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Application: BASE

Application Table of Contents

About the Application

The application is organized into 9 sections. The information in Sections 1–4 is about the organization overall. 

Section 1. Organization Information

Questions 1-26 ask for basic administrative and fiscal information about your organization.
#Data ItemField OptionsInstructions
1Legal organization name
2Common name (doing business as [DBA])
3Address line 1
4Address line 2
5City
6State
7ZIP
8County
9Public health region• Bellwood
• West Chicago
• Champaign
• Marion
• Metro East
• Peoria
• Rockford
• Multiple
Select the public health region where you primarily provide services or that pertains to this application per the Illinois Department of Public Health (IDPH) Health Regions map.
9aIf you chose multiple, please briefly describe which regions will be served by the strategies funded under this award.
10Organization phone
11Organization website address (optional)
12Type of organization• Nonprofit
• For profit
• Tax exempt
13Year founded/incorporated
14Illinois Department of Human Services/Division of Substance Use Prevention and Recovery (IDHS/SUPR) licenses, if any
15Primary contact name
16Primary contact title
17Primary contact email address
18Primary contact phone
19Alternative contact name
20Alternative contact title
21Alternative contact email address
22Alternative contact phone
23Indirect cost election• Federally negotiated rate
• 10% de minimis
• No indirect costs election
Select your indirect cost election. If you select “Federally negotiated rate,” complete the next question.
24Negotiated Indirect Cost Rate Agreement (NICRA) letterDocument upload (if applicable)Upload as Attachment A (if applicable).
25Current or planned organizational chartDocument upload (required)Upload as Attachment B.
26Current fiscal year organizational budgetDocument upload (required)Upload as Attachment C.

Section 2. Pre-Qualification Information

Questions 27-34 ask for organizational information and attestations to verify eligibility to receive an award.
#Data ItemField InformationInstructions
27Federal or State Employer Identification Number (FEIN/EIN)
28Form W-9, Request for Taxpayer Identification Number and CertificationDocument upload (required)Upload as Attachment D.
29Unique Entity Identifier (UEI)
30Illinois Secretary of State File ID
31Do you attest that your organization is not on the Federal Excluded Parties List?Yes
No
32Do you attest that your organization is not on the Illinois Stop Payment list?Yes
No
33Do you attest that your organization is not on the Department of Healthcare and Family Services Provider Sanctions list?Yes
No
34Do you attest that your organization is in good standing with the Illinois Secretary of State?Yes
No

Section 3. Internal Controls

Questions 35-79 ask about administrative and management controls within the organization. These questions are used to assess organizational risk.
#Data ItemField OptionsInstructions
35Describe the organization’s accounting system. (2.01)• Manual and/or Spreadsheet Driven
• Automated - Off the shelf
• Automated - Written in-house or by consulting firm
• Not Applicable
36Does the accounting system require users to have separate sign in/log on credentials for access and approval? (2.02)• Yes
• No
37Have any new accounting systems been implemented during the last fiscal year? (2.03)• Yes
• No
38Does the accounting system or do related written policies and procedures separate the receipt and expenditure of grant funds at the grant level? (2.04)• Tracked outside of the accounting system with spreadsheets
• Tracked in the accounting system
39Does the accounting system or do written policies and procedures include a formal chart of accounts that allows users to record transactions by the categories of the approved budget? (2.05)• Yes
• No
40How often are the general ledger accounts reconciled? (2.06)• Monthly
• Quarterly
• Semi-annually
• Annually
• Not applicable
41Does the organization require monthly bank reconciliations? (2.07)• Yes
• No
42Does the organization have written policies and procedures regarding proper segregation of duties for fiscal activities that include, but are not limited to, a) authorization of transactions, b) recordkeeping for receipts and payments, and c) cash management? (2.08)• Yes
• No
43Does the organization have written review and approval processes for financial and program-related reporting? (3.01)• Yes
• No
44Are the annual financial statements prepared in accordance with Generally Accepted Accounting Principles (GAAP) or on a basis acceptable by the regulatory agency? (3.02)• Yes
• No
45Does the organization have written policies and procedures to ensure program performance measures and deliverables align with the program spending plan? (3.03)• Yes
• No
46Has the organization taken steps to ensure the individuals who prepare, review, and approve reports have the financial and/or program-related required knowledge, skills, and abilities? (3.04)• Always
• Sometimes
• Never
• Not applicable
47Who prepares the organization’s financial statements? (3.05)• Trained staff who work for the organization
• Financial consultants who are not from the organization’s audit firm
• Independent auditors who conduct the financial statement audit
48Who prepares the organization’s program performance reports? (3.06)• Trained staff who work in the specific program
• Grant Managers or Program Directors
• Organizational management outside of the program
49Does the organization have written policies and procedures that support compliance with cost principles? (4.01)• Yes
• No
50Does the organization have written policies and procedures for allocating costs? (4.02)• Yes
• No
51Are costs recorded consistently with regulations and written policies and procedures to address uniformity both in grant awards and in the organization’s other activities? (4.03)• Yes
• No
52Does the organization charge indirect costs? (4.04)• Yes
• No
53Does the organization keep adequate documentation to support all costs charged to its grant awards? (4.06)• Yes
• No
54Does the organization have a governing body (for example, Board of Directors, Board of Trustees, City Council, County Board, Leadership, Legislature, Governor’s Office)? (4.07)• Yes
• No
55Is financial information, including budget to actual revenue and expenditure reports, provided to leadership or the governing body members? (4.08)• Always
• Sometimes
• Never
56Is the governing body engaged in audit function activities such as selection of an audit firm, the audit firm’s presentation of audit results, or follow-up on corrective action of audit findings? (4.09)• All audit function activities
• Some audit function activities
• Not involved in audit activities
57Does the organization make purchases of equipment of $5,000 or more with grant funding? (4.10)• Yes
• No
58Is a control system in place with adequate safeguards to prevent loss, damage, theft, or unauthorized use of property? (4.13)• Yes
• No
59Does the organization have written policies and procedures for proper authorization of property disposals? (4.14)• Yes
• No
60Does the organization have written policies and procedures for purchasing goods and services with grant funds? (4.15)• Yes
• No
61Does the organization have written policies and procedures that forbid employees, management officers, or agents from participating in the selection, award or administration of a contract supported by a grant award if there is a real or apparent conflict of interest? (4.16)• Yes
• No
62Does the organization have written policies and procedures that forbid contractors who develop or draft specifications, requirements, statements of work (scope of services) or requests for proposals from competing for such procurements? (4.17)• Yes
• No
63Does the organization have written policies and procedures that document subrecipient and contractor determinations? (4.18)• Yes
• No
64In those determinations, has the organization identified any subrecipients? (4.19)• Yes
• No
65Does the organization have written policies and procedures for assessing subrecipient risk and monitoring program implementation? (4.20)• Yes
• No
66Does the accounting system or do related written policies and procedures identify expenses in excess of available budget? (4.21)• Yes
• No
67Are adequate controls in place to ensure that necessary budget revisions receive prior approval from the grantor when applicable? (4.22)• Yes
• No
68Does the organization have written policies and procedures for allocating personnel time and effort by funding source? (4.23)• Yes
• No
69Does the organization have written policies and procedures to ensure that all salaries and wages charged to grants accurately reflect work performed (i.e., time and effort or after-the-fact payroll verification)? (4.24)• Yes
• No
70Does the organization have written policies and procedures to ensure accurate tracking of grant deliverables and performance measures? (4.25)• Yes
• No
71Does the organization have written policies and procedures to make sure program activities are allowable under the grant agreement and state and federal regulations? (4.26)• Yes
• No
72Are the terms of the executed agreement and budget shared with the performance or program management staff? (4.28)• Yes
• No
73Does the organization have written policies and procedures for keeping documentation of participant eligibility determinations? (4.29)• Yes
• No
74Have there been any changes in key organizational personnel since the last audit, such as changes to Fiscal and Administrative Management, the Executive Director, and/or Program Management? (5.01)• Yes
• No
75Has the organization had a financial statement audit conducted in the past year? (5.02)• Yes
• No
76What type of audit was conducted? (5.03)• Financial audit conducted in accordance with Generally Accepted Auditing Standards
• Financial audit conducted in accordance with Generally Accepted Government Auditing Standards
• Single Audit/Program Specific Audit in accordance with CFR2 200.501
77Did the audit find significant deficiencies or material weaknesses? (5.04)• Yes
• No
78Financial Audit Report for the current fiscal yearDocument upload (optional, if available)Upload as Attachment E, if available.
79Has the organization submitted financial and program-related reporting in a timely manner and as required for prior grant awards?• Always
• Sometimes
• Rarely

Section 4. Organization Attestations

Questions 80-85 ask for verification of capacity and truthfulness of information in the application.
#Data ItemField InformationInstructions
80By entering my name, title, and date, I attest that I am authorized to submit the application on my organization’s behalf.[Name]
[Title]
[Date]
Enter requested information in fields.
81I attest that my organization is committed to processing a subaward within six (6) weeks from the Notice of Award.
82I attest that my organization is responsible for performance and monitoring of external partners, subcontractors, and subrecipients (as allowed by the grant agreement).• Yes
• No
83I attest that I have reviewed the terms and conditions within this Notice of Funding Opportunity in its entirety and my organization meets the eligibility criteria and has the capacity to fulfill the scope of services described.• Yes
• No
84I certify that the statements herein are true, complete, and accurate to the best of my knowledge. I agree to comply, on behalf of my organization, with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)• Yes
• No
85Conflict of Interest Disclosure

Upload Conflict of Interest Form as Attachment F.
• Yes
• No

Section 5. Executive Summary

Questions 86-87 ask for an overview of your organization and the services you plan to deliver if awarded funding.
#Data ItemField InformationEvaluation Criteria
86Please select the strategies or which you are requesting funding.[Select Multiple]
Strategy 1
Strategy 2
Strategy 3
Strategy 4
(0 points)
87Summarize the following:
• The population of focus to be served through prevention program activities, including geographic, demographic, and other relevant characteristics.
• The reason why this population and strategy(ies) were selected.
• An overview of the services to be provided for each prevention strategy selected (if more than one).
• Your organization’s experience providing similar services, including timeframes.
• The relevant expertise of the staff bid in the proposal.
Up to 1,500 words(5 points)
• The response addresses all elements of the question.
• The response provides a specific description of a population of focus and explains the need for the proposed program for that population.
• The response demonstrates that the organization has the experience and expertise to successfully implement the proposed program.

Section 6. Need and Opportunity

Questions 88-89 ask for an overview of the population served and services delivered by your organization.
#Data ItemField InformationEvaluation Criteria
88What population do you serve, and how has the opioid crisis impacted your service area?

Describe
• The geographic area,
• Demographic information (age, gender, race, ethnicity, language spoken, etc.),
• Other characteristics (veteran status, housing situation, trauma history, etc.),
• Information about opioid use disorder, fatal and nonfatal overdoses, and other relevant information.

Please cite the source of any data included.
Up to 1,500 words(15 points)
• The response addresses all elements of the question.
• The applicant serves a clearly defined population that is disproportionately affected by the opioid crisis.
• The service area is disproportionately affected by the opioid crisis, as defined in Section B.4, including at least one of the following:
o High opioid fatality rates per 100,000 capita
o Concentrated poverty
o Concentrated firearm violence
o Other conditions that hinder the communities reaching their full potential for health and well-being
• The applicant has an established track record of serving a clearly defined population that is affected by health, economic, and other health disparities.
• The response includes relevant data, including sources.
89What is the population of focus for the proposed program(s)?
If you have selected more than one strategy, please address the population for each.
• Describe the specific geographic area to be served. If proposing services in Cook County, the ZIP code(s) must be included.
• Include U.S. Census or other relevant data (such as board of education or criminal justice) describing the age, gender, racial, and ethnic demographics and other relevant population-level data.
Up to 2,000 words(20 points)
• The response addresses all elements of the question.
• The specific population to be served is clearly defined and in accordance with the priority populations noted herein.
• The population of focus is disproportionately affected by the opioid crisis.
• The proposed program fills an unmet need.
• The response includes relevant data, including sources.

Section 7. Experience and Capacity

Questions 90-95 ask how your organization’s work and approach are aligned with the intent of the opioid settlement funds, your experience in managing previous grants, and about your cultural and linguistic capacity.
#Data ItemField InformationEvaluation Criteria
90How do your mission and experience reduce harm from opioid use disorder in your community?Up to 500 words(5 points)
• The response addresses all elements of the question.
• The applicant’s mission and experience are consistent with the proposed program.
• The applicant demonstrates understanding of how opioid settlement funds must be used.
91How does your hiring approach ensure your staffing reflects the populations you serve?

Discuss how your current staff demographics are reflective of the racial/ethnic community served, and describe any changes to hiring processes necessary for ensuring cultural and linguistic appropriateness.
Up to 1,000 words(5 points)
• The response addresses all elements of the question.
• The response includes relevant data regarding staff diversity, which corresponds to the population the applicant serves.
• The applicant understands how to staff the proposed program to meet the needs of the population of focus.
92Provide up to five examples of grants or contracts that your organization has successfully managed in the past 5 years, with awarding agencies, dates, and dollar amounts.
Include any current fiscal year funding from IDHS/SUPR or IDPH.
Select “not applicable” if you have not received previous grants or contracts.
Checkbox for not applicable

or

Table below
(5 points)
• The response addresses all elements of the question.
• The applicant demonstrates experience with grants management.
• The applicant demonstrates experience with services that address the opioid epidemic.
• The applicant demonstrates experience:
o Providing services like the proposed program.
o Addressing health disparities.
o Working with youth and emerging adults.
93Identify the staff who will deliver services and describe their experience and qualifications.
If you have selected more than one strategy, please address the staff for each.
For new staff, describe your plan to hire people with the necessary qualifications and characteristics.
Up to 2,000 words(5 points)
• The response addresses all elements of the question.
• The applicant understands the experience and expertise required to implement the proposed program.
94Identify the community partners needed to ensure the success of the program, and describe your organization’s experience with these partners.

If you have selected more than one strategy, please address the community partners for each.
Up to 2,000 words(5 points)
• The response addresses all elements of the question.
• The response identifies a sufficient range of partners to support the proposed program.
• The applicant has existing connections to community partners.
95Describe how you will make sure services are culturally and linguistically appropriate based on the diversity of the population to be served.Up to 1,000 words(5 points)
• The response addresses all elements of the question.
• The applicant has policies and procedures in place to identify the service needs of the population of focus, including disparities in access.
• The applicant follows the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care.
• The applicant is prepared to provide interpreters and other accommodations.

Section 8. Quality

Questions 96-98 ask for an explanation of the implementation approach and anticipated outcomes of the proposed activities to be funded.
#Data ItemField InformationEvaluation Criteria
96Describe how your organization will implement the proposed prevention program by task.
In your answer, describe how you will:
• Identify and engage the priority population.
• Tailor prevention to the individual needs of the priority populations.
Up to 2,500 words(10 points)
• The response addresses all elements of the question.
• The response provides sufficient detail to understand how services will be delivered.
• The response clearly connects the proposed program to the needs of the population of focus.
• The service projections are clear and reasonable in relation to the budget request.
97Describe the intended outcomes of the proposed program and how these are related to the needs described in your proposal. Describe expected outcomes quantitively (e.g., number of partnerships or number of people to be served), when applicable.Up to 500 words(10 points)
• The response addresses all elements of the question.
• The response lists specific outcomes that are related to the proposed program.
• The outcomes listed are connected to the needs of the population of focus.
98Provide a detailed timeline for your proposed approach that includes hiring of staff, anticipated linkage agreements, and other coordination activities needed to accomplish the goals and objectives.Upload Project Plan as Attachment G (required)(5 points)
The response addresses all elements of the question.
• The timeline proposed includes all required program elements.
• The timeline includes realistic milestones.
• The response includes relevant data, including sources.

Section 9. Budget

Questions 99-101 request information about the project budget.
#Data ItemField InformationInstructions
99Total funding requested for the period of performance[currency](0 points)
100Please select your preferred payment term as described in Section G.2. of this document.• Advance Payment and Reconcile Method
• Reimbursement Method
• Working Capital Advance Method
(0 points)
101The budget and narrative must tie fiscal activity to program objectives and deliverables and must demonstrate that all proposed costs are
• Reasonable and necessary,
• Allocable, and
• Allowable as defined by program regulatory requirements and Uniform Guidance (2 CFR 200), as applicable.
Upload the Prevention Budget Workbook as Attachment H to submit your project budget and advance payment request.
(required)
(5 points)
• The budget is filled out completely.
• Salaries, benefits, and other expenditures appear reasonable for the community in which the proposed program will take place.
• Indirect costs meet guidelines (attach NICRA agreement letter if applicable).
• All line items correspond to elements of the proposed program.

Revisions

3/20/2024: The executive summary questions were previously under the attestation section. Corrected.

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