduced or withdrawn. To the extent that the grant is for services, and if so terminated, the MDE shall be liable only for payment in accordance with payment provisions of the grant for services rendered prior to the effective date of termination. The MDE, by written notice, may terminate the application for nonperformance of the application at any time during the term of the program. The applicant agrees that work, data, etc. created under the auspices of the program shall be turned over to the MDE upon such termination. The MDE, in whole or in part, may terminate the program for cause by written notification. Furthermore, the MDE and the applicant may terminate the agreement, in whole or in part, upon mutual agreement. Either the Mississippi Department of Education or the awardee may terminate this agreement at any time by giving written notice to the other party of such termination and specifying the effective date thereof. The applicant shall be paid an amount which bears the same ratio to the total compensation as the services actually performed bear to the total services of the contractor covered by the agreement, less payments of compensation previously made; 8. This agreement, and all matters or issues collateral to it, shall be governed by, and constructed in accordance with, the laws of the State of Mississippi; and 9. Applicant shall not assign or sub-grant in whole or in part, its rights or obligations under this agreement without prior written consent of MDE. Any attempted assignments without said consent shall be void and of no effect.

_____________ Original Signature of Superintendent __________________________________________________ Typed or Printed Name of Superintendent Date

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PART C SELECTION CRITERIA

Only one award will be made. Administrative Support The school district Superintendent and the school site Principal must complete Part E of this application – a checklist confirming their support of this program. Readiness The school district must demonstrate readiness through documentation of a School Health Council and district and/or local wellness policy. Attach as Part F of this application. Funding This grant is a one (1) year grant totaling $50,000. Future funding is contingent upon legislative appropriation. Sustainability The school district must confirm a plan for program sustainability should funding be cut in future years. Nurse The nurse hired must be a Registered Nurse (RN) with a current Mississippi license. He or she must report data monthly to the Office of Healthy Schools/Bureau of Health Services. The nurse must devote at least twenty-five percent (25%) of his/her time to tobacco education and/or programs. Current School Nurse(s) given priority. Those school districts identified as not having a school nurse will be

Nurse:Student Ratio The National Association of School Nurses recommends a nurse:student ratio of 1:750 in a general education population. That is the goal for this program, both statewide and within the districts. Districts with the highest nurse:student ratio will be given priority. District Enrollment In the case of districts with the same ratio, student enrollment will be a determinant for funding.

Please answer the following questions: 1. How many school nurses are currently in the district? ____________________ 2. What is the current enrollment of the school district? _____________________ 3. What is your nurse:student ratio? ________________________ The highlighted numbers in the table are an example to aid in your calculation of the ratio. (a) # of School Nurse(s) in District 2 (b) District Enrollment 900 (b) (a)=1:(c) Nurse:Student Ratio 1:450

For office use only Data confirmed by OHS/BHS staff ___________ Date ______________ Initials ______________ 6

PART D BENCHMARKS & PROGRAM ASSURANCES October 2009 January 2010 June 2010 $25,000 $15,000 $10,000 Initial payment for grant award, contract with nurse, and assurance of compliance with reporting requirements Second payment following completion of first semester monthly reporting requirements Final payment following completion of annual reporting requirements

As an applicant for this school nurse grant, I hereby confirm the following:          We understand the importance of administrative support to the success of our school nurse, and ensure that support at both the district and school level. We understand the benchmark table above and agree to its terms. We understand that our attendance may be required at a meeting(s) during the grant period. Documentation of our School Health Council and our district and/or local wellness policy is attached as Part F of this application. Our school nurse is a Registered Nurse (RN) with a current Mississippi license. Our school nurse will participate in monthly data collection, as required in Part E of this grant agreement. Our school nurse will participate in mandatory training, provided by The Office of Healthy Schools, on at least an annual basis. Our school nurse will devote at least twenty-five percent (25%) of her time to tobacco education and/or programs. Funds received from this grant will only be used to support the school nurse program.

________________________________________________________________________________________ Original Signature of Superintendent Date

________________________________________________________________________________________ Typed or Printed Name of Superintendent

________________________________________________________________________________________ Original Signature of School Principal Date

________________________________________________________________________________________ Typed or Printed Name of School Principal

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PART E SCHOOL NURSE CRITERIA & DATA COLLECTION ELEMENTS The Criteria for a School Nurse is included as part of this application for communication of qualifications, job duties and data collection elements. This same information is included in the Mississippi School Nurse Procedures & Standards of Care Manual, a copy of which should be in your school nurse clinic. This information does not have to be returned with the application; however, we do require that you acknowledge receipt and understanding of the documents below. 

We have reviewed the Criteria for a School Nurse, understand its content with regard to school nurse qualifications and job performance, and ensure our school nurse will work within the standard and scope set forth.

PART F DOCUMENTATION OF READINESS Application is not complete without documentation of your School Health Council and district and/or local wellness policy. Please use the attached form for reporting your School Health Council, and include a copy of your wellness policy with this application.

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SCHOOL HEALTH COUNCIL REPRESENTATION School District Superintendent School Principal School Health Coordinator School District Food Service Director School District Business Officer School District Public Relations Officer Community Leader Parent Parent Student Student Teacher Teacher School Staff Health Care Professionals Business/Industry Representative Government Official MSU Cooperative Extension Agent Social Services Agencies Attorneys Law Enforcement Officials Clergy College/University Personnel Media On-site Coordinator Other: (identify) Other: (identify) Other: (identify) Other: (identify) Other: (identify) PRINTED NAME SIGNATURE

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