zilongwang/ReadingBank huggingface dataset:
D.1 Overview The templates defined in this implementation guide, in conjunction with document-level templates from the C-CDA R2, provide a positive attestation as to the presence or absence of all relevant clinical and administrative information from a single encounter between a provider and a patient. When these documents are created by a conformant EHR, the provider is able to communicate all information relative to the encounter with the patient and assert a specific reason why information for each “required” section is not included (see section 3.4 on use of null flavors). If the provider then applies a digital signature to the document, the result is a non- repudiation declaration of the encounter information. D.2 Purpose document templates are designed for use when the provider needs to exchange a more comprehensive set of clinical information than is supported by the C-CDA R2 document-level templates and/or must declare why information for specific section-level or entry-level templates are not included. For example, payers may allow providers to submit any information they feel substantiates that a services is medically necessary and appropriate under the applicable coverage determination rules. The ability to submit any supporting documentation is a provider’s right under these rules and the ability to declare why specific information is not available which allows payers to avoid requesting additional documentation from the provider when such a request cannot be fulfilled. D.3 Document Template Use This table describes the use of one or more document templates to describe the relevant clinical information in a single encounter between a provider and patient. Table 46: Document Template Use Structured Documents Complete Documents Templates C-CDA R2 C-CDA R2 Encounter Type Complete Encounter Document Complete Document Time Boxed Document Complete Procedure Document Compete Op Note Document Diagnostic Imaging Document Unstructured Document Office Visit Base n/a n/a As Needed As Needed As Needed As Needed Consult Base n/a n/a As Needed As Needed As Needed As Needed Home Health Base n/a As Needed As Needed As Needed As Needed As Needed LTC As Needed Base Per period As Needed As Needed As Needed As Needed Hospitalization As Needed Base Per period As Needed As Needed As Needed As Needed Legend: Base – primary document for this type of encounter (e.g. Complete Encounter Document)
3 Grade III, 7mm, 10mm 4 Grade III, mid-facial (buccal) 10 mm, 10mm 5 Missing, replaced by Maryland Bridge N/A N/A 6 Missing, replaced by Maryland Bridge N/A N/A 7 Missing, replaced by Maryland Bridge N/A N/A 4 Grade III, mid-facial (buccal) 10 mm, 10mm 25 Grade I, distal 1mm, 3mm 26 Grade I, distal 1mm, 3mm 27 Grade II, distal 5mm, 3mm 28 Grade III, distal 9mm, 3mm 29 Grade II, distal 6mm, 3mm 30 Grade I, distal 1mm, 3mm Dr. inputs his 900 character narrative in the text box provided by his EMR. He has completed his exam.
When conformance statements are nested (or have subordinate clauses) the conformance statements are to be read and interpreted in hierarchical These hierarchical clauses can be interpreted as "if then, else" clauses. Thus... This structuredBody SHOULD contain zero or one [0..1] component (CONF:1098-29066) such that it contain exactly one [1..1] Plan of Treatment Section (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1098-29067). ...is understood as: It is recommended (SHOULD) that the structureBody contains a component. If the component exists, then it must contain a Plan of Treatment Section (V2), else the component does not exist, and the conformance statement about the Plan of Treatment Section (V2) should be skipped. In the case the higher level conformance statement is a SHALL, there is no conditional clause. Thus... This structuredBody SHALL contain exactly one [1..1] component (CONF:1098-29086) such that it contain exactly one [1..1] (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.5.1:2014-06-09) (CONF:1098-29087). ...means that the structuredBody is always required to have a component. Cardinality The cardinality indicator (0..1, 1..1, 1..*, etc.) specifies the allowable occurrences within a document instance. The cardinality indicators are interpreted with the following format “m…n” where m represents the least and n the most: 0..1 zero or one 1..1 exactly one 1..* at one 0..* zero or more 1..n at least one and not more than n When a constraint has subordinate clauses, the scope of the cardinality of the parent constraint must be clear. In the next figure, the constraint says exactly one participant is to be present. The subordinate constraint specifies some additional characteristics of that participant.
Life Support 75779-9 89666000 CPR SNOMED CT LOINC 225204009 (note 2) IV Fluids and Support SNOMED CT 75791-4 LOINC 281789004 Antibiotics SNOMED CT LOINC 304251008 (note 2) Resuscitation SNOMED CT 75793-0 (AD-19) Other Directive LOINC 71388002 (note 2) Other Directive SNOMED CT Note 1: Vocabulary binding for observation/../code: SHOULD be selected from ValueSet AdvanceDirectiveTypeCode urn:oid:2.16.840.1.113883.1.11.20.2 STATIC 2006-10-17 (CONF:1198-8651). Note 2: There are open issues with the codes selected from SNOMED CT to represent this concept. This cross walk will need to be maintained over time as either code system is updated for the Advance Directive TypeCode value set definition is updated.
Structure of This Guide Two volumes comprise this HL7 Implementation Guide for CDA® Release 2: Personal Advance Care Plan. Volume 1 provides narrative introductory and background material pertinent to this implementation guide, including information on how to understand and use the templates documented in Volume 2. Volume 2 contains the normative Clinical Document Architecture (CDA) templates for this guide along with lists of all templates, code systems, value sets, and changes from the previous version. Primary Editor Lisa R. Nelson Life Over Time Solutions LisaRNelson@cox.net David Tao, D.Sc. ICSA Labs Brett Marquard River Rock Associates Brian Scheller, MBA Healthwise, Incorporated Co-Chair: Calvin Beebe Mayo Clinic L. Scott Brown MyDirectives Co-Chair: Austin Kreisler SAIC Consultant to CDC/NHSN Monica Williams-Murphy, MD Huntsville Hospital Emergency Physician and Medical Director for Advance Care Planning and End of Life Education
75788-0 LOINC 61420007 Tube Feeding SNOMED CT LOINC 78823007 Life Support SNOMED CT 75779-9 LOINC 89666000 CPR SNOMED CT LOINC 225204009 (note 2) IV Fluids and Support SNOMED CT 75791-4 LOINC 281789004 Antibiotics SNOMED CT LOINC 304251008 (note 2) Resuscitation SNOMED CT (AD-19) Directive LOINC 71388002 (note 2) Other Directive SNOMED CT Note 1: Vocabulary binding for observation/../code: SHOULD be selected from ValueSet AdvanceDirectiveTypeCode urn:oid:2.16.840.1.113883.1.11.20.2 STATIC 2006-10-17 (CONF:1198-8651). Note 2: There are open issues with the codes selected from SNOMED CT to represent this concept. This cross walk will need to be maintained over time as either code system is updated for the Advance Directive TypeCode value set definition is updated.
assignedCustodian 1..1 1..1 id 1..* name 0..1 legalAuthenticator 1..1 time 1..1 signatureCode 1..1 @code 1..1 S documentationOf 0..1 MAY serviceEvent 1..1 @classCode 1..1 2.16.840.1.113883.5.6 (HL7ActClass) = PCPR performer 1..* @typeCode 1..1 2.16.840.1.113883.5.90 (HL7ParticipationType) = PRF time 0..1 MAY assignedEntity 1..1 id 1..1 @root 1..1 2.16.840.1.113883.4.6 @extension 1..1 representedOrganization 1..1 id 0..1
automatically by device the data (e.g., hospital) (may be assigned to the report automatically) QRDA is partially constructed automatically by device, partially constructed by quality manager Device; Quality Manager Organization that owns and Reports the data (e.g., hospital) A designated person in the organization (such as the Quality Manager) QRDA is constructed manually (e.g., by an organization that have an EHR) Quality Manager Organization that owns and Reports the data (e.g., hospital) A designated person in the organization (such as the Quality Manager) QRDA Category III Body Constraints A QRDA Category III document contains a Reporting Parameters Section and a Measure section. contain exactly one [1..1] component (CONF:17217). This component SHALL contain exactly one [1..1] structuredBody (CONF:17235). This structuredBody SHALL contain exactly one [1..1] component (CONF:17281) such that it SHALL contain exactly one [1..1] (templateId:2.16.840.1.113883.10.20.17.2.1) (CONF:17282). This structuredBody SHALL contain exactly one [1..1] component (CONF:17283) such that it SHALL contain exactly one [1..1] (templateId:2.16.840.1.113883.10.20.27.2.1) ().
observation 1..1 0..* MAY @typeCode 1..1 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP observation 1..1 0..* MAY @typeCode 1..1 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP observation 1..1 0..* MAY @typeCode 1..1 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP observation 1..1 0..* MAY @typeCode 1..1 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP observation 1..1 0..* MAY @typeCode 1..1 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP observation 1..1 0..* MAY @typeCode 1..1 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = COMP
Numeric Response Pattern [observation: templateId 2.16.840.1.113883.10.20.33.4.4 (open)] <place holder for providing context information (Informative)> 15: Numeric Question Response Pattern Contexts Used By: Contains Entries: Responses Organizer (required) Question Response Media Pattern Question Response Reference Range Pattern Table 16: Numeric Response Pattern Constraints Overview Name Verb Data Type CONF# Fixed Value observation[templateId/@root = '2.16.840.1.113883.10.20.33.4.4'] @classCode 1..1 SHALL NC:xxxxx 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL NC:xxxxx 2.16.840.1.113883.5.1001 (ActMood) = EVN templateId 1..1 SHALL NC:xxxxx @root 1..1 SHALL NC:xxxxx 2.16.840.1.113883.10.20.33.4.4 id 1..1 SHALL code 1..1 SHALL CE NC:xxxxx @code 1..1 SHALL @codesystem 1..1 SHALL NC:xxxxx originalText 1..1 SHALL NC:xxxxx text 0..1 SHALL ED NC:xxxx statusCode 1..1 NC:xxxxx @code 1..1 SHALL NC:xxxxx 2.16.840.1.113883.5.14 (ActStatus) = completed value 1..1 SHALL referenceRanage 0..* SHOULD NC:xxxxx entryRelationship 0..1 SHOULD @typeCode 1..1 SHALL CD NC:xxxxx REFR observationMedia 1..1 SHALL NC:xxxxx contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (NC:xxxxx).
This part of the guide describes the clinical statement entry templates used within the sections of the Questionnaire Response document. Entry templates contain constraints that are required for conformance. Each entry-level template description contains the following information: Key template metadata (e.g., templateId, etc.) Description and explanatory narrative. Required CDA acts, participants and vocabularies. Optional CDA acts, participants and vocabularies. Entry-level templates may also describe an id element, which is an identifier for that entry. This id may be referenced within the document, or by the system receiving the document. The id assigned must be globally unique. Responses Organizer [organizer: templateId 2.16.840.1.113883.10.20.33.4.1 (open)] This template is used to create groupings of other entries (or templates) that share a common context e.g. question responses related to a specific health domain or topic. The organizer/@classCode is equal to CLUSTER to group entries into a compound statement. The organizer/code could be used to indicate question responses to a specific health domain e.g. nutrition or mental status. The sequenceNumber is used to indicate the relative order of a question response represented by the generic observation class. Table 9: Responses Organizer Contexts Used By: Contains Entries: Questionnaire Response Section Pattern (required) Numeric Question Response Pattern Multiple Choice Question Response Pattern Text Response Pattern Analog Slider Response Pattern 10: Response Organizer Constraints Overview XPath Verb Data Type CONF# Fixed Value organizer[templateId/@root = '2.16.840.1.113883.10.20.33.4.1']
<insert name> Community Drug Action Team Welcome, Introductions Acknowledgement of Country Previous Meeting’s Minutes Previous Meeting’s Actions List Budget update — Auspice Liaison Funding Applications* Review of CDAT Action Plan Current Projects and Activities Working Group Updates* Guest Presentation/Major Discussion Topic* Skills Training/Information Update* Other Business Next Meeting
placements unless approved by the Field Placement Co-ordinator. Students are expected to attend and remain with the agency, organization or institution agreed upon for the duration of the placement. Your agency will be contacted by the Field Placement Specialist several months before placements start to ask you how many students you will be able to offer a placement to as well as a description of your agency and the placement position. Once this is received and once a student has completed the necessary requirements, they may contact you for the interview. Once approved, students are expected to call or email the contact person to set up an interview. It is their responsibility to come to the interview well prepared bringing a resume, references and a goal sheet with them. Agencies are asked to interview the students as if they were applying for a job in order to ascertain their suitability to the field placement. Agencies may not always end up with the student of their choice but should still get a student whom they have interviewed and feel comfortable offering the placement opportunity to. The agency is always at liberty to not offer a placement position to any of the students interviewed. The College may ask for feedback about any student who is not chosen so that the student can use this as a learning opportunity. All students are asked to prepare themselves by looking at their goals for learning and then researching appropriate agencies. The student is asked to look at not only his/her interests but also areas requiring improvement in terms of professional development or experience. Supports Available
2018 Rendezvous on the Clark Fork Presented by Coeur d’ Alene Galleries Quinn’s Hot Springs Resort May 16, 2018 to May 18, 2018 TENTATIVE Agenda 1-22-2018 Wednesday May 16th Arrivals Begin * Check In 4:00 p.m. 4:00 p.m. Gallery Welcome desk – entrance to Paradise Hall Gallery Room opens – Paradise Hall (open during all events) Dinner on your own – Quinn’s recommends reservations for Harwood House. Tavern dinner menu available in Quinn’s Tavern Restaurant 7:00 p.m. - 8:00 p.m. – Paradise Hall Event Intro – Buddy Le, Coeur d’ Alene Galleries Presentation – Seth Hopkins, Director of Booth Western Art Museum Hosted Beer & Wine with light snack Quinn’s Resort & Coeur d’ Alene Galleries 8:00 p.m. on Soakin’ Thursday May 17th 8:00 a.m. Gallery Room opens – (open during all events) 8:00 a.m.- 9:00 a.m. Full breakfast is available in Harwood House restaurant 9:00 a.m. - 9:45 a.m. – Paradise Hall Event Intro – Buddy Le, Coeur d’ Alene Galleries “Collection Factors” - Buddy Le, Coeur d’ Alene Galleries Buddy will give tips on building a collection that will stand the test of time. 9:45 a.m. – 10:45 a.m. – Paradise Hall “Conserving your Collection” - Joe Abbrescia Joe will give us a Conservation 101 course.
10:45 a.m. – 11:00 a.m. Break 11:00 a.m. - 11:45 a.m. – Paradise Hall **TENTATIVE** “C.M. Russell and the American West” Paul Paul will be speaking to us his new Montana PBS documentary on Charlie Russell 12:00 p.m. – 1:30 p.m. – Paradise Hall Lunch, Paradise Hall – included in Room Package. 1:45 p.m. - 2:30 p.m. – Paradise Hall “Art as an - Ron Nicklas, Coeur d’ Alene Galleries Treat your art collection like other assets in your portfolio. Tips on insuring, appraisals and estate planning for your collection as well as options for liquidating artwork. 3:00 p.m. – 5:00 p.m. – Outdoor Deck, Paradise Hall Artist Paint Out with questions from the collectors. Martin Grelle, Michael Dudash, Brent Cotton, & Jeremy Winborg Sponsored by The Art Spirit Education Collaborative Hosted Appetizers & Bar 6:00 p.m. – 8:00 p.m. – Paradise Hall Buffet Dinner, Paradise Hall – included in room package Cash Bar – No Host Semi-Casual Attire 8:00 p.m. on Soakin’ Friday May 18th 8:00 a.m.- 9:00 a.m. Full breakfast is available in Harwood House restaurant 9:00 a.m. – 10:00 a.m. – Paradise Hall “We’re all in this together” Moderated forum with the artists – a fun interactive round table with guests, artists, and gallerists. 11:00 a.m. out
Provide a sample of a weekly plan that includes goals for children’s learning and development, a brief description of planned learning experiences, and also accommodations for children with special needs. Indicate the age group(s) for which the plan is intended. Weekly Theme Age Group Vocabulary Words Factual Statements Standard Learning Objectives: Through participating in the planned centers, how will the children understand the concepts? Example: The children will use senses to explore objects in the environment as they discover that an apple has seeds inside of it when it is cut open. The children will ========================================================================= Desired Standard Outcome: ______________________________________________________________ Goal to meet it: (As they/when they/by/through/etc) __________________________________________ Monday Tuesday Wednesday Thursday Friday Group Time (songs, stories, games, etc.) Gross Motor / Outdoor Activities (1 idea each day) Small group activities/centers (1 activity in each curriculum area) Language & Literacy Music Art Science Math Special Needs Accommodations (Hearing, seeing, speech, limited mobility, medical condition, physically impaired, 30 months or less, intellectually impaired etc.) 1 special need: Choose 2 activities from above and write how you would adjust the activity for the special need. Statement of Competence II: To advance physical and intellectual competence CDA Competency Standard II Functional Areas Definitions
CS IV CS / RP IV a Communication with Families How do you ensure that families are kept aware of what’s happening in their child’s daily/weekly life in your program? CS / RP IV b Awareness of Children’s Home Life
Print off and place at least THREE Resource IV.4 articles BEHIND this page. Statement of Competence V: To ensure a well-run, purposeful program that is responsive to participant needs CDA Competency Standard V Functional Areas Definitions V. To ensure a well-run, purposeful program responsive to participant needs 12. Program Management 12. Candidate is a manager who uses observation, documentation, and planning to support children’s development and learning and to ensure effective operation of the classroom or group. The Candidate is a competent organizer, planner, record keeper, communicator, and a cooperative co-worker. I will
Planning a safe, healthy learning environment 26 hrs + Advancing children’s physical and intellectual development 25 hrs + Supporting children’s Social & Emotional development 19 hrs + Building productive relationships with Families 9 hrs + Managing an effective program 32 hrs + Maintaining a commitment to Professionalism 22 hrs + Observing and recording children’s behavior 20 hrs + Understanding principles of development 22 hrs + TOTAL possible Education hours 175 hrs or more TOTAL possible Lab Experience Hours 791 hrs or more PRESCHOOL CDA EXPERIENCE HOURS outside of the LHS Early Childhood Pathway Courses In order to count for lab experience hours, the professional experience setting needs to include at least a group of 5 children between the ages of 3-5 years old. A total of 10 must be enrolled in the center. Name: __________________________________ Date Time In Time Out Total # of Minutes Location of Experience Verification
CITY OF COMMUNITY DEVELOPMENT GRANTS 2017 GRANT YEAR 2017 Application for Community Development Funds CDBG, HOME, and Social Service Fund DEADLINE FOR SUBMISSION: October 28, 2016 AGENCY NAME: AGENCY DUNS #: PROGRAM NAME: DATE SUBMITTED: AMOUNT OF FUNDS REQUESTED: $ (Please submit 2 copies of this application) TYPE OF REQUEST: Complete Sections: Housing (capital expense) A, B, D, E, F (skip section C) Non-housing (capital expense) A, B, C, E, F (skip section D) Ongoing operations (not capital expense) A, B, C, E, F (skip section D) Program/Project costs (not capital expense) A, B, C, E, F (skip section D)
2 Telephone Monthly Charges X 3 Electric Power Installation X 4 Electric Power Distribution Wiring X 5 Electric Power Monthly Charges X 6 Water Service – Installation X 7 Water Service - Monthly Costs X 8 Heating & Cooling Costs X 9 Light Bulbs X 10 Periodic Job Site Clean-Up X 11 Clean X 12 Dump Permits and Fees X 13 Trash Removal and Hauling X 14 Flagman and Traffic Control X 15 Dust Control X 16 SWPP Installation & Maintenance X 17 SWPP Inspection X 18 Temporary Road Construction X 19 Temporary Road Maintenance X 20 Trash Chute & Hopper X
13.01 – Classification of Project (Table A) - Page 4 of 4 Hoisting Direct Cost of Work Construction Phase Services General Requir. Other See Below Paid by Owner 1 Hoist & Tower Rental X 2 Hoist Landing & Fronts X 3 Hoist Operator X 4 Hoist Material Skips/ Hoppers X 5 Erect & Dismantle Cranes and Hoists X 6 Crane Rental X 7 Crane Operators X 8 Crane Raising/ Jumping Costs X 9 Temporary Elevator Rental X 10 Elevator Operation Costs X 11 Cage Rider at Elevator X 12 Forklift Rental X 13 Forklift Operator X 14 Hoisting Safety Inspections X 15 Fuel, Repairs, Maintenance, Service X Main Office 1 Corporate Executives OHP 2 Principal in Charge OHP 3 Operation Manager OHP 4 Project Executive OHP 5 Estimating OHP 6 Value Engineering OHP 7 Scheduling OHP 8 Drafting and Detailing OHP 9 Purchasing & Writing Contracts OHP 10 Accounting & Bookkeeping OHP 11 Safety & E.E.O Officer OHP 12 Secretarial OHP 13 Clerk/Typist OHP 14 Computer/Data Processing OHP 15 Legal - General and Pertaining to Project OHP 16 Travel & Subsistence OHP 17 Fringe Benefits & Burden OHP 18 Vacation Time/Main Office OHP 19 Bonuses/Main Office OHP End of Table A
34 OFOI Equipment X 35 Commissioning Agent - Enhanced for LEED X 36 Commissioning Coordiantion X 37 Foundation Structural Design X 38 Dewatering System Engineering X 40 Environmental (Branding) Graphics/ Signs – Coordination, scope and solicitation. Allow 4 design meetings with user groups. X 41 Environmental (Branding) Graphics/ Signs – Design X
(Limit response to 250 words) 3. What is the owner doing to restore the building? (Limit response to 250 words) PFP- Libraries: 1. What is the number of cardholders (area-wide LMI requirement)? Note the recent five (5) year for this data. (Limit response to 250 words) 2. What is the trend of circulation data? Have there been more or less users and/or more activity from existing users? (Limit response to 250 words) MSRP – Main Street Revitalization Program: 1. Explain how the lead applicant and the Indiana Main Street organization are working together for a successful project. (Limit response to 250 words) 2. Please explain any downtown economic development initiatives in the community, including local financing initiatives (low-interest bank loans, local RLF’s, etc). response to 250 words) 3. Explain the financial participation of business owners (façades only). (Limit response to 250 words) 4. Document blighted conditions with color pictures, etc (in Appendix.) 5. Answer the following items and attach documentation in the Appendix: Yes No Community Designated as a Nationally Accredited Main Street Organization. Yes No The Main Street Organization has a long-term strategic plan. Yes No The district is listed on the Indiana or National Register of Historic Places.* Yes No The district is eligible for listing on the Indiana or National Register of Historic Places.* Yes No The Main Street Organization has a sustainability/fundraising plan in place. * Project may either be listed on or eligible for listing on the Indiana or National Register of Historic Places. Both cannot be checked “Yes”.
Committee members may not have any potential conflicts of interest with any of the individuals, firms, or agencies under review (e.g., family relationships, close friendships, business dealings) and no person who might potentially receive benefits from CDBG-assisted activities may participate in the selection, award, or administration of a contract supported by CDBG funding if he or she has a real or apparent conflict of interest. Name Title/Office/Position 1. 2. 3. 4. Task 1.2: Determine the of Services Determine the scope of services needed to successfully apply for and administer the CDBG-DR contract. The scope of work should itemize the tasks needed, with timeframes and achievable goals. The providers shall furnish pre-funding and post-funding grant administrative services to complete the disaster recovery projects, including, but not limited to the following: Sample scopes of work: Administration of Work Pre-Funding Services Grant Administrator will develop project scope and complete CDBG-DR application. The provider will work with the City/County and Engineering, if applicable, to provide the concise information needed for submission of complete disaster recovery funding application and related documents. The required information shall be submitted in a format to be described by the GLO. Post-Funding Services Grant Administrator will administer and complete infrastructure, utilities, housing and eligible projects approved for disaster recovery funding. The selected administrative firm must follow all requirements of the Texas CDBG Disaster Recovery program. Some services are specific to the type of project funded (e.g. Infrastructure, Rental Housing, Non-Rental Housing) General Administration Services – General Administrative Duties Construction Management Grant Administration Services – Infrastructure Administrative Duties Acquisition Duties Environmental Services Grant Administration Services – Rental Housing Administrative Duties Project Case Management
Category Activity Partial Action Plan A Future Action Plan(s) Total CDBG DR funds Partial Action Plan A Number Metric Districts Housing Acquisition and Development for Homeownership $1,450,000 7 Units (Homes) 1, 2 Removal of Blight $600,000 12 (Houses) 1, 2, 3 Housing Repair $300,000 10 Units (Homes) 1, 2, 3 Replacement of Multi-Family Housing $500,000 13 Units (Housing Units) 1, 2 Historic Preservation $200,000 2 Units (Homes) 1,2,3 HOUSING TOTAL $3,050,000 $3,050,000 $6,100,000 Economy Workforce Training $250,000 100 People 1, 2, 3 Business Recovery Loan Program $300,000 10 Businesses 1, 2, 3 Renewal $500,000 n/a 2 ECONOMY TOTAL $1,050,000 $750,000 $1,700,000 Infrastructure Streets and Sidewalks $5,070,000 46,500 ft. 9,500 ft. Roadway Sidewalks 1, 2 Parks $536,000 1 Park 3 Schools $3,700,000 2 School Buildings 1, 2 INFRASTRUCTURE TOTAL $9,306,000 $3,600,000 $12,906,000 Admin. Administration $500,000 n/a n/a n/a ADMINISTRATION TOTAL $500,000 $590,000 $1,090,000
Address Phone Email Amount Requested Total Project Cost Partner Jurisdictions List all partner counties or municipal jurisdictions: Project Type (Check all that Apply) Fiber: Tower: Planning: Fixed Wireless: Wireless: Estimated Individuals to be Served Estimated Households to be Served Estimated Cost Per Person Estimated Cost Per LMI Person Estimated Businesses to be Served Estimated Community Anchor Institutions Estimated Miles Number of Towers Project Name Summary Describe the location, type of project, proposed route, number of locations (households, businesses, community anchor institutions) to be connected, project partners, minimum service level, and the community and economic development rationale for the project. Congressional District Region County Category Technology and Innovation Activity (Choose One) Broadband Planning $30,000-$125,000 Broadband Construction Up to $1.25 million Broadband Pilot or Demonstration Project Up to $500,000 Broadband Matching Funds Required National Objective (choose one) Benefit to LMI Persons Elimination of Slum/Blight Urgent Need
1.2 - Project Overview –Type Existing Service Profile Type of Project (Planning, Matching Funds, Pilot, etc.) Area Service Provider(s)/Potential Partners Area Electric Utility(ies) Current Services / Speeds Desired Services / Speeds DSL Satellite Broadband Other Estimated Cost Profile Estimated Individuals to be Served Estimated Cost Per Person Estimated Households to be served Estimated Cost Per LMI Person 1.3 - Funding Source Amount Loan or Grant Application Submitted Funding Secured Commitment Letter Attached CDBG Request $ Yes/No Date No Yes/No Local Funds $ Other $ Other $ $ $ Total $ Explain the plan and schedule for obtaining additional or unsecured funds.
SECTION 4 – EEO BENEFICIARY ANALYSIS / LMISD / FAIR HOUSING Minority Data: Use 2012-2016 ACS Data. If not available, use U.S. Census data, to determine minority composition. Indicate Data Source for Minority Data: Total Population of Applicant Minority Population of Applicant Percentage of Minority Population of Applicant Data Source for Minority Data Beneficiary Analysis: Use 2012-2016 ACS Data. If not available, use U.S. Census data to determine minority composition of the census tract(s)/block group(s) most closely approximating the project area. Indicate Data Source below. Census data from Census.gov or factfinder2.census.gov. Attach source documentation. Must be consistent with areas listed in Section 2.3: Eligibility. Data Source for Demographic Data: Census Tract Group Pop. of Census Tract(s) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Hispanic Non-Hispanic American Indian or Alaska Native and White Asian and White Black or African American and White American Indian or Alaska Native and Black or African American Balance of Individuals Reporting More Than One Race (Male/Female) Single/Head of Household by Gender Disabled Total Percent Describe the actions undertaken to “Affirmatively Further Fair Housing”. See Fair Housing Review Criteria.
Collaboration: Builds and maintains effective relationships, with team, colleagues, Members and external partners and supporters. Values diversity, sees it as a source of competitive strength. Approachable, good listener, easy to talk to. Creativity: Develops and encourages new and innovative solutions. Willing to take disciplined risks. Integrity: Honest, encourages openness and transparency; demonstrates highest levels of integrity REGIONAL DIRECTOR PRESENTATION Jim is the Regional Director for West and Central Africa since April 2017; He is a senior international development and humanitarian executive with significant experience across Africa, Asia, Eastern Europe and the Americas. He has extensive governance and leadership experience in complex global organizations working as a Chief Executive, Secretary General, and Chief Financial Officer in several NGOs, including Plan International, ChildFund Alliance and VSO International. Jim has also led field operations at local, national and regional levels, overseeing programme development, design and quality; policy and advocacy; and humanitarian interventions in many difficult and challenging contexts. Jim has lived and worked in developing countries, in remote village, conflict and disaster areas and urban slums for over 25 years. CHILD SAFEGUARDING 3: The post holder will have contact with children and/or young people either frequently (e.g. once a week or more) or intensively (e.g. four days in one month or more or overnight) because they work country programs; or are visiting country programs; or because they are responsible for implementing the police checking/vetting process staff. We need to keep children safe so our selection process reflects our commitment to the protection of children from abuse. APPLICATION INFORMATION Please apply using a cover letter and up-to-date CV as a single document. Please also include details of your current remuneration and salary expectations. A copy of the full role profile can be found at Applicants are advised that Save the Children International does not require any payment or expense during the entire recruitment process. Any request in this direction should be immediately reported as contrary to the values and practices of our organization.
8. Will this project have a significant impact on the environment? See page __ YES NO IF YES, PLEASE EXPLAIN: *IMPORTANT: ALL APPLICANTS MUST SUBMIT THEIR DUNS NUMBER. NON-PROFITS MUST INCLUDE THEIR 501 (C )(3) DOCUMENTATION, A LISTING OF THE MEMBERS OF THEIR BOARD OF DIRECTORS OR EQUIVALENT, AND A COPY OF THEIR LAST AUDIT. Budget Information & Project Funding Total Cost of Project $ Grant Amount Requested $ Percentage Total Total of Other Funding Other Agencies Applied to for Funds Name Amount Status (Check) $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved
Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined Proposed Budget Budget Category Amount Description Project Cost $ Project Salary $ Project Fringe $ Architect / Engineer $ Consultant $ $ Total Budget Request Matching Funds Budget Category Community Development Share Agency / Municipal Share Other Federal & State Funds Other Source Share Total Program Budget Project Cost $ $ $ $ $ Project Salary $ $ $ $ $
Project Fringe $ $ $ $ $ Architect / Engineer $ $ $ $ $ Consultant $ $ $ $ $ Total $ $ $ $ $ Project Activity Timetable Government Agency County of Union Date (Month and Year) Fiscal Year 2019 – 2020; September 1, 2019 to August 31, 2020 Project Project Activities First Quarter Second Quarter Third Quarter Fourth Quarter Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
Name Amount Status (Check) $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined Proposed Budget Budget Category Amount Description Project Cost $ Project Salary $ Project Fringe $ Architect / Engineer $
Consultant $ $ Total Budget Request Matching Funds Budget Category Community Development Share Agency / Municipal Other Federal & State Funds Source Share Total Program Budget Project Cost $ $ $ $ $ Project Salary $ $ $ $ $ Project Fringe $ $ $ $ $ Architect / Engineer $ $ $ $ $ Consultant $ $ $ $ $ Total $ $ $ $ $ Project Activity Timetable Government Agency County of Union Date and Year) Fiscal Year 2017 – 2018; September 1, 2017 to August 31, 2018 Project Project Activities Quarter Second Quarter Third Quarter Fourth Quarter Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
Total Cost of Project $ Grant Amount Requested $ Percentage Total Total of Other Funding Agencies Applied to for Funds Name Amount Status (Check) $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined Proposed Budget Budget Category Amount Description
Project Cost $ Project Salary $ Project Fringe $ Architect / Engineer $ Consultant $ $ Total Budget Request Matching Funds Budget Category Community Development Share Agency / Municipal Share Other Federal & State Funds Other Source Share Total Program Budget Project Cost $ $ $ $ $ Project Salary $ $ $ $ $ Project Fringe $ $ $ $ $ Architect / Engineer $ $ $ $ $ Consultant $ $ $ $ $ Total $ $ $ $ $ Project Activity Timetable Government Agency County of Union
3. If providing services or improvements to a facility not owned by the applicant, the applicant must submit a long-term lease agreement (at minimum 10 years) and letter from the owner confirming agreement to participate in this project. 4. Include of proper zoning and conformance to building and fire codes for an acquired, leased, or improved facility. Projects requiring land use and/or zoning change will not be considered. AGENCY INFORMATION (please refer to page 15 of application instructions) I. Project Title: Organization or Agency: DUNS # Fed. I.D. #
F. PROGRAM DELIVERY: (please refer to page 19-20 of application instructions) I. Describe Program Goals and Objectives II. Program Goals and Objectives Chart (please refer to pages 20-23 of application instructions) (Each program goal requires a separate chart- see page 11 of application for template.) III. Agency Experience with the Specific Services Proposed for CDBG Support IV. Responsibilities of Staff, Volunteers and Consultants in this Program/Project V. Résumés and Job Descriptions VI. Organization Chart of Staff VII. Long-Term for Sustaining the Proposed Program/Project
Total Cost of Project $ Grant Amount Requested $ Percentage Total Total of Other Funding Other Agencies Applied to for Funds Name Amount Status $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined $ Pending Approved Declined Proposed Budget Budget Category Amount Description
Converse, Niobrara and Natrona Counties Big Horn, Hot Springs, Park and Washakie Counties Campbell, Crook, Sheridan, Johnson and Weston Counties Kim Rightmer East Central Regional Director 300 South Wolcott, Ste 300 Casper, WY 82601 Phone: (307) 577-6012 Fax: (307) 577-6032 Cell: (307) 287-2309 Email: Leah Bruscino Northwest Regional Director 143 South Bent, Ste B Powell, WY 82435 (307) 754-5785 Fax: (307) 754-0368 Cell: (307-421-0140) Email: leah.bruscino@wyo.gov Dave Spencer Northeast Regional Director PO Box 608 Sheridan, WY 82801 Cell: (307) 689-1320 Sweetwater and Carbon Counties Fremont and Teton Counties Albany, Goshen, Platte and Laramie Counties Pat Robbins South Central Regional Director 1400 Dewar Drive, Ste 208A Rock Springs, WY Phone: (307) 382.3163 Fax: (307) 382-3217 Cell: (307) 389-0867 Email: Roger Bower West Central Regional Director 213 West Main Street, Ste B Riverton, WY Phone: (307) 857-1155 Fax: (307) 857-0873 Cell: (307) 851-0908 Email: Heather Tupper Southeast Regional Director 214 W 15th Street Cheyenne, WY 82002 Phone: (307) 777-2804 Cell: (307) 772-1265 Email: heather.tupper@wyo.gov Sublette, Lincoln and Uinta Counties Send 2 hard copies and 1 digital copy of completed applications to: Elaina Zempel Southwest Regional Director 1100 Pine Avenue, Ste 3F Kemmerer, WY 83101 Phone: (307) 877-2203 Fax: (888) 507-4482 Cell: (307) 723-1510 Email: elaina.zempel@wyo.gov Sandy Quinlan CDBG Program Manager Wyoming Business Council 214 W. 15th Street Cheyenne, WY 82002 Phone: (307) 777-2825 Fax: (307) 777-2838 Email: sandy.quinlan@wyo.gov
SECTION V: FOR APPLICATOINS PROPOSING TO CREATE JOBS (DOWNTOWN DEVELOPMENT OR ECONOMIC DEVELOPMENT INFRASTRUCTURE APPLICATIONS): Jobs must be expressed in Full Time Equivalents (FTE’s) Wage data must exclude fringe benefits Retained jobs are defined as jobs that otherwise be lost to the state if the business were to cease operations or move from Wyoming Do not include the business owners in the calculations as owners are not typically salaried employees Year One Jobs Retained New Jobs Average Annual Wage Level of Education Required Mgmt/Admin Technical Professional Office/Cerlical Sales Skilled Crafts Other Total for Year One Year Two Original Retained Jobs & Created Year 1 New Jobs Created In Year 2 Average Annual Wage Level of Education Required Mgmt/Admin Technical Professional Office/Clerical Sales Skilled Crafts Other Total for Year Two Year Three Original Retained Jobs & Jobs Created 1 & 2 New Jobs Created in Year 3 Average Annual Wage Level of Education Required Mgmt/Admin Technical Professional Office/Clerical Sales Skilled Crafts for Year Three
Converse, Natrona, Niobrara and Platte Counties Campbell, Crook, Johnson, Sheridan and Weston Counties Big Horn, Hot Springs, Park and Washakie Counties Kim Rightmer East Central Regional Director 300 South Wolcott, Ste 300 Casper, WY 82601 Phone: (307) 577-6012 Email: Brandi Harlow Northeast Regional Director P.O. Box 706 Wright, WY 82732 Phone: (307) 689-1320 Email: brandi.harlow@wyo.gov Amy Quick Northwest Regional Director 1508 Stampede Ave Cody, WY 82414 Phone: (307) 421-0140 Email: Fremont and Sweetwater Counties Lincoln, Sublette, Teton and Uinta Counties Albany, Goshen, Platte and Laramie Counties Rebecca Eusek South Central Regional Director 1400 Dewar Drive, Ste 208A Rock Springs, WY 82901 (307) 389-0867 Email: Elaina Zempel Southwest Regional Director 1100 Pine Avenue, Ste 3F Kemmerer, WY 83101 Phone: (307) 877-2203 Email: elaina.zempel@wyo.gov Heather Tupper Southeast Regional Director 214 W 15th Street Cheyenne, WY 82002 Phone: (307) 777-2804 Email: heather.tupper@wyo.gov Send 2 hard copies and 1 digital copy of completed applications to: Stephanie Horton Brayden Connour CDBG Project Manager BRC/CDBG Project Manager Wyoming Business Council Wyoming Business Council 214 W. 15th Street 214 West 15th Street Cheyenne, WY 82002 Cheyenne, WY 82002 (307) 777-2813 Phone: (307) 777-2811 Email: Email: bradyen.connour2@wyo.gov
CAPITAL PROJECTS ONLY CDBG FUNDS WILL BE RECAPTURED IF THE CAPITAL PROJECT DOES NOT COMMENCE WITHIN 18 MONTHS OF BEING AWARDED CDBG FUNDS. PROPERTY INFORMATION (Complete only if the project involves property acquisition and/or rehabilitation. Request for capital dollars under CDBG may not exceed $300,000 (unless it is determined that the significance of the project is such that additional funds are necessary to make it viable). Where is the project located or to be located? If the project is to be located at a specific location, please give the address. Describe the current use of the proposed location for the project. If the proposed project is for a specific location, do you have site control (deed, contract of sale)? □Yes □No If no, please describe plans for obtaining site control with an estimated date for when you plan to have site control. If the proposed project is for a specific location, what is the current zoning for the site? Demonstrate how the proposed project is in compliance with local zoning codes and land use designations or describe any zoning or land use challenges currently being reviewed that may affect the project. 5. Indicate the anticipated start and completion date for the project. This must include all phases of the activity. 6. Does the project have community approval? 7. What will be the proposed use of the project on completion? 8. A source and use budget must be submitted when requesting funds for a capital project.
ADECA Community and Economic Development Division Statewide Initiatives Unit Staff Contact Information Staff Name Telephone # E-Mail Address Shabbir Olia CED Division Chief (334) 242-5468 Kathleen Rasmussen Statewide Initiatives Unit Chief CDBG/Labor (334) 353-0323 Christopher Perkins Engineer/Environmental (334) 353-1028 Ray CDBG/Bidding and Contracting/ Property Management (334) 353-3409 Dave Veatch CDBG/Fair Housing/Civil Rights (334) 353-0233 Elaine Dobbs-Patterson IDIS/State Grants/RPTA (334) 353-5360 Reed Collar CDBG Supervisor/Disaster Supervisor (334) 353-3265 Tammy Perdew CDBG/Disaster/NSP Coordinator/ Healthy Initiative Program (334) 353-3266 Scott Stewart OMBE/CDBG/Acquisition/Relocation (334) 353-3966 Teresa Nobles Administrative Assistant (334) 242-0492 Kelly Chasteen ARC Coordinator (334) 353-2909 Fax # (334) 353-3527 July 2018
Name of Agency Typed Name and Title of Agency Official Agency Official’s Signature Date of Signature Telephone Number of Agency Official e-Mail Address of Agency Official CDBG PROGRAM Project Proposal Checklist Program Year 2017-18 Organization: Project: Items to include for this application: Check if Included Application Information / Documentation CDBG Economic Development Application A Application – Original and copies B Application – in Word format sent via email or other electronic means () C Table I – Adopted Budget for FY 2016-17 D Table II – Proposed Budget for FY 2017-18 E Evidence of Insurance Coverage F Program Intake Policies and Procedures and Privacy Notice to include for each organization (Do not duplicate for each copy of each application.): Check if Included with this Application Indicate with which Application Item is Included Organizational Information / Documentation A Most Recent Audited Financial Statement B List of Board of Directors and Affiliations C Organizational Chart
DRAW-DOWN TABLE Draw Number Invoice Numbers Claimed on Draw Payee/ Contractor Invoice Amount Date Funds were Received (in general account) Date Funds were Received (in specific account) Payment Date Check Number Date Check Cleared Breakdown of Funds Local $ CDBG $
E Project Pro Forma F Evidence of Insurance Coverage G Program Intake Policies and Procedures and Privacy Notice Items to include for each organization (Do not duplicate for each copy of the application.): Check if Included with this Application Indicate with which Application Item is Included Organizational Information / Documentation A Most Recent Audited Financial Statement B List of Board of Directors and Affiliations C Organizational Chart PLEASE INCLUDE A COPY OF THIS CHECKLIST WITH YOUR ORIGINAL APPLICATION.
Benefits Specific and Limited Low-Income Clientele The following chart must be completed if (B) is checked in Item 1. The numbers to be listed below are the numbers of unduplicated individuals benefiting from the project or program for which you are requesting funding. The totals in the blue cells must match. The totals in the orange cells must match. Income Hispanic / Latino Race Households Below 30% 31% to 50% 51% to 80% Above 80% (all others) Total Yes No Total White Black or Native Hawaiian or Other Pacific Islander Asian American Indian or Alaskan Native Mixed Race Total People Skokie Residents Benefits Housing The following chart must be completed if (C) is checked in Item 1. The numbers to be listed below are the numbers of unduplicated individuals benefiting from the project or program for which you are requesting funding. The totals in the blue cells must match. Income Hispanic / Latino Race Households Below 30% 31% to 50% 51% to 80% Above 80% (all others) Total Yes No Total White Black or Native Hawaiian or Other Pacific Islander Asian American Indian or Alaskan Native Mixed Race Households Benefits Jobs The following chart must be completed if (D) is checked in Item 1. The numbers to be listed below are the numbers of unduplicated individuals benefiting from the project or program for which you are requesting funding. Expected low-income hires are those people from households that are low-income at the time of hire, not after the time of hire. Full-Time Jobs Part-Time Jobs Total Part-Time Weekly Hours Expected Full-Time Hires Expected Part-Time Hires
Priority Needs Check the highest priority need to be addressed by the project. (Please select only one.) Anti-Crime Programs Crime Awareness Economic Development Commercial Rehabilitation Micro-Enterprise Assistance Non-Homeless Housing Renter – Elderly Renter – Small Family Renter – Large Family Other Housing Owner-Occupied Infrastructure Street Improvements Sidewalks Tree Planting Public Facilities (Physical Improvement Projects) General Public Facilities Handicapped Centers Parks/Recreational Facilities Parking Facilities Health Facilities Public Services (Administrative Support Activities) General Public Services Handicapped Services Transportation Services Employment Training Health Services Mental Health Services Screening for Lead-Based Paint Senior Programs Senior Centers Senior Services Youth Youth Centers Child Care Centers Youth Services Child Care Services Homeless Individuals Emergency Shelter Transitional Housing Job Training Case Management Mental Health Care Housing Placement Life Skills Training Homeless Person in Families with Children Emergency Shelter Transitional Housing Job Training Case Management Child Care Substance Treatment Mental Health Care Housing Placement Life Skills Training