Health Care and Senior Facilities Request for Proposals Port of Long Beach Mitigation Grant Program

Transcription

1 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, 2013 Health Care and Senior Facilities Request for Proposals Port of Long Beach Mitigation Grant Program Application Due Date: 4 p.m. April 30, 2013 Release Date: March 19, 2013

2 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, 2013 Workshops The Port will host two workshops to inform applicants about the grant program, application process, and application requirements. A question and answer session will follow the workshop presentation. Potential applicants are highly encouraged to attend one of these workshops. Workshop 1 Date: Tuesday, March 26 Time: 6-7:30 pm Location: Miller Family Health Education Center 3820 Cherry Avenue Long Beach, CA Workshop 2 Date: Wednesday, March 27 Time: 2-3:30 pm Location: Mark Twain Library 1401 E. Anaheim Street Long Beach, CA ii

3 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, 2013 Table of Contents Page 1 DESCRIPTION OF FUNDING OPPORTUNITY ELIGIBILITY INFORMATION IMPACT ZONES ELIGIBLE APPLICANTS ELIGIBLE PROJECTS PROJECT TYPES, PERFORMANCE CRITERIA AND DEMONSTRATION REQUIREMENTS HEALTH CARE PROJECTS ADDITIONAL PROJECT OPTIONS ALLOWABLE EXPENSES EVALUATION CRITERIA AND PROPOSAL SCORING APPLICATION CONTENT AND FORMAT APPLICATION PROCESS ONLINE APPLICATION PROPOSAL NARRATIVE CONTENT PROPOSAL NARRATIVE FORMAT DISBURSEMENT OF FUNDING DISBURSEMENT OF FUNDING CONTRACTING MATCHING FUNDS AND PARTNERSHIPS MONITORING AND RECORDKEEPING REQUIREMENTS APPLICATION SUBMITTAL ASSISTANCE AND CONTACT INFORMATION List of Tables Table 1: Health Care Projects - Project Ranking... 6 List of Figures Figure 1. Geographic Preference Zones... 2 Attachments Attachment A Health Care Programs Application (Example Only) Attachment B Summary of Eligibility and Application Content Requirements Attachment C - Pro-Forma Contract iii

4 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, Description of Funding Opportunity This Request for Proposals (RFP) solicits applications for the Health Care and Senior Facilities Mitigation Grant Program (Grant Program). The Grant Program is authorized under the Health Care and Senior Facilities Mitigation Grant Program Guidelines (Guidelines) amended by the Board of Harbor Commissioners on March 18, The Guidelines present policies and Grant Program goals, define eligibility criteria for applicants and projects, and discuss funds disbursement. The Guidelines are available in hard-copy from the Port of Long Beach and are posted on the Port of Long Beach website: The goal of this Grant Program is: To lessen the impact of cumulative air pollution from Port development projects by supporting health programs and facilities that serve children, the elderly, pregnant women, and people with respiratory/cardiopulmonary illnesses and impairments. Health care and senior organizations and facilities may attempt to meet this goal through: Direct indoor pollution reduction to lessen human health impacts associated with pollutionrelated respiratory/ cardiopulmonary illnesses, and other related pollutant effects; Screening and diagnostic tests to identify human health issues; Outreach to sensitive populations; and Educational outreach programs that teach sensitive populations how to manage their symptoms. In this round of funding, only one project category will be eligible for awards: Health Care Projects. Health Care Projects are projects that identify, detect, or diagnose pollution-related respiratory and cardiopulmonary problems. Health Care Projects also include outreach and education programs to identify and reduce respiratory illness triggers and to inform sensitive populations on how to manage their symptoms. 2 Eligibility Information 2.1 Impact Zones Three zones of impact were established for purposes of ranking each applicant based on the distance of each facility or program to the Port or the Port s transportation routes. Facilities or programs serving sensitive populations within 1 mile of the Port or these transportation routes are in Zone 1, facilities/programs within 2 miles are in Zone 2, and facilities/programs within 3 miles are in Zone 3, as presented in Figure 1. Facilities and programs serving sensitive populations in the areas located northeast of the Port and Port s transportation routes will be designated Zones 1a, 2a, and 3a and will be given priority over Zones 1b, 2b, and 3b. 1

5 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, 2013 Figure 1. Geographic Preference Zones This is a small-scale map provided for demonstrational purposes only. A large scale map with zoom functions is available at Eligible Applicants All applicants must serve children, the elderly, pregnant women, and/or people with pollution-related respiratory/ cardiopulmonary illness or impairments in the impact zones. In addition, the applicant 2

6 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, 2013 must be a facility properly licensed under the California Health and Safety Code, 1 a government agency or a 501(c) 3 nonprofit organization that provides education, outreach and/or health care to sensitive populations. 2.3 Eligible Projects Grant funds must be used for projects directly benefitting populations in impact zones 1, 2, and/or 3. The Port has identified Health Care Projects that are designed to identify, detect or diagnose respiratory and cardiopulmonary problems. These projects include outreach and education programs to identify and reduce respiratory and cardiopulmonary illness triggers and to educate sensitive populations on how to manage symptoms. 3 Project Types, Performance Criteria and Demonstration Requirements Grant-funded projects must incorporate best practices, verifiable technology and best available evidence to decrease respiratory/cardiopulmonary illness or impairments. 3.1 Health Care Projects Health Care Projects are intended to identify, diagnose, or reduce the impacts of respiratory and cardiopulmonary problems and can include programs that identify and reduce asthma triggers and educate sensitive populations on how to manage their symptoms. Health Care Projects must meet at least one of the following objectives: Reduce the exposure of children, the elderly, pregnant women, and/or those with respiratory or cardiopulmonary illnesses to port-related air pollution; Ameliorate health impacts of pollution-related respiratory or cardiopulmonary illnesses; and Educate, train or monitor sensitive populations. The Port has identified program components demonstrated to have a positive impact on sensitive populations with pollution-related respiratory/ cardiopulmonary illness or impairments. Eligible Health Care Projects may contain any or all of the following components: Screening and diagnosis (including purchase of diagnostic equipment); Education; and Outreach and coordination of care. Screening and Diagnosis Applicants may request funding for programs that provide early detection of respiratory/ cardiopulmonary ailments using specialized diagnostic equipment and/or screening tests. These tests may take place in a facility, through a mobile outreach mechanism or during in-home visits. Applicants may request funding for the purchase of diagnostic equipment, such as spirometers or skin test kits, 1 Under the following sections of the California Health and Safety Code: 1200, 1250, 1500, 1569, 1570, 1725, 1745, 1760, 1765, and The text of these sections can be found here: 3

7 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, 2013 which can be used to test sensitive pollution lung functions and/or other asthma-related or DPMaffected ailment markers. Applicants will need to provide the following: A detailed description of equipment to be purchased; How the equipment and its use will help identify air quality related health impacts; The cost of the device; and How the applicant will use the equipment (e.g. outreach program, patient visits, etc.). Applicants will also need to demonstrate that the equipment will be part of an education or outreach program or include at least one of the following elements: Screening for respiratory and other cardiopulmonary problems; Specialized medical diagnosis; Individualized family health education sessions; and Training and workshops for health care providers. Education Applicants may request funding to establish programs that educate people on what they can do to minimize exposure to air pollutants. Programs can include: An in-home or other community-based setting to identify items that contribute to an unhealthy breathing environment and to recommend changes; and Periodic educational seminars to discuss ways to minimize exposure to indoor and outdoor air pollution. Applicants will need to provide a detailed description of the type of education program they plan to pursue, the target audience, and how the program will be implemented. Outreach and Coordination of Care Applicants may request funding to establish outreach programs that help identify and establish contact with people susceptible to pollution-related respiratory/cardiopulmonary ailments or that provide early intervention, continued education, evidence-based interventions, or frequent follow-up to prevent poor health outcomes. Proposed programs could also be used to ensure that people are getting consistent, scientifically based information. Outreach programs may provide, but would not be limited to, the following services: On-site pulmonary function and allergy skin testing or other diagnostic tests at facilities serving sensitive populations within zones 1, 2 and/or 3; Implementation of an electronic registry to monitor patient symptoms and progress; One-on-one counseling and health care; Coordination of care across all elements of the complex health care system; Expanded access to service and staff (increased hours or after-hours availability); A mobile outreach program or mobile clinic that visits facilities serving sensitive populations within zones 1, 2 and/or 3 ; and 4

8 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, 2013 Trained community health worker visits to families in their homes to discuss signs, symptoms, triggers including a home environmental assessment, locations for testing and other asthma related services, medications, equipment use, and a course of action if an asthma attack occurs. Applicants would need to include in their application a detailed description of the goals of the outreach program, who will benefit, and how the program will be implemented. 3.2 Additional Project Options Applicants may apply for projects not specifically listed in this RFP if the applicant believes a particular project would help mitigate air pollution impacts and is consistent with the goal of this Grant Program. Such applications must be consistent with the Guidelines and RFP. Proposals for additional projects must describe the project type, capital and maintenance costs, if applicable, expected air pollution reductions, and/or exposure reductions, and sensitive group benefitted. In addition, the applicant must justify the efficacy of the proposed technology or program by referencing relevant technical studies or regulatory agency approval. Applicants are strongly encouraged to contact the Port prior to applying for projects in this category. 4 Allowable Expenses Applicants should be aware that there is no guarantee of future years funding under the Grant Program. Thus, the Grant Program is not intended to fund ongoing operational expenses. Rather, applicants should propose one-time expenditures that launch new programs or enhance or expand existing programs by allowing them to serve more clients, improve efficiency, launch new strategies or substantially improve existing strategies. Examples of costs eligible for funding under the Grant Program are listed below. The applicant will need to demonstrate a need for funding beyond the following list of allowable expenses. Equipment, supplies and installation costs; Test kits; Diagnostic equipment; Staff training related to the project goals; Computer software; Staff costs for program expansions/enhancements; Translation services for materials and/or public meetings; Printed materials and education videos; Professional program evaluation services; Mileage reimbursement and/or travel costs directly related to client outreach (mileage at the current IRS reimbursement rate of $.555 per mile); Other tangible and direct costs related directly to the project; and Administrative overhead capped at 15% of total funding requested and includes but is not limited to the following: - Fuel, electricity and utilities costs; - Rent and facility costs; - Computer/tech support; - General office supplies; 5

9 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, Taxes, insurance, and licensing fees; and - Indirect labor costs (accounting, human resources, etc.). Note: If you request funding for 15% administrative overhead, you will not separately be awarded funding for the administrative components, such as rent, tech support, or indirect labor costs. 5 Evaluation Criteria and Proposal Scoring Funds will be awarded to the highest ranked applications based on the point system presented in Table 1 (Health Care Projects). Facilities and organizations serving populations in Zones 1b, 2b, and 3b, although eligible to apply for funding, will be allocated half the application points available to comparable projects proposed in Zones 1a, 2a, and 3a. If the project will benefit more than one zone, the applicant should provide a breakdown of the estimated number of beneficiaries in each zone. In addition, since one of the chief objectives of the Grant Program is to maximize the number of beneficiaries for dollars spent, points will be awarded based on the number of people benefitted by the proposed project per $10,000 of Port-awarded dollars as well as the methodology used to achieve program goals. Table 1: Health Care Projects - Project Ranking Allocation Points Project Beneficiaries Project beneficiaries are elderly, children, pregnant women, or people with respiratory/cardiac pulmonary illnesses Y/N Geographic Preference Zone [1] 0-15 Number of People Benefited per $10,000 [2] 0-13 Strength of Application Criteria Project description 0-15 Methodology 0-20 Applicant experience 0-20 Performance measures 0-5 Resources, capability and response 0-4 Budget justification 0-3 Strength of supporting documentation [3] 0-5 Total 100 Notes: [1] Zone 1(15 points), Zone 2 (10 points), Zone 3 (3 points). Allocation of points for geographic preference zones are reduced compared to Facility Improvement projects because Health Care Program projects can serve people from several zones. Programs serving populations in multiple zones will be awarded an average of the allowable points. [2] Beneficiaries are defined as the number of people who are directly served by the health care program, not the catchment population or number of potential clients; for example, you would use the number of patients directly seen by a mobile clinic, not the number of children at the school, visited by the mobile clinic. Number of people benefitted per $10,000 of Port funds: >500 people (13 points), people (9 points), people (5 points), <100 people (2 points). [3] Strength of supporting information includes the organization s most recent financial audit, most recent annual report, resumes of key personnel, and/or other documents as determined in the RFP. 6

10 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, Application Content and Format 6.1 Application Process There are two parts to the application process: (1) An online application requesting basic contact and project information, and (2) a proposal narrative, which must be uploaded during the online application process. Applicants may be asked to upload additional documents as well. Applicants applying for multiple projects must submit separate applications for each project. 6.2 Online Application All applications must be filled out electronically by following the application link at The application requests the following information: Contact information for the primary contact and the person authorized to execute contracts; Location of facility (address and by impact zone); Project type; Budget costs; Funding request; Manufacturer certifications, if applicable; Proposal narrative (upload); and Supporting documentation (upload). The online application contains further instructions. Printed copies of the applications are included in Attachment A for illustrative purposes only. Hard copy applications will not be accepted. 6.3 Proposal Narrative Content This section summarizes the contents of the proposal narrative for eligible applicants and projects. The proposal must contain the following elements: Project description; Methodology; Applicant experience; Performance measures; Resource, capability and response; Budget justification; and Supporting documentation. Project Description The project description should provide sufficient information to evaluate the project. The description should be succinct, well organized, informative, and should avoid redundancies. The project description should include: Description of how the proposed project will meet the goal specified in Section 1; Description of the need for and significance of the project in the community; Description of how sensitive populations would benefit; and Description of program components such as testing, diagnostic, education, and outreach. 7

11 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, 2013 Methodology The applicant should provide a succinct narrative of the methodology that will be used to meet the goals and objectives for the program and should include a description of strategies and methods to be used and their appropriateness for accomplishing the specific goals of the proposed project, program requirements, and expectations for this grant program. Applicant Experience The applicant should provide a narrative of the facility s or organization s background, ownership, organization, and experience. The narrative should include: Number of years facility, program or organization has been in business; Previous similar projects and their efficacy; Strength of key accomplishments on past projects; Financial sustainability (financial audit, profit and loss statement, as described under Required Documentation below); and Qualifications and experience of project personnel. Performance Measures The applicant should provide a description of performance measures for each proposed project that includes specific techniques or tracking metrics that will be used to assess performance and efficacy of the proposed project. For projects requiring ongoing maintenance or operations, records must be kept for five years. 2 Performance measures should include a succinct description of metrics used to assess success, efficacy, and adherence to program goals and a description of how the organization will track these metrics. The following are intended as examples and can include, but not be limited to: Increase in number of people reporting improvement of asthma symptoms; Decreased hospitalizations; Decreased number of missed school days; and Copies of seminar sheets, participation roll-call sheets, training forms. Resources and Capabilities The applicant should: Discuss the adequacy of facilities and resources relevant to the goals of the project; Describe sufficiency of staffing for the magnitude of the project; Describe appropriateness of staff for reaching the target population; Discuss the organization s ability to sustain the program beyond the life of the grant; and Demonstrate collaborative arrangements with other organizations if applicable. Budget Justification The applicant should provide a succinct narrative and budget table to explain the requested grant amount. The applicant should also account for prevailing wage laws, if applicable. See Section 7.2 for 2 The Grant Program will not provide funding for operations and maintenance. However, in order to establish the efficacy of the project, the Port reserves the right to review records for a period of up to 5 years. 8

12 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, 2013 more information on prevailing wage. The applicant should include a budget justification that specifically describes how each item will support the achievement of proposed objectives and should include the following: A description of each cost element; and An explanation of how each cost element contributes to meeting the project s objectives/goals. If requesting funds for staffing, the applicant must provide staff titles, annual salaries, and the number of positions for which funding is requested. The applicant may request funds for administrative overhead not to exceed 15% of the total grant request. Administrative overhead includes facility rent, utilities, fuel, general office supplies, and general administrative support. These items should not be included in your funding request in addition to the 15% administrative overhead allowance. The budget justification must be concise and is not to be used to expand the project narrative. Supporting Documentation Supporting materials, such as resumes, letters of support, audits, and budget justifications must be submitted as attachments. These attachments can be uploaded during the online application process as pdf, Word, or Excel documents. Required documentation: Cost estimates (if applicable); A copy of the organization s financial audit conducted within the last two years; A copy of the organization s Profit and Loss statement; and Biographies of key personnel. Optional documentation: Additional budget details; Additional methodology details; and Letters of support (limited to 5 letters). 6.4 Proposal Narrative Format The proposal narrative the project description, methodology, applicant experience, performance measures, resource, capability and response, and budget justification cannot exceed five singlespaced, one-sided typed 8.5" x 11" pages with at least 11 point standard typeface font and 1 margins all around. Proposals in excess of the 5-page limit will not be considered. There is no page limit for supporting documentation, though the applicant is encouraged to provide succinct supporting information. Attachment B contains a summary of the eligibility and application content requirements described in this section. 7 Disbursement of Funding 7.1 Disbursement of Funding There is $1 million allocated for funding for this round of the Health Care Program. Grant funds will be awarded by the Board of Harbor Commissioners based on recommendations from Port Staff following application review by the Mitigation Grants Advisory Committee. 9

13 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, 2013 An organization may apply for multiple projects. Each project must be submitted as a separate proposal and application. A single organization may not receive more than $250,000 from this round of Health Care and Senior Facilities grant funding. The Port reserves the right to conduct site visits prior to funding. 7.2 Contracting All grant awardees will be required to execute a contract with the Port that lays out the terms and conditions of the grant award. A pro forma contract is provided in Attachment C. This contract must be executed within one year of award. Awardees unable or unwilling to execute a contract within that timeframe forfeit their rights to the funds. The funds may be reallocated to other projects on the wait list or reserved for future rounds of Health Care and Senior Facilities Grant Program funding. The contract requires grant awardees to commence their projects no later than six months following execution of the contract. In addition, the contract contains the Port s standard indemnification clause and requires satisfactory evidence of insurance for certain projects and compliance with California Labor Code Section 1770 regarding the payment of prevailing wages for all public works as defined in California Labor Code Section Matching Funds and Partnerships Matching Funds Projects that have or will receive funding from other sources are encouraged. Although such projects will not be awarded extra points, it is anticipated that such projects will result in a greater number of beneficiaries per Port-awarded dollars and as such would rank higher. Applicants should provide project information, received grants, and note if any of them are being conducted under grant funding from other agencies. Partnerships Partnerships and collaborations, in which organizations work together to maximize the value of the project and benefits to the public, are encouraged. In a partnership situation, the Port will contract with one organization designated as a lead agency. Lead agencies will be responsible for executing subcontracts with other organizations, ensuring fulfillment of the grant s objectives, managing grant funds for the entire project, and meeting reporting/audit requirements. Subcontractors or partners must meet eligibility, program, and other requirements as specified in the Grant Program Guidelines or in the lead agency s contract. 8 Monitoring and Recordkeeping Requirements Grant fund awardees will be required to submit documentation that may include, but is not limited to, the following: Receipts or invoices illustrating the capital and installation cost for the project; Photos of the unit or site before and after project implementation; Copies of seminar sheets, participation roll-call sheets, training forms, etc.; For projects requiring ongoing maintenance or operations, 5 years worth of records; and Performance metrics. 10

14 Health Care and Senior Facilities RFP Port of Long Beach Mitigation Grant Program March 19, 2013 Performance measures, monitoring, and recordkeeping requirements will be individual to each applicant and will be stipulated in the contract and/or contract exhibits. Additional documentation may be required per the grantee s specific contract. 9 Application Submittal All applications must be submitted electronically at Due Date: 4 p.m. April 30, 2013 Late Applications: Late applications will not be accepted under any circumstances. 10 Assistance and Contact Information Port Staff are available to answer questions during the application acceptance period individually and during scheduled community workshops. In order to expedite assistance, inquiries can be directed to: Lora Granovsky Program Coordinator Grants@polb.com GRANT Guidelines, program announcements, applications, clarifications and frequently asked questions can be obtained by accessing the Port web site at 11

15 Attachment A Health Care Program Application (Example Only)

16 Mitigation Grants Program - Health Care and Senior Facilities March 2013 Health Care Projects Welcome to the online application for the Health Care and Senior Facilities Mitigation Grant Program. You have selected the application for a Health Care Project. These projects include education, outreach, diagnostic, and monitoring programs to reduce the health-related impacts of air pollution. Before You Begin: 1. Read the Request for Proposals available at 2. Verify your eligibility and project specifications. 3. Create an account on the next page. This account will allow you to save your answers and log in and out of the form. Once you hit the submit button on the final page, you will not be able to make changes to your application. Please note, if you are applying for multiple projects, you must create a new username and account for each application submitted. 4. To return to a previous page, use the previous button. Do not use your Web browser s back button Please remember, the application deadline is April 30 at 4 p.m. * Indicates Response Required Next >> Problems or questions:

17 Mitigation Grants Program - Health Care and Senior Facilities March 2013 Progress: 13% Complete Form Login Account (optional) New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form. * Indicates Response Required << Previous Next >> Problems or questions:

18 Mitigation Grants Program - Health Care and Senior Facilities March 2013 Progress: 25% Complete Section 1: Applicant Information * Organization Name * Mailing Address * City, State * Zip Primary Contact Information * First Name * Last Name * Title * Phone Number * Address * Indicates Response Required << Previous Next >> Problems or questions:

19 Mitigation Grants Program - Health Care and Senior Facilities March 2013 Progress: 38% Complete Section 2: Project Information * Project Zone 1a 2a 3a 1b 2b 3b * Organization Type: Government Agency 501(c)3 Nonprofit Facility licensed under the California Health and Safety Code If you selected "Facility licensed under the California Health and Safety Code," please provide your 9-digit facility number issued by the State of California. * Indicate the estimated number of people that will benefit directly from your project by zone. "Beneficiaries" are the people who come in direct contact with the service providers, not the catchment population of potential clients. Enter 0 if there are no beneficiaries in that zone. 1a 2a 3a 1b 2b 3b Per Year Over Life of Project * Are the beneficiaries elderly, children, pregnant women, or people suffering from respiratory/cardiovascular impairments? Yes No * Explain how you derived the number of beneficiaries. * Indicates Response Required

20 Mitigation Grants Program - Health Care and Senior Facilities March 2013 Progress: 50% Complete Section 3: Project Costs * Briefly summarize your project costs. You may provide additional details in the "Budget Justification" portion of your project narrative. If requesting funds for personnel, you must provide staff titles, annual salaries, and the number of positions for which funding is requested in your project narrative. Please be sure your totals are correct. Enter 0 if there are no costs relating to that category. Construction Costs Total Costs Grant Funds Requested Equipment Costs Personnel Costs Administrative Costs (not to exceed 15% of total cost) TOTAL * Total amount of grant funding requested: If your project has matching funds (direct or in-kind), please list the amount and source of funding. * Indicates Response Required << Previous Next >> Problems or questions:

21 Mitigation Grants Program - Health Care and Senior Facilities March 2013 Progress: 63% Complete Section 4: Proposal Narrative Your proposal may not exceed five single-spaced pages on 8.5" x 11" paper with at least 1" margins all around. For additional formatting requirements, see the RFP. Upload documents in Word, PDF, or Excel formats. The proposal must contain the following elements: - Project description - Methodology - Applicant experience - Performance measures - Resource, capability, and response - Budget justification - Supporting documentation If you have problems uploading attachments, please call GRANT. * Please submit your proposal narrative here Browse... Upload Delete Upload Supporting Documents * Organization's most recent financial audit Browse... Upload Delete * Profit and Loss Statement Upload Delete Browse... Other Supporting Documents Upload Delete Browse... * Indicates Response Required << Previous Next >> Problems or questions:

22 Mitigation Grants Program - Health Care and Senior Facilities March 2013 Progress: 75% Complete Section 5: Application Review * I certify that this application has been reviewed and approved by an officer of the eligible organization with authority to enter into contracts. Yes No * Name: * Title: For a copy of your submitted application please list your and up to two additional s in the spaces provided below. Address: Address: Address: * Indicates Response Required << Previous Next >> Problems or questions:

23 Mitigation Grants Program - Health Care and Senior Facilities March 2013 Progress: 88% Complete Section 6: Application Submittal Thank you for completing the Health Care Projects application. By selecting SUBMIT the application will be finalized and you will not be able to make further changes. * Indicates Response Required << Previous Submit Problems or questions:

24 Your application has been submitted. Your information has been received by our staff and will be reviewed shortly. Please print this page for your records. You may also print your application using the Printer Friendly Receipt button below. Printer Friendly Receipt Reference #:

25 Attachment B Summary of Eligibility and Application Content Requirements (for more details, see Section 6) Eligibility Applicants Projects Application Requirements Basic Application Proposal Narrative Project Description Methodology Applicant Experience Performance Measures Resources and Response Must serve children, the elderly, pregnant women, and/or people with respiratory or cardiopulmonary illness in the zones, and one of the following: Licensed under California Health and Safety Code sections 1200, 1250, 1500, 1569, 1570, 1725, 1745, 1760, 1765, and 1770 Government agency 501(c)3 nonprofit organization that provides education, outreach, and/or health care to sensitive populations Must provide at least one of the following elements: Screening and diagnosis Education Outreach and care coordination Must include all of the following elements: Contact information for the primary contact and the person authorized to execute contracts Location of facility (address and by impact zone) Project type Budget costs Funding request Manufacturer certifications, if applicable Must include all of the following elements: Description of how the project will meet the goal specified in Section 1 Description of the need for and significance of the project in the community Description of how sensitive populations would benefit Description of program components such as testing, diagnostic, education, and outreach Must describe strategies and methods to be used and their appropriateness for accomplishing the specific goals of the proposed project, program requirements, and expectations for this grant program. Must include all of the following elements: Number of years facility, program or organization has been in business Previous similar projects and their efficacy Strength of key accomplishments or past projects Financial sustainability (financial audit, profit and loss statement, as described under Required Documentation below) Qualifications and experience of project personnel Must describe performance measures for each proposed project, including specific techniques or tracking metrics that will be used to assess performance and efficacy of the proposed project. Must include all of the following elements:

26 Discuss the adequacy of facilities and resources relevant to the goals of the project Describe sufficiency of staffing for the magnitude of the project Describe appropriateness of staff for reaching the target population Discuss the organization s ability to sustain the program beyond the life of the grant Demonstrate collaborative arrangements with other organizations if applicable Budget Justification Supporting Documentation - REQUIRED Supporting Documentation - OPTIONAL Must include all of the following elements: A description of each cost element An explanation of how each cost element contributes to meeting the project s objectives/goals Must include all of the following elements: A copy of the organization s financial audit conducted within the last two years A copy of the organization s Profit and Loss statement Biographies of key personnel May include the following elements: Additional budget details Additional methodology details Letters of support (limited to 5 letters)

27 Attachment C Pro-Forma Contract

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