IMPORTANT - PLEASE READ CAREFULLY

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1 GEN 44.1 REV: 10/1/15 CENTRAL ILLINOIS AGENCY ON AGING, INC. Instructions for Caregiver Training & Education Services: Personal Care Application for Funds Under Title III Older Americans Act IMPORTANT - PLEASE READ CAREFULLY General Information Application Forms Copies To Be Sent Allowable Costs Social Services FY Application Checklist Addendum 16-1 The attached caregiving training and education services application forms are intended for the use of applying for funding under Titles III-E of the Older Americans Act through the Central Illinois Area Agency on Aging. Service providers should keep original blank application forms on file, and make copies as necessary for completing the application forms and submitting future revised pages as requested. Service providers are to provide the Central Illinois Agency on Aging, Inc. (CIAA) with one (1) original and one (1) copy, each with original signatures, of the application forms and required attachments by the deadline, or the service provider will not be considered for funding. Service providers should retain one (1) copy of completed application forms for their own records. Service providers should consult with the CIAA Program Management Department staff regarding allowable costs under the Older Americans Act Title III-E. Insert the name of service(s) in column headings in the same order on the budget and program pages. The checklists outline the required application pages and attachments which must be submitted to CIAA, as well as compliance to application instructions. Two (2) copies of the checklists must be submitted to CIAA. Provider Agency Emergency Contacts Service providers are required to complete this page indicating the staff persons to be contacted should an emergency situation arise. This list of contacts must be submitted to CIAA. Page 1 - Application Instructions This page must have the original signature of the authorized individual to commit the service provider organization to this application and all assurances, requirements, and agreements requested as a result of this application. Fill out all requested information. ---Applicant Agency Name and Address ---Project Name and Address ---FEIN - Federal Employer Identification Number ---Application Period ---Type of Request ---Agency Designation ---Minority Operation ---Service Area

2 Service(s) Applied For: Service providers are required to indicate the total costs and the annualized number of client and units for each service. Each service should be listed on Lines 1 through 5. Service providers must fill in the information requested in Columns A, B and C, and must calculate the projected Unit Costs (Column D) for each service. For the amount to be entered in Column E, divide the Area Agency amount requested on page six (6) of the application by the annualized number of units. Name, Signature, Title, and Date: Each of the two (2) copies submitted to Central Illinois Agency on Aging must carry original signatures of the individual authorized to commit the organization to any agreement that might result from this application. Page 2 Application Instructions Part A - Program Design & Management Please complete a separate Page Two for each service. Enter the name of the proposed service in the space provided. ALL APPLICANTS: Must address the following components in narrative form: 1. Service Description. The services and service activities to be provided. Service providers shall refer to Caregiver Services: Training and Education/ Personal Care, Attachment V; Section of the Service Providers Policy and Procedure Manual for service definitions, activities and standards. 2. Management. Describe the funded staffing and supervision pattern for all employees (paid and volunteer) involved in the service. Service providers should also include an organizational chart. Describe training topics and training frequency, along with background check frequency, including pre-service and in-service training to be provided to all employees (paid and volunteer). 3. Rationale. Provide evidence which supports that there is a local need for the proposed service and describe how the proposed service fits within CIAA area-wide and county priority areas. 4. Service Area. Indicate the geographic area to be served and provide addresses and telephone number of the central location and if applicable, branch offices. 5. Availability/Accessibility. Describe the availability/accessibility of the proposed service. The description must address the following: a. Hours and days the proposed service will be made available to clients; b. Note any agency policies which would limit services to an individual client; c. Describe whether service facilities are accessible to individuals with disabilities; and, d. Describe provisions for addressing client emergency service delivery needs in offhours, weekends, holidays, staff absences, and in disaster and/or weather-related emergencies. 2

3 3 GEN REV:. 10/1/15 REQUIRED INFORMATION FOR SPECIFIC SERVICES: In addition to the information requested above, service providers are to respond to the service-specific information requested below. Caregiver Services: Training and Education/ Personal Care: The target population shall include persons aged 60 years of age or older providing informal support. Describe the specific services to be provided. Page 3 - Application Instructions Part B is to be Completed by All Applicants. Part B - Targeting Program Performance Plan & Objectives: Please note one (1) Targeting Program Performance Plan can be completed for all proposed Title III-E services. 1. Performance Plan: Describe in detail, the major characteristics of the proposed service area, giving special emphasis to the socio-economic composition and size of the population 60 years of age and older, and the rational for the services cited in Part A above. Based on the demographic information provided and expressed need (rationale) for the service the provider is required to develop a plan with time frames to identify the steps the service provider plans to take to target service delivery to eligible individuals, targeting services to persons in greatest economic need, with special emphasis given to serving low income minority individuals. In addition, efforts should be described for obtaining participant input, and the service providers plan to implement changes (if necessary) to service delivery based on such participant input. 2. Performance Objectives: Describe briefly the action step(s) the services provider propose to conduct in order to accomplish the Targeting Performance Plan during FY2016 FY Performance Objective Target Dates: Indicate the month and year the service provider propose to complete each Performance Objective during FY2016 FY2018. REQUIRED INFORMATION FOR SPECIFIC SERVICES: In addition to the information requested above, service providers are also to include in the Targeting Performance Plan, the following service-specific information requested below. Caregiver Training and Education: Personal Care Service Providers: Service Providers are required to specify how they intend to satisfy the service needs of older individuals with greatest economic need, older individuals with greatest social need, and older individuals at risk for institutional placement, low-income minority individuals and older individuals residing in rural areas in the service area. Page 4 Application Instructions Part C Is To Be Completed By All Applicants. Part C - Publicity/Coordination Program Performance Plan & Objectives: Please note, only one (1) Publicity/Coordination Program Performance Plan is to be completed for all proposed Title III-E services. 1. Performance Plan: Describe, in narrative form, the service provider s overall efforts

4 in reaching persons in need of services. Describe the service provider s activities in conducting special publicity and outreach efforts to those in greatest economic need, with special emphasis given to low income minority individuals. In addition, describe the service provider s coordination activities with other agencies/organizations, including specific agencies who serve low income minority individuals. Based on the overall efforts provided in the Publicity/Coordination Performance Plan, develop a plan with time frames identifying the steps the applicant plans to take to reach those in need of the services(s) proposed. 2. Performance Objectives: Describe briefly the action step(s) the service provider propose to conduct in order to accomplish the proposed Performance Plan in FY2016 FY Performance Objective Target Dates: Indicate the month and year the service provider propose to complete each Performance Objective during FY2016 FY2018. REQUIRED INFORMATION FOR SPECIFIC SERVICES: In addition to the information requested above, service providers are also to include in the Publicity/Coordination Performance Plan, the following service-specific information requested below. Caregiver Training and Education/Personal Care Service Providers: Describe the number of older adults who will be served by the program and also describe coordination efforts with other local agencies, townships, and churches such as, but not limited to, Central Illinois Agency on Aging, Triad, etc. in providing these services. Page 5 - Application Instructions Part D Caregiver Training and Education Service Priority Narrative Please describe how your organization will incorporate caregiving training and education programs into Area-Agency funded service delivery system as part of the FY2016-FY2018 Older Americans Act Service Delivery System. The definition for caregiving training and education services is listed below to assist in the development of your organization s service priority. Definition: Training and education services/personal care provide family caregivers with opportunities to acquire knowledge and skills in the areas of health, nutrition, financial literacy, and in making decisions which address their caregiving roles through personalized in-home instruction and/or formally structured group presentations that are designed to address the physiological needs of care recipients. Also, service providers have the legislative mandate to advocate on behalf of older persons who reside in Illinois and to work in cooperation with other State and federal programs to provide for the needs of older disaster victims. Service providers are required to have disaster plans, so as to expedite the delivery of necessary services when a disaster occurs. Page 6 - Application Instructions Please attach your emergency/disaster plan. Part E - Program Budget Narrative Costs associated with all CIAA funded services can be listed on Page Six. If more room is needed, additional copies of Page Six can be made. Please label additional copies as 6A, 6B, etc. 4

5 GEN REV:. 10/1/15 In narrative form, describe and list in detail the specific dollar costs contained in the program budget. The service provider must be specific to the extent that all costs are included. Use additional pages to complete narrative if necessary and label additional copies of Page Six as 6A, 6B, etc. Personnel. Describe and list in dollar amounts personnel costs for each proposed service, including the costs per position (PT/FT). Also describe administrative costs, direct service costs, and volunteer/in-kind costs. (Please note: State minimum wage is $8.25 per hour (effective 7/1/10). Fringe. Describe in dollar amounts the portion of the employer's personnel costs per proposed service which represents fringe benefits. List benefits by type (Social Security, Workman's Comp,etc), and percentage rate and actual cost per benefit type. Rent. Describe and list in dollar amount costs associated with space (rent), janitor, and utilities, per proposed service. Communications. Describe and list in dollar amount costs associated with telephone, postage, etc. for each proposed service. Travel. Describe and list in dollar amount anticipated travel costs for each proposed service. NOTE: The maximum reimbursement rate for fiscal year 2016 is $0.505 cents per mile. Training & Conferences. Describe and list in dollar amount costs anticipated for tuition/ conferences, meals, lodging, and travel for each proposed service. Consultants. Describe any reasonable and necessary costs for essential services that cannot be provided by persons receiving salary support under this application for each proposed service. Describe the function of each consultant. Equipment & Supplies. List the type of equipment by quantity, specific item, and list unit cost for each proposed service. Describe office supplies, which are those supplies used by program staff to carry out the operational functions for each proposed service. Do not list any supplies under the "Other" budget category. Audit. NOTE: Audit costs are allowable only if Federal expenditures from all funding sources total $500,000 or more. Insurance. A Certificate of Liability Insurance signed by authorized agency personnel is required. Other. Describe and list in dollar amounts all other costs which are not classified in any previous categories for each proposed service. For insurance, describe automobile, professional liability/bonding, building and equipment. Program Income. Service providers receiving Area Agency funds must afford program participants the opportunity to contribute to all or part of the cost of the services received. Program Income shall only include those contributions anticipated from service recipients for each proposed service. Program Income shall be applied to direct program costs prior to calculated local match obligations. To calculate program income, multiply the number of service units projected for each service by the average anticipated contribution per unit. 5

6 Local Cash. Indicate the amount of all non-federal resources to be utilized in fulfillment of the local match requirement for each proposed service. Please describe and list in dollar amounts the specific source(s) of local cash. Sources of local cash may include but are not limited to United Ways, township and/or community support, corporate support, and other fund raising activities. In-Kind Resources. Describe and list in dollar amounts all non-federal in-kind resources to be utilized in the fulfillment of the local match requirement for each proposed service. Sources of in-kind may include but are not limited to volunteer time and donated space. Page 7 Application Instructions Part I Administrative Accountability and Budgeting 10 Personnel Detail This Budget page should reflect the total projected Personnel expenses. Names and job titles of all individuals working with the proposed project, including staff and volunteers, should be displayed, with corresponding number of regular work or volunteer hours per week. Page 8 Application Instructions Part F - Program Budget Costs associated with all CIAA funded services can be listed on Page Eight. Please enter each service in the space provided per column heading and in the same order as on page one (1). Budget Categories Column 1, Lines 1 through 13. Enter the amount per budget category per service. The amounts should match what was described in narrative form in Part E on page 6 of the Application instructions. Total Costs - Column 1, Line 14. Add the amounts listed in budget categories, Lines 1 through 13 and enter onto Line 14. Program Income - Column 1, Line 15. Enter the projected Program Income amount per service. The amount should match what was described in narrative form in Part E on page 6 of the Application instructions. Net Costs - Line 16. Calculate the NET COSTS by subtracting Program Income (Line 15) and from the Total Program Costs (Line 14) for each respective service. Enter resulting amount onto Line 16. Local Contributions (Cash) Column 2, Lines 1 through 13. Enter the amount of all non-federal cash resources to be utilized in fulfillment of the local match requirements for each proposed service. The amount entered in Column 2 should match the local cash amount described in Part E on page 6 of the Application instructions. Local Contributions (In-Kind) Column 3, Lines 1 through 13. Enter the amount of all non-federal in-kind resources to be utilized in the fulfillment of the local match requirement for each service. The amount entered on Line 16 should match the in-kind amount described in Part E on page 6 of the Application instructions. Area Agency Funds Requested - Column 5, Line 17. Enter the amount contained in the Service Provider's FY2016 Award Notification. The Area Agency Award (Line 17) should also equal the 6

7 amount calculated by subtracting Local Contribution-Cash (Column 2) and Local Contribution In- Kind (Column 3) from the Net Costs (Line 16). PLEASE NOTE: Older Americans Act and Illinois General Revenue Fund monies may be used to pay not more than 75 percent of the net costs of these activities. The local share of the total program net cost of the service or services funded by the CIAA shall be in cash and/or "in-kind" from public, local, and/or private sources. Page 9 Application Instructions Part G - Program Unit and Demographic Information Enter the name of the applicant, proposed services, and county (ies) information. Line A - Units of Service. Enter the projected number of units to be provided. Line B - Total. Enter the projected number of different persons to be served. C. Distribution Line 1 Ethnicity a. Hispanic or Latino a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. b. Not Hispanic or Latino Line 2 - Race a. White Hispanic - a person of Spanish or Portuguese culture with origins in Mexico, South or Central American, or the Caribbean Islands, regardless of race. b. White-Non Hispanic - a person having origins in any of the peoples of Europe, the Middle East, or North Africa. c. American Indian or Native Alaskan - a person having origins of any of the original peoples of North America (including Central America), and who maintains tribal affiliation or community. d. Asian a person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. e. Black or African American a person having origins in any of the black racial groups of Africa. f. Native Hawaiian or Other Pacific Islander a person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands. Line 3 - Greatest Economic Need means the need resulting from an income at or below the poverty threshold established by the Department of Health and Human Services Poverty Guidelines for All States (Except Alaska and Hawaii) and the District of Columbia. 7

8 Size of Family Unit Poverty Guidelines 1... $11, $15, $20, $24, $28, $32, $36, $40,890 For family units with more than 8 members, add $4,160 for each additional member. 75+ means older persons who are 75 years of age and above. Limited English Speaking means an older person who uses another language (besides English) as his/her principle means of communication. NOTE: Line 1 (a + b); Line 2 (a through f); Lines 5 & 6; and Lines 7 & 8; must each equal Line B total per proposed persons to be served. Enter totals for unit and demographic information for social service providers only in the "Total Column". Page 10 Application Instructions Governing Board Composition Two (2) copies of this page must be submitted to the Area Agency. Complete this page by entering the service provider s present Governing Board Composition. In addition, please indicate the Board President on the form. Page 11 Application Instructions Advisory Council Composition Two (2) copies of this page must be submitted to the Area Agency. Page 12 Application Instructions Signature Authorization Form The service provider must complete this form per instructions. The appropriate signatures must be entered on this form. Two (2) copies of this form must be submitted to the Area Agency. Page 13 Application Instructions Publicity And Equipment Purchase Agreement Service providers who are requesting to purchase equipment items in FY 2016 must complete two (2) copies of this page. Page 14 Application Instructions 8

9 Inventory List Service providers who have previously purchased equipment with CIAA Older Americans Act and/or General Revenue Fund monies must complete an updated Inventory Control Form. Equipment requests in the FY 2016 Budget should not be included in this equipment listing. An updated Inventory Control Form will be submitted after new equipment has been actually purchased. Two (2) copies of this form must be submitted. Page 15 Application Instructions Non-Discrimination Policy All providers of services receiving funds under the Area Agency s Plans are required to comply with and provide notice of this policy. Page 16 - Application Instructions Addendum 16 1: Provider Agency Emergency Contacts Part H - Assurances Fiscal Year 2016 Grant Assurances, Bribery Clause certification, Assurance of Compliance with Title VI of the Civil Rights Act of 1964, Assurance of Compliance with Section 507 of the Rehabilitation Act of 1973, as Amended; and Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Pursuant to 45 CFR Part 76, Drug Free Workplace, Certification Older Americans Act Programs Nondiscrimination Policy, CIAA Funding Statement, Reporting Requirements for Title III and Title VII of the Older Americans Act, and Certification for Contracts, Grants, Loans, and Cooperative Agreements, are included in this part. Assurances, Pages 1 16: I. FY 2016 Assurances A. General Administration (1) B. Provision of Services (4) II. Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973 (7) III. Assurance of Compliance with the Department of Health and Human Services Regulation under Title VI of the Civil Rights Act of 1964 (8) IV. Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion (9) V. Bribery Clause Certification (10) VI. Requirements of the Drug Free Workplace Act (11 12) VII. Older Americans Act Programs Nondiscrimination Policy (13) VIII. CIAA Funding Statement (14) IX. Reporting Requirements for Title III and Title VII of the Older Americans Act (15) X. Certification for Contracts, Grants, Loans, and Cooperative Agreements (16) All assurances must be signed and dated. The original signature of the Head of the Governing Body or Owner is required. Fiscal Years Attachments: I. FY 2015 Poverty Guidelines II. State of the Planning and Service Area III. Funding Policies 9

10 IV. Section 200: General Service Requirements V. Section : Caregiver Services Training and Education/Personal Care VI. Section 600: Appeals of Probation, Suspension, Termination and Other Adverse Action GEN REV: 10/1/15 10

Example Application DO NOT SUBMIT

Example Application DO NOT SUBMIT Supervised Agricultural Experience (SAE) Grant Application Grant Information Amount: $1,000.00 Applicant Information Last Name First Name FFA ID Gender DOB Dues Paid Contact Information Address City State