**U.S. Department of Health and Human Services**

**Health Resources and Services Administration**

**Maternal and Child Health Bureau**

> *Healthy Tomorrows Partnership for Children Program (HTPC)*

*HRSA-06-076*

*Catalog of Federal Domestic Assistance (CFDA) No. 93.110*

**PROGRAM GUIDANCE**

**NEW COMPETITIVE ANNOUNCEMENT**

Fiscal Year 2006 []{.mark}

**Application Due Date: September 12, 2005**

**Release Date: *July 25, 2005 ***

> Contact Name: Jose Belardo, JD, MSW
>
> Titles, Offices: Director, HTPC; Division of Research Training and
> Education
>
> Telephone: (301) 443-0757/0757
>
> Fax: (301) 443-4842

Date of Issuance: July 25, 2005

> Authority: ***Social Security Act, Title V, § 501 (a) (2) and § 502
> (a) (1), 42 U.S.C. 701***

[]{.mark}

***EXECUTIVE SUMMARY and OVERVIEW***

***Healthy Tomorrows Partnership for Children Program (HTPC)***

Thank you for your interest in the **Healthy Tomorrows Partnership for
Children Program (HTPC) Competition.** Grant support is available from
the Division of Research, Training and Education (DRTE), part of the
Maternal and Child Health Bureau (MCHB) of the Health Resources and
Services Administration (HRSA) in the U.S. Department of Health and
Human Services (DHHS). We are aware that preparation of this application
will involve a considerable commitment of time and energy. **Please read
the guidance carefully before completing the application.**

**Purpose:**

The purpose of this program is to stimulate innovative community-based
programs that employ prevention strategies to promote access to health
care for children and their families nationwide. As stated above, HTPC
funding supports **direct service** projects, **not** research projects.

It is anticipated that **HTPC** grants will be awarded to approximately
**9** recipients. **The intent of HTPC grants are**: 1) to support the
development of family-centered, community-based initiatives that plan
and implement innovative and cost-effective approaches for focusing
resources to promote community defined preventive child health and
developmental objectives for vulnerable children and their families,
especially those with limited access to quality health services; 2)
foster/promote collaboration among community organizations, individuals,
agencies, businesses, and families; 3) involve pediatricians and other
pediatric health professionals in community-based service programs; and
4) build community and statewide partnerships among professionals in
health, education, social services, government, and business to achieve
self-sustaining programs to assure healthy children and families.

**Qualified Applicants:**

As cited in 42 CFR Part 51a.3 (a), any public or private entity,
including an Indian tribe or tribal organization (as defined at 25
U.S.C. 450b) is eligible to apply for Federal funding under this part.
Community-based organizations, including faith-based organizations, are
eligible to apply. An eligible applicant must have both direct fiduciary
and administrative responsibility over the project.

**Number of Grants and** **Funds Available Per Year:**

Up to \$450,000 is available to fund up to 9 HTPC grants per year
(\$50,000 available per grant, per year) for five years.

Project Period:

It is anticipated that approved projects will be funded effective March
1, 2006. Pending

availability of funds and adequate progress, project periods for the
grants under this competition

will be up to five years, starting March 1, 2006 and concluding on
February 28, 2011.

**Application Due Date:** September 12, 2005

**Programmatic Assistance**

Additional information related to the overall program issues or
technical assistance may be obtained by contacting:

Jose Belardo, JD, MSW

Maternal and Child Health Bureau

5600 Fishers Lane, Room 18A55, Rockville, MD 20857

Telephone: (301) 443-0757/0757; Fax: (301) 443-4842

E-Mail: jbelardo@hrsa.gov

**Business, Administrative and Fiscal Inquiries**

Applicants may obtain additional information regarding business,
administrative, or fiscal issues related to this grant announcement by
contacting:

> Theda P. Duvall
>
> Lead Grants Management Specialist
>
> HRSA, Division of Grants Management Operations
>
> 5600 Fishers Lane, Room 11A-16
>
> Rockville, Maryland 20857
>
> Telephone: 301-443-3414
>
> E-mail: <tduvall@hrsa.gov>
>
> Fax: 301-443-6686

**TABLE OF CONTENTS**

**Overview 2**

**Executive Summary 2**

**I. Funding Opportunity Description 6**

> 1\. Purpose 6
>
> 2\. Background 6

**II. Award Information 8**

Type of
Award.......................................................................................
8

> Summary of Funding 8

**III. Eligibility Information 8**

> 1\. Eligible Applicants 8
>
> 2\. Cost
> Sharing/Matching.........................................................8

**IV. APPLICATION and SUBMISSION INFORMATION 9**

1.  Address to Request Application Package 9

2.  Content and Form of Application Submission 10

> Application Format Requirements 10
>
> Application Format 11
>
> i\. Application Face Page 11
>
> ii\. Table of Contents 11
>
> iii\. Application Checklist 12
>
> iv\. Budget 12
>
> v\. Budget Justification 12
>
> vi\. Staffing Plan and Personnel Requirements 14
>
> vii\. Assurances 14
>
> viii\. Certifications 14

ix. Project Abstract 14

x.  Program Narrative 15

xi. Appendices 19

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3.  Submission Dates and Times 20

4.  Intergovernmental Review 21

5.  Funding Restrictions 21

6.  Other Submission Requirements 21

> Paper Submission 21
>
> Electronic Submission 22

**V. APPLICATION REVIEW INFORMATION 24**

1.  Review Criteria 24

2.  Review and Selection Process 26

**VI. AWARD ADMINISTRATION INFORMATION 26**

1.  Award Notices 26

2.  Administrative and National Policy Requirements 26

3.  Reporting 28

**VII. AGENCY CONTACTS 30**

**VIII. TIPS FOR WRITING A STRONG APPLICATION 31**

**Attachment a 32**

#### I. Funding Opportunity Description

**1. Purpose:**

> The purpose of this program is to stimulate innovative community-based
> programs that employ prevention strategies to promote access to health
> care for children and their families nationwide. As stated above, HTPC
> funding supports **direct service** projects, **not** research
> projects.
>
> It is anticipated that **HTPC** grants will be awarded to
> approximately **9** recipients. **The intent of HTPC grants are
> to**: 1) support the development of family-centered, community-based
> initiatives that plan and implement innovative and cost-effective
> approaches for focusing resources to promote community defined
> preventive child health and developmental objectives for vulnerable
> children and their families, especially those with limited access to
> quality health services; 2) foster/promote collaboration among
> community organizations, individuals, agencies, businesses, and
> families; 3) involve pediatricians and other pediatric health
> professionals in community-based service programs; and 4) build
> community and statewide partnerships among professionals in health,
> education, social services, government, and business to achieve
> self-sustaining programs to assure healthy children and families.

**2. Background :**

**Maternal and Child Health Bureau and Title V of the Social Security
Act:** In 1935, Congress enacted Title V of the Social Security Act
authorizing the Maternal and Child Health Services Programs. This
remarkable legislation has provided a foundation and structure for
assuring the health of mothers and children in our nation for more than
65 years. Title V was designed to improve health and assure access to
high quality health services for present and future generations of
mothers, infants, children and adolescents, including those with
disabilities and chronic illnesses, with special attention to those of
low income or with limited availability of health services.

> Today, Title V is administered by the Maternal and Child Health Bureau
> (MCHB) which is a part of the Health Resources and Services
> Administration (HRSA) in the U.S. Department of Health and Human
> Services (DHHS). Under Title V of the Social Security Act, the
> Maternal and Child Health Services Block Grant program has three
> components---Formula Block Grants to States, Special Projects of
> Regional and National Significance (SPRANS), and Community Integrated
> Service Systems (CISS) grants. Using these authorities, the MCHB has
> forged partnerships with States, the academic community, health
> professionals, advocates, communities and families to better serve the
> needs of our nation's children.
>
> The mission of MCHB is to provide national leadership and to work, in
> partnership with States, communities, public-private partners, and
> families to strengthen the maternal and child health (MCH)
> infrastructure, assure the availability of medical homes, and build
> the knowledge and human resources, in order to assure continued
> improvement in the health, safety, and well-being of the MCH
> population. The MCH population includes all America's women, infants,
> children, adolescents and their families, including fathers and
> children with special health care needs (CSHCN).
>
> The goals of MCHB are to:

1\) *Provide National Leadership for Maternal and Child Health***---**To
provide national leadership by creating a shared vision and goals for
MCH, strengthening the knowledge base, forging MCH partnerships,
promoting family participation in care and providing graduate level and
continuing education training to assure interdisciplinary MCH public
health leadership nationwide;

2\) *Eliminate Health Barriers and Disparities*---To develop and promote
health services and systems of care designed to eliminate disparities
and barriers across the MCH population and train an MCH workforce that
is culturally competent and reflects an increasingly diverse population;

3\) *Assure Quality of Care*---To build analytic capacity to assess and
assure quality of care, develop and promote health services and systems
designed to improve quality of care and assure appropriate follow-up
services; and

4\) *Improve the Health Infrastructure and Systems of Care*---To build
analytic capacity for assessment, planning and evaluation, to use the
best available evidence to develop and promote guidelines and best
practices, and assist states and communities to plan and develop
comprehensive, integrated health service systems.

> **The Healthy Tomorrows Partnership for Children Program (HTPC)**:
>
> The Healthy Tomorrows Partnership for Children Program (HTPC) is a
> collaborative partnership between the American Academy of Pediatrics
> (AAP) and the Maternal and Child Health Bureau (MCHB). In keeping with
> their commitment to attain optimal physical, mental, social and
> emotional health for all children and their families, the AAP has
> joined with the MCHB to strengthen their efforts to prevent disease,
> promote health and assure access to health care for this Nation\'s
> children and their families. The initiative utilizes the AAP\'s
> network of health professionals, including 59 State chapters and more
> than 55,000 child health experts in the United States.
>
> The HTPC grant program has been developed to support special projects
> that demonstrate how States, local agencies, organizations, businesses
> and communities can work together to improve the health status of
> children and their families. In some instances, the improvement in
> health status may be achieved through creative modifications in the
> health care system. By focusing upon the importance of prevention and
> the benefits of pediatric care, local and corporate leaders and
> governments, working as partners within their communities, will be
> able to develop creative approaches for improving the health of
> children and families in their community. HTPC funding supports
> **direct service** projects, **not** research projects. HTPC
> applicants **MUST** represent a **new** initiative (i.e., project that
> was not previously in existence) within the community or an innovative
> **and/or new component** that builds upon existing community
> resources.
>
> The HTPC is an initiative to stimulate innovative children's health
> care efforts designed to prevent disease and disability and promote
> health and access to health services in local communities across
> America. The HTPC will assist children and their families to achieve
> their developmental potentials through a community-based partnership
> of pediatric resources and community leadership. This partnership will
> promote efforts to meet the health and developmental needs of pregnant
> women, infants, children, and adolescents and children with special
> health care needs and their families. This initiative is designed to
> improve access to health care for the nation's medically needy
> children, while improving the quality and reducing the overall
> long-term costs of health care in America through health promotion,
> prevention and early intervention.

#### II. Award Information

**Type of Award**

Funds will be awarded as grants.

**Summary of Funding**

-   The HTPC will provide funding (pending availability of funds) during
    Federal fiscal years 2006 -2010. Projects will be awarded for up to
    five years.

-   **Approximately \$450,000 is expected to be available yearly to fund
    9 HTPC grantees (\$50,000 per grant, per year).**

-   Funding beyond the first year is dependent on the availability of
    appropriated funds, grantee satisfactory performance, and a decision
    that funding is in the best interest of the Federal government.

#### III. Eligibility Information

> **1. Eligible Applicants**
>
> As cited in 42 CFR Part 51a.3 (a), any public or private entity,
> including an Indian tribe or tribal organization (as defined at 25
> U.S.C. 450b) is eligible to apply for Federal funding under this part.
> Community-based organizations, including faith-based organizations,
> are eligible to apply. An eligible applicant must have both direct
> fiduciary and administrative responsibility over the project.
>
> Applicants must have or plan to establish an Advisory Board of
> individuals and organizations including, but not limited to, agencies
> responsible for administering block grant programs under Title V of
> the Social Security Act, consumers of project services, providers,
> local health departments, hospitals and health centers funded under
> Section 330 of the Public Health Service Act, community-based
> organizations, and other significant entities appropriate for
> participation in the project. Documentation of the existence of an
> Advisory Board meeting the requirements outlined above or plans to
> establish one that will meet these requirements must be included in
> the letter of transmittal for the submission with details in the
> project narrative of each application.
>
> **2. Cost Sharing/Matching**
>
> There is no cost sharing or matching requirement for this funding
> opportunity.

#### IV. Application and Submission Information

> **1. Address to Request Application Package**
>
> Applicants must submit proposals using the Application Form 5161.
> These forms contain additional general information and instructions
> for proposal narratives and budgets. The face sheet and budget forms,
> for PHS Application Form 5161, may be obtained by:
>
> []{.mark}
>
> \(a\) Downloading from <http://www.hrsa.gov/grants/forms.htm>
>
> Or
>
> \(b\) Contacting the HRSA Grants Application Center at:
>
> The Legin Group, Inc.
>
> 901 Russell Avenue, Suite 450
>
> Gaithersburg, MD 20879
>
> Telephone: 877-477-2123
>
> [<HRSAGAC@hrsa.gov>.]{.underline}
>
> Please specify CFDA #93.110, HRSA 06-076 on application materials for
> HTPC.
>
> Instructions for preparing portions of the application that must
> accompany Application Forms 5161 appear in the "Application Format"
> section below.
>
> **2. Content and Form of Application Submission**

**Application Format Requirements**

> If applying on paper, **the entire application may not exceed 80 pages
> in length**, including the abstract, project and budget narratives,
> attachments, any appendices and letters of commitment and support.
> Pages must be numbered consecutively.
>
> If applying on-line, the total size of all uploaded files may not
> exceed the equivalent of 80 pages when printed by HRSA, approximately
> 10 MB. This 80 page limit includes the abstract, project and budget
> narratives, attachments, appendices and letters of commitment and
> support.
>
> **Applications, whether submitted on paper or electronically, that
> exceed the specified limits (80 pages or approximately 10 MB, or that
> exceed 80 pages when printed by HRSA) will be deemed non-compliant. 
> All non-compliant applications will be returned to the applicant
> without further consideration.**  

a.  **Number of Copies (Paper Applications only):** Please submit
    one (1) original and two (2) unbound copies of the application.
    Please do not bind or staple the application. Application must be
    single sided.

> b\. **Font:** Please use an easily readable typeface, such as Times
> Roman, Courier, CG
>
> Times, or Arial. The text and table portions of the application must
> be submitted in not less than 12 point and 1.0 line spacing.
> Applications not adhering to 12 point font requirements may be
> returned.
>
> []{.mark}
>
> c\. **Paper Size and Margins:** For scanning purposes, please submit
> the application on 8 ½" x 11" white paper. Margins must be at least
> one (1) inch at the top, bottom, left and right of the paper. Please
> left-align text.
>
> d\. **Numbering:** Please number the pages of the application
> sequentially from page 1 (face page) to the end of the application,
> including charts, figures, tables, and appendices.
>
> e\. **Names:** Please include the name of the applicant on each page.
>
> f\. **Section Headings**: Please put all section headings flush left
> in bold type.
>
> **Completed Application Standard Forms and Budget Justification**
>
> In addition to completing the required application forms in the PHS
> 5161-1, there are specific requirements pertaining to the budget that
> must be completed.

**Application Format**

> Applications for funding must consist of the following documents in
> the following order:

**i. Application Face Page**

> Application Form 5161-1 is provided is provided with the application
> package. Prepare this page according to instructions provided in the
> form itself. For information pertaining to the Catalog of Federal
> Domestic Assistance, the Catalog of Federal Domestic Assistance Number
> is 93.110.
>
> **DUNS Number**
>
> All applicant organizations are required to have a Data Universal
> Numbering System (DUNS) number in order to apply for a grant from the
> Federal Government. The DUNS number is a unique nine-character
> identification number provided by the commercial company, Dun and
> Bradstreet. There is no charge to obtain a DUNS number. Information
> about obtaining a DUNS can be found at
> <http://www.hrsa.gov/grants/preview/dunsccr.htm> or call
> 1-866-705-5711. Please include DUNS number next to OMB Approval Number
> on the application face page. Application ***will not*** be reviewed
> without a DUNS number.
>
> Additionally, the applicant organization will be required to register
> with the Federal Government's Central Contractor Registry (CCR) in
> order to do business with the Federal Government, including
> electronic. Information about registering with the CCR can be found at
> <http://www.hrsa.gov/grants/preview/dunsccr.htm>.

**ii. Table of Contents**

> Provide a Table of Contents for the remainder of the application
> (including appendices), with page numbers.
>
> **iii Application Checklist**
>
> A complete application will include the following:

-   Letter of Transmittal indicating Program Name (Healthy Tomorrows)
    and announcement number, HRSA 06-076.

-   Face Page-Application for Federal Assistance Standard Form 424.

-   Table of Contents

-   Budget Information (Standard Form 424-A)

-   Budget Justification

-   Key Personnel Form

-   Federal Assurances (Standard Form 424-B)

-   Project Abstract

-   Program Narrative (not to exceed 30 pages, double space)

-   Appendices (not to exceed 48 pages)

> 1\. Required Performance Measures and Related Forms

2\. Organizational

a\. Position Descriptions for all Project staff

b\. Biographical Sketch of Key Personnel

3\. Project Organizational Chart

4\. Advisory Board/Coalition

a\. Membership Roster

5\. Collaboration

a\. Letter from State MCH Director

b\. Letter from State AAP President and/or Representative

c\. Letter from other MCH and/or collaborating agencies

6\. Other Relevant Forms

-   Diskette containing Abstract

    **iv. Budget**

> Use Application Form 5161-1; provided with the application package.
>
> Please complete Sections A, B, E, and F, and then provide a line item
> budget for each grant year using the budget categories in the SF 424A.

**v. Budget Justification**

> Provide a narrative that explains the amounts requested for each line
> in the budget. The budget justification should specifically describe
> how each item will support the achievement of proposed objectives. The
> budget period is for ONE year. However, the applicant must submit
> one-year budgets for each of the subsequent project period years (5
> years) at the time of application. Line item information must be
> provided to explain the costs. The budget justification must clearly
> describe each cost element and explain how each cost contributes to
> meeting the project's objectives/goals. Be very careful about showing
> how each item in the "other" category is justified. The budget
> justification MUST be concise. Do NOT use the justification to expand
> the project narrative.
>
> **Budget for Multi-Year Grant Award**
>
> This announcement is inviting applications for project periods up to 5
> years. Awards, on a competitive basis, will be for a one‑year budget
> period, although project periods may be for up to 5 years.
> Applications for continuation grants funded under these awards beyond
> the one-year budget period but within the 5 year project period will
> be entertained in subsequent years on a noncompetitive basis, subject
> to availability of funds, satisfactory progress of the grantee and a
> determination that continued funding would be in the best interest of
> the Government.
>
> **Caps on Expenses**
>
> Applicants may not request federal funding that exceeds an **annual**
> amount of \$50,000. Applications that request funding which exceeds
> the annual \$50,000 amount will be returned without consideration.

**Include the following in the Budget Justification narrative:**

> Personnel Costs: Personnel costs should be explained by listing each
> staff member who will be supported from funds, name (if possible),
> position title, percent full time equivalency, annual salary, and the
> exact amount requested for each project year which mainly covers
> indirect cost.
>
> Indirect Costs: Indirect costs are those costs incurred for common or
> joint objectives which cannot be readily identified but are necessary
> to the operations of the organization, e.g., the cost of operating and
> maintaining facilities, depreciation, and administrative salaries. For
> institutions subject to OMB Circular A-21, the term "facilities and
> administration" is used to denote indirect costs. If the applicant
> does not have an indirect cost rate, you may obtain one by visiting
> the Division of Cost Allocation website: http://rates.psc.gov/.
>
> Fringe Benefits: List the components that comprise the fringe benefit
> rate, for example health insurance, taxes, unemployment insurance,
> life insurance, retirement plan, tuition reimbursement. The fringe
> benefits should be directly proportional to that portion of personnel
> costs that are allocated for the project.
>
> Travel: List travel costs according to local and long distance travel.
> For local travel, the mileage rate, number of miles, reason for travel
> and staff member/consumers completing the travel should be outlined.
> The budget should also reflect the travel expenses associated with
> participating in meetings and other proposed trainings or workshops.
> Each applicant must include funds in the proposed budget for one trip
> for up to two people to Washington, DC for a **mandatory annual
> grantee meeting.**
>
> Equipment: List equipment costs and provide justification for the need
> of the equipment to carry out the program's goals. Extensive
> justification and a detailed status of current equipment must be
> provided when requesting funds for the purchase of computers and
> furniture items.
>
> Supplies: List the items that the project will use. In this category,
> separate office supplies from medical and educational purchases.
> Office supplies could include paper, pencils, and the like; medical
> supplies are syringes, blood tubes, plastic gloves, etc., and
> educational supplies may be pamphlets and educational videotapes.
> Remember, they must be listed separately.
>
> Subcontracts: To the extent possible, all subcontract budgets and
> justifications should be standardized, and contract budgets should be
> presented by using the same object class categories contained in the
> Standard Form 424A. Provide a clear explanation as to the purpose of
> each contract, how the costs were estimated, and the specific contract
> deliverables.
>
> Other: Put all costs that do not fit into any other category into this
> category and provide and explanation of each cost in this category. In
> some cases, grantee rent, utilities and insurance fall under this
> category if they are not included in an approved indirect cost rate.)

**vi.** **Staffing Plan and Personnel Requirements**

> Applicants must present a staffing plan and provide a justification
> for the plan that includes education and experience qualifications and
> rationale for the amount of time being requested for each staff
> position. Position descriptions that include the roles,
> responsibilities, and qualifications of proposed project staff must be
> included in Appendix 2. Copies of biographical sketches for any key
> employed personnel that will be assigned to work on the proposed
> project must be included in Appendix 2.
>
> **vii. Assurances**
>
> Standard Form 424B, Form PHS 5161 is provided with the application
> package.
>
> **viii. Certifications**
>
> Pages 17-19, Form PHS 5161 is provided with the application package.

**ix. Project Abstract**

Provide a summary of the application. Because the abstract is often
distributed to provide information to the public and Congress, please
prepare this so that it is clear, accurate, concise, and without
reference to other parts of the application. It must include a brief
description of the proposed grant project including the needs to be
addressed, the proposed services, and the population group(s) to be
served.

Use Form 6 (OMB 0915-0272, Exp. date 1-31-2006) of the MCHB
Discretionary Group Performance Measures, Financial Demographic Data
Elements on in Attachment A on page 45 to complete the abstract.

The project abstracts of all approved and funded applications will be
widely distributed to MCHB grantees, Title V programs, academic
institutions, and government agencies.

**x. Program Narrative**

> **The project narrative may not exceed 30 pages.** The page limit
> includes any referenced charts or figures but does not include the
> project abstract (separate page limit is given above), the budget
> justification, tables, or appendices. Only double-spaced, one-sided
> pages are acceptable.
>
> Applications that exceed the maximum number of pages specified will
> not be accepted for review and will be returned to the applicant.
>
> The program narrative provides a comprehensive framework and
> description of all aspects of the proposed program. It should be
> succinct, self-explanatory and well organized so that reviewers can
> understand the proposed project.
>
> Use the following section headers for the Program Narrative:
>
> **1. Introduction**
>
> This section should briefly describe the purpose of the proposed
> project.
>
> **2. NEED**
>
> **Needs Assessment:**
>
> The purpose of the needs assessment is to provide a clear description
> of the current status, capacity and needs of the disparate
> population(s) living in the proposed project area.
>
> To further justify a need in the proposed project area, applicants are
> encouraged to reference relevant data for the project area indicated
> in the needs assessment. If project area-specific data is not
> available, estimates may be submitted using county or city level
> figures. Applicants must cite sources, year, and formulae for
> estimates, where applicable, for each item. Applicants should
> highlight existing disparities observed in the proposed project area
> for any of these variables. Applicants are encouraged to utilize all
> data sources available. Information contained in the narrative should
> identify and explain any variances in the project area (e.g., hospital
> catchments areas, regional health care centers or trend in crime or
> substance abuse/drug trafficking).

Specific components of the application's needs assessment must include
the following:

-   Problem Statement: Applicant should provide a brief problem
    statement that succinctly summarizes the current needs of the target
    population. The problem statement should include a summary of
    problems/factors impacting the project area and delineate those
    problems/factors to be addressed by the proposed models of
    intervention.

-   Provide a demographic profile of the project area, type (i.e., rural
    or urban) and by race and ethnic origin (i.e., White, Black,
    Hispanic, American Indian/Alaskan Native, Asian/Pacific Islander).
    Please include data on poverty, average educational level,
    employment status, and major industries.

-   [Identification of Target Population]{.underline}

> While services cannot be denied to any eligible member of the
> community, a HTPC project under this competition may focus its efforts
> and interventions on a particular subpopulation of the community that
> exhibits disparities in its maternal and child health. Be sure to
> describe the needs of this population as indicated in the needs
> assessment section above.

**3. GOALS AND OBJECTIVES**

> Identify project goals and objectives that are responsive to the
> identified needs, and requirements of the program. Objectives should
> be time-framed, measurable, and consistent with the purpose and
> requirements of the program.
>
> **4. PROPOSED METHODOLOGY AND PLAN**
>
> The proposed project must employ an innovative approach to improve
> access to health services and **represent a [new
> initiative]{.underline}**[^1] **or a [new component of an existing
> activity]{.underline}**[^2] that will build upon, expand, and enhance
> the families, and community's abilities to meet the needs of its
> children.
>
> **a. Model of Intervention:**
>
> The applicant should describe the proposed model of service
> intervention, including:

-   Proposed strategies.

-   Anticipated/actual providers/contractors of component services.

-   Outline proposed Pediatrician Involvement.

-   All funding sources (including in-kind contributions); and

-   Projected service utilization levels.

> **b. Collaboration and Coordination**
>
> Within each community, there is a system involving a broad array of
> providers and public and private agencies who deliver maternal and
> child health care. Applicants need to receive ongoing support from and
> be linked to appropriate components of their State, AAP chapter, and
> other agencies that collaborate with the proposed project. The purpose
> of this collaboration is to promote cooperation, integration, and
> dissemination of information with Statewide systems and with other
> community services funded under the Maternal and Child Health Block
> Grant.
>
> Applicants **must** provide documentation, in the form of a letter of
> planned ongoing involvement, of collaborative relationships between
> the proposed project and any entities serving the target population,
> especially those involving State Title V MCH agency linkages, State
> American Academy of Pediatrics President and/or Representative, and
> other relevant MCH Agencies, if applicable.
>
> Applicants can locate information on how to contact their State Title
> V Program by going to the following website:
> <http://mchb.hrsa.gov/programs/blockgrant/directors.htm>.
>
> Additionally, applicants may contact Bob Moore, American Academy of
> Pediatrics (AAP), at 1-800-433-9016 x4080 in order to obtain
> information on how to contact state and/or local representatives of
> the AAP.
>
> Of particular importance is close collaboration with the Medicaid and
> SCHIP agencies. Since many within the target population are Medicaid
> recipients or will be Medicaid or SCHIP eligible, and Medicaid
> financing of services (including possible development of program
> waivers) will be essential, projects must maintain early, consistent,
> and ongoing linkages to and involvement with their State and local
> Medicaid and Title V MCH agencies in planning and operations.
>
> Other relevant State agencies include those responsible for Title X
> family planning, State Children's Health Insurance Program (SCHIP),
> Administration for Children, Youth and Families (ACYF), Early Head
> Start, substance abuse, mental health, child welfare, education, early
> intervention, child care, and job opportunities. Linkage issues which
> might be addressed include waivers, Medicaid coordinated care,
> simplified eligibility applications, collaboration and/or co-location
> of services.
>
> **c. Advisory Board**
>
> HTPC projects must have or establish and maintain for the life of the
> project, a community-based Advisory Board of individuals and
> organizations. Each applicant must have either an existing board or
> include a plan for the implementation of an Advisory Board. This
> advisory body is expected to:

-   Recommend policy for and contribute to the development of the
    application;

-   Contribute to, review, and recommend approval of the organizational
    approach for assuring local determination and integration;

-   Provide advice regarding program direction;

-   Participate in discussions related to allocation and management of
    project resources;

-   Have in place conflict of interest policies governing all
    activities;

-   Be aware of program management and activities such as data
    collection, monitoring and evaluation, public education, and
    assuring continuity of care; and

-   Share responsibility for the identification and maximization of
    resources and community ownership to sustain project services beyond
    the project period.

> The Advisory Board must include representation that reflects a
> partnership of consumers, local pediatric provider community,
> community organizations and groups, both public and private, with a
> working interest, skills, or resources that can be brought to bear on
> the problem outlined by the proposed project. The individual members
> must have sensitivity to and an understanding of the needs of the
> project area. The members should feel they have a significant advisory
> role and commitment to the plan for project implementation. This can
> be facilitated through the participation of consumers, community
> leaders, and service provider representatives in developing the
> application. Those members selected to represent an agency or group
> should have the authority to make decisions for the entity they
> represent.
>
> Delineate the anticipated role(s) the Advisory Board will play in
> implementation of this HTPC project. Discuss activities they will
> implement that are specifically related to the proposed project,
> including the frequency of meetings, public forums, and
> training/conferences.
>
> In Appendix 4 of the application, describe the membership providing a
> complete list of members and their representative agencies.

**5. MONITORING/EVALUATION**

> **a. Evaluation Plan**
>
> Evaluation is critically important for quality improvement and
> assessing the value-added contribution of MCHB/HRSA investments.
> Consequently, all MCHB discretionary grant projects are expected to
> incorporate a carefully designed and well-planned evaluation protocol
> capable of demonstrating and documenting measurable progress toward
> achieving the stated goals.
>
> The evaluation protocol should be based on a clear rationale relating
> the grant activities, the project goals, and evaluation measures. The
> measurements of progress toward goals should **at least include some
> process measures and may include outcome measures, if feasible.** A
> project lacking a complete evaluation protocol as part of the planned
> activities will not be funded.
>
> **b. Resources/Capabilities**
>
> Applicant organizations are expected to have sound systems, policies,
> and procedures in place for managing funds, equipment, and personnel
> to receive grant support. Applicants who propose subcontracting these
> administrative or fiduciary responsibilities for the project **will
> [not]{.underline}** be approved for funding. All successful applicants
> must perform a substantive role in carrying out project activities and
> not merely serve as a conduit for an award to another party or to
> provide funds to an ineligible party (see Chapter 8, Post Award
> Administration, Contracts for Substantive Programmatic Work, of the
> PHS Grants Policy Statement). The grantee organization will hire key
> personnel, will be responsible for communication with the Advisory
> Board/Committee (if an applicant is an Advisory Board, it will be
> responsible for communication within the Board and with the
> community), and will coordinate the preparation and submission of
> required reports and continuation grant applications for future years.
> The applicant will have primary responsibility for monitoring the
> progress of the project toward its objectives, including monitoring
> contract deliverables.
>
> Any budget requests/modification proposals must be coordinated and
> jointly signed by Project Director and Chief Fiscal Officer. Contract
> Monitoring should be an ongoing process. It is expected that each
> grantee monitors and meets individually with each approved service and
> evaluation contractor at a minimum of twice per year to review scope
> of services, staffing, costs, accuracy/quality and promptness of
> service data reporting, and project/consumer feedback on service
> satisfaction.
>
> Briefly describe your (applicant) agency, its history, past
> experiences, and current capacities in MCH, especially in
> community-based initiatives. Provide an organizational chart of the
> agency, including how the administration and the fiscal management of
> the proposed project will be integrated into the current
> administration. Describe the staffing plan (excluding contractor's
> staff) which identifies positions that will provide personnel for
> essential programmatic, fiscal and evaluation activities. Key
> personnel should have adequate qualifications, appropriate experience
> and allocated time (% FTE) to fulfill their proposed responsibilities.
> Position descriptions and curricula vitae of Key Personnel for the
> project should be placed in Appendix 1; also, include a chart to show
> communication and supervision/monitoring pathways with project staff,
> contractors and the Advisory Board, including a brief description of
> the process for making decisions and operating relationships between
> and among the applicant, individual service providers, and Advisory
> Board.
>
> Summarize the coordination among key program, fiscal, and evaluation
> staff; identify to what extent members of each group will work jointly
> with contractor staff on monitoring and technical assistance
> activities; outline the methodologies for soliciting, awarding, and
> the fiscal and program monitoring of contracts and subcontracts.
> Samples of formal agreements and letters of understanding with
> appropriate, actual or anticipated major contractors can be included
> in the appendix. Methodologies used for quality assurance (including
> client satisfaction) of all activities and services should also be
> summarized and sample documents provided if available.
>
> Describe your history of management and oversight involving other
> grant or contractual funds. If deficiencies have been noted in the
> most recent internal/external audit, review or reports on the
> applicant organization's financial management system and management
> capacity or its implementation of these systems, policies and
> procedures, identify the corrective action taken to remedy the
> deficiencies**.**
>
> **c. Sustainability**
>
> This section must include plans for sustaining program services beyond
> the HTPC funding period.

**xi. Appendices of the Application**

> Please provide the following items to complete the content of the
> application. Please note that these are supplementary in nature, and
> are not intended to be a continuation of the project narrative. Be
> sure each appendix is clearly labeled.

1\) Appendix 1: Performance Measures and Related Forms

> If funded, your organization will be expected to address Performance
> Measures and complete related data collection sheets in future annual
> progress reports. Also, with this submission of the application, your
> organization **must complete** **Forms 1, 2, 4, 6, and 7** (OMB
> 0915-0272, Exp. date 1-31-2006) also located in Attachment A of this
> guidance.

2)  Appendix 2: Position Descriptions for Key Personnel

> Position descriptions should spell out specifically administrative
> direction (from whom it is received and to whom it is provided),
> duties and responsibilities (what is done and how), and the minimum
> qualifications (the minimum requirements of education, training, and
> experience necessary for accomplishment of the job). Keep each to one
> page in length as much as is possible.
>
> Also;
>
> Biographical Sketches of Key Personnel
>
> Include biographical sketches for persons occupying the key positions
> described in Appendix A (above), not to exceed two pages in length. In
> the event that a biographical sketch is included for an identified
> individual who is not yet hired, please include a letter of commitment
> from that person with the biographical sketch.
>
> 3\) Appendix 3: Project Organizational Chart
>
> Provide a one-page figure that depicts the organizational structure of
> the project, including subcontractors and other significant
> collaborators.
>
> 4\) Appendix 4: Advisory Board/Coalition (i.e., Membership Roster)
>
> 5\) Appendix 5: Documentation of Ongoing Collaboration
>
> Include letters of project period collaboration/partnerships with
> State Title V and/or MCH Director, State AAP President and/or other
> designated AAP representative, and from other MCH and/or collaborating
> agencies.

6)  Appendix 6: Other Relevant Items

    **3. Submission Dates and Times**

    **Application Due Date**

> The due date for applications under this grant announcement is
> **September 12, 2005 at 5:00 P.M., Eastern Standard Time.**
>
> Applications will be considered as meeting the deadline if they are
> either:
>
> \(1\) Received on or before the due date; or
>
> \(2\) Post marked or E marked on or before the due date, and received
> in time for the Independent Review Committee review.
>
> The Grants Management Officer (GMO) or a higher level designee may
> authorize an extension of published deadlines when justified by
> circumstances such as acts of God (e.g. floods or hurricanes),
> widespread disruptions of mail service, or other disruptions of
> services, such as a prolonged blackout. The authorizing official will
> determine the affected geographical area(s).
>
> **Electronic Submission:**
>
> Applications must be submitted by 5:00 P.M. ET. To ensure that you
> have adequate time to follow procedures and successfully submit the
> application, we recommend you start submission no later that noon on
> the due date. Applications submitted electronically will be time/date
> stamped electronically, which will serve as receipt of submission.
>
> **Paper Submission:**
>
> If you choose to submit a paper application, the Grant Application
> Center will mail an acknowledgement of receipt to the applicant
> organization's Program Director.
>
> In the event that questions arise about meeting the application due
> date, applicants must have a legibly dated receipt from a commercial
> carrier or the U.S. Postal Service. Private metered postmarks will not
> be accepted as proof of timely mailing.
>
> Late applications: Applications which do not meet the criteria above
> are considered late applications. Health Resources and Services
> Administration (HRSA) shall notify each late applicant that its
> application will not be considered in the current competition.

**4. Intergovernmental Review**

EO 12372 **does not** apply to this program.

**5. Funding Restrictions**

> Applicants responding to this announcement may request funding for a
> project period of up to 5 years, at no more than \$50,000 per year.
> Awards to support projects beyond the first budget year will be
> contingent upon Congressional appropriation, satisfactory progress in
> meeting the project's objectives, and a determination that continued
> funding would be in the best interest of the government.
>
> Under current OMB regulations, funds under this announcement **may not
> be used for research proposals; only direct services proposals will be
> accepted for review.**

**6. Other Submission Requirements**

**Paper Submission**

> Paper applications, if you choose to submit paper copy, please send
> the original and 2 copies of the application to:
>
> The HRSA Grants Application Center
>
> The Legin Group, Inc.
>
> Attn: Healthy Tomorrows Partnership for Children Program
>
> Program Announcement No. HRSA-06-076
>
> CFDA No. 93.110
>
> 901 Russell Avenue, Suite 450
>
> Gaithersburg, MD 20879
>
> Telephone: 877-477-2123

In the event that questions arise about meeting the application due
date, applicants must have a legibly dated receipt from a commercial
carrier or the U.S. Postal Service. Private metered postmarks will not
be accepted as proof of timely mailing.

> Whether you submit electronically or via paper, please understand that
> we will not consider additional information and/or materials submitted
> after your initial application.  You must therefore ensure that all
> materials are submitted together, whether electronically or on paper.

**Electronic Submission**

> You may submit your application to us either in electronic or paper
> format. To submit an application electronically, please use the
> [http://www.Grants.gov](http://www.grants.gov/) apply site. If you use
> Grants.Gov you will be able to download a copy of the application
> package, complete it off-line, and then upload and submit the
> application via the Grants.gov site. You may not e-mail an electronic
> copy of a grant application to us.
>
>  
>
> Please note the following if you plan to submit your application
> electronically via Grants.Gov:
>
>  

-   Electronic submission is voluntary

```{=html}
<!-- -->
```
-   When you enter the Grants.Gov site, you will find information about
    submitting an application electronically through the site, as well
    as the hours of operation. We strongly recommend that you do not
    wait until the application deadline date to begin the application
    process through Grants.Gov.  The registration process is a separate
    process from submitting an application.  **Applicants are,
    therefore, encouraged to register early**.  The registration process
    can take approximately two weeks to be completed.  Therefore,
    registration should be done in sufficient time to ensure it does not
    impact your ability to meet required submission deadlines.  You will
    be able to submit your application online anytime after you receive
    your e-authentication credentials.

-   To use Grants.gov, you, as the applicant, must have a DUNS Number
    and register in the Central Contractor Registry (CCR). You should
    allow a minimum of five days to complete the CCR registration.

-   You will not receive additional point value because you submit a
    grant application in paper format.

-   You may submit all documents electronically, including all
    information typically included on the SF424 and all necessary
    assurances and certifications.

-   Your application must comply with any page limitation requirements
    described in this program announcement.

-   After you electronically submit your application, you will receive
    an automatic acknowledgement from Grants.Gov that contains a
    Grants.Gov tracking number. The Health Resources and Services
    Administration will retrieve your application from Grants. Gov.

-   You may access the electronic application for this program on
    [http://www.Grants.gov](http://www.grants.gov/).

-   You must search for the downloadable application package by the CFDA
    number.

-   The grants.gov website provides customer support via (800)
    518-GRANTS (this is a toll-free number) or through e-mail at
    [**support@grants.gov**](mailto:support@grants.gov).  The customer
    support center is open from 7:00 a.m. to 9:00 p.m. Eastern time,
    Monday through Friday, except federal holidays, to address
    grants.gov technology issues.  For technical assistance to program
    related questions, contact the number listed in the Program Section
    of the program you are applying for.

>  
>
> Online applications are required to submit ONLY one form in signed
> hard copy: the SF-424/5161 Face Sheet, since all other elements of the
> application have been captured and transmitted electronically. 
>
>  
>
> **Formal submission of the electronic application:**  Applications
> completed online are considered formally submitted when the
> Authorizing Official electronically submits the application to HRSA. 
> However, to complete the submission requirements, a hard-copy of the
> SF-424/5161 Face Sheet must be printed, signed, and submitted to the
> HRSA Grants Application Center.  The SF-424/5161 can be printed from
> the online application.
>
>  
>
>  For an online application, the signed SF-424/5161 must be sent to the
> HRSA GRANTS APPLICATION CENTER at the above address and received by
> HRSA by no later than five days after the September 12, 2005 due date.
>
>   
>
> Applications will be considered as having met the deadline if: (1) the
> application has been successfully transmitted electronically by your
> organization's Authorizing Official through Grants.Gov or before the
> deadline date and time, and (2) the signed SF-424/5161 Face Sheet is
> received by HRSA no later than five days after the deadline date.
>
>  
>
> REMINDER:  Only applicants who apply online are permitted to forego
> hard-copy submission of all application forms EXCEPT the signed
> SF-424/5161.
>
>  
>
> If the application is submitted as a hard-copy, the rules of
> submission as described elsewhere in this guidance must be followed.\"

#### V. Application Review Information

1\. Review Criteria

> Applicants should pay strict attention to addressing all these
> criteria, as they are the basis upon which the reviewers will evaluate
> their application. Applications will be reviewed and ranked according
> to the following 7 criteria:
>
> Criterion 1. Need 15 points
>
> Criterion 2. Response 30 points
>
> Criterion 3. Evaluative Measures 15 points
>
> Criterion 4. Impact 15 points
>
> Criterion 5. Resources/Capabilities 15 points
>
> Criterion 6. Support Requested 10 points
>
> Total 100 points

Criterion 1: Need (15 points)

> A. The extent to which the application describes the problem and
> associated
>
> contributing factors to the problem.
>
> B. The extent to which the demonstrated need(s) of the targeted
> population to be served

are adequately described and supported in the needs assessment.

> C. The extent to which the proposed project plan addresses the
> documented need(s) of the targeted population, including attention to
> the cultural and linguistic needs of consumers.

Criterion 2: Response (30 points)

> A. The extent to which the proposed project responds to the "Purpose"
> included in the program description.
>
> B. The extent to which there is clarity of the proposed goals and
> objectives and their relationship to the identified project.
>
> C. The extent to which the activities described in the application are
> capable of addressing the problem and attaining the project
> objectives.

D.  The extent to which the proposed project employs an innovative
    approach to improve access to health services and represents a [new
    initiative]{.underline} or a [new component of existing
    activity]{.underline} that will build upon, expand, and enhance the
    families, and communities abilities to meet the needs of its
    children.

E.  The extent to which the project's plan's objectives are measurable,
    logical, time-framed, and appropriate in relation to the specific
    problems identified.

F.  The extent to which the project adequately describes how they will
    integrate pediatrician involvement into its overall plan.

G.  The extent of actual or planned involvement of the State, State AAP
    chapter, and local MCH agencies is demonstrated by a letter
    proposing significant ongoing involvement throughout the 5-year
    project period from the State Title V agency director, State AAP
    chapter president, and a copy of Memorandums of
    Agreement/Understanding with MCH and/or other collaborating agencies
    who will be involved in your project.

H.  The extent to which the role and plan of action of the Advisory
    Board in the implementation of the proposed project plan are
    adequately described.

> I. The extent to which the Advisory Board includes, or plans to
> include appropriate
>
> representation of project area consumers, providers, representatives
> from the local pediatric provider community, and other key
> stakeholders.

CRITERION 3: Evaluative Measures (15 points)

> A. The effectiveness of the method proposed to monitor and evaluate
> the project results. Evaluative measures must be able to assess 1) to
> what extent the program objectives have been met and 2) to what extent
> these can be attributed to the project.
>
> B. The extent to which the plan to measure program performance is well
> organized and adequately described.

CRITERION 4: Impact (15 points)

> A. The extent and effectiveness of plans for dissemination of project
> results and/or the extent to which project results may be national in
> scope and/or degree to which the project activities are replicable,
> and/or the sustainability of the program beyond the Federal Funding.

CRITERION 5: Resources/Capabilities (15 points)

> A. The extent to which the project personnel are qualified by training
> and/or experience to implement and carry out the projects. The
> capabilities of the applicant organization, and quality and
> availability of facilities and personnel to fulfill the needs and
> requirements of the proposed project.

CRITERION 6: Support Requested (10 points)

> A. The reasonableness of the proposed budget in relation to the
> objectives, the complexity of the activities, and the anticipated
> results.
>
> B. The extent to which budget line items are well described and
> justified in the budget

justification.

> C. The extent to which key personnel have adequate time devoted to the
> project to achieve project objectives.

**2. Review and Selection Process**

> The Division of Independent Review is responsible for managing
> objective reviews within HRSA. Applications competing for federal
> funds receive an objective and independent review performed by a
> committee of experts qualified by training and experience in
> particular fields or disciplines related to the program being
> reviewed. In selecting review committee members, other factors in
> addition to training and experience may be considered to improve the
> balance of the committee, e.g., geographic distribution,
> race/ethnicity, and gender. Each reviewer is screened to avoid
> conflicts of interest and is responsible for providing an objective,
> unbiased evaluation based on the review criteria noted above. The
> committee provides expert advice on the merits of each application to
> program officials responsible for final selections for award.

#### VI. Award Administration Information

> **1. Award Notices**
>
> Each applicant will receive written notification of the outcome of the
> objective review process, including a summary of the expert
> committee's assessment of the application's merits and weaknesses, and
> whether the application was selected for funding. Applicants who are
> selected for funding may be required to respond in a satisfactory
> manner to Conditions placed on their application before funding can
> proceed. Letters of notification do not provide authorization to begin
> performance. The Notice of Grant Award, which is signed by the Grants
> Management Officer and is sent to the applicant agency's Authorized
> Representative, is the authorizing document. It will be sent prior to
> the start date of March 1, 2006.
>
> **2. Administrative and National Policy Requirements**

Successful applicants must comply with the administrative and national
policy requirements outlined in 45 CFR Part 74 or 45 CFR Part 92, as
appropriate.

**PUBLIC POLICY ISSUANCE**

**HEALTHY PEOPLE 2010**

> **Healthy People 2010** is a national initiative led by HHS that sets
> priorities for all HRSA programs. The initiative has two major goals:
> (1) To increase the quality and years of a healthy life; and (2)
> Eliminate our country's health disparities. The program consists of 28
> focus areas and 467 objectives. HRSA has actively participated in the
> work groups of all the focus areas, and is committed to the
> achievement of the Healthy People 2010 goals.
>
> Applicants must summarize the relationship of their projects and
> identify which of their programs objectives and/or sub-objectives
> relate to the goals of the Healthy People 2010 initiative.
>
> Copies of the Healthy People 2010 may be obtained from the
> Superintendent of Documents or downloaded at the Healthy People 2010
> website: [http://www.health.gov/healthypeople/document]{.underline}/.

[]{.mark}

**Smoke Free Workplace**

> The Public Health Service strongly encourages all award recipients to
> provide a smoke-free workplace and to promote the non-use of all
> tobacco products. Further, Public Law 103-227, the Pro-Children Act of
> 1994, prohibits smoking in certain facilities (or in some cases, any
> portion of a facility) in which regular or routine education, library,
> day care, health care or early childhood development services are
> provided to children.

**Public Health System Reporting Requirements**

> This program is subject to the Public Health System Reporting
> Requirements (approved under OMB No. 0937-0195). Under these
> requirements, the applicant must prepare and submit a Public Health
> System Impact Statement (PHSIS). The PHSIS is intended to provide
> information to State and local health officials to keep them apprised
> of proposed health services grant applications submitted by
> community-based nongovernmental organizations within their
> jurisdictions.
>
> Applicants are required to submit the following information to the
> head of the appropriate State and local health agencies in the area(s)
> to be impacted no later than the application receipt due date:
>
> 1\. A copy of the face page of the application (PHS Application Form
> 5161) and
>
> 2\. A summary of the project (PHSIS), not to exceed one page, which
> provides:

\(a\) A description of the population to be served,

\(b\) A summary of the services to be provided, and

\(c\) A description of the coordination planned with the appropriate
state sand local health agencies.

> **The Abstract of may be used in lieu of the one-page Public Health
> System Impact Statement (PHSIS).**

**Copyrighted Material**

> With respect to copyrightable material that might be developed as a
> part of the grant activity, please note the following grants policy
> statement:
>
> If any copyrightable material (e.g., audiovisuals, software,
> publications, curricula and training materials, etc.) is developed
> under this grant (by the grantee, sub grantee, or contractor) the
> Department of Health and Human Services (HHS) shall have a
> royalty-free, nonexclusive and irrevocable right to reproduce,
> publish, or otherwise use, and authorize others to use the work, for
> purposes which further the objectives of the Maternal and Child Health
> (MCH) program. All contracts or other arrangements entered into by the
> grantee for the purpose of developing or procuring such material shall
> specifically reference and reserve the rights of HHS with respect to
> the material. The grantee shall provide three copies of all such
> copyrightable material upon the request of the MCH Bureau.

**3. Reporting**

> The successful applicant under this guidance must:
>
> A. Comply with audit requirements of Office of Management and Budget
> (OMB) Circular A-133. Information on the scope, frequency, and other
> aspects of the audits can be found on the Internet at
> [www.whitehouse.gov/omb/circulars](http://www.whitehouse.gov/omb/circulars);
>
> B. Submit a Payment Management System Quarterly Report. The reports
> identify cash expenditures against the authorized funds for the grant.
> Failure to submit the report may result in the inability to access
> grant funds. Submit report to the:
>
> Division of Payment Management
>
> DPM/FMS/PSC/ASAM/HHS
>
> PO Box 6021
>
> Rockville, MD 20852
>
> Telephone: (301) 443-1660

C.  Submit a Financial Status Report. A financial status report is
    required **within 90 days**

**of the end of each grant year.** The report is an accounting of
expenditures under the

project that year;

> D. Submit an annual Progress Report and Final Report. A successful
> applicant under this notice will submit reports in accordance with the
> provisions of the general regulations that apply ("Monitoring and
> Reporting Program Performance" 45 CFR Part 74.51 and Part 92.40). The
> progress report will be included in the continuation application each
> year. The progress report should include: (1) a brief summary of
> overall project accomplishments during the reporting period, including
> any barriers to progress that have been encountered and
> strategies/steps taken to overcome them; (2) progress on specific
> goals and objectives as outlined in this application and revised in
> consultation with the Federal project officer; (3) current staffing,
> including the roles and responsibilities of each staff and a
> discussion of any difficulties in hiring or retaining staff; (4)
> technical assistance needs; and (5) a description of linkages that
> have been established with other programs. All projects **must**
> submit a final report within 90 days of completing their project.
>
> []{.mark}
>
> E. **Performance Measurement:**
>
> MCHB views program accountability, including monitoring and
> assessment, as an important tool for ongoing program improvement. All
> MCHB supported programs must, at minimum monitor program activities
> and report annually, utilizing performance measures.
>
> The Government Performance and Results Act (GPRA), Public Law 103-62,
> requires that each Federal program establish performance measures that
> can be reported as part of the budgetary process, thus linking funding
> decisions with performance and reviewing related outcome measures to
> see if there were improved outcomes for the target population.
>
> In fiscal year 2003, MCHB's performance measures for discretionary
> grants were approved by the Office of Management and Budget (OMB).
> MCHB must include these measures and other related forms required in
> its annual reports to Congress on the actual performance achieved by
> its programs compared to that proposed in the performance plan.
> Performance measures and related forms specific to this grant program
> are included in this guidance. Program activities, as measured by
> these performance measures, should have a collective contributory
> effect to positively impact the outcome measures for the target
> population.

HTPC performance measures and related forms are included in this
guidance in Attachment A. If funded, your organization will be expected
to document annual progress on the identified HTPC performance measures
in **future** annual reports. Successful applicants receiving grant
funds are required, within in **30 days** of the Notice of Grant Award
(NGA), to register in HRSA's Electronic Handbooks (EHBs) and
electronically complete the program specific data forms that appear in
Attachment A of this guidance.  This requires the provision of budget
breakdowns in the financial forms based on the grant award amount, the
project abstract and other grant summary data, and objectives for the
performance measures.

> . Program activities, as measured by these performance measures,
> should have a collective contributory effect to positively impact the
> outcome measures for the target population.

#### VII. Agency Contacts

> Applicants are encouraged to request assistance in the development of
> the application.
>
> **Business, Administrative and Fiscal Inquiries**
>
> Applicants may obtain additional information regarding business,
> administrative, or fiscal issues related to this grant announcement by
> contacting:
>
> Theda P. Duvall
>
> Lead Grants Management Specialist
>
> HRSA, Division of Grants Management Operations
>
> 5600 Fishers Lane, Room 11A-16
>
> Rockville, Maryland 20857
>
> Telephone: 301-443-3414
>
> E-mail: <tduvall@hrsa.gov>
>
> Fax: 301-443-6686
>
> **Programmatic Assistance**
>
> Additional information related to the overall program issues or
> technical assistance may be obtained by contacting:

Jose Belardo, JD, MSW

Maternal and Child Health Bureau

5600 Fishers Lane, Room 18A55

Rockville, MD 20857

Telephone: (301) 443-0757

E-Mail:jbelardo@hrsa.gov

FAX: (301) 443-4842

#### 

#### VIII. Tips for Writing a Strong Application

[]{.mark}

> **Include DUNS Number.** You must include DUNS Number to have your
> application reviewed. Application ***will not*** be reviewed without a
> DUNS number. A DUNS number is required. To obtain a DUNS number,
> access [www.dunandbradstreet.com](http://www.dunandbradstreet.com/) or
> call 1-866-705-5711. Please include DUNS number next to OMB Approval
> Number on the application face page.
>
> **Keep your audience in mind.** Reviewers will use only the
> information contained in the application to assess the application.
> Therefore, the applicant should be sure the application and responses
> to the program requirements and expectations are complete and clearly
> written. Do not assume that reviewers are familiar with the applicant
> organization. Keep the review criteria in mind when writing the
> application.
>
> **Start preparing the application early.** Allow plenty of time to
> gather required information from various sources.
>
> **Follow the instructions in this guidance carefully.** The
> instructions call for a particular organization of the materials, and
> reviewers are accustomed to finding information in specific places.
> Don't have reviewers hunting through your application for information.
>
> **Be brief, concise, and clear.** Make your points understandable.
> Provide accurate and honest information, including candid accounts of
> problems and realistic plans to address them. If any required
> information or data is omitted, explain why. Make sure the information
> provided in each table, chart, attachment, etc., is consistent with
> the proposal narrative and information in other tables.
>
> **Be organized and logical.** Many applications fail because the
> reviewers cannot follow the thought process of the applicant or
> because parts of the application do not fit together.
>
> **Be careful in the use of appendices.** Do not use the appendices for
> information that is required in the body of the application. Be sure
> to cross-reference all tables and attachments located in the
> appendices to the appropriate text in the application.
>
> **Carefully proofread the application.** Misspellings and grammatical
> errors will impede reviewers in understanding the application. Be sure
> pages are numbered (including appendices) and that page limits are
> followed. Limit the use of abbreviations and acronyms, and define each
> one at its first use and periodically throughout application.

**Attachment A**

Maternal and Child Health Bureau

## Block Grant Performance Measures

And Related Forms

## Required by HTPC

## 

Division of Research, Training, and Education

**OMB Number 0915-0272, expiration date January 31, 2006**

+-----------------------------------+----------------+----------------+
| #### 05 PERFORMANCE MEASURE       | The percent of |                |
|                                   | MCHB supported |                |
| **Goal 1: Provide National        | projects that  |                |
| Leadership for MCHB**             | are sustained  |                |
|                                   | in the         |                |
| **(Forge strong collaborative,    | community      |                |
| sustainable MCH partnerships both | after the      |                |
| within and beyond the health      | federal grant  |                |
| sector)**                         | project period |                |
|                                   | is completed.  |                |
| **Level: Grantee**                |                |                |
|                                   |                |                |
| **Category: Sustainability**      |                |                |
+-----------------------------------+----------------+----------------+
| **GOAL**                          | To increase    |                |
|                                   | the            |                |
|                                   | sustainability |                |
|                                   | of MCHB funded |                |
|                                   | projects after |                |
|                                   | their federal  |                |
|                                   | grant project  |                |
|                                   | period is      |                |
|                                   | completed.     |                |
+-----------------------------------+----------------+----------------+
|                                   |                |                |
+-----------------------------------+----------------+----------------+
| **MEASURE**                       | The percent of |                |
|                                   | MCHB funded    |                |
|                                   | projects that  |                |
|                                   | are sustained  |                |
|                                   | in the         |                |
|                                   | community      |                |
|                                   | after the      |                |
|                                   | federal grant  |                |
|                                   | project period |                |
|                                   | is completed.  |                |
+-----------------------------------+----------------+----------------+
|                                   |                |                |
+-----------------------------------+----------------+----------------+
| **DEFINITION**                    | **Numerator:** |                |
+-----------------------------------+----------------+----------------+
|                                   | Number of      |                |
|                                   | designated     |                |
|                                   | MCHB funded    |                |
|                                   | projects that  |                |
|                                   | are sustained  |                |
|                                   | after the      |                |
|                                   | federal MCHB   |                |
|                                   | project        |                |
|                                   | period.        |                |
+-----------------------------------+----------------+----------------+
|                                   | **             |                |
|                                   | Denominator:** |                |
+-----------------------------------+----------------+----------------+
|                                   | Total number   |                |
|                                   | of designated  |                |
|                                   | MCHB funded    |                |
|                                   | projects that  |                |
|                                   | have completed |                |
|                                   | the federal    |                |
|                                   | MCHB project   |                |
|                                   | period during  |                |
|                                   | the reporting  |                |
|                                   | year.          |                |
+-----------------------------------+----------------+----------------+
|                                   | **Units:** 100 | **Text:**      |
|                                   |                | Percent        |
+-----------------------------------+----------------+----------------+
|                                   | The relevant   |                |
|                                   | MCHB supported |                |
|                                   | projects are   |                |
|                                   | defined as     |                |
|                                   | projects that  |                |
|                                   | attempt to     |                |
|                                   | foster         |                |
|                                   | community      |                |
|                                   | partnerships   |                |
|                                   | and build      |                |
|                                   | capacity       |                |
|                                   | and/or program |                |
|                                   | resources that |                |
|                                   | continue as    |                |
|                                   | needed in that |                |
|                                   | community      |                |
|                                   | after federal  |                |
|                                   | funds          |                |
|                                   | discontinue.   |                |
|                                   | These projects |                |
|                                   | include but    |                |
|                                   | are not        |                |
|                                   | limited to     |                |
|                                   | Healthy        |                |
|                                   | Tomorrows,     |                |
|                                   | Healthy Child  |                |
|                                   | Care America   |                |
|                                   | Campaign,      |                |
|                                   | CISS,          |                |
|                                   | Integrated     |                |
|                                   | Services       |                |
|                                   | projects, etc. |                |
|                                   | A "sustained"  |                |
|                                   | project refers |                |
|                                   | to a project   |                |
|                                   | that           |                |
|                                   | demonstrates   |                |
|                                   | the            |                |
|                                   | continuation   |                |
|                                   | of key         |                |
|                                   | elements of    |                |
|                                   | p              |                |
|                                   | rogram/service |                |
|                                   | components     |                |
|                                   | started under  |                |
|                                   | the MCHB       |                |
|                                   | supported      |                |
|                                   | project.       |                |
+-----------------------------------+----------------+----------------+
|                                   |                |                |
+-----------------------------------+----------------+----------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | No related     |                |
|                                   | Healthy People |                |
|                                   | 2010           |                |
|                                   | Objective.     |                |
+-----------------------------------+----------------+----------------+
|                                   |                |                |
+-----------------------------------+----------------+----------------+
| **DATA SOURCE(S) AND ISSUES**     | -   The final  |                |
|                                   |     project    |                |
|                                   |     report     |                |
|                                   |     (submitted |                |
|                                   |     after the  |                |
|                                   |     grant      |                |
|                                   |     period     |                |
|                                   |     ends) for  |                |
|                                   |     each MCHB  |                |
|                                   |     supported  |                |
|                                   |     project    |                |
|                                   |     will       |                |
|                                   |     provide    |                |
|                                   |     the        |                |
|                                   |     necessary  |                |
|                                   |     data.      |                |
|                                   |                |                |
|                                   | -   One        |                |
|                                   |     potential  |                |
|                                   |     source of  |                |
|                                   |     difficulty |                |
|                                   |     is the     |                |
|                                   |     variable   |                |
|                                   |     submission |                |
|                                   |     rate of    |                |
|                                   |     required   |                |
|                                   |     final      |                |
|                                   |     project    |                |
|                                   |     reports by |                |
|                                   |     grantees   |                |
|                                   |     and the    |                |
|                                   |     narrative  |                |
|                                   |     nature of  |                |
|                                   |     final      |                |
|                                   |     project    |                |
|                                   |     reports.   |                |
+-----------------------------------+----------------+----------------+
|                                   |                |                |
+-----------------------------------+----------------+----------------+
| **SIGNIFICANCE**                  | A major        |                |
|                                   | strategy of    |                |
|                                   | MCHB is to     |                |
|                                   | strengthen     |                |
|                                   | public health  |                |
|                                   | infrastructure |                |
|                                   | at the state   |                |
|                                   | and local      |                |
|                                   | level by       |                |
|                                   | providing      |                |
|                                   | small "start   |                |
|                                   | up" grants     |                |
|                                   | which          |                |
|                                   | communities    |                |
|                                   | are encouraged |                |
|                                   | to use to      |                |
|                                   | leverage other |                |
|                                   | community      |                |
|                                   | resources.     |                |
|                                   | These grants   |                |
|                                   | are meant to   |                |
|                                   | foster         |                |
|                                   | community      |                |
|                                   | partnerships,  |                |
|                                   | and build      |                |
|                                   | capacity and   |                |
|                                   | program        |                |
|                                   | services that  |                |
|                                   | continue in    |                |
|                                   | the community  |                |
|                                   | after the      |                |
|                                   | federal grant  |                |
|                                   | period ends.   |                |
|                                   | Measuring      |                |
|                                   | sustainability |                |
|                                   | gauges the     |                |
|                                   | effectiveness  |                |
|                                   | of Bureau      |                |
|                                   | resources in   |                |
|                                   | generating     |                |
|                                   | longer-term    |                |
|                                   | community      |                |
|                                   | investments    |                |
|                                   | through its    |                |
|                                   | initial        |                |
|                                   | funding.       |                |
+-----------------------------------+----------------+----------------+

**OMB Number 0915-0272, expiration date January 31, 2006**

+-----------------------------------+-----------------------------------+
| #### 07 PERFORMANCE MEASURE       | The degree to which MCHB          |
|                                   | supported programs ensure family  |
| **Goal 1: Provide National        | participation in program and      |
| Leadership for MCHB**             | policy activities.                |
|                                   |                                   |
| **(Promote family participation   |                                   |
| in care)**                        |                                   |
|                                   |                                   |
| **Level: Grantee**                |                                   |
|                                   |                                   |
| **Category: Family                |                                   |
| Participation**                   |                                   |
+-----------------------------------+-----------------------------------+
| **GOAL**                          | To increase family participation  |
|                                   | in MCHB programs.                 |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **MEASURE**                       | The degree to which MCHB          |
|                                   | supported programs ensure family  |
|                                   | participation in program and      |
|                                   | policy activities.                |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DEFINITION**                    | Attached is a checklist of 6      |
|                                   | elements that demonstrate family  |
|                                   | participation. Please check the   |
|                                   | degree to which the elements have |
|                                   | been implemented.                 |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | Related to Objective 16.23.       |
|                                   | Increase the proportion of        |
|                                   | Territories and States that have  |
|                                   | service systems for Children with |
|                                   | Special Health Care Needs to 100  |
|                                   | percent.                          |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | Attached data collection form to  |
|                                   | be completed by grantees.         |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **SIGNIFICANCE**                  | Over the last decade, policy      |
|                                   | makers and program administrators |
|                                   | have emphasized the central role  |
|                                   | of families as advisors and       |
|                                   | participants in policy-making     |
|                                   | activities. In accordance with    |
|                                   | this philosophy, MCHB is          |
|                                   | facilitating such partnerships at |
|                                   | the local, state and national     |
|                                   | levels. Family/professional       |
|                                   | partnerships have been:           |
|                                   | incorporated into the MCHB Block  |
|                                   | Grant Application, the MCHB       |
|                                   | strategic plan and is a           |
|                                   | requirement in the Omnibus Budget |
|                                   | Reconciliation Act of 1989 (OBRA  |
|                                   | '89), the legislative mandate     |
|                                   | that health programs supported by |
|                                   | Maternal and Child Health Bureau  |
|                                   | (MCHB) Children with Special      |
|                                   | Health Care Needs (CSHCN) provide |
|                                   | and promote family centered,      |
|                                   | community‑based, coordinated      |
|                                   | care.                             |
+-----------------------------------+-----------------------------------+

**OMB Number 0915-0272, expiration date January 31, 2006**

DATA COLLECTION FORM FOR DETAIL SHEET #07

Using a scale of 0-3, please rate the degree to which our grant program
has included families into their program and planning activities.

+------+------+------+------+------------------------------------------+
| *    | *    | *    | *    | **Element**                              |
| *0** | *1** | *2** | *3** |                                          |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Family members participate on        |
|      |      |      |      |     advisory committees or task forces   |
|      |      |      |      |     and are offered training, mentoring  |
|      |      |      |      |     and reimbursement.                   |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Financial support (financial grants, |
|      |      |      |      |     technical assistance, travel, and    |
|      |      |      |      |     child care) is offered for parent    |
|      |      |      |      |     activities or parent groups.         |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Family members participate in the    |
|      |      |      |      |     planning, implementation and         |
|      |      |      |      |     evaluation of the program's          |
|      |      |      |      |     activities.                          |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 4.  Families members work with their     |
|      |      |      |      |     professional partners to provide     |
|      |      |      |      |     training ( pre‑service, in-service   |
|      |      |      |      |     and professional development) to     |
|      |      |      |      |     MCH/CSHCN staff and providers.       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 5.  Family members are hired as paid     |
|      |      |      |      |     staff or consultants to the program  |
|      |      |      |      |     (a family member is hired for his or |
|      |      |      |      |     her expertise as a family member).   |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 6.  Family members of diverse cultures   |
|      |      |      |      |     are involved in all of the above     |
|      |      |      |      |     activities.                          |
+------+------+------+------+------------------------------------------+

0=Not Met

1=Partially Met

2=Mostly Met

3=Completely Met

Total the numbers in the boxes (possible 0‑18 score) \_\_\_\_\_\_\_\_\_

**OMB Number 0915-0272, expiration date January 31, 2006**

+-----------------------------------+-----------------------------------+
| # 10 PERFORMANCE MEASURE          | The degree to which MCHB          |
|                                   | supported programs have           |
| **Goal 2: Eliminate Health        | incorporated cultural competence  |
| Barriers & Disparities**          | elements into their policies,     |
|                                   | guidelines, contracts and         |
| **(Develop and promote health     | training.                         |
| services and systems of care      |                                   |
| designed to eliminate disparities |                                   |
| and barriers across MCH           |                                   |
| populations)**                    |                                   |
|                                   |                                   |
| **Level: Grantee**                |                                   |
|                                   |                                   |
| **Category: Cultural Competence** |                                   |
+-----------------------------------+-----------------------------------+
| **GOAL**                          | To increase the number of MCHB    |
|                                   | supported programs that have      |
|                                   | integrated cultural competence    |
|                                   | into their policies, guidelines,  |
|                                   | contracts and training.           |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **MEASURE**                       | The degree to which MCHB          |
|                                   | supported programs have           |
|                                   | incorporated cultural competence  |
|                                   | elements into their policies,     |
|                                   | guidelines, contracts and         |
|                                   | training.                         |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DEFINITION**                    | Attached is a checklist of 23     |
|                                   | elements that demonstrate         |
|                                   | cultural competency. Please check |
|                                   | the degree to which the elements  |
|                                   | have been implemented. The answer |
|                                   | scale is 0-69. Please keep the    |
|                                   | completed checklist attached.     |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | Related to Objective 16.23:       |
|                                   | Increase the proportion of States |
|                                   | and jurisdictions that have       |
|                                   | service systems for children with |
|                                   | or at risk for chronic and        |
|                                   | disabling conditions as required  |
|                                   | by Public Law 101-239.            |
|                                   |                                   |
|                                   | Related to Objective 23.11        |
|                                   | (Developmental) Increase the      |
|                                   | proportion of State and local     |
|                                   | public health agencies that meet  |
|                                   | national performance standards    |
|                                   | for essential public health       |
|                                   | services.                         |
|                                   |                                   |
|                                   | Related to Objective 23.15        |
|                                   | (Developmental) Increase the      |
|                                   | proportion of Federal, Tribal,    |
|                                   | State, and local jurisdictions    |
|                                   | that review and evaluate the      |
|                                   | extent to which their statutes,   |
|                                   | ordinances, and bylaws assure the |
|                                   | delivery of essential public      |
|                                   | health services.                  |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | -   Attached data collection form |
|                                   |     to be completed by grantees.  |
|                                   |                                   |
|                                   | -   There is no existing national |
|                                   |     data source to measure the    |
|                                   |     extent to which MCHB          |
|                                   |     supported programs have       |
|                                   |     incorporated cultural         |
|                                   |     competence elements into      |
|                                   |     their policies, guidelines,   |
|                                   |     contracts and training.       |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **SIGNIFICANCE**                  | Over the last decade, researchers |
|                                   | and policymakers have emphasized  |
|                                   | the central influence of cultural |
|                                   | values and cultural/linguistic    |
|                                   | barriers: health seeking          |
|                                   | behavior, access to care, and     |
|                                   | racial and ethnic disparities. In |
|                                   | accordance with these concerns,   |
|                                   | cultural competence objectives    |
|                                   | have been: (1) incorporated into  |
|                                   | the MCHB strategic plan; and (2)  |
|                                   | in guidance materials related to  |
|                                   | the Omnibus Budget Reconciliation |
|                                   | Act of 1989 (OBRA '89), which is  |
|                                   | the legislative mandate that      |
|                                   | health programs supported by MCHB |
|                                   | Children with Special Health Care |
|                                   | Needs (CSHCN) provide and promote |
|                                   | family centered, community‑based, |
|                                   | coordinated care.                 |
+-----------------------------------+-----------------------------------+

**OMB Number 0915-0272, expiration date January 31, 2006**

**DATA COLLECTION FORM FOR DETAIL SHEET #10**

Using a scale of 0-3, please rate the degree to which your grant program
has incorporated the following cultural competence elements into your
policies, guidelines, contracts and training.

+------+------+------+------+------------------------------------------+
| *    | *    | *    | *    | **Element**                              |
| *0** | *1** | *2** | *3** |                                          |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **CORE FUNCTIONS:** Our organization     |
|      |      |      |      | incorporates the following culturally    |
|      |      |      |      | competent core function elements:        |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Performs needs/assets assessments    |
|      |      |      |      |     with the culturally diverse groups   |
|      |      |      |      |     we serve.                            |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Collects and analyzes data according |
|      |      |      |      |     to different cultural groups (e.g.   |
|      |      |      |      |     race, ethnicity, language).          |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Designs services to meet the needs   |
|      |      |      |      |     of culturally diverse groups (e.g.   |
|      |      |      |      |     use of traditional healers, flexible |
|      |      |      |      |     times of services, language          |
|      |      |      |      |     services).                           |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 4.  Uses data on different groups for    |
|      |      |      |      |     program development.                 |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 5.  Considers barriers and the provision |
|      |      |      |      |     of appropriate strategies to address |
|      |      |      |      |     them.                                |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 6.  Evaluates and monitors quality       |
|      |      |      |      |     services (via customer satisfaction  |
|      |      |      |      |     surveys, focus groups, chart         |
|      |      |      |      |     reviews).                            |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to incorporate         |
|      |      |      |      | cultural competence in the core          |
|      |      |      |      | functions? *None\_\_\_ Informal\_\_\_    |
|      |      |      |      | Formal\_\_\_ In process\_\_\_*           |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **TRAINING/HUMAN RESOURCES**: Our        |
|      |      |      |      | organization incorporates the following  |
|      |      |      |      | culturally competent training/human      |
|      |      |      |      | resource elements:                       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Employs a culturally diverse and     |
|      |      |      |      |     linguistically and culturally        |
|      |      |      |      |     competent staff.                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Ensures the provision of training,   |
|      |      |      |      |     both in orientation and ongoing      |
|      |      |      |      |     professional development, for staff, |
|      |      |      |      |     volunteers, contractors and          |
|      |      |      |      |     subcontractors in the area of        |
|      |      |      |      |     cultural and linguistic competence.  |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to incorporate         |
|      |      |      |      | cultural competence in training and      |
|      |      |      |      | human resources?                         |
|      |      |      |      |                                          |
|      |      |      |      | *None\_\_\_ Informal\_\_\_ Formal\_\_\_  |
|      |      |      |      | In process\_\_\_*                        |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **COLLABORATION:** Our organization      |
|      |      |      |      | collaborates with informal community     |
|      |      |      |      | leaders/groups (e.g. natural networks,   |
|      |      |      |      | informal leaders, spiritual leaders,     |
|      |      |      |      | ethnic media, family advocacy groups) in |
|      |      |      |      | various aspects of the following         |
|      |      |      |      | categories::                             |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Program planning                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Service delivery                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Evaluation/monitoring of services    |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **COLLABORATION:** Our organization      |
|      |      |      |      | collaborates with families of culturally |
|      |      |      |      | diverse groups in various aspects of the |
|      |      |      |      | following categories:                    |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 4.  Program planning                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 5.  Service delivery                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 6.  Evaluation/monitoring of services    |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to support the above   |
|      |      |      |      | mentioned collaborative activities?      |
|      |      |      |      | *None\_\_\_ Informal\_\_\_ Formal\_\_\_  |
|      |      |      |      | In process\_\_\_*                        |
+------+------+------+------+------------------------------------------+

**OMB Number 0915-0272, expiration date January 31, 2006**

+------+------+------+------+------------------------------------------+
|      |      |      |      | **RESOURCE ALLOCATION:** Our             |
|      |      |      |      | organization's allocation of resources   |
|      |      |      |      | adequately meets the unique access,      |
|      |      |      |      | information and service needs of         |
|      |      |      |      | culturally diverse groups in the         |
|      |      |      |      | following program areas:                 |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Planning                             |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Implementation                       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Evaluation/Monitoring (e.g. customer |
|      |      |      |      |     satisfaction surveys, focus groups)  |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to support the         |
|      |      |      |      | allocation of fiscal resources for the   |
|      |      |      |      | needs and services for culturally        |
|      |      |      |      | diverse groups?                          |
|      |      |      |      |                                          |
|      |      |      |      | *None\_\_\_ Informal\_\_\_ Formal\_\_\_  |
|      |      |      |      | In process\_\_\_*                        |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **CONTRACTS:** Our agency puts language  |
|      |      |      |      | in contracts that addresses our goals to |
|      |      |      |      | incorporate cultural competence for      |
|      |      |      |      | culturally and linguistically diverse    |
|      |      |      |      | groups in the following areas**:**       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Needs/assets assessments             |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Outreach                             |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Specialized services                 |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 4.  Training for                         |
|      |      |      |      |     contractors/subcontractors           |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 5.  Sufficient funds to support 1-e      |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 6.  Reporting requirements for a-e       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to support monitoring  |
|      |      |      |      | of contractors/ subcontractors?          |
|      |      |      |      |                                          |
|      |      |      |      | *None\_\_\_ Informal\_\_\_ Formal\_\_\_  |
|      |      |      |      | In process\_\_\_*                        |
+------+------+------+------+------------------------------------------+

0=Not Met

1=Partially Met

2=Mostly Met

3=Completely Met

Total the numbers in the boxes (possible 0‑69 score)
\_\_\_\_\_\_\_\_\_\_

**OMB Number 0915-0272, expiration date January 31, 2006**

**FORM 1**

**MCHB PROJECT BUDGET DETAILS FOR FY \_\_\_\_\_\_\_**

**1. MCHB GRANT AWARD AMOUNT** \$\_\_\_\_\_\_\_\_\_**\_**

**2. UNOBLIGATED BALANCE** \$\_\_\_\_\_\_\_\_\_**\_**

**3. MATCHING FUNDS** (Required: Yes \[ \] No \[ \] If yes, amount)
\$\_\_\_\_\_\_\_\_\_\_

> A. Local funds \$\_\_\_\_\_\_\_

B.  State funds \$\_\_\_\_\_\_\_

C.  Program Income \$\_\_\_\_\_\_\_

D.  Applicant/Grantee Funds \$\_\_\_\_\_\_\_

> E. Other funds \$\_\_\_\_\_\_\_

**4. OTHER PROJECT FUNDS** (Not included in 3 above)
\$\_\_\_\_\_\_\_\_\_\_

> A. Local funds \$\_\_\_\_\_\_\_

B.  State funds \$\_\_\_\_\_\_\_

C.  Program Income (Clinical or Other) \$\_\_\_\_\_\_\_

D.  Applicant/Grantee Funds (includes in-kind) \$\_\_\_\_\_\_\_

> E. Other funds (including private sector, e.g., \$\_\_\_\_\_\_\_
>
> Foundations)

**5**. **TOTAL PROJECT FUNDS** (Tota2l lines 1 through 4)
\$\_\_\_\_\_\_\_\_\_\_

**6. FEDERAL COLLABORATIVE FUNDS**

(Source(s) of additional Federal funds contributing to the project)

A.  Other MCHB Funds (Do not repeat grant funds from Line 1)

> 1\) SPRANS \$\_\_\_\_\_\_\_\_
>
> 2\) CISS \$\_\_\_\_\_\_\_\_
>
> 3\) SSDI \$\_\_\_\_\_\_\_\_
>
> 4\) Abstinence Education \$\_\_\_\_\_\_\_\_
>
> 5\) Healthy Start \$\_\_\_\_\_\_\_\_

6)  EMSC \$\_\_\_\_\_\_\_\_

7)  Bioterrorism \$\_\_\_\_\_\_\_\_

8)  Traumatic Brain Injury \$\_\_\_\_\_\_\_\_

9)  State Title V Block Grant \$\_\_\_\_\_\_\_\_

10) Other \_\_\_\_\_\_\_\_\_\_\_\_\_ \$\_\_\_\_\_\_\_\_

```{=html}
<!-- -->
```
B.  Other HRSA Funds

> 1\) HIV/AIDS \$\_\_\_\_\_\_\_\_

2.  Primary Care \$\_\_\_\_\_\_\_\_

3.  Health Professions \$\_\_\_\_\_\_\_\_

4.  Other \_\_\_\_\_\_\_\_\_\_\_\_ \$\_\_\_\_\_\_\_\_

> Other Federal Funds

1\) CMS \$\_\_\_\_\_\_\_\_

5.  SSI \$\_\_\_\_\_\_\_\_

6.  Agriculture (WIC/other) \$\_\_\_\_\_\_\_\_

7.  ACF \$\_\_\_\_\_\_\_\_

8.  CDC \$\_\_\_\_\_\_\_\_

9.  SAMHSA \$\_\_\_\_\_\_\_\_

10. NIH \$\_\_\_\_\_\_\_\_

11. Education \$\_\_\_\_\_\_\_\_

12. Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \$\_\_\_\_\_\_\_\_

> \$\_\_\_\_\_\_\_\_
>
> \$\_\_\_\_\_\_\_\_

**7. TOTAL COLLABORATIVE FEDERAL FUNDS**
\$[\_\_\_\_\_\_\_\_]{.underline}

**OMB Number 0915-0272, expiration date January 31, 2006**

**INSTRUCTIONS FOR COMPLETION OF FORM 1**

**MCH BUDGET DETAILS FOR FY \_\_\_\_**

Line 1. Enter the amount of the Federal MCHB grant award for this
project.

Line 2. Enter the amount of carryover from the previous year's award, if
any (the unobligated balance).

Line 3. Indicate if matching funds are required by checking the
appropriate choice. If matching funds are required, enter the total
amount of the matching funds received or committed to the project. List
the amounts by source on lines 3A through 3D as appropriate. Do not
include "overmatch" funds. Any additional funds over and above the
amount required for matching purposes should be reported in Line 4.
Where appropriate, include the dollar value of in-kind contributions.

Line 4. Enter the amount of other funds received for the project, by
source on Lines 4A through 4E, specifying amounts from each source. Do
not include those amounts included in Line 3 above. Also include the
dollar value of in-kind contributions.

Line 5. Enter the sum of lines 1 through 4

Line 6. Line 6. Enter the amount of other Federal funds received on the
appropriate lines (A.1 through C.9) **other** than the MCHB grant award
for the project. Such funds would include those from other Departments,
other components of the Department of Health and Human Services, or
other MCHB grants or contracts.

Line 6C.1. Enter only project funds from the Center for Medicare and
Medicaid Services. Exclude Medicaid reimbursement, which is considered
Program Income and should be included on Line 3C or 4C.

If lines 6A.10, 6B.4, or 6C.9 are utilized, specify the source(s) of the
funds in the order of the amount provided, starting with the source of
the most funds. If more space is required, add a footnote at the bottom
of the page showing additional sources and amounts.

Line 7. Enter the sum of Lines 6A.1 through 6C.9.

NOTE: MCHB Training Grants must fill out Section "V. Detailed Budget" of
the currently approved HRSA-6025 in addition to this form.

**OMB Number 0915-0272, expiration date January 31, 2006**

**FORM 2**

**PROJECT FUNDING PROFILE**

> [FY]{.underline} [FY]{.underline} [FY]{.underline} [FY]{.underline}
> [FY]{.underline}\_\_\_\_\_
>
> [Budgeted Expended]{.underline} [Budgeted Expended]{.underline}
> [Budgeted Expended]{.underline} [Budgeted Expended]{.underline}
> [Budgeted Expended]{.underline}

1\. [MCHB Grant]{.underline}

[Award]{.underline} [Amount]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$
\$\_\_\_\_\_\_\_\_\_

(*Line 1, Form 2)*

2\. [Unobligated]{.underline}

[Balance]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_\_\_

*(Line 2, Form 2)*

3\. [Matching]{.underline}

[Funds]{.underline}

[(If required)]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$
\$\_\_\_\_\_\_\_\_\_

(*Line 3, Form 2)*

4*.* [Other Project]{.underline}

[Funds]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_\_\_

(*Line 4, Form 2)*

5\. [Total Project]{.underline}

[Funds]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_\_\_
(*Line 5, Form 2)*

6\. [Total Federal]{.underline}

[Collaborative]{.underline}

[Funds]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_\_\_

*(Line 7, Form 2)*

**OMB Number 0915-0272, expiration date January 31, 2006**

**INSTRUCTIONS FOR THE COMPLETION OF FORM 2**

**PROJECT FUNDING PROFILE**

**Instructions:**

Complete all required data cells. If an actual number is not available,
use an estimate. Explain all estimates in a footnote.

The form is intended to provide at a glance funding data on the
estimated budgeted amounts and actual expended amounts of an MCH
project.

> For each fiscal year, the data in the columns labeled Budgeted on this
> form are to contain the same figures that appear on the Application
> Face Sheet and Lines 1 through 7 of Form 1. The lines under the
> columns labeled Expended are to contain the actual amounts expended
> for each grant year that has been completed.

**OMB Number 0915-0272, expiration date January 31, 2006**

#### FORM 4

**PROJECT BUDGET AND EXPENDITURES**

**By Types Of Services**

**FY \_\_\_\_\_ FY \_\_\_\_\_**

**[TYPES OF SERVICES]{.underline} [Budgeted]{.underline}
[Expended]{.underline} [Budgeted]{.underline} [Expended]{.underline}**

**I. [Direct Health Care Services]{.underline}** \$ \$ \$ \$
[\_\_\_\_\_\_\_\_\_]{.underline}

> (Basic Health Services and Health
>
> Services for CSHCN.)

**II. [Enabling Services]{.underline}** \$ \$ \$ \$
[\_\_\_\_\_\_\_\_\_\_]{.underline}

> (Transportation, Translation,

Outreach, Respite Care, Health

> Education, Family Support Services,

Purchase of Health Insurance,

> Case Management, and Coordination
>
> with Medicaid, WIC, and Education.)

**III.** **[Population-Based Services]{.underline}** \$ \$ \$
\$\_\_\_\_\_\_\_\_\_\_\_

> (Newborn Screening, Lead Screening,
>
> Immunization, Sudden Infant Death
>
> Syndrome Counseling, Oral Health,
>
> Injury Prevention, Nutrition, and

Outreach/Public Education.)

**IV.** **[Infrastructure Building Services]{.underline}** \$ \$ \$ \$
[\_\_\_\_\_\_\_\_\_\_\_]{.underline}

> (Needs Assessment, Evaluation, Planning,
>
> Policy Development, Coordination,
>
> Quality Assurance, Standards Development,
>
> Monitoring, Training, Applied Research,

Systems of Care, and Information Systems.

**TOTAL \$ \$ \$ \$ [\_\_\_\_\_\_\_\_\_\_\_]{.underline}**

**OMB Number 0915-0272, expiration date January 31, 2006**

**INSTRUCTIONS FOR THE COMPLETION OF FORM 4**

**PROJECT BUDGET AND EXPENDITURES BY TYPES OF SERVICE**S

Complete all required data cells. If an actual number is not available,
make an estimate. Please explain all estimates in a footnote.
Administrative dollars should be allocated to the appropriate level(s)
of the pyramid on lines I, II, II or IV. If an estimate of
administrative funds use is necessary, one method would be to allocate
those dollars to Lines I, II, III and IV at the same percentage as
program dollars are allocated to Lines I through IV.

Note: Lines I, II and II are for projects providing services. If grant
funds are used to build the infrastructure for direct care delivery,
enabling or population-based services, these amounts should be reported
in Line IV (i.e., building data collection capacity for newborn hearing
screening).

Line I [Direct Health Care Services]{.underline} - enter the budgeted
and expended amounts for the appropriate fiscal year completed and
budget estimates only for all other years.

> **Direct Health Care Services** are those services generally delivered
> one-on-one between a health professional and a patient in an office,
> clinic or emergency room which may include primary care physicians,
> registered dietitians, public health or visiting nurses, nurses
> certified for obstetric and pediatric primary care, medical social
> workers, nutritionists, dentists, sub-specialty physicians who serve
> children with special health care needs, audiologists, occupational
> therapists, physical therapists, speech and language therapists,
> specialty registered dietitians. Basic services include what most
> consider ordinary medical care, inpatient and outpatient medical
> services, allied health services, drugs, laboratory testing, x-ray
> services, dental care, and pharmaceutical products and services. State
> Title V programs support - by directly operating programs or by
> funding local providers - services such as prenatal care, child health
> including immunizations and treatment or referrals, school health and
> family planning. For CSHCN, these services include specialty and
> sub-specialty care for those with HIV/AIDS, hemophilia, birth defects,
> chronic illness, and other conditions requiring sophisticated
> technology, access to highly trained specialists, or an array of
> services not generally available in most communities.

Line II [Enabling Services]{.underline} - enter the budgeted and
expended amounts for the appropriate fiscal year completed and budget
estimates only for all other years.

> **Enabling Services** allow or provide for access to and the
> derivation of benefits from, the array of basic health care services
> and include such things as transportation, translation services,
> outreach, respite care, health education, family support services,
> purchase of health insurance, case management, coordination of with
> Medicaid, WIC and educations. These services are especially required
> for the low income, disadvantaged, geographically or culturally
> isolated, and those with special and complicated health needs. For
> many of these individuals, the enabling services are essential - for
> without them access is not possible. Enabling services most commonly
> provided by agencies for CSHCN include transportation, care
> coordination, translation services, home visiting, and family
> outreach. Family support activities include parent support groups,
> family training workshops, advocacy, nutrition and social work.

Line III [Population-Based Services]{.underline} - enter the budgeted
and expended amounts for the appropriate fiscal year completed and
budget estimates only for all other years.

> **Population Based Services** are preventive interventions and
> personal health services, developed and available for the entire MCH
> population of the State rather than for individuals in a one-on-one
> situation. Disease prevention, health promotion, and statewide
> outreach are major components. Common among these services are newborn
> screening, lead screening, immunization, Sudden Infant Death Syndrome
> counseling, oral health, injury prevention, nutrition and
> outreach/public education. These services are generally available
> whether the mother or child receives care in the private or public
> system, in a rural clinic or an HMO, and whether insured or not.

Line IV [Infrastructure Building Services]{.underline} - enter the
budgeted and expended amounts for the appropriate fiscal year completed
and budget estimates only for all other years.

> **Infrastructure Building Services** are the base of the MCH pyramid
> of health services and form its foundation. They are activities
> directed at improving and maintaining the health status of all women
> and children by providing support for development and maintenance of
> comprehensive health services systems and resources including
> development and maintenance of health services standards/guidelines,
> training, data and planning systems. Examples include needs
> assessment, evaluation, planning, policy development, coordination,
> quality assurance, standards development, monitoring, training,
> applied research, information systems and systems of care. In the
> development of systems of care it should be assured that the systems
> are family centered, community based and culturally competent.

Line V [Total]{.underline} -- enter the total amounts for each column,
budgeted for each year and expended for each year completed.

**OMB Number 0915-0272, expiration date January 31, 2006**

> **FORM 6**

**MATERNAL & CHILD HEALTH DISCRETIONARY GRANT**

**PROJECT ABSTRACT**

**FOR FY\_\_\_\_**

**PROJECT:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**I. PROJECT IDENTIFIER INFORMATION**

1\. Project Title:

2\. Project Number:

3\. E-mail address:

**II. BUDGET**

1\. MCHB Grant Award \$\_\_\_\_\_\_\_\_\_\_\_\_\_

(Line 1, Form 2)

2\. Unobligated Balance \$\_\_\_\_\_\_\_\_\_\_\_\_\_

(Line 2, Form 2)

3\. Matching Funds (if applicable) \$\_\_\_\_\_\_\_\_\_\_\_\_\_

> (Line 3, Form 2)

4\. Other Project Funds \$\_\_\_\_\_\_\_\_\_\_\_\_\_

> (Line 4, Form 2)

5\. Total Project Funds \$\_\_\_\_\_\_\_\_\_\_\_\_\_

> (Line 5, Form 2)

#### III. TYPE(S) OF SERVICE PROVIDED (Choose all that apply)

\[ \] Direct Health Care Services

> \[ \] Enabling Services
>
> \[ \] Population-Based Services
>
> \[ \] Infrastructure Building Services

##### PROJECT DESCRIPTION OR EXPERIENCE TO DATE

> A. Project Description

1.  Problem (in 50 words, maximum):

2.  Goals and Objectives: (List up to 5 major goals and time-framed
    objectives per goal for the project)

> Goal 1:

Objective 1:

Objective 2:

Goal 2:

Objective 1:

Objective 2:

Goal 3:

Objective 1:

Objective 2:

Goal 4:

Objective 1:

Objective 2:

3.  Activities undertaken to meet project goals

4.  Specify the primary *Healthy People 2010* objectives(s) (up to
    three) which this project addresses:

> a\.
>
> b\.
>
> c\.

5\. Coordination (List the State, local health agencies or other
organizations involved in the project and their roles)

6\. Evaluation (briefly describe the methods which will be used to
determine whether process and outcome objectives are met)

##### Continuing Grants ONLY

##### Experience to Date (For continuing projects ONLY):

2\. Website URL and annual number of hits

##### KEY WORDS

#### VI. ANNOTATION 

**OMB Number 0915-0272, expiration date January 31, 2006**

> **INSTRUCTIONS FOR THE COMPLETION OF FORM 6**

###  PROJECT ABSTRACT

**NOTE:** All information provided should fit into the space provided in
the form. The completed form should be no more than 3 pages in length.
Where information has previously been entered in forms 1 through 5, the
information will automatically be transferred electronically to the
appropriate place on this form.

**Section I -- Project Identifier Information**

Project Title: List the appropriate shortened title for the project.

Project Number: This is the number assigned to the project when funded,
and will, for new projects, be filled in later.

E-mail address: Include electronic mail addresses

#### Section II -- Budget - These figures will be transferred from Form 1, Lines 1 through 5. 

#### Section III - Types of Services

#### Indicate which type(s) of services your project provides, checking all that apply (consistent with Form 5)Section IV -- Program Description OR Current Status (DO NOT EXCEED THE SPACE PROVIDED)

A. New Projects only are to complete the following items:

1.  A brief description of the project and the problem it addresses such
    as preventive and primary care services for pregnant women, mothers,
    and infants; preventive and primary care services for children; and
    services for Children with Special Health Care Needs.

2.  Up to 5 goals of the project, in priority order. Examples are: To
    reduce the barriers to the delivery of care for pregnant women, to
    reduce the infant mortality rate for minorities and "services or
    system development for children with special healthcare needs." MCHB
    will capture annually every project's top goals in an information
    system for comparison, tracking, and reporting purposes; you must
    list at least 1 and no more than 5 goals. For each goal, list the
    two most important objectives. The objective must be specific (i.e.,
    decrease incidence by 10%) and time limited (by 2005).

3.  List the primary Healthy people 2010 goal(s) that the project
    addresses.

4.  Describe the programs and activities used to attain the goals and
    objectives, and comment on innovation, cost, and other
    characteristics of the methodology, proposed or are being
    implemented. Lists with numbered items can be used in this section.

5.  Describe the coordination planned and carried out, in the space
    provided, if applicable, with appropriate State and/or local health
    and other agencies in areas(s) served by the project.

6.  Briefly describe the evaluation methods that will be used to assess
    the success of the project in attaining its goals and objectives.

    B.  For continuing projects ONLY:

    ```{=html}
    <!-- -->
    ```
    1.  Provide a brief description of the major activities and
        accomplishments over the past year (not to exceed 200 words).

    2.  Provide website and number of hits annually, if applicable.

**Section V - -Key Words**

Key words describe the project, including populations served. Choose key
words from the included list.

**Section VI -- Annotation**

> Provide a three- to five-sentence description of your project that
> identifies the project's purpose, the needs and problems, which are
> addressed, the goals and objectives of the project, the activities,
> which will be used to attain the goals, and the materials, which will
> be developed.

**OMB Number 0915-0272, expiration date January 31, 2006**

**FORM 7**

DISCRETIONARY GRANT PROJECT

SUMMARY DATA

1.  **Project Service Focus**

> \[ \] Urban/Central City \[ \] Suburban \[ \] Metropolitan Area (city
> & suburbs)
>
> \[ \] Rural \[ \] Frontier \[ \] Border (US-Mexico)

2.  **Project Scope**

> \[ \] Local \[ \] Multi-county \[ \] State-wide
>
> \[ \] Regional \[ \] National

3.  **Grantee Organization Type**

> \[ \] State Agency

\[ \] Community Government Agency

\[ \] School District

\[ \] University/Institution Of Higher Learning (Non-Hospital Based)

\[ \] Academic Medical Center

\[ \] Community-Based Non-Governmental Organization (Health Care)

\[ \] Community-Based Non-Governmental Organization (Non-Health Care)

\[ \] Professional Membership Organization (Individuals Constitute Its
Membership)

\[ \] National Organization (Other Organizations Constitute Its
Membership)

\[ \] National Organization (Non-Membership Based)

\[ \] Independent Research/Planning/Policy Organization

\[ \] Other
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

4.  **Project Infrastructure Focus** (from MCH Pyramid) if applicable

\[ \] Guidelines/Standards Development And Maintenance

\[ \] Policies And Programs Study And Analysis

\[ \] Synthesis Of Data And Information

\[ \] Translation Of Data And Information For Different Audiences

\[ \] Dissemination Of Information And Resources

\[ \] Quality Assurance

\[ \] Technical Assistance

\[ \] Training

\[ \] Systems Development

\[ \] Other

**5. Products and Dissemination**

+--------------------------------------------------------+-------------+
| # PRODUCTS                                             | #  NUMBER   |
+--------------------------------------------------------+-------------+
| Peer reviewed Journal Article                          |             |
+--------------------------------------------------------+-------------+
| Book/Chapter                                           |             |
+--------------------------------------------------------+-------------+
| Report/Monograph                                       |             |
+--------------------------------------------------------+-------------+
| Presentation                                           |             |
+--------------------------------------------------------+-------------+
| Doctoral Dissertation                                  |             |
+--------------------------------------------------------+-------------+
| Other:                                                 |             |
+--------------------------------------------------------+-------------+

**OMB Number 0915-0272, expiration date January 31, 2006**

**6. Demographic Characteristics of Project Participants for Clinical
Services Projects**

+-----------+--------+------+--------+--------+-------+-------+-----+---+
|           | **RACE |      |        |        |       | **E   |     |   |
|           | (In    |      |        |        |       | THNIC |     |   |
|           | dicate |      |        |        |       | ITY** |     |   |
|           | all    |      |        |        |       |       |     |   |
|           | that   |      |        |        |       |       |     |   |
|           | ap     |      |        |        |       |       |     |   |
|           | ply)** |      |        |        |       |       |     |   |
+===========+========+======+========+========+=======+=======+=====+===+
|           | Am     | A    | Black  | Native | White | His   | Not |   |
|           | erican | sian | or     | Ha     |       | panic | Hi  |   |
|           | Indian |      | A      | waiian |       | or    | spa |   |
|           | or     |      | frican | or     |       | L     | nic |   |
|           | Alaska |      | Am     | Other  |       | atino |     |   |
|           | Native |      | erican | P      |       |       | or  |   |
|           |        |      |        | acific |       |       | Lat |   |
|           |        |      |        | Is     |       |       | ino |   |
|           |        |      |        | lander |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| # Pregn   |        |      |        |        |       |       |     |   |
| ant Women |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| ##        |        |      |        |        |       |       |     |   |
|  Children |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| Children  |        |      |        |        |       |       |     |   |
| with      |        |      |        |        |       |       |     |   |
| Special   |        |      |        |        |       |       |     |   |
| Health    |        |      |        |        |       |       |     |   |
| Care      |        |      |        |        |       |       |     |   |
| Needs     |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| Women     |        |      |        |        |       |       |     |   |
|           |        |      |        |        |       |       |     |   |
| (Not      |        |      |        |        |       |       |     |   |
| Pregnant) |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| ## Other  |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| ##        |        |      |        |        |       |       |     |   |
|           |        |      |        |        |       |       |     |   |
| ## TOTALS |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+

######### Clients' Primary Language(s)

######### \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

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

######### Resource/TA and Training Centers ONLY

######### **Answer all that apply.**

a.  Characteristics of Primary Intended Audience(s)

> \[ \] Policy Makers/Public Servants
>
> \[ \] Consumers

\[ \] Providers/Professionals

b\. Number of Requests Received/Answered: \_\_\_/\_\_\_\_

c.  Number of Continuing Education credits provided: \_\_\_\_\_\_\_

d.  Number of Individuals/Participants Reached: \_\_\_\_\_\_\_

e.  Number of Organizations Assisted: \_\_\_\_\_\_\_

f.  Major Type of TA or Training Provided:

> \[ \] continuing education courses,

\[ \] workshops,

\[ \] on-site assistance,

\[ \] distance learning classes

\[ \] other

**OMB Number 0915-0272, expiration date January 31, 2006**

> **INSTRUCTIONS FOR THE COMPLETION OF FORM 7**

###  PROJECT SUMMARY

**NOTE:** All information provided should fit into the space provided in
the form. Where information has previously been entered in forms 2
through 9, the information will automatically be transferred
electronically to the appropriate place on this form.

**Section 1 -- Project Service Focus**

Select all that apply

#### 

#### Section 2 -- Project Scope

#### Choose the one that best applies to your project.

#### Section 3 -- Grantee Organization Type

#### Choose the one that best applies to your organization.

### Section 4 -- Project Infrastructure Focus

If applicable, choose all that apply.

**Section 5 -- Products and Dissemination**

Indicate the number of each type of product resulting from the project.

#### Section 6 -- Demographic Characteristics of Project Participants (for Clinical Services Projects)

#### Please fill in each of the cells as appropriate. 

#### Section 7 -- Clients Primary Language(s) (for Clinical Services Projects)

#### Indicate which languages your clients speak as their primary language, other than English. List up to three.

#### Section 8 -- Resource/TA and Training Centers (Only)

Answer all that apply.

[^1]: New Initiative: program/activity/initiative that has never existed
    (e.g., development of community playground safety program, new oral
    health program, development of case management program to ensure
    that infants are immunized, etc.)

[^2]: New Component of Existing Activity: existing health program that
    proposes to expand services by adding a new component (e.g.,
    addition of clinical dietician in obesity program, addition of
    outreach workers to pediatric practice, addition of peer mentors to
    pre-existing school violence program, etc.)