Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 975 - COMMUNITY HEALTH CENTER EXPANSION › Subpart B - GRANTS TO EXPAND FEDERALLY QUALIFIED HEALTH CENTER PROGRAMS › Section 975.223 - Grant Application

Current through Register Vol. 48, No. 28, July 12, 2024
a) Once
				the applicant fulfills the requirements of Sections
				975.221 and
				975.222, a grant
				application can be submitted. The application shall include the following:
1) The legal name of the applicant;
2) The name and title of the applicant's
				chief officers and key managers;
3)
				The applicant's address;
4) A
				general description of the applicant, including its business and business
				experience;
5) The applicant's
				telephone number and fax number;
6)
				The applicant's FEIN;
7) The
				applicant's Illinois Department of Human Rights number;
8) The applicant's DUNS number;
9) The project director's name and e-mail
				address;
10) A detailed description
				of the project for which grant funding is requested. This will include a
				summary of the applicant's plan of action to address the goals of either:
A) Establishing a new CHC site to provide
				primary health care services to medically underserved populations or areas or
				to provide primary health care services to the uninsured population of
				Illinois; or
B) Expanding the
				services of an existing CHC site to provide primary health care services to
				medically underserved populations or areas or primary health care services to
				the uninsured population of Illinois. (Section 10(a) of the Act)
11) A project narrative that
				includes the following:
A) The proposed
				service area, including a map depicting the boundaries of the service area and
				the identification of other FQHCs, FQHC Look-Alikes, local health departments
				and hospitals within the service area;
B) A statement of need for the project,
				including a brief description of the project and its needs and expected
				accomplishments. The narrative shall also provide a brief description of the
				financial and facility resources for the project;
C) The project objectives, documenting the
				measurable objectives that the project will accomplish, including appropriate
				measuring metrics;
D) A plan of
				operation describing the implementation plan for the objectives and a timetable
				for their achievement;
E) A plan
				describing how the project will be evaluated to ascertain if the objectives
				have been achieved, including documenting the project's progress in meeting the
				particular needs of the project's service area; and
F) A budget listing the total dollar amount
				needed for the project, including the amount to be provided by the applicant
				and other funding sources and the amount of funding requested through the
				grant. The applicant shall identify all revenue sources and amounts and provide
				budget estimates, including expenditures for the duration of the project. The
				project's budget shall include the following costs (if applicable):
i) Personal services, including salaries and
				hourly compensation for officers, directors, and key employees;
ii) Benefits;
iii) Travel;
iv) Commodities/supplies;
v) Equipment;
vi) Facility
				construction/renovation;
vii)
				Contractual;
viii)
				Printing;
ix)
				Telecommunications;
x)
				Patient/client care; and
xi)
				Administrative costs.