Title VI -- Grants for Native Americans

**APPLICATION GUIDELINES**

The application may be presented in any format but it must meet the
criteria specified in the Older Americans Act, sections 612(a), 612(b),
and 612(c) for Title VI, Part A and section 631 for Title VI, Part C. It
must also meet the criteria specified in title 45 of the Code of Federal
Regulations, section 1326.19. However, you may find this guide helpful.

**Tribal Organization
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Address
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Telephone Number \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Fax Number
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**E-mail Address \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ EIN
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**DUNS Number
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Tribal Chairman
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Principal Official Signature
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Age of eligibility used by Tribe: \_\_\_\_\_\_**

# Number of elders eligible within

**the planned service area: Age 60+ \_\_\_\_\_\_**

**Under age 60**

**(if applicable) \_\_\_\_\_\_**

**Total \_\_\_\_\_\_**

**Source of population statistics**

**used to establish eligibility**

**(Section 614(b)). Check one: U.S. Census \_\_\_\_\_**

**Tribally Determined \_\_\_\_\_\_**

**(include certification)**

**Applying for: Part A only \_\_\_\_\_\_\_**

**Parts A and C \_\_\_\_\_\_\_**

\- 2 -

**Geographic Location:**

The applicator must provide an appropriate narrative description of the
geographical area to be served and an assurance that procedures will be
adapted to ensure against duplicate services being provided to the same
recipients. You may submit a map with the service area identified if you
wish.

**Resolutions(s):**

The tribal organization representing a federally recognized Tribe must
submit an original copy of the Tribal council resolution authorizing
participation in Title VI, Part A or Title VI, Part A and Part C for the
grant period April 1, 2005 to March 31, 2008. If the tribal organization
represents a consortium of more than one Tribe, a resolution is required
from each participating Tribe, specifically authorizing representation
by the tribal organization for the purpose of Title VI of the Older
Americans Act for the grant period April 1, 2005 to March 31, 2008.

Program Assurances:

Title VI, Part A Program Assurances must be included in the application.
The Title VI, Part A Program Assurances are those provisions identified
in section 614(a) of the Older Americans Act, and in the title 45 of the
Code of Federal Regulations section 1326.19(d), issued August 31, 1988.
The tribal organization must state that it agrees to abide by all the
provisions for the entire project being applied for April 1, 2005 --
March 31, 2008. (Program Assurances are included in this application
guide.)

Certification Forms:

Certifications are required of the applicant regarding lobbying;
debarment, suspension, and other responsibility matters; and drug-free
workplace requirements. Please note that a duly authorized
representative of the tribal organization must attest to the applicant's
compliance with these certifications. (Certification forms are included
in this application guide.)

\- 3 -

**Objectives and Need for Assistance:**

This section must include objectives, expressed in measurable terms,
which are related to the core services and evidence based preventive
services to be addressed by the tribal organization. This section must
also include a discussion of how the needs that will be addressed by the
core services were determined.

**Program Description - Nutrition and Support Service Program:**

A.  [Nutrition:]{.underline}

    1.  Will the Tribal Organization be providing nutrition services
        directly? \_\_\_yes \_\_\_ no

    2.  If no, describe how they will be provided.

    3.  Describe the nutrition services to be provided under Title VI,
        including:

> a\) Congregate meal program:
>
> 1\) How many meal sites? \_\_\_\_\_\_
>
> 2\) How many days per week will meals be provided at each site?
> \_\_\_\_\_\_

3)  What meals will be provided: (i.e., breakfast, lunch, supper):

4)  How will the elder access the meals (i.e., call to register, sign-up
    at the senior center in advance, etc.)?

\- 4 -

> 5\) How many elders do you expect to serve: per day \_\_\_\_

week \_\_\_\_

year \_\_\_\_

b)  Home delivered meals program:

> 1\) How will you determine eligibility for home delivered meals?
>
> 2\) What meals will be provided (i.e., breakfast, lunch, supper)?
>
> 3\) How will meals be delivered and how often will they be delivered?
> (For example: a hot meal will be delivered by van once a day/5 days a
> week.)

4)  How will elders access the meals (i.e., call, etc)?

5)  How many elders do you expect to serve per day \_\_\_\_\_\_

> week \_\_\_\_\_\_
>
> year \_\_\_\_\_\_

c)  Guest meals:

> 1\) What is your policy for guest meals? (Who can receive a guest
> meal, under what circumstances, etc.)
>
> 2\) What do you charge for guest meals? \_\_\_\_\_\_\_\_\_\_
>
> \- 5 -

d)  Contributions:

> 1\) How are contributions collected?

2)  How are contributions used?

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e)  Other nutrition services:

> 1\) What other nutrition services will be provided, how often will
> they be provided and who will provide them? (Other nutrition services
> include nutrition screening, nutrition education, nutrition
> counseling, traditional foods, etc.)?

2)  How will you inform elders of the other nutrition services that are
    available?

3)  How will elders access the services?

\- 6 -

4\. Describe the methods, facilities, and staff to be used in preparing,
serving, and delivering meals. If volunteers are used, specify their
role.

5\. Describe how you will assure that each meal provides one-third RDA
and are consistent with the USDA/DHHS Dietary Guidelines for both
congregate and home delivered meals.

6\. Describe the results and benefits expected from providing nutrition
services and how you will assess the results and benefits.

B. [Information and Assistance:]{.underline}

1\. If no Title VI funds are to be used for information and assistance
services, how will these services be provided?

\- 7 -

2\. Describe what information and assistance services will be provided,
including:

a\) What information and assistance services will be provided?

b\) How they will be provided.

c\) Who will provide them?

d\) How you will notify elders about the information and assistance
services.

e\) How elders will access the service

3\. Describe the results and benefits expected in providing information
and assistance services and how you will assess the results and
benefits.

C. [Other Supportive Services:]{.underline}

1\. Describe what supportive services other than nutrition and
information and assistance will be provided, including:

\- 8 -

a\) What supportive services other than nutrition and information and
assistance will be provided?

b\) How will each of the other supportive services be provided and how
many elders will receive each service?

c\) Describe the results and benefits expected in providing other
supportive services and how you will assess this.

D. [Coordination with Title III:]{.underline}

Describe specifically how Title VI and Title III resources will be
coordinated within the Title VI service area and what efforts will be
made to increase coordination.

\- 9 -

Program Description -- Title VI, Part C, Native American Caregiver
Support Program:

> A. [Information:]{.underline}
>
> 1\. What percentage of the Title VI, Part C budget will be used for
> information services? \_\_\_\_\_\_\_\_\_\_\_
>
> 2\. If no Title VI funds are to be used for information, how will
> these services be provided?

3\. Describe what information services will be provided, including:

a.  What information will be provided?

b.  How information will be provided.

c.  Who will provide the information?

d.  How many caregivers will receive information services?

e.  How will you notify caregivers about the information services?

> \- 10 -

f.  How will caregivers access this information?

> 4\. Describe the results and benefits expected in providing
> information services and how you will assess the results and benefits.

B.  [Assistance:]{.underline}

> 1\. What percentage of the Title VI, Part C budget will be used for
> assistance services? \_\_\_\_\_\_\_\_\_\_\_
>
> 2\. If no Title VI funds are to be used for assistance to accessing
> information and services, how will this be provided?

3\. Describe what assistance services will be provided, including:

> a\) What assistance will be provided?
>
> b\) How assistance will be provided.
>
> \- 11 -
>
> c\) Who will provide the assistance?
>
> d\) How many caregivers will receive assistance services?
>
> e\) How will you notify caregivers about the assistance services?
>
> f\) How will caregivers access this assistance?
>
> 4\. Describe the results and benefits expected in providing assistance
> services and how you will assess the results and benefits.

\- 12 -

C.  [Counseling/Support Groups/Training:]{.underline}

> 1\. What percentage of the Title VI, Part C budget will be used for
> counseling/support groups/training services? \_\_\_\_\_\_\_\_\_\_\_
>
> 2\. If no Title VI funds are to be used for counseling/support
> groups/training, how will these services be provided?
>
> 3\. Describe how these services will be provided to the caregiver?

D.  [Respite:]{.underline}

> 1\. What percentage of the Title VI, Part C budget will be used for
> respite services? \_\_\_\_\_\_\_\_\_\_\_
>
> 2\. If no Title VI funds are to be used for intermittent and temporary
> respite services, how will these services be provided?
>
> \- 13 -

3.  Describe how these services will be provided to the caregiver?

4.  To be eligible for respite services, the elder must meet the OAA
    definition of "frail elder". Describe how you will meet this
    requirement.

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E.  [Supplemental Services:]{.underline}

> 1\. What percentage of the Title VI, Part C budget will be used for
> respite services? \_\_\_\_\_\_\_\_\_\_\_
>
> 2\. If no Title VI funds are to be used for supplemental services, how
> will these services be provided?
>
> 3\. Describe what other services, as defined by the tribe, will be
> provided to the caregiver providing care to frail elders.
>
> \- 14 -
>
> 4\. To be eligible for supplemental services, the elder must meet the
> OAA definition of "frail elder". Describe how you will meet this
> requirement.

[Coordination:]{.underline}

> 1\. Describe your coordination activities in providing the supportive
> services for caregivers.

[Quality Assurance:]{.underline}

> 1\. Describe the standards and quality assurance mechanisms you will
> implement for your program.