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Request for Application
Illinois HIV/AIDS
Communities of Color
Initiative
HIV Prevention, Education, and Care Program
September 1, 2005 – June 30, 2006
Illinois Department of Public Health
Center for Minority Health Services
535 West Jefferson, 5th Floor
Springfield, Illinois 62761
Phone: 217-785-4311
Fax: 217-558-7181
Illinois Department of Public Health
Center for Minority Health Services
Illinois HIV/AIDS
Communities of Color
Initiative
HIV Prevention, Education, and Care Program
July 25, 2005
Request for Application for State Fiscal Year 2006
Application Package Contents:
• Program Summary
• Background and Purpose
• General Information
• Instructions for Application
• Grant Application Forms
Program Summary
Title: Illinois HIV/AIDS Communities of Color Initiative
HIV Prevention, Education, and Care Program
Issued By: Illinois Department of Public Health
Center for Minority Health Services
Application Processing: Applications must be received no later than:
• August 19, 2005
• Applications received after this time will not be
reviewed
• Fax copies will not be accepted
• Submit one signed original and four (4) photocopies
of the application
Who may apply: Eligible applicants include the following: community-based
organizations, non-profits, private associations, religious
organizations, voluntary organizations, organizations serving
youth, organizations serving ethnic populations, schools/school
districts, and collaboratives of government and community-based
organizations. Local health departments and other governmental
agencies are not eligible to apply; however, may participate as a
member of a coalition, partnership, or collaborative.
Only organizations based in Illinois are eligible to compete for these
funds, and all applicants must submit a letter of support from their
regional HIV prevention lead agency.
Funding Source: Illinois General Revenue Funds
Funding Period: September 1, 2005 – June 30, 2006
Note: Please follow all grant application instructions carefully. Any
application not containing all requested information will be considered non-
responsive and will not be entered into the review process. The application
will be returned with notification that it did not meet the submission
requirements.
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Background
The HIV and AIDS case rates among African Americans and Hispanics/Latinos are the highest
among all racial/ethnic groups in Illinois. The current, and continuing, higher rates among these
groups indicate that they are disproportionately affected by HIV disease.
Purpose
The Illinois Department of Public Health Center for Minority Health Services is requesting
proposals for HIV Prevention, Education, and Care Programs targeted to communities of color.
The Center for Minority Health Services is specifically looking for community-based
organizations with the capacity to reach African Americans and Hispanics/Latinos by developing
and implementing prevention programs that are science-based yet culturally innovative and
unique. Successful applicants will have demonstrated their capacity in working with the target
population.
Applicants must identify anticipated project results that are consistent with the overall program
purpose. Project results should fall within the following general categories increase the number
of high risk individuals from the target population who understand their risk factors and change
their risky behavior; increase the number of high risk individuals from the target population who
test for HIV and return for their HIV test results; and increase the number of HIV positive
individuals from the target population who are linked into HIV/AIDS care and treatment services
within forty-eight hours of their HIV diagnosis.
The Grantee will:
1. Address all of the identified project results.
2. Demonstrate how you will identify and engage individuals from the target population with
HIV prevention messages.
3. Demonstrate how you will integrate HIV prevention messages into larger program activities.
4. Develop and implement strategies that are culturally innovative through solicitation of
unique ways of contacting and exposing individuals from the target population to the HIV
prevention messages in both group and individual settings.
5. Develop and implement interventions that are science based and CDC approved to target
communities of color.
6. Identify smaller community based organizations that do not have the capacity to reach the
target population and help develop the infrastructure to reach the target population. At the
end of the grant period, the smaller community based organization will have to successfully
demonstrate capacity in reaching the target population.
7. Collaborate with the Center for Minority Health Services Evaluation Team to document data
for formative, process and outcome evaluations for the HIV prevention programs developed
by the grantee.
To qualify for funding Grantee must:
1. Grantee and/or key staff members must have at least two years of experience serving the
target population.
2. Grantee must be a minority-based organization as defined by the Congressional Black
Caucus and provide documentation with proposal. A statement to that effect will not be
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sufficient.
3. Grantee must have demonstrated the capacity to successfully work with members of the
target population.
4. Grantee must have experience and documented proof of linkages with appropriate local
stakeholders.
Scopes of Service:
1. Develop and/or implement HIV prevention and education strategies to target population.
2. By January 30, 2006, deliver a mid-year report.
3. By June 30, 2006, document the HIV prevention and education program. This final report
will include:
• A final program plan discussing findings, limitations, and any recommendations
from the program
• A complete report offering graphical presentations on process data
• A final outcome study on knowledge, attitudes and behaviors based on the
implementation of the culturally unique strategy developed by the grantee.
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How to Apply
The Illinois Department of Public Health Center for Minority Health Services has established
a two-step process for awarding funds consisting of a letter of intent and a full application
package. A letter of intent is requested, but not required.
Letter of Intent
The Illinois Department of Public Health Center for Minority Health Services requests that
potential applicants submit a letter, no longer than one page, indicating the applicant’s intention to
submit a complete application. This letter should be submitted by August 8, 2005 to:
Doris Turner, Chief
Center for Minority Health Services
Illinois Department of Public Health
535 West Jefferson Street, 5th Floor
Springfield, Illinois 62761-0001
Letters may be faxed to 217-558-7181. These letters will be considered non-binding, but will
allow the Center for Minority Health Services to appropriately assemble peer review panels.
Application
The completed application must include the following sections. Each area of each section
must be completed in full and as specified.
I. Cover Page (form provided)
II. Application for Public Health Program Grant (form provided)
III. Applicant Contact Information (form provided)
IV. Collaborator List (form provided)
V. Executive Summary (1 page maximum)
VI. Organizational Capacity (1 page maximum)
Provide a brief overview of the organization’s history, mission, services offered,
recent accomplishments, and the qualifications of project staff to implement the
proposed program. Provide documentation of organization’s status as a minority
based organization as defined by the Congressional Black Caucus. This should be
submitted as an appendix document. Also identify any other State of Illinois or
federal funds currently received, or applied for, by your organization.
VII. Project Summary (1 page maximum)
Cover key aspects of the program plan, goal, and objectives.
VIII. Program Plan
Program plan must clearly describe how the proposed project will be carried out;
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describe in detail specific activities and strategies planned to achieve each
objective; for each activity describe how it is to be done, when it is to be done,
where it will be done, who will do it, and for whom it is to be done; describe any
project-specific products to be developed (e.g., resource directory, brochures, data
bases, minority health status report, public service announcements, videos);
provide a realistic time line chart which lists each objective, the activities under
each objective, the specific month(s) each activity will be implemented and the
individual(s) responsible for the listed activities by project title/position.
IX . Program Goals
Identify how the proposed project relates to the Illinois Department of Public
Health Center for Minority Health Services HIV/AIDS Communities of Color
Initiative.
X. Program Budget
Use the forms provided to prepare a budget with sufficient resources to implement
the project. If necessary, the forms may reproduced. The instructions for
completion of the forms can be found after each budget page. A list of allowable
costs is also included.
XI. Budget Justification
Use the form provided to submit additional justification for specific line items
listed in the program budget. For example, all personal services, contracts and
sub-grants must be justified in this section. Justification should clearly indicate
why items being requested are essential to the achievement of the project
objectives.
XII. Letters of Support
A letter of support from the regional HIV prevention lead agency.
XIII. Appendices
Documentation of minority-based organization status, letters of support, relevant
supporting documents, resumes of project coordinator and key staff, and a list of
any State of Illinois or federal funds currently received, or applied for, by your
organization.
Please note: Applications not containing the required number of copies and
all of the above-required information will not be reviewed. No exceptions.
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Review Criteria for Applications
All eligible applications will be competitively evaluated by the Grant Evaluation Committee
using the following 100 point scale.
• Organizational capacity (20 points)
Ability to manage the project as determined by qualifications and
appropriateness of proposed staff or requirements for “to be hired” staff and
consultants; proposed staff level of effort; previous program experience of the
organization; and the organizational structure and proposed project
organizational structure.
• Statement of need and project rationale (20 points)
Demonstrates knowledge of the stated problem, access to the target
population/community and acceptance within the population/community to be
served; demonstrates successful outcome(s) of past efforts and activities with
the target population.
• Soundness of proposed plan and strategy (40 points)
Appropriateness of proposed approach and specific activities for each
objective; logic and sequencing of the planned approaches in relation to the
objectives and program evaluation; soundness of any proposed partnerships
(e.g., coalitions), if applicable; and likelihood of successful implementation of
the project.
• Proposed budget, narrative, and potential for matching funds (20 points)
Demonstrates sufficient and prudent allocation of resources to successfully
implement the project.
• Bonus-Letter of support for the project from local collaborators (5
points)
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Evaluation
The Illinois Department of Public Health Center for Minority Health Services requires that
all grantees collaborate with the Center for Minority Health Services Evaluation team to
document data for formative, process and outcome evaluations for the HIV programs
developed by the grantee. Additionally submission of monthly, mid-year, and final program
reports is required.
Format Requirements
Applications must be typed using 12-point or larger font, single-spaced, and one-sided.
Margins may not be less than one inch on all sides.
Application Deadlines
August 8, 2005 Letter of Intent Due
August 19, 2005 Application Due
August 24, 2005 Ineligible Applicants Notified
August 26, 2005 Awardees Notified Via Phone
September 1, 2005 Funding Begins
January 30, 2006 Mid-Year Program Report Due
June 30, 2006 End of Project Funding Period
August 10, 2006 Final Reimbursement Requests Due
Payment Methodology
Funds awarded to successful applicants will be provided on a reimbursement basis. The
grantee will document actual expenditures incurred for conducting program activities by
submitting an Illinois Department of Public Health Reimbursement Certification Form with
appropriate documentation. After review and approval of program expenditures, a voucher
will be prepared and processed through the Office of the State Comptroller for payment.
Reimbursement requests must be submitted monthly. The final reimbursement request
must be received by August 10, 2006.
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Submission of Applications
Applications may be mailed or hand-delivered to:
Doris Turner, Chief
Center for Minority Health Services
Illinois Department of Public Health
535 West Jefferson Street, 5th Floor
Springfield, Illinois 62761-0001
Applications must be received no later than 5:00 p.m. (CST) on Friday, August 19, 2005.
No applications will be accepted after that time.
It shall not be sufficient to show that the application was mailed, or hand-delivery was
commenced, before the scheduled closing time for receipt of applications.
Faxed or electronic submissions will not be eligible for review.
For questions related to the content of the grant application, please contact:
Doris Turner, Chief
Center for Minority Health Services
Illinois Department of Public Health
535 West Jefferson Street, 5th floor
Springfield, IL 62761
Phone: 217-785-4311
TTY: 800-547-0466
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Illinois Department of Public Health – Center for Minority Health Services
Fiscal Year 2006 Illinois HIV/AIDS Communities of Color Grant Program
HIV Prevention, Education, and Care Program
Grant Application Cover Page
LEAVE BLANK FOR IDPH USE ONLY
Number Date Received
1. TITLE OF PROJECT (please type or print legibly)
2. Organization Tax Identification Number:
3. Total Amount of Funding Requested $
4. Fiscal Contact:
Name (Last, First, Middle)
Title
Organization
Address
Phone: Fax: E-Mail
Fiscal Officer Assurance: I agree to accept responsibility for the fiscal conduct of this project and t
provide required financial reports if a grant is awarded as a result of this application.
Fiscal Officer (signature) Date
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ILLINOIS DEPARTMENT OF PUBLIC HEALTH - CENTER FOR MINORITY HEALTH SERVICES
535 WEST JEFFERSON STREET, 5TH FLOOR - SPRINGFIELD, ILLINOIS 62761-0001
APPLICATION FOR HIV/AIDS COMMUNITIES OF COLOR INITIATIVE
HIV PREVENTION, EDUCATION, AND CARE PROGRAM
GRANT
IMPORTANT NOTICE: This state agency is requesting disclosure of information that is necessary to
accomplish the statutory purpose outlined under 30 ILCS 105/1 et. seq. Failure to provide this information
may prevent this application from being processed.
APPLICANT ORGANIZATION:
PROJECT CONTACT:
ADDRESS:
TELEPHONE: FAX: E-MAIL:
PROJECT TITLE:
AMOUNT REQUESTED: $
PROJECT PROGRAM: HIV Prevention, Education, and Care Program
TYPE OF ORGANIZATION (must include documentation in appendix)
Governmental Entity Not-for-Profit Corporation Corporation
Medical/Health Care Provider Corp. Tax Exempt Organization
Other (please describe)
LEGISLATIVE DISTRICT State Senate: State Representative:
Congressional:
APPLICATION CERTIFICATION
To the best of my knowledge, the data and statements in this application are true and correct.
The applicant agrees to comply with all State/Federal statutes and Rules/Regulations
applicable to the program. My signature indicates that I have the authority to enter into
contracts on behalf of the applying organization.
Typed name of authorized official Signature
Title Date
Page 12
Applicant Contact Information:
Project Title:
Organization:
Project Contact:
Name:
Title:
Address:
Telephone:
FAX:
Email:
Fiscal Contact:
Name:
Title:
Address:
Telephone:
FAX:
Email:
Authorizing Agent:
Name:
Title:
Address:
Telephone:
FAX:
Email:
Page 13
Collaborator List
Project Title:
Organization:
Contact:
Title:
Address:
Telephone:
FAX:
E-mail:
Project Role:
Organization:
Contact:
Title:
Address:
Telephone:
FAX:
E-mail:
Project Role:
(Make copies of form if necessary)
Page 14
ALLOWABLE COSTS FOR REIMBURSEMENT
Illinois Department of Public Health Center for Minority Health Services
GRANT AGREEMENT
To be reimbursed under Illinois Department of Public Health Center for Minority Health Services
Grant Agreement, expenditures must meet the following criteria:
Be necessary and reasonable for proper and efficient administration of the program and not be a
general expense required to carry out the overall responsibilities of the agency.
Be authorized, or not prohibited under federal, state or local laws or regulations.
Must conform to any limitations or exclusions set forth in the applicable rules, program
description, or grant agreement.
Must be accorded consistent treatment through application of generally accepted accounting
principles appropriate to the circumstances.
Must not be allocable to, or included as, a cost of any state or federally financed program in
either the current or a prior period.
Be net of all applicable credits.
Be specifically identified with the provision of a direct service or program activity.
Be an actual expenditure of funds in support of program activities, documented by check number
and/or internal ledger transfer of funds.
Examples of allowable costs include but not limited to the following:
Personal Services:
Gross salary paid to agency employees directly involved in the provision of program services;
Employer’s portion of fringe benefits actually paid on behalf of direct services employees;
examples include FICA (social security), life/health insurance, workers compensation insurance,
unemployment insurance and pension/retirement benefits.
Contractual Services:
Conference registration fees
Contractual employees (requires prior program approval)
Repair and maintenance of furniture and equipment
Postage, postal services, UPS or other carrier costs
Software for support of program objectives
Subscriptions
Training and education costs
Payments (or pass-through) to subcontractors or sub grantees are to be shown in the Contractual
Services section - all subcontracts or sub grants require an attached detail line item budget
supporting this contractual amount.
Allocation of the applicable portion of the following costs are allowable only if approved by the
program and the allocation methodology is approved as part of the application process.
Rent or lease space or facilities
Utility costs
Insurance
Copy machine rental or lease
Costs of improvements to real property
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Travel:
Mileage (at state rate unless specifically noted otherwise)
Airline or rail transportation expenses
Lodging
Per diem and meal costs
Operation costs of agency owned vehicles
Commodities (Supplies):
Office supplies
Medical supplies
Educational and instructional materials and supplies, including booklets and reprinted pamphlets
Household, laundry, and cleaning supplies
Parts for furniture and office equipment
Equipment items costing less that $100.00 each
Printing (included in Supplies):
Letterpress, offset printing, binding, lithographing services
Photocopy paper, other paper supplies
Envelopes, letterhead, etc.
Equipment (requires prior written approval):
Items costing over $100.00 each with useful life of more than one year
Equipment costs shall include all freight and installation charges
Office equipment and furniture
Allowable medical equipment
Reference and training materials and exhibits
Books and films
Telecommunications (included in Contractual Services):
Telephone services
Answering services
Installation, repair, parts and maintenance of telephones and other communication equipment
Unallowable costs include, but are not limited to:
Indirect cost plan allocations
Bad debts
Contingencies or provisions for unforeseen events
Contributions and donations
Entertainment, alcoholic beverages, and gratuities
Fines and Penalties
Interest and financial costs
Legislative and lobbying expenses
Real property payments and purchases
Page 16
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM
BUDGET SECTION, Summary
Applicant Agency: Date:
Program: FEIN:
BUDGET SUMMARY
Sources of Funds IDPH Components (specify)
Total for the Applicant and Requested
LINE ITEM (Category) Program Other from IDPH
Personal Services
Contractual Services
Supplies
Travel
Equipment
Patient Care 0
TOTAL, Direct Costs 0
SOURCES OF FUNDS - Applicant and Other Sources Required Match Other Support Total
TOTAL, Applicant and Other Sources
Budget Section, Page 1
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM
BUDGET SECTION, Personal Services
Applicant: Date:
Program: FEIN:
Number of Percent of Total for Sources of Funds IDPH Components (specify)
PERSONAL SERVICES (Position title and Name of Monthly Months time on the Applicant Requested
Incumbant) Salary Budgeted Program Program and Other from IDPH
PERSONAL SERVICES, Subtotal 0 0 0
FRINGE BENEFITS 0 0 0
PERSONAL SERVICES AND FRINGE TOTAL 0 0 0
Budget Section, Page 2
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM
BUDGET SECTION, Contractual Services
Applicant: Date:
Program: FEIN:
Sources of Funds IDPH Components (specify)
Total for the Applicant and Requested
CONTRACTUAL SERVICES (Itemize) Program Other from IDPH
Telephone
Internet
Postage
Occupancy
Utilities
Evaluation
TOTAL, Contractual Services
Budget Section, Page 3
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM
BUDGET SECTION, Supplies and Travel
Applicant: Date:
Program: FEIN:
SUPPLIES (Itemize)
Sources of Funds IDPH Components (specify)
Total for the Applicant and Requested
Program Other from IDPH
TOTAL, Supplies 0 0 0
TRAVEL (Itemize)
Sources of Funds IDPH Components (specify)
Total for the Applicant and Requested
Program Other from IDPH
TOTAL, Travel 0 0 0
Budget Section, Page 4
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM
BUDGET SECTION, Equipment and Patient Care
Applicant: Date:
Program: FEIN:
EQUIPMENT (Itemize)
Sources of Funds IDPH Components (specify)
Total for the Applicant and Requested
Program Other from IDPH
TOTAL, Equipment 0 0 0
PATIENT CARE (Itemize)
Sources of Funds IDPH Components (specify)
Total for the Applicant and Requested
Program Other from IDPH
TOTAL, Patient Care
Budget Section, Page 5
BUDGET JUSTIFICATION
Project Title
PERSONAL SERVICES
CONTRACTUAL SERVICES
SUPPLIES
TRAVEL
EQUIPMENT
PATIENT CARE
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM
Fringe Benefit Worksheet
Applicant: Date:
Program: FEIN:
Fringe Benefits -
FICA (Sociat Security)
Pension/Retirement
Group Health Insurance
Group Life Insurance
Unemployment Insurance
Workmen's Compensation
Other:
TOTAL, Fringe Benefits Rate
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