Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 630 - MATERNAL AND CHILD HEALTH SERVICES CODE › Subpart D - ADMINISTRATIVE REQUIREMENTS › Appendix E - Application and Plan for Public Health

Current through Register Vol. 48, No. 28, July 12, 2024
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
535 WEST JEFFERSON STREET
SPRINGFIELD, ILLINOIS 62761
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM
				  GRANT
1. PROGRAM TITLE:
				  ______________________________________________________
BRIEF SUMMARY:
				  _____________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
2.
APPLICATION ORGANIZATION:
NAME:
				  _________________________________________________
ADRESS:
				  _______________________________________________
__________________________________________________________
TELEPHONE: (__)
				  _________________________________________
FEIN NUMBER:
				  ___________________________________________
PROJECT DIRECTOR:
				  _____________________________________
__________________________________________________________
FINANCE OFFICER:
				  _______________________________________
__________________________________________________________
__________________________________________________________
3.
APPLICANT CERTIFICATION:
To the best of my knowledge, the data and
				  statements in this application are true and correct. The applicant agrees to
				  comply with all State/Federal statutes and Rules/Regulations applicable to the
				  program
AUTHORIZED OFFICIAL:
				  ____________________________________
__________________________________________________________
__________________________________________________________
DateSignature
4.
TYPE OF ORGANIZATION:
_______________ LOCAL HEALTH DEPARTMENT
_______________ PRIVATE NON-PROFIT AGENCY
_______________ OTHER
__________________________________________________________
__________________________________________________________
5. GRANT SUPPORT REQUESTED:
BEGINNINGENDINGAMOUNT
__________________________________________________________
6.
TYPE OF APPLICATION:
INITIALCONTINUATIONREVISION
__________________________________________________________
__________________________________________________________
7.
LEGISLATIVE DISTRICT:
CONGRESSIONAL
				  ________________________________________
LEGISLATIVE
				  ________________________________
(State Senate)
REPRESENTATIVE _____________________
(State Representative)
__________________________________________________________
8.
DATE OF SUBMISSION:
__________________________________________________________
MonthDateYear
__________________________________________________________
9.
IMPORTANT NOTICE:
This state agency is requesting disclosure of
				  information that is necessary to accomplish the statutory purpose as outlined
				  under 30 ILCS 105. Failure to provide this information may prevent this form
				  from being processed. This form has been approved by the Forms Management
				  Center.
__________________________________________________________
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
APPLICATION AND PLAN FOR PUBLIC
				  HEALTH PROGRAM GRANT
PROGRAM NARRATIVE OR PROGRESS REPORT
INSTRUCTIONS: Please complete a narrative in accordance with
				  the instructions found in "Rules and Regulations" for the specific project for
				  which you are requesting funds. If this is a continuation application, please
				  use this page as a progress report in accordance with instructions in the
				  "Rules and Regulations". Following the narrative, please attach a listing of
				  all sites of service and their addresses for this project.
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM
				  GRANT
DATE FROM:THROUGH:
DATE FROM:
THROUGH:
SUMMARY BUDGET FOR THIS PERIOD
SOURCE OF FUNDS
Budget
Applicant
Amount
Total
And
Assistance
For
Other
Requested
Program
__________________________________________________________
1. PERSONAL SERVICES
__________________________________________________________
2. CONTRACTUAL SERVICES
__________________________________________________________
3. SUPPLIES
__________________________________________________________
4. TRAVEL
__________________________________________________________
5. PATIENT CARE
__________________________________________________________
6. EQUIPMENT
__________________________________________________________
7. TOTAL DIRECT COSTS
__________________________________________________________
SOURCE OF FUNDS - APPLICANT
				  &CODE MATCHING OR
				  COSTOTHER
OTHER CATEGORY
				  ONLYPARTICIPATION
_____________ $ REQUIREMENTS _ $
				  ____________
TOTAL_____________ $
				  ________________ _ $ ____________
__________________________________________________________
USE ADDITIONAL SHEETS IF NECESSARY
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM
				  GRANT
DATE FROM:11219
THROUGH:
DETAILED BUDGET FOR THIS PERIOD (TOTAL
							 COST)
MONTHLY SALARY RATE
NUMBERMONTHS BUDGETED
PERCENT TIME
BUDGET TOTAL FOR PROGRAM
CODE APPLICANT AND OTHER
SOURCE OF FUNDS AMOUNT ASSISTANCE
							 REQUESTED
(1)
(2)
(3)
(4)
(5)
(6)
1. PERSONAL SERVICES (Position Title & Name of
							 Incumbent)
FRINGE BENEFITS
(Rate)
CATEGORY TOTAL
__________________________________________________________
USE ADDITIONAL SHEETS IF NECESSARY
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM
				  GRANT
DATE FROM:
THROUGH:
DETAILED BUDGET FOR THIS PERIOD:
BUDGET TOTAL FOR PROGRAM
CODE
APPLICANT AND OTHER
AMOUNT ASSISTANCE REQUESTED
________
_____
________
________
(3)
(4)
(5)
_________________________
______________________________________________________________________
2. CONTRACTUAL SERVICES:
Itemize
______________________________________________________________________
CATEGORY TOTAL
$
$
$
______________________________________________________________________
3. SUPPLIES
Itemize
______________________________________________________________________
CATEGORY TOTAL
$
$
$
______________________________________________________________________
4. TRAVEL: Itemize
Mileage (Rate per mile: ¢)
Lodging
Meals/Per Diem Commercial
Transportation Other:
______________________________________________________________________
CATEGORY TOTAL
$
$
$
______________________________________________________________________
USE ADDITIONAL SHEETS IF NECESSARY
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM
				  GRANT
DATE FROM:
THROUGH:
DETAILED BUDGET FOR THIS PERIOD:
BUDGET TOTAL FOR PROGRAM
CODE
APPLICANT AND OTHER
AMOUNT ASSISTANCE REQUESTED
________
_____
________
________
(3)
(4)
(5)
_________________________
______________________________________________________________________
5. PATIENT CARE:
Itemize
______________________________________________________________________
CATEGORY TOTAL
$
$
$
______________________________________________________________________
6. EQUIPMENT
Itemize
______________________________________________________________________
CATEGORY TOTAL
$
$
$
______________________________________________________________________
7. TOTAL COSTS
$
$
$
______________________________________________________________________
USE ADDITIONAL SHEETS IF NECESSARY
ILLINOIS DEPARTMEN OF PUBLIC HEALTH
APPLICATION AND PLAN FOR HEALTH SERVICES
				  GRANT
DATE FROM:11219THROUGH: ________
BUDGET JUSTIFICATION
INSTRUCTIONS:
Show justification for specific items or categories
							 listed in the detailed budget for which the need is not self-evident.
							 Justifications should clearly indicate that the times being requested are
							 essential to the achievement of the stated project objectives and the conduct
							 of the proposed procedures.
_____________________________________________________________________
USE ADDITIONAL SHEET IF
				  NECESSARY