### Appendix A -- Checklist for Formatting Requirements and Screenout Criteria for SAMHSA Grant Applications

*SAMHSA's goal is to review all applications submitted for grant
funding. However, this goal must be balanced against SAMHSA's obligation
to ensure equitable treatment of applications. For this reason, SAMHSA
has established certain formatting requirements for its applications.
**If you do not adhere to these requirements, your application will be
screened out and returned to you without review.** In addition to these
formatting requirements, programmatic requirements (e.g., relating to
eligibility) may be stated in the specific NOFA and in Section III of
the standard grant announcement. Please check the entire NOFA and
Section III of the standard grant announcement before preparing your
application.*

-   Use the PHS 5161-1 application.

-   Applications must be received by the application deadline or have
    proof of timely submission, as detailed in Section IV-3 of the grant
    announcement.

-   Information provided must be sufficient for review.

-   Text must be legible.

• Type size in the Project Narrative cannot exceed an average of 15
characters per inch, as measured on the physical page. (Type size in
charts, tables, graphs, and footnotes will not be considered in
determining compliance.)

• Text in the Project Narrative cannot exceed 6 lines per vertical inch.

-   Paper must be white paper and 8.5 inches by 11.0 inches in size.

-   To ensure equity among applications, the amount of space allowed for
    the Project Narrative cannot be exceeded.

• Applications would meet this requirement by using all margins (left,
right, top, bottom) of at least one inch each, and adhering to the page
limit for the Project Narrative stated in the specific funding
announcement.

• Should an application not conform to these margin or page limits,
SAMHSA will use the following method to determine compliance: The total
area of the Project Narrative (excluding margins, but including charts,
tables, graphs and footnotes) cannot exceed 58.5 square inches
multiplied by the page limit. This number represents the full page less
margins, multiplied by the total number of allowed pages.

• Space will be measured on the physical page. Space left blank within
the Project Narrative (excluding margins) is considered part of the
Project Narrative, in determining compliance.

*To facilitate review of your application, follow these additional
guidelines. Failure to adhere to the following guidelines will not, in
itself, result in your application being screened out and returned
without review. However, the information provided in your application
must be sufficient for review. Following these guidelines will help
ensure your application is complete, and will help reviewers to consider
your application.*

-   The 10 application components required for SAMHSA applications
    should be included. These are:

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-   Face Page (Standard Form 424, which is in PHS 5161-1)

-   Abstract

-   Table of Contents

-   Budget Form (Standard Form 424A, which is in PHS 5161-1)

-   Project Narrative and Supporting Documentation

-   Appendices

-   Assurances (Standard Form 424B, which is in PHS 5161-1)

-   Certifications (a form within PHS 5161-1)

-   Disclosure of Lobbying Activities (Standard Form LLL, which is in
    PHS 5161-1)

-   Checklist (a form in PHS 5161-1)

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-   Applications should comply with the following requirements:

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-   Provisions relating to confidentiality, participant protection and
    the protection of human subjects specified in Section IV-2.4 of the
    FY 2005 standard funding announcements.

-   Budgetary limitations as specified in Section I, II, and IV-5 of the
    FY 2005 standard funding announcements.

-   Documentation of nonprofit status as required in the PHS 5161-1.

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```
-   Pages should be typed single-spaced in black ink, with one column
    per page. Pages should not have printing on both sides.

-   Please number pages consecutively from beginning to end so that
    information can be located easily during review of the application.
    The cover page should be page 1, the abstract page should be page 2,
    and the table of contents page should be page 3. Appendices should
    be labeled and separated from the Project Narrative and budget
    section, and the pages should be numbered to continue the sequence.

-   The page limits for Appendices stated in the specific funding
    announcement should not be exceeded.

-   Send the original application and two copies to the mailing address
    in the funding announcement. Please do not use staples, paper clips,
    and fasteners. Nothing should be attached, stapled, folded, or
    pasted. Do not use heavy or lightweight paper or any material that
    cannot be copied using automatic copying machines. Odd-sized and
    oversized attachments such as posters will not be copied or sent to
    reviewers. Do not include videotapes, audiotapes, or CD-ROMs.

**Appendix B -- Program Specific Assurances**

**That Must Be Met by Capacity Expansion Site Applicants**

In accordance with the Public Health Service Act 520G, all Capacity
Expansion Site applications must contain the following assurances. Only
applicants that are able to provide the following assurances will be
eligible for this grant.

I hereby certify that the State, political subdivision of the State,
Indian tribe, or tribal organization
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ applying
for the TCE Jail Diversion Grant assures the following:

-   Community-based mental health services will be available for
    individuals who are diverted from the criminal justice system.

-   The services offered to jail diversion clients will be based on
    current research findings and include case management, assertive
    community treatment, medication management and access, integrated
    mental health and co-occurring substance abuse treatment, and
    psychiatric rehabilitation.

-   The services offered to jail diversion clients will be coordinated
    with social services, including life skills training, housing
    placement, vocational training, education job placement, and health
    care.

-   There will be relevant interagency collaboration between the
    appropriate criminal justice, mental health, and substance abuse
    systems.

-   The federal support provided by this grant will be used to
    supplement and not supplant, State, local, Indian tribe, or tribal
    organization sources of funding that would otherwise be available.

-   The jail diversion program will be integrated with pre-existing
    systems of care for those persons with mental illness.

[]{.mark}

[]{.mark}

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_

Signature of the chief executive of the State, political

subdivision of the State, Indian tribe, or tribal organization Date

**Appendix C -- Summary of Evaluation Components**

The Technical Assistance and Policy Analysis (TAPA) Center for Jail
Diversion was awarded funding in 2002 by SAMHSA/CMHS to serve as a
national resource center for jail diversion program information,
research, technical assistance, and policy analysis. It also serves as a
coordinating center for the CMHS Jail Diversion Targeted Capacity
Expansion (TCE) Grant Program, which funded 10 programs in 2002, 7
programs in 2003, and 3 programs in 2004. In this capacity, the TAPA
Center designed and coordinates a multi-site evaluation of the CMHS Jail
Diversion TCE grantee programs.

The multi-site evaluation addresses the following types of questions of
interest to policy makers, researchers, and communities engaged in
developing programs:

-   What volume of activities (e.g. screening, assessment, evaluations)
    go into identifying people for diversion?

-   How many people are determined eligible/ineligible for jail
    diversion and what are their characteristics?

-   What services do people who are diverted receive?

-   Do people who are diverted improve over time in the following areas
    as a result of services received through the jail diversion program?

    -   Reduced arrests/less time spent in jail?

    -   Reduced substance use?

    -   Obtain housing?

    -   Report higher functioning?

    -   Improved mental health?

    -   Improved physical health?

SAMHSA/CMHS, the TAPA Center, and grantees (including evaluators,
program directors/staff, and consumer representatives) participated in
the design of the multi-site evaluation and selection of measures. The
TAPA Center provides grantee sites with trainings and supportive
materials on each evaluation component as well as human subjects
protections.

Grantees are required to comply with human subjects protection
regulations. This entails the following activities:

-   Filing a Federalwide Assurance with the Office of Human Research
    Projections (OHRP) at the Department of Health and Human Services
    designating an Institutional Review Board (IRB);

-   Obtaining IRB approval for the evaluation;

-   Prisoner certification by the IRB and obtaining approval thereof
    from OHRP;

-   Obtaining informed consent from evaluation participants

-   Assuring that participant information is kept confidential by:

    -   training interviewers to keep all information obtained
        confidential

    -   obtaining releases from participants, where appropriate, that
        comply with state and federal law, including HIPAA

    -   Requesting a Certificate of Confidentiality from SAMHSA

The TAPA Center provides in-depth training by conference call about
human subject protections to all grantees.

The following sources of data are included in the TAPA-coordinated
evaluation of the jail diversion TCE programs and are described below:

-   Events Program

-   Person Tracking Program

-   Baseline, 6-Month, and 12-Month Interviews

-   Service use data

-   Arrest data

**[Events Program]{.underline}**

The Events Program is designed to capture the volume of activities
("events") that jail diversion programs engage in to determine whom the
program will serve. These activities/events include screenings,
assessments, evaluations and court decisions. Basic information about
each event is recorded in a Microsoft Access database provided to the
grantees by the TAPA Center. The following non-identifying information
is included: demographics; charge level and category; and whether the
individual is determined to be eligible/ineligible as a result of each
event.

Grantees send data extracts from this program to the TAPA Center on a
bi-monthly basis.

**[Person Tracking Program]{.underline}**

The Person Tracking Program is designed to record basic information on
all individuals who are diverted and served with grant funds, and to
help grantees keep track of interview dates for those program
participants who agree to take part in the evaluation (see "Interview"
section below).

The following types of information about jail diversion program
participants is recorded in a Microsoft Access database provided to
grantees by the TAPA Center:

-   Demographics

-   Diagnosis

-   Charge level and category

-   Point of diversion (e.g. pre-booking, post-booking, probation
    violation)

-   Condition of diversion (e.g. charges not filed, deferred
    prosecution, condition of bail, etc.)

-   Target arrest/incident date, jail release date, program enrollment
    date

-   Status in the evaluation

For those individuals who consent to participate in the evaluation, the
Person Tracking Program assists grantees in keeping track of which
interviews have been completed or pending. The Person Tracking Program
calculates and displays the allowable window of dates within which the
interviews are to be completed. The Person Tracking Program also
contains fields for participant contact information to facilitate the
location of individuals for follow-up interviews.

Grantees submit bi-monthly data extracts, stripped of identifying
information, to the TAPA Center.

**[Interviews]{.underline}**

Each jail diversion program participant should be approached to request
their consent for participation in the evaluation. Participants who
grant consent are interviewed at Baseline (within 7 days of enrollment
into the jail diversion program), at 6 months from the Baseline
interview (within a 60-day window) and at 12 months (within a 60-day
window. The interviews take approximately 45 minutes to administer.
While program staff may administer Baseline interviews, only evaluation
staff who are not in any way involved in providing services to program
participants may administer follow-up interviews. Data from these
interviews (and from other evaluation components) are collected for
evaluation purposes only and may not be used for program-related
purposes.

The main component of the Baseline, 6- and 12-month interviews are
Government Performance and Results Act (GPRA) measures, which include
the following areas (self-report):

-   Demographics

-   Drug and alcohol use

-   Family and living conditions

-   Education, employment and income

-   Crime and criminal justice status

-   Mental and physical health problems and treatment

In addition, the interviews include the following additional measures:

-   Community Connections trauma scale to gauge traumatic events in the
    past year and lifetime (Baseline only)

-   Colorado Symptom Index to gauge symptoms of mental illness (all
    interviews)

-   Perceived coercion to enter jail diversion program (Baseline only)

-   Mental Health Statistics Improvement Program quality of life
    measures (6 and 12 months only)

-   Service use (6 and 12 months only)

Grantees mail the interview instruments to the TAPA Center for data
entry. Data are returned periodically to the grantees.

[Service Use]{.underline}

In addition to self-reported service use, grantees must collect
information from official sources, such as statewide/agency management
information systems or other agency records, about the following types
of services received following diversion:

-   Psychiatric emergency room (ER)

-   Other crisis services

-   Psychiatric inpatient/hospital

-   Mental health and substance abuse outpatient services

-   Case management

-   Medication management/monitoring

-   Residential treatment/community living arrangements

-   Detoxification

-   Vocational/rehabilitation

-   Community support

-   Jail services

These data are recorded on a data collection form designed by the TAPA
Center. Data on all services received in the 6 months following
diversion are required. ER and hospitalization episodes must also be
collected for 1 year following diversion.

[Arrest and Jail Days Data]{.underline}

Grantees must collect arrest and jail days data from officials sources,
such as a statewide criminal justice database. These data are recorded
on a data collection form designed by the TAPA Center. Grantees record
data on each arrest (and the jail days associated with those arrests)
that occurred during the period of 1 year prior to jail diversion and
the period of 1 year following jail diversion.

**Appendix D-- Glossary**

[]{.mark}

**[Best Practice:]{.underline}** Best practices are practices that
incorporate the best objective information currently available from
recognized experts regarding effectiveness and acceptability.

**[Catchment Area:]{.underline}** A catchment area is the geographic
area from which the target population to be served by a program will be
drawn.

**[Cooperative Agreement:]{.underline}** A cooperative agreement is a
form of Federal grant. Cooperative agreements are distinguished from
other grants in that, under a cooperative agreement, substantial
involvement is anticipated between the awarding office and the recipient
during performance of the funded activity. This involvement may include
collaboration, participation, or intervention in the activity. HHS
awarding offices use grants or cooperative agreements (rather than
contracts) when the principal purpose of the transaction is the transfer
of money, property, services, or anything of value to accomplish a
public purpose of support or stimulation authorized by Federal statute.
The primary beneficiary under a grant or cooperative agreement is the
public, as opposed to the Federal Government.

**[Cost Sharing or Matching:]{.underline}** Cost-sharing refers to the
value of allowable non-Federal contributions toward the allowable costs
of a Federal grant project or program. Such contributions may be cash or
in-kind contributions. For SAMHSA grants, cost-sharing or matching is
not required, and applications will not be screened out on the basis of
cost-sharing.  However, applicants often include cash or in-kind
contributions in their proposals as evidence of commitment to the
proposed project. This is allowed, and this information may be
considered by reviewers in evaluating the quality of the application.

**[Fidelity:]{.underline}** Fidelity is the degree to which a specific
implementation of a program or practice resembles, adheres to, or is
faithful to the best practice model on which it is based. Fidelity is
formally assessed using rating scales of the major elements of the best
practice model. A toolkit on how to develop and use fidelity instruments
is available from the SAMHSA-funded Evaluation Technical Assistance
Center at [http://tecathsri.org](http://tecathsri.org/) or by calling
(617) 876-0426.

**[Grant:]{.underline}** A grant is the funding mechanism used by the
Federal Government when the principal purpose of the transaction is the
transfer of money, property, services, or anything of value to
accomplish a public purpose of support or stimulation authorized by
Federal statute. The primary beneficiary under a grant or cooperative
agreement is the public, as opposed to the Federal Government.

**[In-Kind Contribution]{.underline}**: In-kind contributions toward a
grant project are non-cash contributions (e.g., facilities, space,
services) that are derived from non-Federal sources, such as State or
sub-State non-Federal revenues, foundation grants, or contributions from
other non-Federal public or private entities.

**[Logic Model:]{.underline}** A logic model is a diagrammatic
representation of a theoretical framework. A logic model describes the
logical linkages among program resources, conditions, strategies,
short-term outcomes, and long-term impact.

**[Practice]{.underline}:** A practice is any activity, or collective
set of activities, intended to improve outcomes for people with or at
risk for substance abuse and/or mental illness. Such activities may
include direct service provision, or they may be supportive activities,
such as efforts to improve access to and retention in services,
organizational efficiency or effectiveness, community readiness,
collaboration among stakeholder groups, education, awareness, training,
or any other activity that is designed to improve outcomes for people
with or at risk for substance abuse or mental illness.

**[Practice Support System]{.underline}:** This term refers to
contextual factors that affect practice delivery and effectiveness in
the pre-adoption phase, delivery phase, and post-delivery phase, such as
a) community collaboration and consensus building, b) training and
overall readiness of those implementing the practice, and c) sufficient
ongoing supervision for those implementing the practice.

#### Stakeholder: A stakeholder is an individual, organization, constituent group, or other entity that has an interest in and will be affected by a proposed grant project.

**[Sustainability:]{.underline}** Sustainability is the ability to
continue a program or practice after SAMHSA grant funding has ended.

**[Target Population:]{.underline}** The target population is the
specific population of people whom a particular program or practice is
designed to serve or reach.

**[Wraparound Service:]{.underline}** Wraparound services are
non-clinical supportive services---such as child care, vocational,
educational, and transportation services---that are designed to improve
the individual's access to and retention in the proposed project.

### Appendix E - National Registry of Effective Programs and Practices

To help SAMHSA's constituents learn more about science-based programs,
SAMHSA's Center for Substance Abuse Prevention (CSAP) created a National
Registry of Effective Programs and Practices (NREPP) to review and
identify effective programs. NREPP seeks candidates from the practice
community and the scientific literature. While the initial focus of
NREPP was substance abuse prevention programming, NREPP has expanded its
scope and now includes prevention and treatment of substance abuse and
of co-occurring substance abuse and mental disorders, and
psychopharmacological programs and workplace programs.

NREPP includes three categories of programs: Effective Programs,
Promising Programs, and Model Programs. Programs defined as Effective
have the option of becoming Model Programs if their developers choose to
take part in SAMHSA dissemination efforts. The conditions for making
that choice, together with definitions of the three major criteria, are
as follows.

[**Promising
Programs**](http://modelprograms.samhsa.gov/template_cf.cfm?page=promising_list)
have been implemented and evaluated sufficiently and are scientifically
defensible. They have positive outcomes in preventing substance abuse
and related behaviors. However, they have not yet been shown to have
sufficient rigor and/or consistently positive outcomes required for
Effective Program status. Nonetheless, Promising Programs are eligible
to be elevated to Effective/Model status after review of additional
documentation regarding program effectiveness. Originated from a range
of settings and spanning target populations, Promising Programs can
guide prevention, treatment, and rehabilitation.

[**Effective
Programs**](http://modelprograms.samhsa.gov/template_cf.cfm?page=effective_list)
are well-implemented, well-evaluated programs that produce consistently
positive pattern of results (across domains and/or replications).
Developers of Effective Programs have yet to help SAMHSA/CSAP
disseminate their programs, but may do so themselves.

[**Model
Programs**](http://modelprograms.samhsa.gov/template_cf.cfm?page=model_list)
are also well-implemented, well-evaluated programs, meaning they have
been reviewed by NREPP according to rigorous standards of research.
Their developers have agreed with SAMHSA to provide materials, training,
and technical assistance for nationwide implementation. That helps
ensure the program is carefully implemented and likely to succeed.

Programs that have met the NREPP standards for each category can be
identified by accessing the NREPP Model Programs Web site at
[www.modelprograms.samhsa.gov](http://www.modelprograms.samhsa.gov/).

**Appendix F - Evidence-Based Practices:\
Shaping Mental Health Services Toward Recovery**

The Substance Abuse and Mental Health Services Administration (SAMHSA)
and its Center for Mental Health Services (CMHS) are pleased to
introduce six Evidence-Based Practice Implementation Resource Kits to
encourage the use of evidence-based practices in mental health.

1.  Illness Management and Recovery

2.  Medication Management Approaches in Psychiatry

3.  Assertive Community

4.  TreatmentFamily Psychoeducation

5.  Supported Employment

6.  Co-occurring Disorders: Integrated Dual Diagnosis Treatment

The Kits were developed as one of several SAMHSA/CMHS activities
critical to its science-to-services strategy and can be found at
**[http://www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/default.asp.]{.underline}**

The Kits contain many useful resources, including:

-   Information Sheets for all stakeholder groups

-   Introductory videos

-   Practice demonstration videos

-   Workbook or manual for Practitioners

Each of the six Resource Kits is described below.

**Illness Management and Recovery**

The Illness Management and Recovery program strongly emphasizes helping
people to set and pursue personal goals and to implement action
strategies in their everyday lives. The information and skills taught in
the program include:

-   Recovery strategies

-   Practical facts about mental illness

-   The Stress-Vulnerability Model and strategies for treatment

-   Building social support

-   Using medication effectively

-   Reducing relapses and coping with stress

-   Coping with problems and symptoms

-   Getting needs met in the mental health system

**Medication Management Approaches in Psychiatry**

The Medication Management Approaches in Psychiatry program focuses on
using medication in a systematic and effective way, as part of the
overall treatment for severe mental illness. The ultimate goal is to
ensure that medications are prescribed in a way that supports a person's
recovery efforts. The program includes:

-   Guidelines and steps for medication decision making, based on
    current Evidence and outcomes

-   Systematic monitoring and record keeping of medications

-   Consumer and family member Involvement

**Assertive Community Treatment**

The goal of Assertive Community Treatment is to help people stay out of
the hospital and to develop skills for living in the community, so that
their mental illness is not the driving force in their lives. Assertive
community treatment offers services that are customized to the
individual needs of the consumer, delivered by a team of practitioners,
and available 24 hours a day. The program addresses needs related to:

-   Symptom management

-   Housing

-   Finances

-   Employment

-   Medical care

-   Substance abuse

-   Family life

-   Activities of daily life

**Family Psychoeducation**

Family Psychoeducation involves a partnership among consumers, families
and supporters, and practitioners. Through relationship building,
education, collaboration, problem solving, and an atmosphere of hope and
cooperation, family psychoeducation helps consumers and their families
and supporters to:

-   Learn about mental illness

-   Master new ways of managing their mental illness

-   Reduce tension and stress within the family

-   Provide social support and encouragement to each other

-   Focus on the future

-   Find ways for families and supporters to help consumers in their
    recovery

# 

# Supported Employment 

# Supported Employment is a well-defined approach to helping people with mental illnesses find and keep competitive employment within their communities. Supported employment programs are staffed by employment specialists who have frequent meetings with treatment providers to integrate supported employment with mental health services. The core principles of this program include:

-   Eligibility based on consumer choices and preferences

-   Supported employment as an integrated treatment

-   Continuous follow-along supports

-   Help with moving beyond the patient role and developing new
    employment-related Roles as part of the recovery process

**Co-occurring Disorders: Integrated Dual Diagnosis Treatment**

Integrated Dual Diagnosis Treatment is for people who have co-occurring
disorders, mental illness and a substance abuse addiction. This
treatment approach helps people recover by offering both mental health
and substance abuse services at the same time and in one setting.

This approach includes:

-   Individualized treatment, based on a person's current stage of
    recovery

-   Education about the illness

-   Case management

-   Help with housing

-   Money management

-   Relationships and social support

-   Counseling designed especially for people with co-occurring
    disorders

### Appendix G -- Logic Model Resources

Chen, W.W., Cato, B.M., & Rainford, N. (1998-9). Using a logic model to

plan and evaluate a community intervention program: A case study.
*International Quarterly of Community Health Education*, *18*(4),
449-458.

Edwards, E.D., Seaman, J.R., Drews, J., & Edwards, M.E. (1995). A
community approach for Native American drug and alcohol prevention
programs: A logic model framework. *Alcoholism Treatment Quarterly*,
*13*(2), 43-62.

Hernandez, M. & Hodges, S. (2003). *Crafting Logic Models for Systems of
Care: Ideas into Action*. \[Making children's mental health services
successful series, volume 1\]. Tampa, FL: University of South Florida,
The Louis de la Parte Florida Mental Health Institute, Department of
Child & Family Studies.
[http://cfs.fmhi.usf.edu](http://cfs.fmhi.usf.edu/) or phone (813)
974-4651

Hernandez, M. & Hodges, S. (2001). Theory-based accountability. In M.
Hernandez & S. Hodges (Eds.), *Developing Outcome Strategies in
Children\'s Mental Health*, pp. 21-40. Baltimore: Brookes.

Julian, D.A. (l997). Utilization of the logic model as a system level
planning and evaluation device. *Evaluation and Planning,* *20*(3),
251-257.

Julian, D.A., Jones, A., & Deyo, D. (1995). Open systems evaluation and
the

logic model: Program planning and evaluation tools. *Evaluation and
Program*

*Planning,* *18*(4), 333-341.

Patton, M.Q. (1997). *Utilization-Focused Evaluation* (3^rd^ Ed.), pp.
19, 22,

241\. Thousand Oaks, CA: Sage.

Wholey, J.S., Hatry, H.P., Newcome, K.E. (Eds.) (1994). *Handbook of
Practical Program Evaluation.* San Francisco, CA: Jossey-Bass Inc.

**Appendix H -- Part 3 Sample Budget and Justification**

**ILLUSTRATION OF A SAMPLE DETAILED BUDGET AND**

**NARRATIVE JUSTIFICATION TO ACCOMPANY**

**SF 424A: SECTION B FOR 01 BUDGET PERIOD**

**[OBJECT CLASS CATEGORIES]{.underline}**

**[Personnel]{.underline}**

**Job Annual Level of Salary being**

**Title** **Name Salary Effort Requested**

Project

Director J. Doe \$30,000 1.0 \$30,000

Secretary Unnamed \$18,000 0.5 \$ 9,000

Counselor R. Down \$25,000 1.0 \$25,000

> **Enter Personnel subtotal on 424A, Section B, 6.a. \$64,000**

**[Fringe Benefits]{.underline}** (24%) \$15,360

> **Enter Fringe Benefits subtotal on 424A, Section B, 6.b. \$15,360**

**[Travel]{.underline}**

2 trips for SAMHSA Meetings for 2 Attendees

(Airfare @ \$600 x 4 = \$2,400) + (per diem

@ \$120 x 4 x 6 days = \$2,880) \$5,280

Local Travel (500 miles x .24 per mile) 120

> **Enter Travel subtotal on 424A, Section B, 6.c. \$ 5,400**

**[Equipment]{.underline}** (List Individually)

> \"Equipment\" means an article of nonexpendable, tangible personal
> property having a useful life of more than one year and an acquisition
> cost which equals the lesser of (a) the capitalization level
> established by the governmental unit or nongovernmental applicant for
> financial statement purposes, or (b) \$5000.

**Enter Equipment subtotal on 424A, Section B, 6.d.**

**[Supplies]{.underline}**

Office Supplies \$500

Computer Software - 1 WordPerfect 500

**Enter Supplies subtotal on 424A, Section B, 6.e. \$1,000**

ILLUSTRATION OF DETAILED BUDGET AND NARRATIVE JUSTIFICATION (cont'd.)

**[Contractual Costs]{.underline}**

**Evaluation**

Job Name Annual Salary being Level of

Title Salary Requested Effort

Evaluator J. Wilson \$48,000 \$24,000 0.5

Other Staff \$18,000 \$18,000 1.0

Fringe Benefits (25%) \$10,500

**Travel**

2 trips x 1 Evaluator

(\$600 x 2) \$ 1,200

per diem @ \$120 x 6 720

Supplies (General Office) 500

Evaluation Direct \$54,920

Evaluation Indirect Costs (19%) \$10,435

Evaluation Subtotal \$65,355

**Training**

Job Name Level of Salary being

Title Effort Requested

Coordinator M. Smith 0.5 \$ 12,000

Admin. Asst. N. Jones 0.5 \$ 9,000

Fringe Benefits (25%) \$ 5,250

**Travel**

2 Trips for Training

Airfare @ \$600 x 2 \$ 1,200

Per Diem \$120 x 2 x 2 days 480

Local (500 miles x .24/mile) 120

**Supplies**

Office Supplies \$ 500

Software (WordPerfect) 500

**Other**

Rent (500 Sq. Ft. x \$9.95) \$ 4,975

Telephone 500

Maintenance (e.g., van) \$ 2,500

Audit \$ 3,000

Training Direct \$ 40,025

Training Indirect \$ -0-

**Enter Contractual subtotal on 424A, Section B, 6.f. \$105,380**

ILLUSTRATION OF DETAILED BUDGET AND NARRATIVE JUSTIFICATION (cont'd.)

**[Other]{.underline}**

Consultants = Expert @ \$250/day X 6 day \$ 1,500

(If expert is known, should list by name)

**Enter Other subtotal on 424A, Section B, 6.h. \$ 1,500**

**Total Direct Charges (sum of 6.a-6.h)**

**Enter Total Direct on 424A, Section B, 6.i. \$192,640**

**[Indirect Costs]{.underline}**

15% of Salary and Wages (copy of negotiated

indirect cost rate agreement attached)

**Enter Indirect subtotal of 424A, Section B, 6.j. \$ 9,600**

**[TOTALS]{.underline}**

**Enter TOTAL on 424A, Section B, 6.k. \$202,240**

**[JUSTIFICATION]{.underline}**

PERSONNEL - Describe the role and responsibilities of each position.

FRINGE BENEFITS - List all components of the fringe benefit rate.

EQUIPMENT - List equipment and describe the need and the purpose of the
equipment in relation to the proposed project.

SUPPLIES - Generally self-explanatory; however, if not, describe need.
Include explanation of how the cost has been estimated.

TRAVEL - Explain need for all travel other than that required by SAMHSA.

CONTRACTUAL COSTS - Explain the need for each contractual arrangement
and how these components relate to the overall project.

OTHER - Generally self-explanatory. If consultants are included in this
category, explain the need and how the consultant's rate has been
determined.

INDIRECT COST RATE - If your organization has no indirect cost rate,
please indicate whether your organization plans to a) waive indirect
costs if an award is issued, or b) negotiate and establish an indirect
cost rate with DHHS within 90 days of award issuance.

[CALCULATION OF FUTURE BUDGET PERIODS]{.underline}

[(based on first 12-month budget period)]{.underline}

Review and verify the accuracy of future year budget estimates.
Increases or decreases in the future years must be explained and
justified and no cost of living increases will be honored. (NOTE: new
salary cap of \$175,700 is effective for all FY 2005 awards.) \*

First Second Third

12-month 12-month 12-month

Period Period Period

Personnel

Project Director 30,000 30,000 30,000

Secretary\*\* 9,000 18,000 18,000

Counselor 25,000 25,000 25,000

TOTAL PERSONNEL 64,000 73,000 73,000

\*Consistent with the requirement in the Consolidated Appropriations
Act, Public Law 108-199.

\*\*Increased from 50% to 100% effort in 02 through 03 budget periods.

Fringe Benefits (24%) 15,360 17,520 17,520

Travel 5,400 5,400 5,400

Equipment -0- -0- -0-

Supplies\*\*\* 1,000 520 520

\*\*\*Increased amount in 01 year represents costs for software.

Contractual

Evaluation\*\*\*\* 65,355 67,969 70,688

Training 40,025 40,025 40,025

\*\*\*\*Increased amounts in 02 and 03 years are reflected of the
increase in client data collection.

Other 1,500 1,500 1,500

Total Direct Costs 192,640 205,934 208,653

Indirect Costs 9,600 9,600 9,600

(15% S&W)

TOTAL COSTS 202,240 216,884 219,603

The Federal dollars requested for all object class categories for the
first 12-month budget period are entered on Form 424A, Section B, Column
(1), lines 6a-6i. The [total]{.underline} Federal dollars requested for
the second through the fifth 12-month budget periods are entered on Form
424A, Section E, Columns (b) -- (e), line 20. The RFA will specify the
maximum number of years of support that may be requested.

**Appendix I - Schematic Outline of the Criminal Justice Processing
Spectrum**