Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 502 - COMMUNITY HEALTH PROGRAM GRANTS POLICY MANUAL AND APPLICATION › Appendix 144-502-A - COMMUNITY HEALTH PROGRAM

Current through 2024-29, July 17, 2024
APPLICATION INSTRUCTIONS
This application is to be developed in two sections. The
				  first section will consist of narrative description of the project and the
				  second section will consist of financial information. It is important that both
				  sections be submitted simultaneously. The application must be submitted as an
				  original and with two copies. A signed cover letter by an authorizing
				  organization official should accompany the application. The cover letter should
				  be a brief abstract describing the objective of the proposal and the basic
				  approach or methodology to reaching the proposed objectives.
Quarterly reporting should be milestones accomplished in
				  accordance with your responses to the narrative questions.
All questions in this section should be answered as
				  completely as possible.
SECTION 1 - PROGRAM DESCRIPTION
This section of your application must be typewritten and
				  double spaced. ALL APPLICANTS must answer the questions in this section.
1 Describe your organization and its
				structure, identifying principals and their backgrounds.
2 Describe Your current available services,
				and your organizations' potential to provide the proposed services from Your
				current base.
3 Describe in detail
				the community commitment to this project. Evidence of support would be in-kind
				services, equipment, space, etc.
4
				Explain how you propose to make this program self-sustaining after the maximum
				allowable grant funding period.
5
				Explain whether or not this program is a replica from another community or if
				it can be replicated in another community.
6 Describe any source of local financial
				support for the proposed program that will exist and provide documentation for
				source.
7 Describe other funding
				sources you intend to use or share with the proposed Program.
8 Describe any subcontracted services you
				anticipate utilizing in this program and Your basis why the services are being
				subcontracted and not provided by you. Please note the requirements in Appendix
				D of this document which your subcontract must meet.
SECTION 1a - PRIMARY HEALTH CARE APPLICANTS
Primary Health Care applicants must answer the following
				  questions in addition to the questions in section 1:
9 Describe the problem you are addressing in
				this Proposal. Include documented need, address community hardship and describe
				any Problems with access your constituents may have.
10 Provide a detailed statement of how you
				propose to address the problem described in item 9. You must include a clear
				statement of goals and achievable objectives; a management plan and timetable
				(not to exceed the 3 year maximum) specifying strategies to accomplish your
				objectives, key actions and milestones, roles and capabilities of responsible
				individuals and organizations.
Demonstrate the ability to coordinate services and
				  programmatic efforts with local primary care providers. Also include a
				  management plan showing objectives, tasks needed in order to achieve those
				  objectives and timetable with measurable milestones, roles of responsible
				  individuals and organizations.
11 Describe with measurable objectives. the
				impact your proposal will have to improve your community's access to health
				care. You should address such things as diversification of services, health
				professional recruitment, transportation, community economics and
				others.
SECTION 1b - HEALTH PROMOTION AND EDUCATION APPLICANTS
Applicants for the Health Promotion and Education awards must
				  answer the following questions in addition to the questions in section 1.
9 Describe the risk factors you are
				addressing in this proposal. Identify the prevalence of the risk factor
				relative to other factors among a targeted population.
10 Describe your target group's special needs
				and characteristics and address whether or not access and participation will be
				a problem in your proposed program.
11 Provide a detailed management plan with a
				clear statement of goals and measurable objectives. Include a, description with
				timetables of the tasks necessary to meet your objectives. You must also
				include organizational resources, capabilities of responsible individuals for a
				3 year period.
APPENDIX A SECTION 2 B UDGETARY AND FINANCIAL -
				  INFORMATION
All grantees receiving Public funds must disclose all related
				  financial information prior to approval of any grant. Further, all CHP funds
				  must be limited to costs associated with the delivery of the service. A
				  financial glossary explaining allowable and non-allowable expenses is enclosed
				  as Appendix C.
The financial section is comprised of a series of forms
				  designed to summarize and justify a provider organization's financial plan. It
				  is necessary for the grantee to determine the following:
(1) all income which may reasonably be
				expected to be received by the provider organization during the grant year; and
(2) all expenses which may
				reasonably be expected to occur during the grant year.
All budgets should be prepared for a three (3) year period
				  unless the program is for a lesser limited time period which should be
				  stated.
The Community Health Program shall determine allowable
				  grantee expenditures based upon the principle of functional accounting (cost
				  sharing). Only balanced budgets will be approved.
INCOME BUDGET FORM (CHPF-003)
On this form, list all anticipated program income for the
				  period of performance of the proposed grant. Include both restricted and
				  non-restricted income. The amounts of the income listed must actually be
				  available to the program.
EXPENSES BUDGET FORM (CHPF-004)
On the Expense Form list all anticipated Program expenses for
				  the period of performance of the grant on an annual basis. Be sure to fill in
				  each years' expense and total all three columns in column 4.
Sub-total each category as requested and provide a total
				  program expense amount on the last line as requested in total program amount
				  column.
All expenses in the Community Health Program must be
				  Justified-on a budget Justification form Expenses such as salaries and fringe
				  benefits which are direct expenses will be documented on CHPF-005. All other
				  direct expenses shall be documented on either CHPF-006, Basis of Distributing
				  Shared Direct Expenses, or on CHPF-007, Other Direct Expense Justification.
				  Indirect costs shall be documented on CHPF-008, General and Administrative
				  Expenses or other approved format.
COMMUNITY HEALTH PROGRAM
PROGRAM INCOME - BUDGET
PERIOD OF
				  PERFORMANCE_____________________________________________
FUNDING SOURCE
YEAR 1
YEAR 2
YEAR 3
1) STATE/FEDERAL
a)
b)
c)
TOTAL
2) LOCAL FUNDING
a.
b.
c.
TOTAL
3) PRIVATE FUNDING
a)
b)
c)
TOTAL
4) PROGRAM INCOME
a) Client Fees
b) Consult Fees
c)
d)
TOTAL
5) OTHER INCOME
a)
b)
c)
TOTAL
TOTAL INCOME
COMMUNITY HEALTH PROGRAM
PROGRAM EXPENSES-BUDGET
(CHPF-004)
LINE ITEM
YEAR 1
YEAR 2
YEAR 3
PERSONNEL EXPENSES
1. Salaries & Wages
2. Fringe Benefits
3. Consultant Fees
4. Providers' Fees
5. TOTAL PERSONNEL EXPENSES
EQUIPMENT
6. Purchases
7. Rental
8. TOTAL EQUIPMENT EXPENSES
SUBCONTRACTS
9. TOTAL SUB-CONTRACTS
ALL OTHER
10. Occupancy Expense
11. Depreciation
12. Utilities
13. Heat
14. Maintenance
15. Telephone
16. Materials & Supplies
17. Travel
18. Insurance
19. Postage
20. General and Administrative (indirect)
21. Other (attach detail)
22. TOTAL ALL OTHER EXPENSES
23. TOTAL EXPENSES (lines 5, 8, 9, & 22)
PERSONNEL. EXPENSES FORM (CHPF-005)
This form provides back-up documentation for lines and 2 of
				  the Expenses Budget Form (CHPF-004).
Complete the form as follows:
Column I Is used to show the number of people to be employed
				  for a particular position at one salary level. Full time persons should be
				  listed. Part-time employment should be indicated by the number of hours spent
				  per week rather than by 1/2 or 1/4 person;
Column 2 Give persons title who will be involved directly in
				  the program.
Column 3 This rate is for one individual. if rates differ,
				  use another line
Column 4 This is the total number- of hours worked for a week
				  for-all personnel listed on that line.
Column 5 Is determined by multiplying column 3 by column
				  4
Column 6 Is the total number of weeks during the period of
				  performance of the grant that that the individual will be working;
Column 7 Is determined by multiplying column 5 by column
				  6
Column 8 Self-explanatory
Column 9 Is determined by multiplying column 7 by column 8 by
				  column I
Total Salary Enter column 7 total in Summary Section, Total
				  Salary for proposed year.
In the fringe benefits section, fill in the name of the
				  benefit in the first column; the percentage applied in determining expenses in
				  the second column; and the dollar amount for each benefit in the third column.
				  Total the percentage and expense columns. Enter total expense for fringe
				  benefits in the proposed year column of the summary section.
Add the Total Salary and Total Fringe. Enter the Total Number
				  of Personnel. Total Salary and Total Fringe should be the same as on lines and
				  I and 2 respectively of the Expenses Form CHPF-004.
COMMUNITY HEALTH PROGRAM
PERSONNEL EXPENSES
(CHPF-005) PROGRAM____________
PERIOD OF PERFORMANCE____________
(1) No. of Personnel
(2) Position or Title
(3) Hourly Rate
(4) Total Weekly Hours
(5) Weekly Salary
(6) Number Weeks
(7) Total Salary for Grant Period
(8) % Time Spent on this Program
(9) Total Program Salary for Grant
FRINGE BENEFITS
Type of Benefit
% Payroll
Expense
SUMMARY
PROPOSED YEAR
Total Salary
Total Fringe
Total Salary & Fringe
Total Number of Personnel
BASIS OF DISTRIBUTING SHARED DIRECT EXPENSES (CHPF-0
				  06)
Direct-costs are costs which can be identified with a
				  particular pro-gram of the sponsoring agency. All direct costs shall be charged
				  directly to the applicable program. Occasionally, a direct cost may be applied
				  to more then one program. CHPF-006 is used to document all direct costs
				  (excluding salaries) listed on the Program Expense form CHPF-004, that are
				  shared between one or more programs.
Complete the form as follows:
(1) Part A, Type of Pool and Part B,
				Distribution of Base: Some common examples of cost pools and allocation bases
				are:
Cost Pools
Distribution Base
Administrative Costs
1. Number of
							 personnel
2. Accumulated costs
3. Percentage of total payroll
Operation and Maintenance of Building
1.
							 Square feet of area occupied
2. Number of personnel
(2)
				Part C, Components of Pool:
List all line items (line items should correspond to line
				  items on Program Expense Form) which are associated with cost pool and are
				  allocated using the some base distribution. In addition, list the total
				  expenses for the line items within the cost pool for the period of the proposed
				  grant.
(3) Part D,
				Allocation of Pool:
All programs sharing in these expenses must be listed. The
				  number of base units assigned to each must be identified and the percentage of
				  total base units assigned to each must be determined.
(4) Part E, Program Costs:
The percentage of units assigned to the Program is multiplied
				  times each line item amount in Part C, Total Expenses, to arrive at the Program
				  costs. The resulting amounts must equal those listed on the corresponding lines
				  of the Program Expense form.
COMMUNITY HEALTH PROGRAM
BASIS OF DISTRIBUTING SHARED DIRECT EXPENSES
A. TYPE OF POOL:
B. DISTRIBUTION BASE:
C. COMPONENTS OF POOL:
TOTAL EXPENSES
CHP PROGRAM EXP
1.
2.
3.
4.
5.
6.
7.
8. TOTAL
$
$
D. ALLOCATION OF POOL:
PROGRAM OR COST CENTER
DISTRIBUTION OF BASE UNITS
% OF TOTAL UNITS
1.
2.
3.
4.
5.
6.
7.
8. TOTAL
OTHER DIRECT EXPENSE JUSTIFICATION (CHPF-007)
This form is used to explain all direct line item expenses
				  listed that are-not shared with another program. Expenses should be briefly and
				  clearly explained.
COMMUNITY HEALTH PROGRAM
OTHER DIRECT EXPENSES (CHPF-007)
PROGRAM:
PERIOD OF
				  PERFORMANCE
line item no. -
Description of line item - Basis of Expense
Total line item exp
GENERAL AND ADMINISTRATIVE EXPENSES (CHPF-008)
A simplified form (CHPF-008) is included for your use, OTHER
				  FORMATS MAY BE USED UPON APPROVAL OF THE GRANT MANAGER.
a. In Section 1, column 1, Total Agency
				Expenses, record all anticipated expenses of the sponsoring agency for the
				period of performance of the proposed grant. In column 2, Exclusions and
				Unallowables, list any expenses not allowable. In column 3. General and
				Administrative Expenses specify the amount of total allowable agency
				expenditures that will be used for general and administrative expenses and that
				will be shared among the sponsoring agency's program.
b. From the total general and administrative
				expenses listed in column 3, line 22 subtract line 23, G & A credits
				applied to general and administrative expenses. G & A CREDITS ARE defined
				as specific purpose funds applied against general and administrative expenses.
				These funds must be deducted from the total allowable general and
				administrative costs to determine net allowable general and administrative
				expenses. CHP funding will be based on not allowable general and administrative
				expenses (section 1, line 24)
c. In
				Section 11, Part A, indicate the basis for the distribution of the general and
				administrative expenses, for example, accumulated costs, number of personnel,
				percentage of total payroll.
d. In
				Section 11, Part 8, record in box (1) the total base units for the entire
				agency. Of that total indicate in box (2) the amount of units assigned to this
				program and (3) the amount of units assigned to all other programs operated by
				the parent agency. Box (4) will always be 100%. Determine in box (5) the
				percentage of the total base units assigned to this program and in box (6)
				determine the percentage of base units assigned to all other programs operated
				by the parent agency.
e. In Section
				II, Part C, determine the Program's share of the general and administrative
				expenses by multiplying the Balance of Administrative Expenses Shared Among
				Programs (Section 1, Line 24) by the Program's Percentage of Base Units
				(Section II, Part 8, Subsection 5 ). This figure should appear on Your Program
				Expense (CHPF-004) in the general and administrative line
				item.