Billing Code: 4165‑16
Department of Health and Human Services
Indian Health Service
Office of Direct Service and Contracting Tribes
Announcement Type: New Limited Competition
Funding Announcement Number: HHS-2010-IHS-NIHOE-0001
Catalog of Federal Domestic Assistance Number: 93.933
Application Deadline Date: September 8, 2010
Review Date: September 10, 2010
Results Notification: September 17, 2010
Earliest Anticipated Start Date: September 15, 2010
I. Funding Opportunity Description
The Indian Health Service (IHS) announces that a National Indian Health Outreach and Education Limited Competition cooperative agreement (CA) is open for receipt of applications from national non-profit organizations specializing in conducting outreach and educational training and technical assistance for Federally recognized Tribes and Tribal organizations. The selected entity and/or entities will carry out outreach and educational training on the Patient Protection and Affordable Care Act, Pub. L. No. 111-148 [H.R. 3590], 124 Stat. 119, (2010), and the Indian Health Care Improvement Reauthorization and Extension Act (IHCIA) (S. 1790), as enacted and amended by the Patient Protection and Affordable Care Act, Pub. L. No. 111-148 [H.R. 3590], § 10221, 124 Stat. 119, 935 (2010). This national outreach and educational program is authorized under Public Health Service Act 301(a)(1). This program is described at 93.933 in the Catalog of Federal Domestic Assistance (CFDA).
The Office of Direct Service and Contracting Tribes (ODSCT) on behalf of the Director, IHS, has designated funds for the Limited Competition National Indian Health Outreach and Education Cooperative Agreement program to further health program objectives in the American Indian/Alaska Native (AI/AN) community with outreach and education efforts in the interest of improving Indian health care. Qualified national American Indian organizations/entities must have experience and expertise on the variety of issues related to the provision of health care to Indian people.
The IHS will accept CA applications for either one of the following:
1. Two entities collaborating and applying as one entity.
2. Two entities applying separately to accomplish appropriately divided program activities.
Type of Awards - Cooperative Agreement
The goal of this program announcement is to conduct outreach and education, training and technical assistance on a national scale for the 564 Federally-recognized Tribes and Tribal organizations on the changes and authorities of the new legislation for the PPACA and the IHCIA.
Description of the Project
Health Care Reform and Indian Healthcare Improvement Act outreach and education.
The selected entity and/or entities will be required to:
a. Complete a summary and written report of the key issues of the PPACA and IHCIA on the IHS, Tribal and Urban (I/T/U) system. Additionally, the selected entity and/or entities will develop material that will be used in educating individual Tribes and Tribal organizations on PPACA and IHCIA major provisions. These documents will be presented to the IHS for review and approval before being shared.
b. Develop a detailed plan for outreach and communication to IHS, national Tribal organizations, and Tribes and Tribal organizations in each of the 12 IHS Areas using the documents developed pursuant to the preceding paragraph. Present this plan to the IHS for review and approval.
c. The entities considering applying for this outreach and educational training and technical assistance can:
1. Apply separately for selected portions offered or
2. Partner with another organization and apply as one entity clearly delineating the portions being addressed by each partner.
II. Award Information
TYPE OF AWARD: Cooperative Agreement. A cooperative agreement will be awarded as the IHS staff will have substantial programmatic involvement with the recipient in carrying out the project as noted in the following delineated roles to further IHS’ health program objectives in the AI/AN community with outreach and education efforts in the interest of improving Indian health care, by informing the AI/AN community of the changes and authorities of the Acts.
COOPERATIVE AGREEMENT – INVOLVEMENT OF PARTIES:
This project is a cooperative agreement between the IHS and the selected entity or entities.
Selected entity is responsible for the following:
1. Facilitate an open exchange of ideas and foster an atmosphere of open communication regarding outreach, educational training and technical assistance about these Acts.
2. Provide the outreach and educational training and technical assistance about these Acts and their changes and requirements that will affect AI/AN whether doing so independently or jointly via a partnership as described previously. The project goals are two-fold for the IHS and the selected entity and/or entities:
a. Communicate IHS approved communication about the content and meaning of the PPACA and the IHCIA,
b. Maximize the provision of outreach, educational training and technical assistance for Tribes and Tribal organizations.
Substantial Federal involvement for this endeavor includes the following:
1. IHS will have final approval of the selection of any consultants.
2. IHS will approve the training and education curriculum content, facts, delivery mode, pre- and post-assessments, and evaluation before any materials are printed and the training is conducted.
3. The IHS Director and the selected entity and/or entities will participate in outreach, training and technical assistance sessions, and
4. IHS will review and approve the final draft products before they are published and distributed.
ESTIMATED FUNDS AVAILABLE: The estimated total amount that is available for this program for the Health Care Reform and Indian Healthcare Improvement Act Outreach and Education is $340,000 and is subject to the availability of funds.
ANTICIPATED NUMBER OF AWARDS: Up to two awards will be made from this funding announcement.
PROJECT PERIOD: September 15, 2010 through December 31, 2010.
AWARD AMOUNT: Awards will be issued as follows:
- Option One: One Entity will be awarded up to $340,000. This application would require that “two entities” collaborate together and submit one application as one entity. Administrative costs will be capped at $40,000.
- Option Two: Two separate entities will be awarded: $170,000 each with administrative costs capped at $20,000 each.
III. Eligibility Information:
1. Eligible applicants include non-profit entities who meet the following criteria:
Eligible entities must have demonstrated expertise in the following areas:
- Representing all Tribal governments and providing a variety of services to Tribes, Area Health Boards, Tribal organizations, and Federal agencies, and playing a major role in focusing attention on Indian health care needs, resulting in progress for Tribes.
- Promotion and support of Indian education, and coordinating efforts to inform AI/AN of Federal decisions that affect Tribal government interests including the improvement of Indian health care.
- National health policy and health programs administration
- Have a national AI/AN constituency and clearly support critical services and activities within the IHS mission of improving the quality of health care for AI/AN people.
- Portray evidence of their solid support of improved healthcare in Indian Country.
IHS will be available to provide technical assistance to eligible applicants that meet the above criteria.
2. Cost Sharing or Matching
This program does not require matching funds or cost sharing.
3. Other Requirements
The funding level noted includes both direct and indirect costs. Administrative costs are capped.
a. Applicant’s budget may not exceed the maximum funding level described above for the budget period.
b. Please refer to Section IV., Part 6, “Funding Restrictions” for further information regarding ineligible activities.
IV. Application and Submission Information
1. Application package may be found on the Grants.gov website: http://www.grants.gov or at: http://www.ihs.gov/NonMedicalPrograms/gogp/gogp_funding.asp. Detailed application instructions for this announcement are downloadable from the Grants.gov website.
2. Content and Form Application Submission
The applicant must include the project narrative as an attachment to the application package. Mandatory documents for all applicants include:
- Application forms:
- Certification Regarding Lobbying.
- Debarment Certification (Primary).
- Drug-free Certification.
- Environmental Tobacco Smoke.
- Maintenance of Effort Certification
- Proof of non-profit status required: 501(c)(3) Non-Profit certification.
- Abstract (one page) summarizing the project.
- Project Narrative (14 page limit).
- Budget Narrative.
- Introduction and Need for Assistance.
- Project Objective(s), Approach and Results and Benefits.
- Project Evaluation.
- Organizational Capabilities and Qualifications.
- Contain a project narrative that does not exceed 14-typed pages that includes the other submission requirements below. The 14-page narrative does not include the abstract, the work plan, standard forms, 501(c)(3) Non-Profit Statement, table of contents, budget, budget justification, and/or other appendix items.
- Be typewritten and single spaced.
- Use black type not smaller than 12 characters per one inch.
- Margins must not be less than one inch.
- Have consecutively numbered pages.
- Biographical sketches for all Key Personnel.
- Documentation of current OMB A-133 required Financial Audit, if applicable. Acceptable forms of documentation include:
- E-mail confirmation from Federal Audit Clearinghouse (FAC) that audits were submitted; or
- Face sheets from audit reports. These can be found on the FAC website: http://harvester.census.gov/fac/dissem/accessoptions.html?submit=Retrieve+Records.
Public Policy Requirements:
All Federal wide public policies apply to IHS grants with exception of the Discrimination policy.
3. Submission Dates and Times
Application must be submitted electronically through Grants.gov by 12:00 midnight Eastern Standard Time (EST) on Wednesday, September 8, 2010. Any application received after the application deadline will not be accepted for processing, and will be returned to the applicant(s) without further consideration for funding.
If technical challenges arise and assistance is required with the electronic application process, contact Grants.gov Customer Support via e-mail to firstname.lastname@example.org or at (800) 518-4726. Customer support is available to address questions 24 hours a day, 7 days a week (except on Federal holidays). If problems persist, contact Paul Gettys, Division of Grants Management (DGM) (Paul.Gettys@ihs.gov) at (301) 443-5204. Please be sure to contact Mr. Gettys at least ten days prior to the application deadline. Please do not contact the DGM until you have received a Grants.gov tracking number. In the event you are not able to obtain a tracking number, call the DGM as soon as possible.
4. Intergovernmental Review:
Executive Order 12372 requiring intergovernmental review is not applicable to this program.
5. Funding Restrictions:
Pre-award costs are allowable pending approval from the awarding agency. However, in accordance with 45 CFR Part 74, all pre‑award costs are incurred at the recipient’s risk. The awarding office is under no obligation to reimburse such costs if for any reason the applicant does not receive an award or if the award to the recipient is less than anticipated.
- The available funds are inclusive of direct and appropriate indirect costs.
- One or two cooperative agreements will be awarded.
- Paper applications will not be accepted and will not be reviewed and will be returned. IHS will not acknowledge receipt of applications.
6. Electronic Submission Requirements:
Use the http://www.Grants.gov website to submit an application electronically and select the “Apply for Grants” link on the homepage. Download a copy of the application package, complete it offline, and then upload and submit the application via the Grants.gov website. Electronic copies of the application may not be submitted as attachments to e-mail messages addressed to IHS employees or offices.
Please be aware of the following:
- Please search for the application package in Grants.gov by entering the CFDA number or the Funding Opportunity Number. Both numbers are located on the first page of this announcement.
- Paper applications are not the preferred method for submitting applications. However, if you experience technical challenges while submitting your application electronically, please contact Grants.gov Support directly at: www.Grants.gov/CustomerSupport or (800) 518-4726. Customer Support is available to address questions 24 hours a day, 7 days a week (except on Federal holidays).
- Upon contacting Grants.gov, obtain a tracking number as proof of contact. The tracking number is helpful if there are technical issues that cannot be resolved and a waiver from the agency must be obtained.
- If it is determined that a waiver is needed, you must submit a request in writing (e-mails are acceptable) to Paul.Gettys@ihs.gov with a copy to Tammy.Bagley@ihs.gov. Please include a clear justification for the need to deviate from our standard electronic submission process.
- If the waiver is approved, the application should be sent directly to the DGM by 5:00 pm on the deadline date of Wednesday, September 8, 2010.
- Applicant(s) are strongly encouraged not to wait until the deadline date to begin the application process through Grants.gov as the registration process for Central Contractor Registry (CCR) and Grants.gov could take up to ten working days.
- Please use the optional attachment feature in Grants.gov to attach additional documentation that may be requested by the DGM.
- All applicants must comply with any page limitation requirements described in this Funding Announcement.
- After you electronically submit your application, you will receive an automatic acknowledgment from Grants.gov that contains a Grants.gov tracking number. The DGM will download your application from Grants.gov and provide necessary copies to the appropriate agency officials. Neither the DGM nor the Program Official will notify applicants that the application has been received.
E-mail applications will not be accepted under this announcement.
Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS)
Applicants are required to have a DUNS number to apply for a grant or cooperative agreement from the Federal Government. The DUNS number is a unique nine digit identification number provided by D&B, which uniquely identifies your entity. The DUNS number is site specific; therefore each distinct performance site may be assigned a DUNS number. Obtaining a DUNS number is easy and there is no charge. To obtain a DUNS number, you may access it through the following website http://fev.dnb.com/webform or to expedite the process call (866) 705-5711.
Another important fact is that applicants must also be registered with the CCR and a DUNS number is required before an applicant can complete their CCR registration. Registration with the CCR is free of charge. Applicants may register online at www.ccr.gov. Additional information regarding the DUNS, CCR, and Grants.gov processes can be found at: www.Grants.gov .
Applicants may register by calling (866) 606-8220. Please review and complete the CCR Registration worksheet located at www.ccr.gov.
V. Application Review and Information
The instructions for preparing the application narrative also constitute the evaluation criteria for reviewing and scoring the application. Weights assigned to each section are noted in parentheses. The narrative is limited to 14 pages.
A. Abstract – one page summary.
B. Criteria - Program Requirements:
1. Identify role of applicant’s coordinating efforts in developing and conducting the PPACA and IHCIA Outreach and Education Training and Technical Assistance.
2. Identify and Describe the PPACA and IHCIA Training and Education Program – refer to Attachment.
- Describe how to ensure the training curriculum content addresses all IHCIA and PPACA requirements describe in the attached document.
- Describe the review and approval of the training materials.
- Describe the review and approval of the training presentation delivery including electronic presentation in large group, small group discussions, and individual responses to questions.
3. Other Deliverables:
- Describe how applicant will ensure that the training will provide a complete educational package for all Tribal Leaders.
- Describe plans for posting materials on the applicant’s Web-sites for all American Indians and Alaska Natives to access.
4. Provide clear timelines for implementation of training.
5. Budget justification should include all cost relevant to the proposed goals and objectives of the proposed program plan.
Project Objectives, Work plan, Consultants and Budget (100 Points Total)
1. Abstract – one page summary.
A. INTRODUCTION AND NEED FOR ASSISTANCE (15 points)
1. Describe the organization's current health, education and technical assistance operations as related to the broad spectrum of health needs of the AI/AN community. Include authorized delegation of authority, i.e., memorandum of agreement from a national organization representative of all AI/AN authorizing entities to act in the health care advocacy role for all AI/AN communities. Include what programs and services are currently provided (i.e., Federally funded, State funded, etc.), any memorandums of agreement with other National, Area or Local Indian Health Board organizations, Department of Health and Human Services’ agencies that rely on the applicant as the primary gateway organization that is capable of providing the dissemination of health information, information regarding technologies currently used (i.e., hardware, software, services, etc.), and identify the source(s) of technical support for those technologies (i.e., in-house staff, contractors, vendors, etc.). Include information regarding how long the applicant has been operating and its length of association/partnerships with Area Health Boards, etc. [historical collaboration].
2. Describe the organization’s current technical assistance ability. Include what programs and services are currently provided, programs and services projected to be provided, memoranda of agreement with other National AI/AN organizations that deem the applicant as the primary source of health policy information for AI/AN, memoranda of agreement with other Area Indian Health Boards, etc.
3. Describe the population to be served by the proposed project. Include a description of the number of Tribes who currently benefit from the technical assistance provided by the applicant.
4. State how previous cooperative agreement funds facilitated education, training and technical assistance nation-wide for AI/AN and relate the progression of health care information delivery and development relative to the current proposed project. (Copies of reports will not be accepted.)
5. Describe collaborative and supportive efforts with National, Area and local Indian Health Boards.
6. Describe how the project relates to the purpose of the cooperative agreement by addressing the following: Identify how the proposed project will address the changes and requirements of the Acts.
B. PROJECT OBJECTIVE(S), WORKPLAN AND CONSULTANTS (45 points)
1. Identify the proposed project objective(s) by addressing the following:
- measurable and (if applicable) quantifiable.
- results oriented.
2. Submit a workplan in the appendix which includes the following information:
- Provide the action steps on a timeline for accomplishing the proposed project objective(s).
- Identify who will perform the action steps.
- Identify who will supervise the action steps taken.
- Identify what tangible products will be produced during and at the end of the proposed project objective(s).
- Identify who will accept and/or approve work products during the duration of the proposed project and at the end of the proposed project.
- Include any training that will take place during the proposed project and who will be attending the training.
- Include evaluation activities planned.
3. If consultants or contractors will be used during the proposed project, please include the following information in their scope of work (or note if consultants/contractors will not be used):
- Educational requirements.
- Desired qualifications and work experience.
- Expected work products to be delivered on a timeline.
If a potential consultant/contractor has already been identified, please include a resume in the Appendix.
C. PROJECT EVALUATION (15 points)
Each proposed objective requires an evaluation component to assess its progression and ensure its completion. Also, include the evaluation activities in the work-plan. Describe the proposed plan to evaluate both outcomes and process. Outcome evaluation relates to the results identified in the objectives, and process evaluation relates to the work-plan and activities of the project.
1. For outcome evaluation, describe:
- What the criteria will be for determining success of each objective.
- What data will be collected to determine whether the objective was met.
- At what intervals will data be collected.
- Who will collect the data and their qualifications.
- How the data will be analyzed.
- How the results will be used.
2. For process evaluation, describe:
- How the project will be monitored and assessed for potential problems and needed quality improvements.
- Who will be responsible for monitoring and managing project improvements based on results of ongoing process improvements and their qualifications.
- How ongoing monitoring will be used to improve the project.
- Any products, such as manuals or policies, that might be developed and how they might lend themselves to replication by others.
- How the project will document what is learned throughout the project period.
3. Describe any evaluation efforts that are planned to occur after the grant period ends.
4. Describe the ultimate benefit for the AI/AN that will be derived from this project.
D. ORGANIZATIONAL CAPABILITIES AND QUALIFICATIONS (15 points)
1. Describe the organizational structure of the organization.
2. Describe the ability of the organization to manage the proposed project. Include information regarding similarly sized projects in scope and financial assistance as well as other cooperative agreements/grants and projects successfully completed.
3. Describe what equipment (i.e., fax machine, phone, computer, etc.) and facility space (i.e., office space) will be available for use during the proposed project.
4. List key personnel who will work on the project. Include title used in the workplan. In the appendix, include position descriptions and resumes for all key personnel. Position descriptions should clearly describe each position and duties, indicating desired qualifications and experience requirements related to the proposed project. Resumes must indicate that the proposed staff member is qualified to carry out the proposed project activities. If a position is to be filled, indicate that information on the proposed position description.
E. CATEGORICAL BUDGET AND BUDGET JUSTIFICATION (10 points)
1. Provide a categorical budget for 4-month budget period requested.
2. If indirect costs are claimed, indicate and apply the current negotiated rate to the budget. Include a copy of the rate agreement in the appendix.
3. Provide a narrative justification explaining why each line item is necessary/relevant to the proposed project. Include sufficient cost and other details to facilitate the determination of cost allowability (i.e., equipment specifications, etc.).
A. Work plan for proposed objectives.
B. Position descriptions for key staff.
C. Resumes of key staff that reflect current duties.
D. Consultant proposed scope of work (as applicable).
E. Indirect Cost Rate Agreement, if applicable.
F. Organizational chart.
G. Application Checklist.
1. Review and Selection Process
Applications will be prescreened by the DGM staff for eligibility and completeness as outlined in the funding announcement. Incomplete applications and applications that are non-responsive to the eligibility criteria will not be referred to the Objective Review Committee (ORC). Applicants will be notified by the DGM, via e-mail, outlining the missing components of the application. To obtain a minimum score for funding, applicants must address all program requirements and provide all required documentation. Applicants that receive less than a minimum score will be informed via e-mail of their application’s deficiencies. A summary statement outlining the strengths and weaknesses of the application will be provided to these applicants. The summary statement will be sent to the Authorized Organizational Representative that is identified on the face page of the application.
A. Proposals will be reviewed for merit by the ORC consisting of Federal and non-Federal reviewers appointed by the IHS.
B. The technical review process ensures objectivity is maintained on the limited competition cooperative agreement application. The application will be evaluated and rated on the basis of the evaluation criteria listed in Section V.1. After review of the application, rating scores will be compiled and the application ranked accordingly on the 1-100 weight points ranking scale. The application must score 60 points or above by the ORC to be considered for funding.
C. Anticipated Announcement and Award Dates. The IHS anticipates the earliest award start date will be September 15, 2010.
VI. Award Administration Information
A. Award Notices
The Notice of Award (NoA) will be initiated by the DGM and will be mailed via postal mail to the selected applicant. The NoA will be signed by the Grants Management Officer and is the authorizing document for which funds are dispersed to the approved entities. The NoA will serve as the official notification of the cooperative agreement award and will reflect the amount of Federal funds awarded, the purpose of the cooperative agreement, the terms and conditions of the award, the effective date of the award, and the budget/project period. The NoA is the legally binding document and is signed by an authorized grants official within the IHS.
B. Administrative and National Policy Requirements.
Grants are administered in accordance with the following regulations, policies, and OMB cost principles:
1. The criteria as outlined in this Program Announcement.
2. Administrative Regulations for Grants: 45 C.F.R., Part 92, Uniform Administrative Requirements for Grants and Cooperative Agreements to State, Local and Tribal Governments; 45 C.F.R., Part 74, Uniform Administrative Requirements for Grants and Agreements with Institutions of Higher Education, Hospitals, and other Non profit Organizations.
3. Grants Policy: HHS Grants Policy Statement, Revised 01/07.
4. Cost Principles: Title 2: Grant and Agreements, Part 225—Cost Principles for State, Local, and Indian Tribal Governments (OMB A-87). Title 2: Grant and Agreements, Part 230—Cost Principles for Non-Profit Organizations (OMB Circular A-122).
5. Audit Requirements: OMB Circular A-133, Audits of States, Local Governments, and Non profit Organizations; S.C., Public Health Service Act Section 301; Healthy People 2010 – The Public Health Service (PHS) is committed to achieving the health promotion and disease prevention objectives of “Healthy People 2010,” a PHS led national activity for setting priority areas. A copy of “Healthy People 2010” and the proposed objectives for “Healthy People 2010” is available at: http://www.healthypeople.gov
2. Indirect Costs
This section applies to all grant recipients that request indirect cost in their application. In accordance with HHS Grants Policy Statement, Part II‑27, IHS requires applicants to have a current indirect cost rate agreement in place prior to award. The rate agreement must be prepared in accordance with the applicable cost principles and guidance as provided by the cognizant agency or office. A current rate refers to the rate covering the applicable activities during the award budget period. If the current indirect cost rate agreement is not on file with the awarding office, the award shall not include funds for reimbursement of indirect costs. However, the indirect cost portion will remain restricted until the current rate is provided to the DGM.
Questions regarding the indirect cost policy may be addressed by the DGM at (301) 443‑5204. Additional information may be obtained at the following website for the National Business Center [Department of the Interior]: National Business Center (NBC) http://www.aqd.nbc.gov/Services/ICS.aspx.
Preparing and Submitting Indirect Cost Proposals
Administrative Costs in Lieu of Indirect Costs:
In lieu of an indirect cost rate agreement, an applicant is allowed to claim indirect costs as administrative costs under direct costing method or as direct costs. Applicant must state that this is their standard way of claiming or recouping administrative costs.
Failure to submit required reports within the time allowed may result in suspension or termination of an active grant, withholding of additional awards for the project, or other enforcement actions such as withholding of payments or converting to the reimbursement method of payment. Continued failure to submit required reports may result in one or both of the following: (1) the imposition of special award provisions; and (2) the non-funding or non-award of other eligible projects or activities. This requirement applies whether the delinquency is attributable to the failure of the grantee organization or the individual responsible for preparation of the reports.
The reporting requirements for this program are noted below. Annual progress reports are required for grantees who have not demonstrated any programmatic or grants management concerns. Quarterly reports are usually recommended when the grantee has reporting issues that warrant more frequent monitoring.
A. Progress Report. Program progress reports are required quarterly. Quarterly program progress reports must be submitted within 30 days at the end of each quarter. These reports will include a brief comparison of actual accomplishments to the goals established for the period, reasons for slippage (if applicable), and other pertinent information as required. A final report must be submitted within 90 days of expiration of the budget/project period.
B. Financial Status Reports. Financial status reports are required quarterly. Quarterly financial status reports must be submitted within 30 days at the end of each quarter. Final financial status reports are due within 90 days of expiration of the budget/project period. Standard Form 269 (long form) will be used for financial reporting.
C. Federal Cash Transaction Reports are due every calendar quarter to the Division of Payment Management, Payment Management Branch, Department of Health and Human Services at: www.dpm.gov . Failure to submit timely reports may cause a disruption in timely payments to your organization.
The Awardee is responsible and accountable for accurate reporting of the Progress Narrative Reports and Financial Status Reports. Final Financial Status Reports (SF‑269) must be verified from the grantee records on how the value was derived. Final reports (narrative and financial) are due within 90 days after each budget period.
VII. Agency Contact(s)
Ms. Roselyn Tso
Acting Director, ODSCT
801 Thompson Avenue, Suite 220
Rockville, Maryland 20852
Telephone: (301) 443-1104
Fax: (301) 443-4666
Grants Management (Business) Concerns
Mr. Andrew Diggs
Grants Management Specialist
801 Thompson Avenue, TMP 360
Rockville, Maryland 20852
Telephone: (301) 443-5204
Fax: (301) 443-9602
IHS CHECKLIST: The following IHS Checklist is included to assist the applicant in proposal preparation and follow-up. Entities are highly encouraged to employ this checklist for their benefit and to submit it as part of the proposal as an attachment in Grants.gov to allow for verification of receipt. This checklist will be utilized by the DGM during their initial screening for eligibility and will be utilized by the ODSCT during their programmatic review for content of the application to ensure required items requested are submitted and the application is eligible for further review via the ORC. This checklist is available upon request to the ODSCT office.
FY 2010 IHS Cooperative Agreement Application Checklist
Applicant Name & Tracking Number:
Signed Paper Submission:
IHS FY 2011 IHS Checklist
501(c)(3) Non-Profit Organization
SF-424 Application for Federal Assistance
SF-424A Budget – Non Construction
PHS 5161 Form – Certification Forms Pages 17-19 and Checklist Pages 25-26
Disclosure of Lobbying Activities
Certification Regarding Lobbying
Debarment Certification (Primary)
Environmental Tobacco Smoke
Maintenance of Effort Certification
Project Narrative (14 pages maximum)
a. Introduction and Need for Assistance
b. Project Objective(s), Workplan & Consultants
c. Project Evaluation
d. Organizational Capabilities & Qualifications
e. Categorical Budget and Budget Justification
a. Work-plan for proposed objectives
b. Position Descriptions for Key Staff
c. Resumes of Key Staff that reflect current duties
d. Scope of Work
e. Consultant proposed scope of work
f. Indirect Cost Rate Agreement if applicable
g. Organizational chart
Applicant Signature / Date:
IHS Grants Management Signature / Date:
IHS Program Office Signature / Date:
The PHS strongly encourages all grant and contract recipients to provide a smoke-free workplace and promote the non-use of all tobacco products. In addition, Pub. L. 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some cases, any portion of the facility) in which regular or routine education, library, day care, health care or early childhood development services are provided to children. This is consistent with the HHS mission to protect and advance the physical and mental health of the American people.
Date: ___________________ _____________________________
Indian Health Service