**Administration on Aging**

**Application Guidelines for Title VI Grants**

**Date Due: 0/0/2008**

*Your 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/B and Section 631 for Title VI,
Part C. Your application must also meet the criteria specified in Title
45 of the Code of Federal Regulations, Section 1326.19. The following
guide may be helpful in drafting your application.*

[Table of Contents and Application Checklist]{.underline}

  ----------------------------------- ------------------ ----------------
  **Item**                            **Found on         **Completed?**
                                      page...**          

  Program information                 3                  

  Required Attachments                4                  

  Management Assessment               5-6                

  Program Description: Part A/B       7-12               

  Program Description: Part C         13-17              
  ----------------------------------- ------------------ ----------------

[Program Information]{.underline}

Tribal Organization:

Address:

Title VI Director/Contact Person:

Phone number: Fax Number:

Email address:

EIN: DUNS Number:

Principle Official Signature:

Age of eligibility used by Tribe:

*Only eligible elders age 60 and older will be counted when determining
your grant allocation. Elders under age 60 can participate in your
program if your Tribe has determined a different age for eligibility,
but they will not be counted toward your authorized total.*

Number of eligible elders within the planned service area:

Age 60 and older:

Under age 60 (*if applicable*):

Total:

Source of population statistics used to establish eligibility \[Section
614 (b)\]:

U.S. Census

Tribal Enrollment Office *(If you use this source, please include
original enrollment certification with all other attachments.)*

[Required Attachments to the Application]{.underline}

**Geographic Location** (suggested length: 5-10 paragraphs)**:** Sec.
1326.19 of the Older Americans Act states that: "All applications shall
include a description of the geographic boundaries of the service area
proposed by the tribal organization." Please provide a short narrative
description of the geographical area to be served. Specify how many
counties your program covers and include the names of the counties. You
may submit a map indicating the geographic boundaries of your program's
service area. Finally, include a description of your program's
procedures that ensure against duplication of services to elders.

**Resolutions:** The tribal organization representing a
Federally-recognized Tribe must submit a **signed and dated 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, 2008
to March 31, 2011. 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, 2008 to March 31, 2011.

**Program Assurances:** The Title VI, Part A/B Program Assurances are
those provisions identified in Section 614 (a) of the Older Americans
Act, and in the Title 445 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
period, April 1, 2008 to March 31, 2011.

**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 (typically the
Chairperson of your tribe) must attest to the applicant's compliance
with these certifications by signing and dating the forms.

[Management Assessment]{.underline}

*The following five questions are designed to help you think about how
you can most successfully manage your program, your budget and ensure
accurate reporting.*

1\) Please describe the results obtained from your program's needs
assessment:

2\) Please describe the results and benefits you expect from your Title
VI program(s):

3\) Please describe how you plan to evaluate your program, and how
often:

4\) Please describe any financial systems your program has in place to
ensure correct use of Title VI funds:

5\) Please describe your system of record keeping (how you ensure an
unduplicated count of elders, how you keep track of home-delivered meals
or information services, etc.):

[Program Description: Nutrition & Supportive Services]{.underline}

[Section A: Nutrition]{.underline}

1\) Will the tribal organization provide nutrition services directly? ⁭
Yes ⁭ No

1a) If no, who will provide nutrition services?

> ⁭ Other Tribal Department
>
> ⁭ Outside Contracted Vendor
>
> ⁭ Outside Service Agency
>
> ⁭ Other:

[Congregate Meal program]{.underline}

2\) How many meal sites does your program operate?

> ⁭ 1 ⁭ 2 ⁭ 3 ⁭ 4 ⁭ 5 or more

3\) How many days per week, and what meals are provided at each site?

  ---------- ------------- --------------- ----------- ------------ -----------
  **Site**   **Number of   **Breakfast**   **Lunch**   **Dinner**   **Snack**
             days meals                                             
             are served**                                           

  1                        ⁭                ⁭            ⁭             ⁭

  2                        ⁭                ⁭            ⁭             ⁭

  3                        ⁭                ⁭            ⁭             ⁭

  4                        ⁭                ⁭            ⁭             ⁭

  5                        ⁭                ⁭            ⁭             ⁭
  ---------- ------------- --------------- ----------- ------------ -----------

4\) Do you require elders to register for congregate meals in advance?

> ⁭ Yes ⁭ No

5\) How many **elders** do you expect to serve?

> Per day:
>
> Per week:
>
> Per year:

7\) How many **guests** (spouses of elders, volunteers, etc.) do you
expect to serve?

> Per day:
>
> Per week:
>
> Per year:

8\) How many **meals** do you expect to serve? Include meals served to
elders, spouses of elders, and volunteers in this count.

> Per year:

[Home-Delivered Meal Program]{.underline}

9\) How will you determine eligibility for home-delivered meals?

> ⁭ Individual assessment ⁭ Referral by medical
>
> ⁭ Other:

10\) What meals will be provided for home delivery?

> ⁭ Breakfast ⁭ Lunch ⁭ Dinner ⁭ Snack

11\) What type of home-delivered meals will be provided?

⁭Hot ⁭ Frozen ⁭ Other:

12\) How many days per week will home delivery occur?

13\) How will meals be delivered?

> ⁭ Tribally-owned vehicle ⁭ Private vehicle
>
> ⁭ Contracted vendor ⁭ Other:

14\) Do you require elders to register for home-delivered meals in
advance?

> ⁭ Yes ⁭ No

15\) How many **elders** do you expect to serve?

Per day:

Per week:

Per year:

16\) How many **meals** do you expect to serve? Include meals served to
spouses of home-bound elders.

Per year:

[Guest Meals & Contributions]{.underline}

17\) Do you offer guest meals? ⁭ Yes ⁭ No

18\) What do you charge for guest meals?

19\) How do you ensure that the price charged for guest meals includes
the full cost of the meal?

⁭Periodic cost analysis

⁭Other:

20\) How do you ensure that the money collected from guest meals is used
to pay for food costs?

> ⁭ Policy or Procedure manual ⁭ Separate budget
>
> ⁭ Other:

21\) How do you collect guest meal fees?

⁭Collection container at meal site ⁭ Sealed envelope

⁭Other:

22\) Do you accept other types of contributions? ⁭ Yes ⁭ No

22 a) If yes, what other contributions do you accept?

> ⁭ Financial donations from the Tribe to Title VI
>
> ⁭ Volunteer hours
>
> ⁭ Outside food donation (from food bank, American Indian Relief
> Council, store)
>
> ⁭ Traditional food (deer,berries,salmon,etc)
>
> ⁭ Other:

[Nutrition Supportive Services]{.underline}

23\) Do you provide nutrition screening? ⁭ Yes ⁭ No

23 a) If yes, how often? ⁭ Annually ⁭ Other:

23 b) Who provides the screening?

> ⁭ Title VI staff ⁭ IHS staff ⁭ Other tribal staff
>
> ⁭ Outside agency ⁭ Other:

24\) Do you provide nutrition education/counseling? ⁭ Yes ⁭ No

24 a) If yes, how often? ⁭ Weekly ⁭ Other:

24 b) Who provides the screening?

> ⁭ Title VI staff ⁭ IHS staff ⁭ Other tribal staff
>
> ⁭ Outside agency ⁭ Other:

25\) How will you inform elders of the available nutrition services?

  ----------------------- ----------------------- -----------------------
  ⁭Tribal newsletter       ⁭Posters                 ⁭Tribal bulletin board

  ⁭Referral                ⁭At congregate meal site ⁭Mail

  ⁭Website                 ⁭Phone                   ⁭Word of mouth

  ⁭Brochure                ⁭Information guide       ⁭Case Manager

  ⁭Attached to home meals  ⁭Senior Center Staff     

  ⁭Other:                                          
  ----------------------- ----------------------- -----------------------

26\) Do you use volunteers? ⁭ Yes ⁭ No

26 a) If yes, what roles do volunteers serve?

> ⁭ Meal Preparation ⁭ Meal set-up ⁭ Clean-up
>
> ⁭ Meal Delivery ⁭ Assist as needed
>
> ⁭ Other:

27\) Who certifies that meals meet the Older Americans Act nutrition
requirements?

> ⁭ Contract Dietician ⁭ Other:

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

28\) What information & assistance services will be provided?

> ⁭ Information for elders about government programs (Food assistance
> programs, Social Security, Supplemental Security Income, LIHEAP, etc.)
>
> ⁭ Information for family members about elder services
>
> ⁭ Assistance in completing applications for services
>
> ⁭ Education about programs and services
>
> ⁭ Other:

28 a) How many units of information and assistance services will you
provide per year?

29\) How will information & assistance services be provided?

> ⁭ Resource guide ⁭ Newsletter ⁭ Guest Speakers
>
> ⁭ Resource fairs ⁭ Web page link ⁭ Health fairs
>
> ⁭ At congregate meals/ during home delivery
>
> ⁭ Other:

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

30\) How many unduplicated elders will receive supportive services?

31\) What other supportive services will be provided? If you plan on
providing a service, how many units will you provide per year?

  ---------------------------------------------------- ------------------
  Service                                              Number of units
                                                       provided per year

  ⁭Outreach                                             

  ⁭Case Management                                      

  ⁭Transportation                                       

  ⁭Legal Assistance                                     

  ⁭Homemaker Service                                    

  ⁭Home Health Aid Service                              

  ⁭Chore                                                

  ⁭Visiting                                             

  ⁭Telephoning                                          

  ⁭Family Support                                       

  ⁭Ombudsman Services                                   

  ⁭Health Promotion and Wellness                        

  ⁭Other (describe service(s)):                         
  ---------------------------------------------------- ------------------

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

32\) How does your program coordinate Title VI and III resources within
your service area?

⁭Regular meetings ⁭ Joint conferences

⁭Shared service providers ⁭ Membership on advisory board

⁭Guest speakers ⁭ Shared resources

⁭Co-development of resource guide

⁭Other:

*Please continue to questions 33-46 if you are applying for Title VI,
Part C (Caregiver) funds. If not, you may stop here and add any
additional pages containing program narratives.*

[Program Description: Caregiver Supportive Services]{.underline}

By accepting Title VI, Part C funding, you agree to provide the
following five caregiver services: Information, Assistance,
Counseling/Support Groups/Training, Supplemental Services, and Respite.
However, if the service is already available from another source in your
service are, Title VI funds should not be used to duplicate the service.

33\) Please complete the following chart:

34\) What topics will your caregiver information services cover?

⁭Accessing services available to them

⁭Physical health, including physical activity

⁭Mental health

⁭Other:

35\) How will you provide the information?

⁭Newsletters ⁭ Website ⁭ Telephone ⁭ Referrals

⁭Bulletin board ⁭ Meetings ⁭ Mailings

⁭Other:

36\) What assistance will you provide?

⁭Case management ⁭ Transportation

⁭Arranging appointments for caregiver services

⁭Other:

37\) Who will provide the assistance?

⁭Title VI Staff ⁭ AAA ⁭ IHS Staff

⁭Other Tribal Department/Agency ⁭ Non-tribal service provider

⁭Other:

38\) How will you notify caregivers about assistance services?

⁭Ads at the Title VI Site

⁭Outreach (phone calls, newsletters, mailings)

⁭Other:

39\) Which services will you provide to caregivers? (Check more than one
if necessary.)

⁭Counseling

⁭Support Groups

⁭Training

40\) What type of supplemental services will you provide to caregivers?

⁭Lending closet

⁭Development of culturally-appropriate training materials

⁭Other:

41\) What type of respite services will you provide to caregivers?

⁭Intermittent in-home care ⁭ Adult daycare ⁭ Institutional

⁭Other:

42\) Who is an eligible respite provider?

⁭Spouse ⁭ Other family member ⁭ Friend

⁭Respite care provider designated by the Title VI program

⁭Other:

43\) How are respite providers compensated?

⁭No compensation

⁭Reimbursed for gasoline/mileage

⁭Voucher based on a set hourly fee

⁭Voucher for a set amount of money for a specific period of time

⁭Other:

44\) How will your program comply with the Older Americans Act
definition of "frail elder" (the elder has two or more impairments in
their activities of daily living (ADLs)?

⁭Assessment of elder by Title VI program staff

⁭Assessment of elder by medical staff

⁭Other:

45\) How will your program coordinate supportive services for
caregivers?

⁭Case manager ⁭ Shared trainings ⁭ Referrals

⁭AAA ⁭ Other Tribal programs

⁭Other:

46\) Does your program have quality standards in place? ⁭ Yes ⁭ No

46 a) If no, please tell us by what date you will have them in place and
how you plan on developing them:

*You have reached the end of the application. Please attach any program
narratives after this page.*