Minnesota Department of Health
Environmental Health Division
Request for Proposals (RFP) for Healthy Housing Grants
July 2014
In roduction
t
The Minnesota Department of Health (MDH) Healthy Homes and Lead Poisoning Prevention
(HHLPP) program encourages primary prevention, provides guidance and support to individuals
exposed to lead, asthma triggers and other unhealthy conditions within their home and fulfills the
three core public health functions of assessment, assurance, and policy/planning.
MDH’s Healthy Housing Grants (HHG), authorized by MS144.9513 and described in this RFP,
provide funding to perform activities related to housing-based health threats, including:
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Implementing and maintaining primary prevention programs
Providing training and technical assistance on mitigation and hazard assessment
Developing and promoting best practices for hazard reduction and outreach
Identifying, characterizing, and mitigating hazards in housing that contribute to adverse
health outcome
Ensuring screening services and other secondary prevention measures are provided
Establishing local or regional collaborative partnerships
The total amount available under this RFP for 8/1/2014 – 6/30/2017 is $720,000 to be awarded in
a three year project period. The funding will be distributed as four (4) healthy home awards of
$120,000 each ($40,000 per year for three years), three (3) healthy home awards of $60,000 each
($20,000 per year for three years) and one mini-grant award of $60,000 ($20,000 per year for
three years). All awards are contingent upon MDH receiving continued funding from the
legislature. Any awarding of grant agreements and cost/time extensions as a result of this RFP
process is subject to final approval by the Commissioner of Health.
Eligible applicants will be local boards of health, community action agencies under section
256E.31, and nonprofit organizations with expertise in providing outreach, education, and
training on healthy housing subjects and in providing comprehensive healthy housing
assessments and interventions. Grantees currently funded under the Swab Team Services
program (per MS144.9512) will not be eligible for the larger awards. Applicants will be required
to leverage matching funds at 10% of direct costs as part of the delivery of services. Applicants
for the mini-grant award may apply for other awards for which they are eligible.
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MDH will be available to provide consultation and guidance during the application process. For
assistance, please contact Dan Symonik, Healthy Homes and Lead Poisoning Prevention
Program, at 651-201-4928 or [email protected] . Please note that MDH staff will not
be able to help with the actual writing of the application or critique drafts.
General Grant Requirements
1. Matching requirements: 10% in-kind matching (based on total direct costs) is required.
In- kind may include staff time, supplies, training opportunities, and educational events.
2. Key personnel must attend training opportunities such as the Essentials for Healthy
Homes Practitioners Course (www.healthyhomestraining.org/Practitioner/index.htm).
Costs associated with training are allowable expenses.
3. Grantees must follow MDH Lead Guidelines (see:
http://www.health.state.mn.us/divs/eh/lead/guidelines/index.html) and other applicable
lead rules when performing lead poisoning prevention and lead hazard reduction work.
4. Grantees must identify staff to be the point of contact and responsible to complete the
grant according to established guidelines.
5. All data collected must be handled consistent with the Minnesota Data Practices Act
(Appendix A). In addition, all residents must be informed of how the data will be used
and of their rights and responsibilities (e.g. Tennessen Warning).
6. Grant activities should target any or all of the following high risk populations:
a. Children under the age of six
b. Low-income, minority populations
c. Elderly population
d. Geographical (e.g. high prevalence of radon)
An applicant may define a different population as high risk within their jurisdiction, but
must provide justification for the choice. Applicants are encouraged to structure goals to
address health inequities (see: www.health.state.mn.us/divs/chs/healthequity ).
7. Grantees must submit quarterly invoices for services performed. MDH will provide an
invoice template to the successful applicant(s) for submitting quarterly expenditures.
If working under a joint grant agreement, one fiscal agent shall submit the quarterly
invoice. The invoice needs to account for all expenses and identify each expense for each
operating agency party to the joint agreement.
8. Grantees must submit quarterly progress reports (template to be provided) that indicate
what work activities were completed, including accountability for associated costs. The
progress reports must clearly link to the services provided listed in the invoice for the
reporting period.
If working under a joint grant agreement, there will be one quarterly progress report. The
report must represent all activities done under the grant for that quarter and identify what
activities were performed by each operating agency.
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Housing-based Health Threats
Minnesota statute (MS144.9513) defines a housing-based health threat as “a chemical, biologic,
or physical agent in the immediate housing environment, including toxic lead, mold, radon, and
indoor allergens and contaminants in carpets, which constitutes a potential or actual hazard to
human health at acute or chronic exposure levels.” All activities must address at least one
housing-based health threat, with preference given to those that address multiple agents. For the
purposes of this RFP a housing-based health threat includes, but is not limited to, the following:
Lead: dust from friction surfaces in homes built before 1978 remains the primary
exposure route for Minnesota children, with just over 2,000 children reporting elevated
blood lead results (over 5 mcg/dL) in 2013. Studies show no safe exposure to lead.
Asthma: Roughly 1 in 14 Minnesotans had asthma in 2013. Environmental factors, which
are often associated with the home, can be a major factor in triggering an asthma attack.
Effective treatment involves medical care and management of environmental triggers.
Radon: About two in five homes across Minnesota have elevated levels of radon, which
is the leading cause of lung cancer for non-smokers. Homes can be tested easily for radon
and can be mitigated by qualified contractors.
Injuries: Over 55,000 falls occurred in Minnesota in 2013, with about half occurring in
the home. Railings, handholds, and non-slip rugs can reduce the risk of injury.
Smoking: In addition to being addictive, smoking increases the risks of heart disease,
stroke, chronic obstructive pulmonary disease, asthma, and many types of cancer. In
2012, 19% of adults were current smokers and 46% of adults were ever smokers.
Excessive moisture: Excess moisture is the critical factor in any indoor mold problem. It
can also attract pests and allow dust mites to multiply. Moisture in homes can be due to
leaks, poor site drainage, and condensation on cold surfaces (windows, exterior walls).
Pests: Pests and vermin are insects and animals such as ants, bedbugs, spiders,
cockroaches, millipedes, silverfish, rats and mice. Pesticides, which can be very toxic,
often are misused during attempts to eliminate pests and vermin.
Carbon monoxide: Sources of CO include: furnaces, gas or kerosene space heaters,
boilers, gas cooking stoves, water heaters, clothes dryers, and fireplaces. CO is dangerous
because it is odorless and colorless. Minnesota law requires homes to have CO alarms.
Fire hazards: There were 42 fire deaths in Minnesota in 2013. Minnesota law requires
every home to have at least one smoke alarm per level.
Private wells: infrequent sampling of wells, which is common in many rural areas, may
allow exposure to unsafe levels of coliform bacteria, nitrates and arsenic.
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Scope of Work
The following items must be addressed in the Work Plan portion of the application. Applicants
should prepare a detailed work plan for the first year of the three year project. Goals and
objectives should include benchmarks for the first year and an outline of the total project period
of three years. Preference will be given to applicants who address a range of issues.
HHG-1 Awards: Applicants for the $120,000, three year, healthy home awards should
include items 1, 5, and 7, along with at least one of the remaining four items listed below in
their proposed scope of work.
HHG-2 Awards: Applicants for the $60,000, three year, healthy home awards should
address at least two of the seven items (any combination) listed below in their proposed
scope of work.
HHG-MG Awards: Applicants for the $60,000 mini-grant award must demonstrate
capacity to develop, advertise, award, manage, and evaluate five competitive mini-grant
awards of $2,000 each annually (15 awards over the three year project period). Individual
mini-grants must address at least one of the seven items listed below.
1. Primary Prevention
Primary prevention is defined as actions “preventing exposure to housing-based health threats
before seeing clinical symptoms or a diagnosis.” Specifically, primary prevention activities may
include, but are not limited to:
• Providing education materials to the general public and to property owners, contractors,
code officials, health care providers, public health professionals, health educators,
nonprofit organizations, and other persons and organizations engaged in housing and
health issues;
• Promoting the use of hazard reduction measures in new housing construction and housing
rehabilitation programs. Health issues include:
 lung cancer due to radon exposure,
 respiratory illness due to moisture related hazards,
 poisonings from CO exposure, and,
 injury due to fires
• Promoting awareness of community, legal, and housing resources; and
• Educating landlords/managers on the cost and health benefits of having a smoke free
facility
Specific housing-based health threats to be addressed, methods for implementation, and target
populations for primary prevention programs should be clearly identified in the application.
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2. Training and Technical Assistance
An essential aspect of a robust healthy homes program is having trained personnel working in the
field and technical assistance available to resolve issues. Courses (see #2 in General
Requirements above) and guidelines (see #3) are available to ensure that current best practices
and policies are followed.
Training and technical assistance may be provided to a wide range of interested parties, including
the general public, contractors, public health workers, health care providers, housing
professionals, and others as appropriate. Subject matter differs from community engagement and
education (see #4 below) in being more technical and targeted towards professional audiences.
Training courses to be provided, target audiences, and demonstration of qualifications to provide
technical assistance should be clearly identified in the application.
3. Developing Evidence-based Best Practices
While effective interventions exist for a number of housing-based health threats (e.g. lead,
asthma, radon, safety, pests) additional work is needed to ensure that scarce resources are used to
the greatest health benefit. Assessment tools must be reliable, easily administered, and based on
validated methods that accurately identify hazards. Intervention protocols should have the
backing of research that demonstrates their effectiveness in eliminating or reducing hazardous
conditions with resulting improvements in health outcomes (e.g., reduced incidence of a
particular injury, improved asthma control) or decreases in the risk of illness or injury.
Applications should identify specific housing-based health threats to be examined, an overview
of methods for gathering data in support of hypotheses, and steps for analyzing and evaluating
results.
4. Community Engagement and Education:
Activities may include, but are not limited to:
• Having a booth / table at community outreach events educating the public on the healthy
homes concepts and provide educational materials.
• Working within schools within your community to insert healthy homes concepts into the
classroom so children are able to bring the messages and actions home.
• Planning and implementing a lead screening event or healthy homes presentation (with
MDH SWAB grantees for children ages 6 and under and pregnant women).
Efforts in communities should, to the greatest extent practical, attempt to educate more people
and organizations about health equity, and to encourage specific steps to advance health equity
across Minnesota (see: http://www.health.state.mn.us/divs/chs/healthequity/ for more
information).
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5. Healthy Homes Assessments and Interventions:
Key grantee personnel (e.g. home inspector, environmental health staff, and public health nurse)
must attend healthy home hazard assessment training (e.g. the Essential for Healthy Homes
Practitioners Training provided by Sustainable Resource Center) in a site to be mutually agreed
upon. Assessments should use the healthy homes check-list (Appendix B) or the Healthy Homes
Rating System (from HUD see:
http://portal.hud.gov/hudportal/HUD?src=/program_offices/healthy_homes/hhrs ) for identifying
housing-based health threats and preparing recommendations for mitigation. Each agency must
identify the high risk population(s) that will be your primary focus and the number of
assessments to be done.
Once health and safety issues have been identified staff/organization must provide appropriate
educational materials, identify resources (carbon monoxide detectors, fire alarms, radon testing
equipment, mattress covers, IPM, etc.,) or programs (tobacco cessation) in the community that
would benefit the family in addressing the safety and health concerns.
Specific requirements regarding the Healthy Home Assessments include:
For HH-1 applicants (required)
Conduct a minimum of 200 Healthy Home Assessments by June 30, 2017.
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Preference will be given to applicants who include assessments of in-home
licensed childcare providers. A list of family child care centers within specific
areas is available at: http://licensinglookup.dhs.state.mn.us/ .
Data from the assessment must be summarized and reported to MDH along with
routine quarterly reports.
Feedback on the use of the healthy homes checklist, list of supplies, issues with
recruitment, barriers to hazard mitigation, or other observations must be provided
to MDH at least annually.
A follow up evaluation must be made with the families who received education
and services to assess effectiveness and durability of interventions.
For HH-2 applicants (if choosing to include this issue in application)
Conduct a minimum of 100 Healthy Home Assessments by June 30, 2017.
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•
Preference will be given to applicants who include assessments of in-home
licensed childcare providers. A list of family child care centers within specific
areas is available at: http://licensinglookup.dhs.state.mn.us/ .
Data from the assessment must be summarized and reported to MDH along with
routine quarterly reports.
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•
•
Feedback on the use of the healthy homes checklist, list of supplies, issues with
recruitment, barriers to hazard mitigation, or other observations must be provided
to MDH at least annually.
A follow up evaluation must be made with the families who received education
and services to assess effectiveness and durability of interventions.
The intervention supplies in the table below are allowable expenses which may be included in the
budget. They should be provided to the homeowner at the discretion of the Home Health
Assessor if the visual assessment indicates need. Their proper use and maintenance, and the
hazard they address, should be fully explained to the resident. Grantee shall not exceed $750 per
house unless prior approval is obtained from MDH. Additional information on budget, including
the application template and accounting system questionnaire, is included in Appendix C.
Allowable costs include:
Cost
Item
Item
Cost
Hygrometer (digital)
$10
Trash cans with sealable covers
$18
Track mats for exterior doors
$20
Night lights (3)
$6
Non-toxic cleaning supplies
$20
Non-skid pads for rugs
$20
Radon test kit (short, long term) $10, $25 Smoke detectors - 3
$45
Carbon monoxide monitor
$40
Fire extinguisher
$35
Batteries
$5
Sheet/pillow covers - 2 rooms
$100
Childproof locks
$10
Vacuum (retail HEPA)
$150
Private well testing
$50
Lead test kits (colorimetric)
$15
Supplies for IPM
$50
Electrical outlet covers
$10
Dehumidifier
$125
Downspouts
$50
Any additional supplies to address specific hazards should be discussed with MDH
6. Coordination with Health Care/Secondary Prevention:
Statute defines secondary prevention as an “intervention to mitigate health effects on people with
housing-based health threats.” In addition to providing screening services, grantees may engage
health care providers to assess and implement methods for coordinating responses to medical
issues stemming from a housing-based health threat. Examples include, but are not limited to:
• Conducting blood lead testing on individuals with exposure risk factors;
• Coordinating with health care providers to assess and mitigate asthma environmental
triggers in the home;
• Coordinating with health care providers to assess and mitigate housing-based health
threats impacting individual patients;
• Performing any other activity to promote better understanding and cooperation between
health care providers and environmental health professionals.
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7. Strategic Planning / Capacity Building:
Establish, improve, or maintain a healthy homes network within the community that meets
routinely and consists of professional staff working for health and housing organizations in the
area; community members; voluntary and professional organizations representing business,
health care providers, and community and faith based organizations. Preference will be given to
applicants who demonstrate collaboration with ongoing healthy homes activities (e.g. HUD
grants, Green Community Criteria).
Goals of the network may include, but are not limited to:
1. Collaborating on Resources; identify opportunities within the community for training
(e.g. Essentials for Healthy Homes Practitioners), education, advocacy, and primary
prevention for housing-based health hazards. Build local capacity to improve children’s
home environments through multi-sector collaboration.
2. Demonstrating the impact of community based multi – sector collaborations that are
focused on addressing unhealthy conditions in homes.
3. Documenting successful strategies and practices for assessing and mitigating housingbased health hazards; identify barriers and systems change opportunities.
4. Helping to find and secure resources to pay for more costly renovations and hazard
reduction measures (e.g. radon, moisture).
Grant Monitoring
The anticipated grant start date is expected to be around October 9, 2014, with subsequent years
beginning at the start of the state fiscal year (July 1). The exact start dates are contingent on all
approvals being obtained and signatures affixed to the agreement. Grant monitoring will consist
of both programmatic review and fiscal review.
Grantees will be required to submit the following:
• All data from home assessments within 30 days of the home visit.
• Invoices and Reports in a format provided by MDH on a quarterly basis.
• An annual summary of projects, successes, barriers, and evaluation.
Application Review and Award Process
This is a competitive grant application. Grants may be awarded to one or more applicants, and
two or more applicants may apply jointly. See Appendix D for additional information relating to
a joint application. As directed by statute, MDH will seek to “geographically balance the
distribution of the grant funding between the seven-county metropolitan area and
nonmetropolitan communities.”
Applications must be delivered to MDH by 5:00 pm CDT on August 29, 2014. Applications
should be no more than 10 pages, single spaced, 12 point font with 1 inch margins. All pages
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should be numbered. Appendices will not be counted in the page limit. Submit five copies. If
dropping off your application, it must be delivered to the MDH loading dock. The loading dock
is clearly marked and located on the west side of the Freeman building.
Applications are not accepted by e-mail or facsimile (fax). Grant applications and questions must
only be addressed to:
Dan Symonik
Minnesota Department of Health
Environmental Health Division
625 Robert Street North
PO Box 64975
St. Paul, Minnesota 55164-0975
Phone: (651) 201-4928
Fax: (651) 201-4606
[email protected]
PLEASE NOTE: All submissions are final. Full and complete applications not received by the
deadline stated above will not be considered.
Only complete applications received or post marked on or before the deadline will be reviewed.
Reviewers will determine which applications best meet the criteria as outlined within the Project
Narrative and Work Plan (Plan). Reviewers will also evaluate the Budget Summary, and
Accounting System and Financial Capability Questionnaire (Questionnaire). All applicants must
use the Plan, Budget Summary and Questionnaire for completing their grant application. These
documents are available at www.health.state.mn.us/lead
H
Scoring
The scoring of applications for HH-1 and HH-2 grants is included in the Work Plan template
(Appendix E) and will be as follows:
A.
B.
C.
D.
Background Information on Organization – 10 points
General Information – 20 points
Experience in hazard assessment/mitigation or community outreach– 20 points
Project Approach – 50 points
The scoring of applications for HH-MG grant is included in the Work Plan template (Appendix
F) and will be as follows:
A.
B.
C.
D.
Background Information on Organization – 15 points
General Information – 15 points
Experience in hazard assessment/mitigation or community outreach– 30 points
Project Approach – 40 points
Reviewers will include staff from across MDH programs and will be required to identify any
conflicts of interest and will not review an application if they have a direct relationship with the
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applicant. Information that was submitted in previous applications and MDH staff’s personal
knowledge of the applicant will not be considered in scoring. Exception: An applicant who
previously received any MDH grant and failed to fulfill the terms of that grant may not be
considered for funding.
Responses to this RFP are considered to be nonpublic until they are opened. Once the grant
application is opened, the name and address of the grantee and the amount requested is
considered to be public data. The rest of the grant application information is considered
nonpublic until the end of the grant review process. After the grant agreements are fully
executed, the remaining information in the grant application becomes public, except for
information defined as trade secret data as defined in Minnesota Statues, section 13.37.
Trade Secrets
Trade Secret Information is defined as “Government data, including a formula, pattern,
compilation, program, device, method, technique or process:
1) That was supplied by the affected individual or organization,
2) That is the subject of efforts by the individual or organization that are reasonable
under the circumstances to maintain its secrecy, and
3) That derives independent economic value, actual or potential, from not being
generally known to, and not being readily ascertainable by proper means by, other
persons who can obtain economic value from its disclosure or use.” Minnesota
Statutes, section 13.37, subdivision 1(b).
Documents that are submitted to MDH that contain trade secret information must:
1) Be put into a separate envelope and clearly marked with the word “trade secret,”
2) Each document that contains the trade secret information must be clearly marked with
the words “trade secret,” and
3) Each document must include a written explanation of how the information meets each
of the three requirements above for trade secret information.
Notification of Awards
Successful applicants will initially be notified verbally and then with a formal letter. Nonsuccessful applicants will be notified with a formal letter.
Grantees will be required to prepare and submit progress reports and cost reimbursement requests
(invoices) to MDH each quarter of the grant year. Reports and invoices must be submitted using
MDH reporting and invoice formats. MDH cannot reimburse a grantee for any expenses incurred
before a grant contract is fully executed. These formats will be provided electronically upon full
execution of the grant agreement.
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Eligible Costs
The Budget template is provided in Appendix C below. Reimbursable costs associated with
providing the services as stated above are as follows.
A. Labor costs which include salary and fringe benefits.
B. Supply and equipment costs.
C. The Essentials for Healthy Homes Practitioners Course (2) per organization ($175 per
person). NOTE: MDH has additional funding available to provide the Essentials course in
regions of the state; course location and number of scholarships available will be
negotiated after awards are distributed.
D. Rent or lease agreements.
E. Mileage for required trainings or meetings pertaining to the grant.
F. Administrative costs of the grantee to conduct the administrative activities of the grant.
Applicants may identify up to 7.5 % of the total annual appropriation for administrative
purposes.
Grant Application Contents
Applicants can go to http://www.health.state.mn.us/divs/eh/lead/topics/index.html to download
the Project Narrative and Work Plan and Budget Summary templates (they are also attached as
appendices to this RFP). These documents MUST be completed and submitted to MDH in order
to be considered for funding.
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Appendix A
MINNESOTA DEPARTMENT OF HEALTH
DATA PRACTICES CHECKLIST
The Minnesota Government Data Practices Act (Minnesota Statutes, chapter 13) governs how the
Minnesota Department of Health (MDH) collects, receives, or maintains data. The Minnesota
Government Data Practices Act requires MDH to:
1. Safeguard the privacy rights of data subjects; and
2. Provide access to government data that may be legally disclosed.
All MDH data are “public” unless otherwise classified by statute or temporary classification.
Data may be classified as “private” or “nonpublic” (data accessible only to the subject of the data
and certain other persons or entities authorized by law), or data may be classified as
“confidential” or “protected nonpublic” (data not accessible to the subject of the data). All data
that are not “public” data will hereafter be called “not public” data. This checklist presents
responsibilities regarding data practices.
UNDERSTANDING OF DATA PRACTICES RESPONSIBILIITES
Responsibilities in dealing with data as follows:
A. DATA RESPONSIBILITIES
• Protect “not public” data on individuals or organizations collected, received, or
maintained in performing the duties of the agreement.
• Protect “not public” data accessed through computer-related media or other media such as
paper files, faxes, written reports, and verbal reports.
B. CONTACT SUPERVISOR
• If doubts exist as to the classification, access, or release of data, a supervisor will be
contacted as soon as possible.
C. ACCESS TO “NOT PUBLIC” DATA
• Protect “not public” data and release them only to those authorized by law to receive
them.
• Share “not public” data with staff only if they need them for their job.
• Contact a supervisor if there are any questions about the release of “not public” data.
D. ACCESS TO PUBLIC DATA
• Make public data available to persons appropriately.
• Contact a supervisor if I have questions regarding any public data.
E. MAINTAIN DOCUMENTS IN A SECURE MANNER
• Physically maintain documents containing “not public” data in a manner that complies
with security safeguards. Possible safeguards for documents that include “not public” data
are: turning documents face down or putting them away when visitors are present or when
•
staff are away from their desk during the day, and storing documents in a locked area
overnight.
Do not leave “not public” documents in public areas such as an open copy machine, fax
machine, or printer.
F. SAFEGUARDS FOR PROTECTING “NOT PUBLIC” DATA
• Consult with a supervisor to learn about appropriate safeguards for “not public” data.
• Do not share “not public” data with any unauthorized person at any time.
• Use professional judgment in the treatment of all private health data. Occasionally, some
private health data will be about my co-workers, persons known personally from private
life, relatives, or famous persons. Use and access the data only as necessary to fulfill grant
obligations.
G. DISPOSE OF DOCUMENTS IN A SECURE MANNER
• Dispose of documents containing “not public” data in a manner that complies with
security safeguards and records retention schedules.
• When it is appropriate to discard paper documents, such as draft documents containing
“not public” data, documents will be shredded.
• Contact a supervisor about how to properly dispose of electronic documents.
H. THREAT OR UNAUTHORIZED ACCESS
• Inform a supervisor immediately if a possible threat to, or the unauthorized access to, or
release of “not public” data is suspected.
Appendix B
Appendix C: Budget Summary
Use this table to itemize your organization’s proposed budget. You may modify the table to
include additional items to reflect all costs associated with each of the main categories, or
describe the cost type in the area provided below the table.
Organization’s Name:
State
Funding
Requested
Labor costs, including salary and fringe benefits
Budget Category
A
Matching
Funds
Total
Proposed
1. Salary
2. Fringe benefits
3. Other associated costs (describe below)
Supply and Equipment Costs
1. In-home supplies (#)
B
2.
3.
4. Other associated costs (describe below)
Trainings
1. Essentials for Healthy Homes (2 per
organization at $175 each)
2. Mileage @ .51
3. Hotel
4. Other associated costs (describe below)
E
1. Rent or lease costs
2. Other associated costs (describe below)
F
Administrative costs*
Total
* Restricted up to 7.5% of the total annual appropriation.
Attach additional pages if necessary for additional descriptions for associated costs
ACCOUNTING SYSTEM AND FINANCIAL CAPABILITY
QUESTIONNAIRE
This form should be used for applicant agencies that: are requesting, or will receive, more than $50,000; are new to state granting;
are recently incorporated (five years or less); had previous unfavorable financial performance with federal and/or state funds; had
significant audit findings; or for any applicant whose financial capacity is unknown or questionable.
No applicants will be excluded from receiving funding based solely on the answers to these questions.
SECTION A: APPLICANT INFORMATION
1. Organization Name and Address
2.Employer
Identification Number
3.Number of Employees
Full Time:
Part Time:
4. When did the applicant receive its 501(c)3 status? (MM/DD/YYYY)?
5. Is the applicant affiliated with or managed by any other organizations (Ex.
regional or national offices)?
YES
NO If “Yes,” provide details:
6a. Total revenue in most recent accounting
period (12 months).
5b. Does the applicant receive management or financial assistance from any other
YES
NO If “Yes,” provide details:
organizations?
6b. How many different funding sources does
the total revenue come from?
7. Does the applicant have written policies and procedures for the following business processes?
a. Accounting
Yes
No
Not Sure If yes please attach a copy of the table of contents
b. Purchasing
Yes
No
Not Sure If yes please attach a copy of the table of contents
c. Payroll
Yes
No
Not Sure If yes please attach a copy of the table of contents
SECTION B: ACCOUNTING SYSTEM
1.Has a Federal or State Agency issued an official opinion regarding the adequacy of the applicants accounting system for the
collection, identification and allocation of costs for grants
Yes
No
Note: If a financial review occurred within the past three years, omit Questions 2 – 6 of this Section and 1-3 of Section C.
a. If yes, provide the name and address of the reviewing agency:
2. Which of the following best describes the accounting system?
b. Attach a copy of the latest review and any
subsequent documents.
Manual
Automated
3. Does the accounting system identify the deposits and expenditures of program funds for each
and every grant separately?
4. If the applicant has multiple programs within a grant, does the accounting system record
the expenditures for each and every program separately by budget line items?
5. Are time studies conducted for an employee(s) who receives funding from multiple
sources?
6. Does the accounting system have a way to identify over spending of grant funds?
Combination
Yes
No
Not Sure
Yes
No
Not Sure
Not Applicable
Yes
No
Not Sure
No Multiple Sources
Yes
No
Not Sure
1. Is a separate bank account maintained for grant funds?
Yes
No
Not Sure
2. If grant funds are mixed with other funds, can the grants expenses be easily identified?
Yes
No
Not Sure
3. Are the officials of the organization bonded?
Yes
No
Not Sure
Yes
No
Not Sure
SECTION C: FUND CONTROL
SECTION D: FINANCIAL STATEMENTS
1. Did an independent certified public accountant (CPA) ever examine the organization’s
financial statements?
SECTION E: CERTIFICATION
I certify that the above information is complete and correct to the best of my knowledge.
1. Signature
3. Title
2. Date
/
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Appendix D
Information Relating to a Joint Application
1. Definition of “joint application”
A “joint application” is a single application submitted by two or more agencies. The application shall
specify the unmet needs which each agency identifies for its target population and the geographic area it
proposes to serve, and shall state how it will address those unmet needs. However, in a joint application,
one or more (but not all) of the unmet needs identified by one agency may be met by another agency that is
a party to the joint application and in doing so may use an appropriate portion of the first agency’s grant.
Each agency entering into a joint application shall perform at least one component service under the
application. A lead agency must be appointed to serve as the fiscal agent.
2. Application
A. There must be one lead agency. A contract between all agencies that are a party to the joint
application must be submitted with the application.
B. The application will need to specifically address the responsibilities of each operating agency.
C. There must be one Project Narrative and Work Plan that corresponds to each operating
agency’s request for funds.
D. There must be a budget for the entire project and also separate budgets to correspond with the
request for funds by each agency that is a party to the joint application.
3. Grant Agreement
A. There will be one grant agreement with the Minnesota Department of Health.
B. A grant agreement between all agencies that are a party to the joint application must be
submitted with the application. (MN Stat. 145A.04, Subd. 5 provides the authority for two or
more Community Health Boards to contract with each other). This must be a legally binding
agreement between the parties. It must include the following information:
1. It must authorize the agencies to submit a joint application and
enter into a joint grant agreement with the Minnesota Department of Health.
2. It must name a lead agency and state that this agency will be the fiscal agent for the
project.
C. It must state that the agencies agree to perform services and divide funds in the manner
specified in the joint application.
D. It must state that all agencies agree, should the Minnesota Department of Health approve and
fund the application, to comply with and be bound by the provisions of the grant agreement
executed between the Department and the lead agency.
4. Scores
There will be one score and one ranking for the entire project proposed by the joint application.
Appendix E: Project Narrative and Work Plan for HH-1 and HH-2 Awards
The project narrative and work plan describes your organization and what you intend to accomplish.
Organization’s Legal Name:
Contact Name and Title:
Mailing Address:
Street Address (if different):
Phone:
Fax:
Email:
A. Background Information on Organization (10 points)
1. Briefly summarize your organization’s history (3).
2. Briefly describe the administrative structure of your organization (1).
3. Briefly explain what current programs and services your organization provides (4).
4. Briefly explain current community relationships with elected officials, faith based organizations,
voluntary and professional organizations, and local businesses (2).
B. General Information (20 points)
1. Describe the service(s) to be provided under the grant and the specific items from the Scope of
Work to be addressed (9).
2. Describe sources of any other funding directed towards accomplishing the same or similar goals
as specified in this RFP, including the source of the required 10% match (3).
3. Affirm that no one under the age of 18 will perform any activities under this grant (1).
4. Describe the plans your organization will use to measure program effectiveness (7).
C.
Experience with hazard assessment/mitigation or community outreach (20 points)
1. Describe what type of home services and community outreach your organization provides (6).
2. Describe any experience you have with educating and promoting healthy homes within your
community (4).
3. Describe any experience you have managing and successfully completing grants (3).
4. Describe any experience your organization has assessing hazards and implementing mitigation
measures (3).
5. Demonstrate your organization’s experience in working with low-income families (4).
D.
Project Approach (50 points)
1. Identify and characterize the population(s) you intend to recruit and briefly describe why they
were chosen (10).
2. Describe how you will recruit within your community to encourage participation in the project
and ensure that goals are met (10).
3. Describe how you will take steps to ensure that activities are culturally appropriate and target
health inequities (5).
4. Describe how you will educate families on how to make their home a safe, secure, and hazard
free home (9).
5. Describe methods to get materials that are needed to complete projects and how are you planning
on distributing them (6).
6. Describe strategies to follow up with families who have been identified as having a home health
hazard or home health related condition (10).
E. Joint Application
If submitting a joint application, describe the organizations’ relationships and how services are
provided jointly. Be sure to designate a lead organization to serve as the fiscal and contractual agent.
Appendix F: Project Narrative and Work Plan for HH-MG Awards
The project narrative and work plan describes your organization and what you intend to accomplish.
Organization’s Legal Name:
Contact Name and Title:
Mailing Address:
Street Address (if different):
Phone:
Fax:
Email:
A. Background Information on Organization (15 points)
1. Briefly summarize your organization’s history (3).
2. Briefly describe the administrative structure of your organization (1).
3. Briefly explain what current programs and services your organization provides (4).
4. Briefly explain current community relationships with elected officials, faith based organizations,
voluntary and professional organizations, and local businesses (7).
B.General Information (15 points)
1. Describe the service(s) to be provided under the grant (4).
2. Describe sources of any other funding directed towards accomplishing the same or similar goals
as specified in this RFP (3).
3. Affirm that no one under the age of 18 will perform any activities under this grant (1).
4. Describe the plans your organization will use to measure program effectiveness (7).
C.
Experience working with communities statewide to identify and address issues and concerns
(30 points)
1. Describe what type of home services and community outreach your organization provides (6).
2. Describe any experience you have with educating and promoting healthy homes (4).
3. Describe any experience you have developing and coordinating statewide projects (8).
4. Describe any experience your organization has issuing and managing grants with community
organizations (8).
5. Demonstrate your organization’s experience in working with low-income families (4).
D.
Project Approach (40 points)
1. Identify the population(s) and geographic area(s) you intend to target (6).
2. Describe how you will recruit and choose organizations to participate (10).
3. Describe how you will meet the 10% matching fund requirement (7).
4. Describe how you will share information between grantees to ensure that best practices are
identified and implemented (7).
5. Describe methods to manage non-performance in grantees (10).
E.Joint Application
If submitting a joint application, describe the organizations’ relationships and how services are
provided jointly. Be sure to designate a lead organization to serve as the fiscal and contractual agent.