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Submission Deadline: September 15, 2017

The Department of Health (DOH) reserves the right without prior notice, to reduce or cancel one or more programs listed in this Request for Applications (RFA). DOH reserves the right to reject all applications, adjust the total available funds or cancel the RFA in part or whole. Funding levels for the total program and budget amounts of individual awards shall be contingent upon continued receipt of funding by DOH, as well as any reduction, elimination or reallocation of funds by a federal grantor, the Executive Office of the Mayor (EOM) and/or the Department of Health. Any adjustments shall be in accordance with authorizing legislation for the use of funds, all DC municipal regulations for grant-making and the applicable federal and DOH terms of agreement.

DEPARTMENT OF HEALTH (DOH) REQUEST FOR APPLICATIONS (RFA)

FY 2018 Opioid Treatment Expansion Initiative

RFA # HAHSTA_OTSP_08.11.17

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Department of Health (DOH) HIV/AIDS, Hepatitis, STD and TB Administration (HAHSTA)

Notice of Funding Availability (NOFA) HAHSTA_OTSP_08.11.17 (RFA)

FY 2018 Opioid Treatment Expansion Initiative

This notice supersedes the notice published in DC Register on 08/04/2017 volume 64/31

The District of Columbia, Department of Health (DOH) is soliciting applications from qualified applicants to provide services in the program and service areas described in this Notice of Funding Availability (NOFA). This announcement provides public notice of the Department of Health's intent to make funds available for the purpose described below. The applicable Request for Applications (RFA) will be released under a separate announcement with guidelines for submitting the application, review criteria and DOH terms and conditions for applying for and receiving funding. General Information:

Funding Opportunity Title: FY2018 Opioid Treatment Expansion Initiative Funding Opportunity Number: FO-HAHSTA-PG-00012-006 RFA ID#: RFA # HAHSTA_OTSP_08.11.17 Opportunity Category: Competitive DOH Administrative Unit: HIV/AIDS, Hepatitis, STD, Tuberculosis Administration DOH Program Bureau Prevention and Intervention Services Division Program Contact: Stacey Cooper, Deputy Division Chief

Stacey.cooper@dc.gov 202/671-4900 Program Description: The Government of the District of Columbia, Department

of Health (DOH), HIV/AIDS, Hepatitis, STD and Tuberculosis Administration (HAHSTA) is soliciting applications from qualified applicants to build capacity among Federally Qualified Health Centers (FQHCs) to prescribe buprenorphine-based treatment to opioid users.

Eligible Applicants Federally-Qualified Health Centers (FQHC). All applicants must be located within and provide services in the District of Columbia.

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Funding Authorization

Notes: 1. DOH reserves the right to issue addenda and/or amendments subsequent to the issuance of this

NOFA, or to rescind the NOFA. 2. Awards are contingent upon the availability of funds. 3. Individuals are not eligible for DOH grant funding. 4. Applicants must have a DUNS #, Tax ID#, be registered in the federal Systems for Award

Management (SAM). 5. Effective September 1, 2016, grant application submissions will be done via the DOH

Enterprise Grants Management System (EGMS). Applicants must register to obtain an EGMS account at least two weeks prior to the submission deadline date.

6. DOH is located in a secured building. Government issued identification must be presented for entrance.

Anticipated # of Awards: Up to 5

Anticipated Amount Available: $850,000.00

Legislative Authorization

FY17 Budget Support Act of 2018 Associated CFDA# Not Applicable Associated Federal Award ID#

Not Applicable

Cost Sharing / Match Required

No RFA Release Date: Friday, 08/18/2017 Pre-Application Meeting (Date) Tuesday, 08/22/2017 Pre-Application Meeting (Time) 10:00 a.m. – 12:00 p.m. Pre-Application Meeting (Location/Conference Call Access)

899 North Capitol Street, NE – 4th Floor

Letter of Intent Due date: Tuesday, 08/22/2017 Application Deadline Date: Friday, September 15, 2017 Application Deadline Time: 6:00 p.m. Links to Additional Information about this Funding Opportunity

DC Grants Clearinghouse https://opgs.dc.gov/page/opgs-district-grants-clearinghouse DOH EGMS https://dcdoh.force.com/GO__ApplicantLogin2

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Table of Contents

CHECKLIST FOR APPLICATIONS 8

I. GENERAL INFORMATION 9 A. KEY DATES B. SOURCE OF GRANT FUNDING C. AMOUNT OF FUNDING AVAILABLE D PERFORMANCE AND FUNDING PERIOD E. ELIGIBLE ORGANIZATIONS/ENTITIES............................................................................

II. BACKGROUND & PURPOSE…………………………………………………………….... A. BACKGROUND ...................................................................................................................... B. PURPOSE .................................................................................................................................

III. PERFORMANCE REQUIREMENTS……………………………………………….........15 A. IMPLEMENTATION……….……………………………………………………………… B. EVALUATION……………………………………………………………………………... C. SUSTAINABILITY…………………………………………………………………………

IV. APPLICATION REQUIREMENTS...………………….………………….……………...15 A. PROJECT NARRATIVE .......................................................................................................... B. BUDGET AND BUDGET JUSTIFICATION ...……………………………………….........

V. EVALUATION CRITERIA………………………………………………………………..16 A. ORGANIZATIONAL CAPACITY .................................................................................... B. PROJECT DESCRIPTION, AND WORK PLAN …………………… C. PERFORMANCE MONITORING AND EVALUATION................................................. D. BUDGET AND BUDGET JUSTIFICATION…………………………………….………

VI. REVIEW & SCORING OF APPLICATION………………………………………….....21

VII. APPLICATION PREPARATION AND SUBMISSION………………………….……..21 A. APPLICATION PACKAGE .................................................................................................. B. APPLICATION SUBMISSION……......................................................................................

VIII. PRE-APPLICATION MEETING ..................................................................................... 24

IX. INTERNET .......................................................................................................................... 24

X. PRE-AWARD ASSURANCES & CERTIFICATIONS .................................................. 25

XI. GRANTEE REQUIREMENTS ........................................................................................... 26 A. GRANT TERMS AND CONDITIONS............................................................................ B. GRANT USES……………............................................................................................. C. CONDITIONS OF AWARD............................................................................................ D. INDIRECT COST............................................................................................................. E. INSURANCE.................................................................................................................... F. AUDITS............................................................................................................................

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G. NONDISCRIMINATION IN THE DELIVERY OF SERVICES.................................... H. QUALITY ASSURANCE…………………………………………………………….....

XII. CONTACT INFORMATION………………………………………………………......29

XIII. APPENDICES ................................................................................................................... 30 A. PROFILE………………………………………………………………………………......31 B. WORK PLAN TEMPLATE……………………………………………………………….32 C. BUDGET FORM AND FORMAT……………………………………………………… D. MANDATORY DISCLOSURES, ASSURANCES AND CERTIFICATIONS (FOR

SIGNATURE) ……………………………………………………………………………….

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District of Columbia Department of Health RFA Terms and Conditions

v11.2016

The following terms and conditions are applicable to this and all Requests for Applications issued by the District of Columbia Department of Health (DOH) and to all awards, if funded under this RFA:

A. Funding for a DOH sub-award is contingent on DOH’s receipt of funding (local or federal) to support the services and activities to be provided under this RFA.

B. DOH may suspend or terminate an RFA pursuant to its own grant making rule(s) or any applicable federal regulation or requirement.

C. The RFA does not commit DOH to make any award.

D. Individual persons are not eligible to apply or receive funding under any DOH RFA.

E. DOH reserves the right to accept or deny any or all applications if the DOH determines it is in the best interest of DOH to do so. An application will be rejected if it does not comply with eligibility requirements, formatting or submission requirements outlined in the RFA. DOH shall notify the applicant if it rejects that applicant’s proposal for review.

F. DOH reserves the right to issue addenda and/or amendments subsequent to the issuance of the RFA, or to rescind the RFA. The prospective applicant is responsible for retrieving this information via sources outlined in the RFA (e.g. DC Grants Clearinghouse).

G. DOH shall not be liable for any costs incurred in the preparation of applications in response to the RFA. The Applicant agrees that all costs incurred in developing the application are the applicant’s sole responsibility. No funds already awarded the applicant under other instruments or agreements shall be used by the applicant to fund the preparation of the application.

H. DOH may conduct pre-award on-site visits to verify information submitted in the application and to determine if the applicant’s facilities are appropriate for the services intended.

I. DOH shall determine an applicant’s eligibility by way of local and federal registries for excluded parties searches and documents and certifications submitted by the applicant.

J. The Applicant Organization must obtain a Data Universal Numbering System (DUNS) number to apply for funding and register for the federal System for Award Management (SAM) at www.sam.gov prior to award.

K. DOH reserves the right to require registry into local and federal systems for award management at any point prior to or during the Project Period. This includes DOH electronic grants management systems, for which the awardee will be required to register and maintain registration of the organization and all users.

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L. DOH may enter into negotiations with an applicant and adopt a firm funding amount or other revision of the applicant’s proposal that may result from negotiations.

M. DOH shall establish terms of agreement for an award funded under this RFA. If funded, the applicant will receive a Notice of Grant Award (NOGA). The NOGA will establish the project period (i.e. the total number of years for which funding has been approved) and define any segments of the Project Period (e.g. initial partial year, or a 12 month budget period). The NOGA shall outline conditions of award or restrictions.

N. Continuation of funding, if awarded shall be based on availability of funds, documented satisfactory progress in interim and annual reports, continued eligibility and determination that the continued funding and activities is in the best interest of the District of Columbia.

O. DOH shall provide the citations to the local or federal statute/s and implementing regulations that authorize the award; all applicable District of Columbia and Federal regulations, including OMB Circulars 2 CFR 200 (effective December 26, 2014) and Department of Health and Services (HHS) published 45 CFR Part 75, and supersedes requirements for any funds received and distributed by DOH under legacy OMB circulars A-102, A-133, 2 CFR 180, 2 CFR 225, 2 CFR 220, and 2 CFR 215; payment provisions identifying how the awardee will be paid for performing under the award; reporting requirements, including programmatic, financial and any special reports required by the funding Agency; and compliance conditions that must be met by the awardee.

P. If there are any conflicts between the terms and conditions of the RFA and any applicable federal or local law or regulation, or any ambiguity related thereto, then the provisions of the applicable law or regulation shall control and it shall be the responsibility of the applicant to ensure compliance.

Additional information about grants management policy and procedures may be obtained at the following site: www.opgs.dc.gov (click on Information) or click here: City-Wide Grants Manual.

If your agency would like to obtain a copy of the DOH RFA Dispute Resolution Policy, please contact the Office of Grants Management and Resource Development at doh.grants@dc.gov or call (202) 442- 9237. Your request for this document will not be shared with DOH program staff or reviewers. Copies will be made available at all pre-application conferences.

CHECKLIST FOR APPLICATIONS • Applicants must be registered in the federal Systems for Award Management (SAM) and

the DOH Enterprise Grants Management System (EGMS).

• Complete your EGMS registration two weeks prior to the application deadline.

• Start constructing and uploading your application components into EGMS at least a week prior to the application deadline.

• The complete Application Package should include the following:

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• Table of Contents • DOH Application Profile • Project Narrative, including the following required appendices:

• Project Work Plan • Budget & Budget Justification • Certifications Assurances & Disclosures (appendix D) • Mandatory Certification Documents • Other Attachments allowed or requested by the RFA (e.g. resumes, letters of

support, Memoranda of Understanding (MOU), etc.)

• Documents requiring signature have been signed by an agency head or AUTHORIZED Representative of the applicant organization.

• The Applicant needs a DUNS number to be awarded funds. Go to Dun and Bradstreet to apply for and obtain a DUNS # if needed.

• The Project Narrative is written on 8½ by 11-inch paper, 1.15 spaced, Arial or Times New Roman font using 12-point type with a minimum of one inch margins. The Project Narrative (excluding work plan and other appendices) is limited to six (6) pages. Applications that do not conform to these requirements will not be forwarded to the review panel.

• The application proposal format conforms to the “Application Elements” listed in the RFA.

• The proposed budget is complete and complies with the budget forms provided in the RFA. The budget narrative is complete and describes the categories of items proposed.

• The proposed work plan is complete and complies with the forms and format provided in the RFA

• The appropriate attachments, including program descriptions, staff qualifications, individual resumes, licenses (if applicable), and other supporting documentation are uploaded.

• Submit your application via EGMS by 6:00pm on the deadline of Friday, September 15, 2017.

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I. GENERAL INFORMATION

Key Dates Request for Application Release Date: August 18, 2017

Pre Application Meeting Date: August 22, 2017

Application Submission Deadline: Friday, September 15, 2017

Anticipated Award Start Date: October 1, 2017

Source of Grant Funding: FY17 Budget Support Act of 2018

• Amount of Funding Available:

Approximately $850,000

Performance and Funding Period:

Date of award through September 30, 2018

Eligible Organizations/Entities:

The following are eligible organizations/entities who can apply for grant funds under this RFA:

Federally Qualified Health Centers (FQHC) and FQHC look-alikes Hospitals

II. BACKGROUND & PURPOSE

Purpose The purpose of this Request for Applications (RFA) is designed to expand the availability of buprenorphine-based Medication-Assisted Treatment (MAT) to address opioid addiction. The District of Columbia Department of Health (DOH) intends to increase the pathways for opioid treatment integrated into a non-stigmatized primary care setting. While methadone treatment has been very successful for many District residents with opioid use disorder (OUD), there remain many individuals who could benefit from buprenorphine-based treatment options. The aim of this RFA is to increase the options for medication-assisted therapy for OUD in the District of

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Columbia by building capacity among primary care providers to prescribe buprenorphine-based treatment with the essential care coordination and wraparound services to ensure individuals achieve successful treatment outcomes. The short-term goals of the RFA include:

Secure a training and capacity building provider to support primary care providers to integrate buprenorphine-based treatment for opioid use disorders

Support Federally Qualified Health Centers (FQHC) to provide or increase provision of buprenorphine-based treatment and care coordination

Enable FQHC to obtain the Medicaid enhanced rate for behavioral health services

Increase the number of providers who are prescribing buprenorphine-based treatment (currently, there are 72 District physicians with waivers and 7 actively prescribing) by 300%

The long term goals of the RFA will include:

Increase the number of persons receiving buprenorphine-based treatment Reduce the number of fatal and non-fatal opioid overdoses Increase the number of prescribers and providers of buprenorphine-based treatment and care coordination Establish a sustainable buprenorphine-based opioid treatment provider network

DESCRIPTION OF FUNDED AREAS Program Area: Hospitals and Federally Qualified Health Centers Funding Period: 10/1/2017 -9/30/2018 Amount Available: $850,000 Number of Awards: Up to 5 Purpose of Area Awards: Hospitals and Federally Qualified Health Centers (FQHC) are in a unique position to provide wraparound services to all communities in need. As part of their designation, FQHC’s are reimbursed under a Medicaid enhanced rate. Recipients of these funds under this category will demonstrate to have access and expertise to the population of focus. Funds can be used to support the development of their capacity to provide opioid recovery support services inclusive of but not limited to; behavioral counseling, vocational rehabilitation, assessment of other socio- economic needs, housing, mental health, addressing general health issues with special emphasis on HIV, hepatitis C and sexually transmitted infections (STI’s), case coordination and case management services. This support ought to be based on evidenced based interventions and proven behavioral models that are most effective with the population of focus.

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Program Core Elements:

Development of a realistic and detailed plan to become an eligible provider for Addiction Prevention and Recovery Administration /Department of Behavioral Health (APRA/DBH) certification.

Development of the staff model that is responsive to a requirements for substance abuse provider in accordance with the DBH standards.

Capacity to bill Medicaid or other third party payers for the provision of substance use support service.

Develop and establish a multidisciplinary network of providers that will engage and work with the funded provider to respond to the needs of the patient. This network must include but is not limited to clinicians willing to prescribe Suboxone or other opioid treatment medications alternatives, mental health providers, vocational/employment support professionals, housing and other related socio-economic recovery needs.

Hospitals or Federally Qualified Health Centers

Description In June 2016, the Department of Health Care Finance (DHCF) released a policy statement to address barriers to access to buprenorphine and a lack of consistency in prior authorizations and dosage requirements. This statement addressed those issues and should make it easier for providers to write prescriptions for the medication. Federally qualified health centers (FQHC) and hospitals have the capacity to prescribe buprenorphine, but they may face barriers to prescribing it. FQHC’s and hospitals have the capacity to provide additional medical and support services to opioid users, but they may need limited support to developing the infrastructure to fully integrate opioid treatment alternatives to methadone. Opioid recovery is a multi-phased process that may include socio-economic assessment and support to patients engaged in recovery. Buprenorphine is one such alternative that may be offered to people in recovery from opioids, but FQHC’s and hospitals need to be aware of the policies developed to address challenges. This program area was designed to support FQHC’s and hospitals in the development and implementation of a plan to implement changes in infrastructure. Additionally, HAHSTA will link the FQHC’s and hospitals to needed capacity building to assist them with becoming certified opioid treatment providers. Ultimately, FQHC’s and hospitals should demonstrate a readiness to become certified by the Department of Behavioral Health (DBH) and Department of Health Care Finance (DHCF) after receiving capacity building and support through receipt of these funds.

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Required Activities and Specific Evaluation Criteria for Program Program Implementation: The applicants must describe their capacity to prescribe buprenorphine to opioid users in recovery. The applicant must also demonstrate their capacity to deliver substance use treatment activities, counseling, socio-economic assessment, support services and medical care. The applicant must include a plan to identify target populations for the intervention, outreach and educational activities for potential participants and providers, and a comprehensive package of support services. The applicants must describe the evidence-based interventions and proven behavioral models that will be used to address members of the target population. A successful applicant will be able to describe their ability to assess patients for recovery readiness. Target Populations: The applicant must describe their ability to access current and former opioid users who may be candidates for buprenorphine. The applicant must provide a detailed narrative of the work they have done with members of the target population and any successes they have had prescribing buprenorphine as an alternative to methadone use. Describe the number of opioid users served throughout the years and the number of patients to be served. Implementation approaches: Applicants must provide a timeline that describes how they will engage opioid users in substance use treatment, their capacity to either provide on-site or linkages to additional support services (i.e., socio-economic assessment, medical care, counseling, medical care), capacity to prescribe buprenorphine and a willingness to become certified as a substance use treatment facility. Fee-for-Service Requirements: As an FQHC or a hospital, the applicant should already have the capacity to bill for services. As such, the applicant must provide proof of their ability to meet fee-for service (FFS) requirements as outlined by Medicaid and other managed care organizations (MCO). Certification readiness: If the applicant is already prescribing buprenorphine, they must provide proof of their capacity to meet federal, state, and/or local qualifications specific to buprenorphine. The provider must also demonstrate evidence of monthly or bi-monthly urine screens, not as a prerequisite for treatment, but for the duration of therapy as a quality measure to assess on-going opioid use in patients on buprenorphine. Staff and infrastructure: The applicants must describe current infrastructure (i.e., are they currently serving substance users, do they prescribe buprenorphine, do they offer have the capacity and ability to provide service as a substance use treatment provider). The successful applicants will demonstrate their experience in working with opioid users, comfort and sensitivity in harm reduction counseling, and helping program participants navigate health systems. Cultural competence: The applicants must describe their ability to deliver the program intervention to opioid users in a culturally appropriate and sensitive manner that does not alienate or stigmatize the target populations. The applicant must demonstrate their ability to deliver

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culturally appropriate messages to a diverse range of participants including gay and non-gay identified men, heterosexual men and women, transgender persons, persons with a history of injection drug use, among other populations. The applicant must also describe how they will address stigma associated with accessing the intervention and HIV prevention in general. Patients that do not present as ready for recovery should be treated with dignity and respect and linked to the services they are ready to access. Linkages: Applicants must demonstrate their capacity to develop a multi-disciplinary network, not limited to clinicians, willing to prescribe buprenorphine or other opioid treatment medications alternatives, mental health providers, vocational/employment support professionals, housing and other related socio-economic recovery needs. A successful applicant will have long-standing relationships with community partners that have the capacity to offer wrap-around services to substance users. Monitoring and Evaluation: The applicant must demonstrate capacity to track participant data (counseling activity, medical visits, screenings and other indicators), and numbers of persons informed and educated.

Definitions: Federally Qualified Health Center (FQHC): All organizations receiving grants under Section 330 of the Public Health Service Act (PHS). FQHCs qualify for enhanced reimbursement from Medicare and Medicaid, as well as other benefits. FQHC Look-Alike: Organization that received enhanced reimbursement from Medicaid but do not have full FQHC status therefore do not receive annual discretionary funds.

Hospital: an institution providing medical and surgical treatment and nursing care for sick or injured people.

Methadone: Methadone is an opioid medication. An opioid is sometimes called a narcotic. Methadone reduces withdrawal symptoms in people addicted to heroin or other narcotic drugs without causing the "high" associated with the drug addiction.

Methadone is used as a pain reliever and as part of drug addiction detoxification and maintenance programs and is only available from certified pharmacies. (https://www.drugs.com/methadone.html)

Opioid: Opioids are a class of drugs chemically similar to alkaloids found in opium poppies. Historically they have been used as painkillers, but they also have great potential for misuse. Repeated use of opioids greatly increases the risk of developing an opioid use disorder. (https://www.samhsa.gov/atod/opioids) Opioid Use Disorder (OUD): Opioid use disorder is defined as a subset of substance use disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). A minimum of 2-3 criteria is required for a mild substance use disorder, 4-5 criteria is moderate, and 6-7 is severe.

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1. Taking the opioid in larger amounts and for longer than intended 2. Wanting to cut down or quit but not being able to do it 3. Spending a lot of time obtaining the opioid 4. Craving or a strong desire to use opioids 5. Repeatedly unable to carry out major obligations at work, school, or home due to opioid

use 6. Continued use despite persistent or recurring social or interpersonal problems caused or

made worse by opioid use 7. Stopping or reducing important social, occupational, or recreational activities due to

opioid use 8. Recurrent use of opioids in physically hazardous situations 9. Consistent use of opioids despite acknowledgment of persistent or recurrent physical or

psychological difficulties from using opioids 10. *Tolerance as defined by either a need for markedly increased amounts to achieve

intoxication or desired effect or markedly diminished effect with continued use of the same amount. (Does not apply for diminished effect when used appropriately under medical supervision)

11. *Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal (Does not apply when used appropriately under medical supervision)

Department of Behavioral Health (DBH): The Department of Behavioral Health provides prevention, intervention and treatment services and supports for children, youth and adults with mental and/or substance use disorders including emergency psychiatric care and community-based outpatient and residential services. (http://dbh.dc.gov/page/about-dbh) Prescription Drug Monitoring Program: The Prescription Drug Monitoring Program (PDMP) aims to improve the District’s ability to identify and reduce diversion of prescription drugs in an efficient and cost effective manner that will not impede the appropriate medical utilization of controlled substances; and to enhance patient care by providing prescription monitoring information that will assure legitimate use of controlled substances in health care, including palliative care, research and other medical and pharmacological uses. (http://doh.dc.gov/service/prescription-drug-monitoring-program) Medication-Assisted Therapy (MAT): Medication-assisted treatment (MAT), including opioid treatment programs (OTPs), combines behavioral therapy and medications to treat substance use disorders. (Substance Abuse and Mental Health Services Administration, https://www.samhsa.gov/medication-assisted-treatment).

Naloxone: Naloxone blocks or reverses the effects of opioids, including extreme drowsiness, slowed breathing, or loss of consciousness.

Naloxone is used to treat an opioid overdose in an emergency situation. This medicine should not be used in place of emergency medical care for an overdose. (https://www.drugs.com/naloxone.html)

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Naltrexone: Naltrexone blocks the effects of opioid medication, including pain relief or feelings of well-being that can lead to opioid abuse. Naltrexone is used as part of a treatment program for opioid or alcohol dependence.

Naltrexone is used to prevent relapse in people who became dependent on opioids and then stopped using it. Naltrexone can help keep you from feeling a "need" to use the opioid. (https://www.drugs.com/mtm/naltrexone.html)

Suboxone: A prescription medication that combines buprenorphine and naloxone. It is used to treat opioid addiction and alcohol dependence. (http://www.suboxone.com/treatment/suboxone-film).

III. PERFORMANCE REQUIREMENTS

In the event that changes in intermediate outcomes are not anticipated during the evaluation period an evaluation plan may be requested.

IV. APPLICATION REQUIREMENTS

A complete application package will include: Table of Contents DOH Application Profile Project Narrative (6-page limit), not including the following required appendices:

• Project Work Plan Budget & Budget Justification Mandatory Certification Documents (see page 25) Signed copy of Assurances Certifications and Disclosures Other attachments allowed or requested by the RFA (e.g. resumes, letters of

support, Memoranda of Understanding (MOU), etc.)

A. Project Narrative The Project Narrative shall be no more than 6 pages, not including appendices, and should consist of three major sections, described below.

1. Organizational Capacity

2. Project Description and Work Plan

3. Performance Monitoring and Evaluation

B. Budget and Budget Justification

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The application should include a combined budget/budget justification using the form provided with this RFA. The budget/budget justification should be directly aligned with the work plan and project description. Note: the electronic submission platform, Enterprise Grants Management System (EGMS), will require additional entry of budget line items and detail. This entry does not replace the required upload of a budget narrative using the required templates.

V. EVALUATION CRITERIA

Eligible applications will be reviewed and scored based on the information provided in the Project Narrative, which incorporate the required activities and specific evaluation criteria for program listed on pages 12-13 and according to the criteria below:

Evaluation and Scoring Criteria Applications will be reviewed by HAHSTA staff for completeness and appropriateness. The overall evaluation will consist of an application and site visit scored assessment based on the criteria listed below. Please review the criteria carefully. The site visit will serve as the primary score of the application. The evaluation assessment will be conducted by staff members from the Virginia, Maryland, and District of Columbia Departments of Health. All eligible organizations that clear the HAHSTA Technical Review will receive an assessment.

50% of Total Score Program Activity Plan (Written proposal) – 50 points Overall, the program activity plan will be scored on the feasibility of being fully and successfully implemented and having an impact on the focus population(s). Focus population(s) must be clearly identified for each activity. The approach includes overcoming barriers to reaching participants effectively over time, and a reasonable plan to assess performance and effect. Proven capacity to deliver same or related services strengthens the feasibility of successful performance. Plan should explicitly include organizational and/or client level targets.

a. Program Activity Narrative – 20 points

The Program activity narrative reflects some elements of the proposed program and supplemental description criteria listed below. (1-10 points) The program activity plan addresses most or all elements of the proposed program and supplemental description criteria listed below. (11-20 points)

b. Work Plan (Required Template Attachment C) – 20 points

A work plan was included in the application. Work plan lacks detail related to objectives, strategies, metrics/targets and or milestones/timeframes. (1-10 points) A work plan was submitted with the application. Work plan is detailed, it includes realistic objectives and strategies, and it contains realistic targets and timeframes. (11-20 points)

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c. Budget (Required Template Attachment E) – 10 points

A budget was submitted with the application. The budget reflects overall cost of the program but lacks detail such as personnel, direct service costs, indirect service costs, etc. (1-5 points) A budget was submitted with the application. Budget is detailed and includes all costs related to the program including but not limited to personnel, direct and indirect costs. (6-10 points)

Proposed Program The proposed program design includes all of the elements which ensure that programs

services will be implemented and delivered without interruption or gaps in services. In addition, program design ensures proper monitoring and evaluation of program quality and performance. Evidence of a sound program design may include:

o Proposed program structure o Implementation plan o Proposed targets o Proposed program oversight o Policies and procedures o Written protocols o Staffing plan/staff background and expertise o Evidence of collaborations

Supplemental Description: The following questions translate some of the key program elements and approaches to how they may be evaluated in your application and should be used to assist your preparation of the program plan.

Opioid Expansion Initiative Program How will you ensure services are culturally sensitive and relevant? How will your agency expand the availability of buprenorphine-based Medication-Assisted

Treatment (MAT) to address opioid addiction? What will your agency do to reduce the number of fatal and non-fatal opioid overdoses? What work will your agency do to increase the number of prescribers and providers of

buprenorphine-based treatment and care coordination? How will your agency establish a sustainable buprenorphine-based opioid treatment provider

network? What qualifications does your staff have to provide buprenorphine-based opioid treatment

services? What training will your staff need? How will you ensure that clients interested in alternatives to methadone treatment receive the

medication? How will you ensure that clients receive additional health screenings as needed?

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50% of Total Score Pre-Decisional Site Visit The next step of the review process is conducted during a pre-decisional site visit (PDSV). Applicants can receive a maximum PDSV score of 50 points. During PDSVs, reviewers will meet with appropriate project management and staff, which may include representatives of governing bodies, executive director, program manager, etc. The PDSV (1) facilitates a technical review of the application and discussion of the proposed program; (2) further assesses an applicant’s capacity to implement the proposed program; and (3) identifies unique programmatic conditions that may require further training, technical assistance, or other resources. Final funding determinations will be based on application scores from the Program Activity Plan and scores from the PDSV. The site visit will be an agency assessment and scoring in the follow areas:

a. Organization Infrastructure – 5 points Applicant organization provided some documents which describe the organization

(1-2 points) Applicant showed strong documentation of organization structure inclusive of

Organizational Chart and staffing plans were furnished (3-5 points)

b. Organizational History of Service Provision – 5 points Applicant organization provided evidence of realistic plans to develop expertise in

providing services to focus population (1-2 points)

Applicant organization provided evidence of services being provided to the population of

focus inclusive of medical treatment and/or care coordination. (3-5 points)

c. Program Management – 5 points

Applicant organization showed plans to develop a management structure in order to ensure that appropriate coordination of service delivery to focus population. (1-2 points)

Applicant organization showed evidence that a management structure is already established

in order to coordinate service delivery to target population. (3-5 points)

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d. Fiscal Systems – 5 points Applicant organization showed limited evidence of sound fiscal management

(1-2 points)

Applicant organization furnished evidence that organization maintains a fiscally sound program (3-5 points)

e. Billing Systems – 5 points Applicant organization’s billing systems shows antiquated systems such as paper invoicing

practices. (1-2 points)

Applicant organization maintains an electronic billing system.

(3-5 points)

f. Organizational Sustainability – 5 points

Applicant organization shows evidence of future plans to ensure program sustainability but does not have the current infrastructure to support it. (1-2 points) Applicant organization demonstrates to have a current infrastructure and plan in place in order to ensure program sustainability. (3-5 pints)

g. Data Collection and Reporting – 5 points

Applicant organization provides evidence of basic patient tracking activities and provision of services. Maintains paper records and lacks an Electronic Medical Record system. (1-2 points)

Applicant organization provides evidence that they maintain a robust electronic medical

record system and ease in generating program information and reports. (3-5 points)

h. Quality Management – 5 points Applicant organization shows plans/intent to develop a quality management program for

clinical services.

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(1-2 points) Applicant organization demonstrates evidence of an established quality management

program and evidence of impact of quality management. (3-5 points)

i. Organizational Access to Population of Focus – 5 points Applicant organization demonstrates plans and interest in developing expertise in serving

the population of focus through partnerships and collaborative activities. (1-2 points)

Applicant organization demonstrates expertise and evidence that they have been serving the

population of focus. (3-5 points)

j. Cultural Competence – 5 points Applicant organization demonstrate willingness and plans to develop cultural competence

via inclusive of capacity building activities, production of materials and other tools to reach the population of focus. (1-2 points)

Applicant organization demonstrates to already be effectively serving the focus population

evidenced by, patient information, retention rates, tools and other materials available and displayed during visit. (3-5 points)

The site visit shall include a tour of the organization, to include the facility where proposed services will be offered. HAHSTA anticipates that site visits will occur between September 17, 2017 and September 22, 2017 and will last approximately four hours. Site visits will be scheduled prior to October 1, 2017. At that time, HAHSTA will share site visit preparation guidelines. Based on the total scores from the site visit and written proposal, HAHSTA will make the final funding determinations. Preference for funding will be given to ensure that the overall portfolio of funded activity best meets the overall programming needs of the Demonstration Project. Funded applicants will be balanced in terms of geographic distribution. Grants will be awarded through the use of DC Appropriated Funds. Please note: A letter of intent to apply for funding is required for this RFA. This information will be used to schedule site visits.

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VI. REVIEW AND SCORING OF APPLICATION

Pre-Screening Technical Review All applications will be reviewed initially for completeness, formatting and eligibility requirements by DOH personnel prior to being forwarded to the external review panel. Incomplete applications and applications that do not meet the eligibility criteria will not advance to the external review. Applicants will be notified that their applications did not meet eligibility.

External Review Panel

The review panel will be composed of neutral, qualified, professional individuals who have been selected for their unique experiences in human services, public health nutrition, health program planning and evaluation, and social services planning and implementation. The panel will review, score and rank each applicant’s proposal based on the criteria outlined in the RFA. Individual panel members are required to provide a summary of strengths and weaknesses found in the application.

Internal Review DOH program managers will review the individual and summary recommendations of the external review panel and make recommendations for awards. Program Managers will weigh the results of the review panel against other internal and external factors in making the final funding determinations. Those factors will include minimally a past performance review, risk assessment and eligibility assessment, including a review of assurances and certifications, and business documents submitted by the applicant, as required in the RFA. DOH will also conduct an excluded parties list search (EPLS) of the organization and executives via the federal System for Award Management (SAM) and conduct a DC Clean Hands review to obtain DC Department of Employment Services and DC Office of Tax and Revenue compliance status.

In this phase of the review process, DOH reserves the right to request clarifying supplemental information from applicants and request on-site pre-decisional reviews for those applicants being considered for award. Any request for supplemental information or on-site visits is not a commitment by DOH to fund the applicant.

The internal review panel prepares and submits a formal recommendation of prospective awardees, funding levels and service/activities to the DOH Director for signature. The DOH Office of Grants Management is responsible for certifying that all District rules and standards were followed for the RFA process.

VII. APPLICATION PREPARATION & SUBMISSION

A. Application Package Only one (1) application per organization will be accepted. An application package consists of an Application Profile, Project Narrative, Budget/Budget Justification, and related Appendices. The Application Profile and Table of Contents should be uploaded to EGMS as one PDF

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document and all other documents including: the Project Narrative, Work Plan, Budget/Budget Justification should be uploaded to EGMS as separate PDF documents.

1. Attachments Table of Contents - Lists major sections of the application with quick reference page

indexing. Failure to include an accurate Table of Contents may result in the application not being reviewed fully or completely.

DOH Application Profile (Appendix A ) Project Narrative (6 page limit) Work plan (Appendix B) Budget and Budget Justification (Appendix C ) Assurances Certifications and Disclosures (Appendix D). Reviewed and Accepted via

EGMS. Scan and upload one SIGNED copy (Appendix D) by the Agency Head or

authorized official.) DOH Standard Grant Terms and Conditions (Reviewed and Accepted via EGMS) Mandatory Certification Documents (Scan and upload ONE PDF file containing all

of the following business documents required for submission uploaded into EGMS): i. A current business license, registration, or certificate to transact

business in the District of Columbia. ii. 501(c)(3) certification (for non-profit organizations)

iii. City Wide Clean Hands Compliance Status Letter (formerly Certificate of Clean hands) Clean Hands Compliance Status letter must be no more than 3 months old from due date of application.

iv. Official list of Board of Directors for the current year and the position that each member holds on letterhead and signed by the authorized executive of the applicant organization; not the CEO.

Note: Failure to submit ALL of the above attachments, including mandatory certifications, will result in a rejection of the application from the review process. The application will not qualify for review.

B. Application Submission Effective October 2016, all District of Columbia Department of Health application submissions must be done electronically via Department of Health’s Enterprise Grants Management System (EGMS), DOH’s web-based system for grant-making and grants management. In order to submit an application under this funding opportunity, the applicant organization must register in EGMS and establish an account for the authorized representative.

If the applicant organization has an account already, please ensure that the Primary Account User is authorized to submit an application on behalf of the organization and his/her account is active. Currently, Secondary Account Users do not have submission privileges but can work in EGMS to prepare (e.g. upload documents, complete forms) the application.

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IMPORTANT: When the Primary Account User is submitting an application, ensure that there are no other transactions on another device being attempted in EGMS under that Primary Account User’s credentials. For security purposes, the system will only acknowledge one transaction and one of the transaction attempts may fail, if done simultaneously.

Register in EGMS

DOH recommends that applicants create an EGMS account, establishing a Primary Account User as the authorized representative at least two weeks prior to the application submission deadline. There is no guarantee that the authorized representative would have an approved account if the registration process does not begin at least two weeks prior to the deadline. Deadline-day registrations may not be approved by the DOH Office of Grants Management in time for submission. To register, complete the following:

IMPORTANT: WEB BROWSER REQUIREMENTS

1. Check web browser requirements for EGMS - The DC DOH EGMS Portal is supported by the following browser versions:

Microsoft ® Internet Explorer ® Version 11 Apple ® Safari ® version 8.x on Mac OS X Mozilla ® Firefox ® version 35 & above (Most recent and

stable version recommended) Google Chrome ™ version 30 & above (Most recent and

stable version recommended)

2. Access EGMS: The user must access the login page by entering the following URL in to a web browser: https://dcdoh.force.com/GO ApplicantLogin2. Click the button REGISTER and following the instructions. You can also refer to the EGMS External User Guide.

3. Determine the agency’s Primary User (i.e. authorized to accept terms of agreement, certify and submit documents, request and accept modifications). The Primary User will determine a Secondary User and send a notification via EGMS for him/her to set-up an account. 4. Your EGMS registration will require your legal organization name, your DUNS # and Tax ID# in order to complete the registration. Your EGMS registration will also require your SAM (System for Award Management) expiration date to be entered into your agency profile. Please ensure that you have an active SAM registration (www.sam.gov).

5. When your Primary Account User request is submitted in EGMS, the DOH Office of Grants Management will review the request. If the requester is NOT the identified Executive Director, DOH Office of Grants Management will make an additional request for the Executive Director to send an email to DOH to confirm that the requester is the authorized representative for EGMS. When requested, your authorized representative

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should send to doh.grants@dc.gov the name, title, telephone number and email address of the desired Primary User for the account. SUBJECT LINE: EGMS PRIMARY USER AGENCYNAME. Note: The email will help to support the validation of authorized users for EGMS. DOH official grant records will also be used. Please reply ASAP to any requests from Office of Grants Management to provide additional information, if needed. 6. Once you register, your Primary Account User will get an auto-notice to upload a “DUNS Certification” – this will provide documentation of your organization’s DUNS. You can simply upload a scanned copy of the cover page of your SAM Registration.

EGMS User Registration Assistance:

Office of Grants Management at doh.grants@dc.gov assists with all end-user registration if you have a question or need assistance: Primary Points of Contact: LaWanda Pelzer (202) 442-8983 and Clara McLaughlin (202) 442-9237. Here are the most common registration issues:

Validation of the authorized primary account user Wrong DUNS, Tax ID or expired SAM registration Web browser

Review the EGMS External User Recorded Webinar for information on the submission process and navigation of EGMS: https://dcnet.webex.com/dcnet/ldr.php?RCID=957d2b20dd173112ea7c2bb1025fcb33 (If you have trouble linking, try Google Chrome and not Internet Explorer)

DEADLINE IS FIRM: September 15, 2017

Submit your application via EGMS by 6:00 p.m., on the deadline date of Friday, September 15, 2017. Applications will not be accepted after the deadline.

VIII. PRE-APPLICATION MEETING A Pre-Application Meeting will be held on Tuesday, August 22, 2017 from 10:00 a.m. 12:00 p.m. at 899 North Capitol Street, NE, 4th Floor Conference Room #406, Washington, DC 20002. The meeting will provide an overview of HAHSTA’s RFA requirements and address specific issues and concerns about the RFA. No applications shall be accepted by any DOH personnel at this conference. Do not submit drafts, outlines or summaries for review, comment, or technical assistance.

IX. INTERNET Applicants who received this RFA via the Internet shall provide the information listed below to the District of Columbia, Department of Health, Office of Grants Monitoring & Program Evaluation. Please be sure to put RFA #HAHSTA_OTSP_08.11.17 in the subject box and to

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include: Name of Organization Key Contact Mailing Address Telephone and Fax Number E-mail Address

This information shall be used to provide updates and/or addenda to the RFA #HAHSTA_OTSP_08.11.17 Opioid Treatment Support Project.

Prepare the application according to the following format:

a) Page length: Program activity plan no more than six (6) pages. The Program Activity Plan file should be labeled “Program Activity Plan” and uploaded into EGMS

b) Font size: 12-point unreduced c) Spacing: Double-spaced d) Paper size: 8.5 by 11 inches e) Page margin size: 1 inch f) Numbering: Sequentially from page 1 to the end of the application, including all

charts, figures, tables, and appendices. g) Complete the Work Plan and Budget templates that can be found on EGMS. Scan

and upload both documents into one file and label them “Work Plan and Budget” for submission in EGMS

X. PRE-AWARD ASSURANCES & CERTIFICATIONS

DOH requires all applicants to submit various Certifications, Licenses, and Assurances at the time the application is submitted. This is to ensure all potential sub-grantees are operating with proper DC licenses. The complete compilation of the requested documents is referred to as the Assurance Package.

DOH classifies assurances packages as two types: those “required to be submitted with applications” and those “required to sign grant agreements.”

A. Assurances Required to Submit Applications (Pre-Application Assurances)

City Wide Clean Hands Compliance Status Letter (formerly Certificate of Clean Hands) 501 (c) 3 certification, must be dated after June 15, 2017. Official List of Board of Directors on letterhead, for current year, signed and dated by the

authorized executive of the Board. (cannot be the CEO) All Applicable Medicaid Certifications A Current Business license, registration, or certificate to transact business in the relevant

jurisdiction B. Assurances required for signing grant agreements for funds awarded through this RFA (Post-Award) Certification Regarding Lobbying; Debarment, Suspension and Other Responsibility

Matters; and Drug-Free Workplace Requirements Comprehensive Automobile Insurance, if applicable for organizations that use company

vehicles to administer programs for services.

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Certification of current/active Articles of Incorporation from DCRA. Proof of Insurance for: Commercial, General Liability, Professional Liability,

Comprehensive Automobile and Worker’s Compensation Certificate of Occupancy Most Recent Audit and Financial Statements

Failure to submit the required assurance package will likely make the application either ineligible for funding consideration [required to submit assurances] or ineligible to sign/execute grant agreements [required to sign grant agreements assurances].

XI. GRANTEE REQUIREMENTS If the applicant is considered for funding based on the results of the completion and receives a Notice of Intent to Fund and subsequently accepts grants award, the following requirements are in effect:

Grant Terms & Conditions All grants awarded under this program shall be subject to the DOH Standard Terms and Condition for all DOH – issued grants. The Terms and Conditions are located in the Attachments and in the Enterprise Grants Management System, where links to the terms and a sign and accept provision is imbedded.

Grant Uses The grant awarded under this RFA shall be used exclusively to pay costs associated with the implementation of the grant.

Payment requests will be monitored by DOH to ensure compliance with the approved budget and work plan.

Conditions of Award As a condition of award, a successful applicant who is issued a Notice of Grant Award (NOGA) will be required to:

1. Revise and resubmit a work plan and budget with justification in accordance with the approved scope of work and assignments prescribed by a DOH Notice of Intent to Fund and any pre-award negotiations with assigned DOH project and grants management personnel.

2. Meet Pre-Award requirements, including submission and approval of required assurances and certification documents, documentation of non-disbarment or suspension (current or pending) of eligibility to receive local or federal funds.

3. Adhere to mutually agreed upon terms and conditions of a grant agreement and Notice of Grant Award issued by the Department of Health and accepted by the

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grantee organization. The grant agreement shall outline the scope of work, standards, reporting requirements, fund distribution terms and any special provisions required by federal agreements.

4. Utilize Performance Monitoring & Reporting tools developed and approved by DOH.

Indirect Cost Indirect costs are costs that are not readily identifiable with a particular project or activity but are required for operating the organization and conducting the grant-related activities it performs. Indirect costs encompass expenditures for operation and maintenance of building and equipment, depreciation, administrative salaries, general telephone services and general travel and supplies. Grant awardees will be allowed to budget for indirect costs of no more than ten percent (10%) of total direct costs.

Insurance All applicants that receive awards under this RFA must show proof of all insurance coverage required by law prior to receiving funds.

Audits At any time or times before final payment and three (3) years thereafter, the District may have the applicant’s expenditure statements and source documentation audited. Grantees subject to A-133 rules must have available and submit as requested the most recent audit reports, as requested by DOH personnel.

Nondiscrimination in the Delivery of Services In accordance with Title VI of the Civil Rights Act of 1964 (Public Law 88-352), as amended, no person shall, on the grounds of race, color, religion, nationality, sex, or political opinion, be denied the benefits of, or be subjected to discrimination under, any program activity receiving funds under this RFA.

Quality Assurance DOH will utilize a risk-based management and monitoring assessment to establish a monitoring plan for the grantee. Grantees will submit interim and final reports on progress, successes, and barriers.

Funding is contingent upon the Grantee’s compliance with terms of the agreement and progress in meeting milestones and targets outlined in the approved work plan. All programs shall be monitored and assessed by assigned project and grants management personnel. The Grantee will receive a performance rating and subject to review at any time during the budget period.

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A final performance report shall be completed by the Department of Health and provided and held for record and use by DOH in making additional funding or future funding available to the applicant. All performance reports are subject to review and oversight by the DOH Office of Grants Management.

POSTAWARD ACTIVITIES

Successful applicants will receive a letter confirming their award. It will also outline the next steps as a sub grantee with the Department of Health.

Grantees must submit monthly data reports and quarterly progress and outcome reports using the tools provided by DOH/HAHSTA and following the procedures determined by DOH/HAHSTA. If you are funded, reporting forms will be provided during your grant-signing meeting with HAHSTA. Continuation of funding for Year 2 is dependent upon the availability of funds for the stated purposes, fiscal and program performance, and willingness to incorporate new District-level directives, policies, or technical advancements that arise from the community planning process, evolution of best practices, or other locally relevant evidence. BUDGET DEVELOPMENT AND DESCRIPTION

You will need to provide a detailed line-item budget and budget justification that includes the type and number of staff you will need to successfully put into place your proposed activities. You must follow the model of the sample budget included Attachment E. HAHSTA may not approve or fund all proposed activities. Give as much detail as possible to support each budget item. List each cost separately when possible. Provide a description for each job, including job title, function, general duties, and activities related to this grant: the rate of pay and whether it is hourly or salary; and the level of effort and how much time will be spent on the activities (give this in a percentage, e.g., 50% of time spent on evaluation). The applicant should list each cost separately when possible, give as much detail as possible to support each budget item, and demonstrate how the operating costs will support the activities and objectives it proposes. The applicant shall use a portion of their proposed budget for evaluation activities. Indirect Costs If your organization has a Federally Negotiated Indirect Cost Agreement, you will be required to submit a copy of that agreement in lieu of providing detail of costs associated with this line. You may charge indirect at a rate not to exceed 10% of the total projected direct costs of your

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program. If your organization does not have a Federally Negotiated Indirect Cost Agreement, you will be required to provide detail of what costs are captured in your indirect cost line not to exceed 10% of the total projected direct cost of your program. HAHSTA CONTACTS Applicants are encouraged to e-mail or fax their questions to the contact person(s) listed below on or before August 22, 2017. Questions submitted after the deadline date will not receive responses. Please allow ample time for questions to be received prior to the deadline date. Contact Person: Stacey L. Cooper

Deputy Bureau Chief, Prevention Government of the District of Columbia, Department of Health HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA) 899 North Capitol Street, NE 4th Floor Washington DC 20002 E-Mail: Stacey. Cooper@dc.gov Phone: 202.671.4900 Fax: 202.671.4860 Direct Budget Questions to Anthony Young: Anthony.Young@dc.gov

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APPENDICES

A. APPLICANT PROFILE

 Department of Health District of Columbia 

Application for Grant Funding

RFA # HAHSTA_ OTPS_08.18.17    RFA Title:   

Release Date: 08/18/17    DOH Administrative Unit:  HIV/AIDS, Hepatitis, STD and TB Administration Due Date: 09/15/17    Fund Authorization:  FY17 Budget Support Act of 2018  New Application Supplemental Competitive Continuation Non-competitive Continuation

 

The following documents should be submitted to complete the Application Package:  Table of Contents  DOH Application Profile  Project Narrative   Work Plan  Budget and Budget Justification  Certifications Assurances Disclosures  All Required Attachments  Other attachments allowed or requested by the RFA (e.g. resumes, MOUs, letters of support) 

Complete the Sections Below.  All information requested is mandatory. 

1. Applicant Profile:   2. Contact Information: 

Legal Agency Name:    Agency Head:   

Street Address:     Telephone #:   

City/State/Zip         Email Address:   

Ward  Location:        

Main Telephone #:    Project Manager:   Main Fax #:    Telephone #:   

Vendor ID:    Email Address:   

DUNS No.:       

   

   

3. Application Profile: 

 

Program Area: Funding Request: 

 

 

Proposal Description:  

      

Enter Name & Title of Authorized Representative                                                               Date

CHA Grantee Work Plan

HAHSTA: Program/ Grant Name: Program Description/Purpose: Primary Target Population: GOAL 1:

Measurable Objectives/Activities: Objective #1 Key activities to meet this objective: Planned Start

Date: Actual Start Date:

Planned Completion Date:

Actual Completion Date:

Key Personnel (Title)

Objective #2: Key activities to meet this objective: Planned Start

Date: Actual Start Date:

Planned Completion Date:

Actual Completion Date:

Key Personnel (Title)

Objective #3: Key activities to meet this objective: Planned Start

Date: Actual Start Date:

Planned Completion Date:

Actual Completion Date:

Key Personnel (Title)

Make additional copies of this page as needed Page ______ of ______

Organization's Name Provide Organization's name as shown on applicationFunding Source Provide Source of Funds for which you are applying

Service Area Provide name of service area for which you are applying. If applying for multiple service area's complete this sheet for each of the service areas you are applying for

Personnel Schedule This section provides projected salary and fringe costs for your proposed program. This schedule provides two options for calculation, salary or hourly wage;

Total The total line will provide the total proposed salary line minus the applicable fringe rate.

Fringe Benefits Provide your agencies fringe benefit rate, as approved in your personnel policy; the justification should include what benefits are covered under fringe; and the fringe rate should be applied to the total salary line.

Total Personnel This line will provide the combined total of proposed salary and fringe costs.

Cosultants/Contractural Provide a list of positions or activities that will be carried out by consultants or through contracts.Provide the unit of payment, this could be by the hour or the completed task; and provide the cost of each unit and the number of units being contracted for.

Occupancy Rent This line item should be calculated using the following formula:Local Funds percentage of space occupied by the proposed program, times the cost per square foot, times 12 months.

EXAMPLE:This example supposes that your program will occupy 100 square feet at a cost of $30. per square foot, per month. 100 sq.ft. x $30.00 per sq. ft. = $3,000 x 12 months for a total of $36,000.

Utilities This line should be caluculated by naming utilities Gas/Electric/Water, as applicable. Provide an overall projected costs of those utilities multiplied by number of months (in most cases 12) of your program.

Occupancy This line should be calculated by naming utilities Gas/Electric/Water, as applicable. If the utilities are included in the determination of client rent subidy, do not include a separate utility line item in the budget.Provide an overall projected costs of those utilities multiplied by the number of months (in most cases 12)of your program.

Program/Administrative RentThis should include any office space or shared program space used to deliver services. This line itemshould be calculated using the following formula. Percentage of space occupied by the proposed program,times the cost per square foot, times 12 months.

EXAMPLE

associated with the beds in the facility minus the income collected in resident rent payment. For additionalinformation consult 24 CFR parts 320-340, and the HUD Grantee Oversight Manual.

Travel/Transportaton This line item should be calculated with two items in mind. If your organization has a policy that allows for Reimbursement for staff's use of their personal vehicles you should complete by filling in the unit as one mile, the unit reimbursement cost per OMB is 50.5 cents per mile, the projected number of miles staff will be traveling and total budget.

For programs who own the facility where each client has their own apartment within the facility, or use multiple funding to cover client rent , the program must determine a reasonable rent standard for the clientclient living space. The rent standard many not exceed fair market rent (FMR) and must consider whetherthe clients share a room or have a private room. The calculation would be the total expected rental cost

and calculated per the Program/Administrative Rent rule as listed above.

of two ways based on the program design and facility ownership. For programs leasing a buildingspecifically and only and only for the purpose of housing clients, the program may budget the entire rentalcost of the lease minus the income generated by resident rent payments (transitional programs only).Programs should not include any administrative or program office space. Those costs should be allocated

: This example supposes that your program will occupy 100 squard feet at a cost of $30 persquare foot, per month. 100 sq.ft. x $30 per spuare foot = $3,000 x 12 months for a total of $36,000.Client Rent SubsidyThis should include the rent associated with the bed space occupied by clients. This is calculated in one

EXAMPLE This example supposes that the total projected travel for the duration of the program will be500 miles. 55.5 cents per mi. x 500 miles = a total budget of $277.50.

The other item that should be included in this line is tokens/farecards for organization's staff. You should provide a projected number that you will need for your program, indicate the unit, the unit cost, number to be purchased and total cost.

Supplies This line should indicate the total projected costs of General Office Supplies needed to administer your program that have a value of $5,000 dollars or less.

Capital Equipment Capital Eqipment are purchases that exceed $5000. These purchases must be pre-approved by HAA

Client Cost This line should include specific client costs related to your program. Ie. Tokens, farecards, incentives (where allowed), and other program appropriate client costs.

Communications This line should include costs associated with maintaining communications necessary to administer your .program. Ie telephone, internet, fax lines, copying. You should complete a projected costs for each item, indicate the unit and numberon the budget sheet.

Other Direct Costs This line should be comprised of direct program costs that cannot be attributed to other budget lines.

Indirect Costs If your Organization has a Federally Negotiated Indirect Cost Agreement, HAA will accept that document in lieu of providing detail of costs associated with this line. You may charge indirect at a rate not to exceed the percentage annotated in the Request for Application. If your Organization does not have a Federally Negotiated Indirect Cost Agreement, you will be required to provide detail of what costs are captured in your indirect cost line.

APPENDIX D.    APPLICANT / GRANTEE ASSURANCES, CERTIFICATIONS & DISCLOSURES 

This  section  includes  certifications,  assurances  and  disclosures made  by  the  authorized  representative  of  the Applicant/Grantee organization.  These assurances and certifications reflect requirements for recipients of local and pass‐through federal funding. 

A.   Applicant/Grantee Representations 

1. The Applicant/Grantee has provided the individuals, by name, title, address, and phone number who are 

authorized to negotiate with the Department of Health on behalf of the organization;  

2. The Applicant/Grantee is able to maintain adequate files and records and can and will meet all reporting 

requirements; 

3. All fiscal records are kept in accordance with Generally Accepted Accounting Principles (GAAP) and account 

for  all  funds,  tangible  assets,  revenue,  and  expenditures  whatsoever;  all  fiscal  records  are  accurate, 

complete and current at all times; and these records will be made available  for audit and  inspection as 

required; 

4. The Applicant/Grantee  is current on payment of all  federal and District  taxes,  including Unemployment 

Insurance  taxes  and  Workers’  Compensation  premiums.  This  statement  of  certification  shall  be 

accompanied by a certificate from the District of Columbia OTR stating that the entity has complied with 

the filing requirements of District of Columbia tax  laws and  is current on all payment obligations to the 

District of Columbia, or is in compliance with any payment agreement with the Office of Tax and Revenue; 

(attach) 

5. The Applicant/Grantee has the administrative and financial capability to provide and manage the proposed 

services and ensure an adequate administrative, performance and audit trail;  

6. If required by DOH, the Applicant/Grantee is able to secure a bond, in an amount not less than the total 

amount of  the  funds  awarded,  against  losses of money  and other property  caused by  a  fraudulent or 

dishonest act committed by Applicant/Grantee or any of its employees, board members, officers, partners, 

shareholders, or trainees; 

7. The  Applicant/Grantee  is  not  proposed  for  debarment  or  presently  debarred,  suspended,  or  declared 

ineligible, as required by Executive Order 12549, “Debarment and Suspension,” and implemented by 2 CFR 

180, for prospective participants  in primary covered transactions and  is not proposed for debarment or 

presently debarred as a result of any actions by the District of Columbia Contract Appeals Board, the Office 

of Contracting and Procurement, or any other District contract regulating Agency;  

8. The  Applicant/Grantee  either  has  the  financial  resources  and  technical  expertise  necessary  for  the 

production, construction, equipment and facilities adequate to perform the grant or subgrant, or the ability 

to obtain them; 

9. The Applicant/Grantee has the ability to comply with the required or proposed delivery or performance 

schedule,  taking  into  consideration all existing and  reasonably expected  commercial and governmental 

business commitments; 

10. The Applicant/Grantee has a satisfactory record of performing similar activities as detailed in the award or, 

if  the  grant  award  is  intended  to  encourage  the  development  and  support  of  organizations  without 

significant previous experience, has otherwise established that it has the skills and resources necessary to 

perform the services required by this Grant. 

11. The Applicant/Grantee has a satisfactory record of integrity and business ethics; 

12. The Applicant/Grantee  either has  the  necessary organization,  experience,  accounting  and   operational 

controls, and technical skills to implement the grant, or the ability to obtain them; 

13. The Applicant/Grantee is in compliance with the applicable District licensing and tax laws and regulations; 

14. The Applicant/Grantee is in compliance with the Drug‐Free Workplace Act and any regulations promulgated 

thereunder; and 

15. The Applicant/Grantee meets all other qualifications and eligibility criteria necessary to receive an award; 

and 

16. The Applicant/Grantee agrees to indemnify, defend and hold harmless the Government of the District of 

Columbia and its authorized officers, employees, agents and volunteers from any and all claims, actions, 

losses, damages, and/or liability arising out of or related to this grant including the acts, errors or omissions 

of any person and for any costs or expenses  incurred by the District on account of any claim therefrom, 

except where such indemnification is prohibited by law.  

B.   Federal Assurances and Certifications 

The Applicant/Grantee shall comply with all applicable District and federal statutes and regulations, including, but not limited to, the following:      

1. The Americans with Disabilities Act of 1990, Pub. L. 101‐336, July 26, 1990; 104 Stat. 327 (42 U.S.C. 12101 

et seq.); 

2. Rehabilitation Act of 1973, Pub. L. 93‐112, Sept. 26, 1973; 87 Stat. 355 (29 U.S.C. 701 et seq.); 

3. The Hatch Act, ch. 314, 24 Stat. 440 (7 U.S.C. 361a et seq.); 

4. The Fair Labor Standards Act, ch. 676, 52 Stat. 1060 (29 U.S.C.201 et seq.); 

5. The Clean Air Act (Subgrants over $100,000), Pub. L. 108‐201, February 24, 2004; 42 USC ch. 85 et.seq.); 

6. The Occupational Safety and Health Act of 1970, Pub. L. 91‐596, Dec. 29, 1970; 84 Stat. 1590 (26 U.S.C. 

651 et.seq.); 

7. The Hobbs Act (Anti‐Corruption), ch. 537, 60 Stat. 420 (see 18 U.S.C. § 1951); 

8. Equal Pay Act of 1963, Pub. L. 88‐38, June 10, 1963; 77 Stat.56 (29 U.S.C. 201); 

9. Age Discrimination Act of 1975, Pub. L. 94‐135, Nov. 28, 1975; 89 Stat. 728 (42 U.S.C. 6101  et. seq.); 

10. Age Discrimination in Employment Act, Pub. L. 90‐202, Dec. 15, 1967; 81 Stat. 602 (29  U.S.C. 621 et. seq.); 

11. Military Selective Service Act of 1973; 

12. Title IX of the Education Amendments of 1972, Pub. L. 92‐318, June 23, 1972; 86 Stat. 235,  (20 U.S.C. 

1001); 

13. Immigration Reform and Control Act of 1986, Pub. L. 99‐603, Nov 6, 1986; 100 Stat. 3359,  (8 U.S.C. 1101); 

14. Executive Order 12459 (Debarment, Suspension and Exclusion); 

15. Medical Leave Act of 1993, Pub. L. 103‐3, Feb. 5, 1993, 107 Stat. 6 (5 U.S.C. 6381 et seq.); 

16. Drug Free Workplace Act of 1988, Pub. L. 100‐690, 102 Stat. 4304 (41 U.S.C.) to include the following 

requirements: 

1) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, 

possession or use of a controlled substance is prohibited in the Applicant/Grantee's workplace 

and specifying the actions that will be taken against employees for violations of such prohibition; 

 

2) Establish a drug‐free awareness program to inform employees about:  

a. The dangers of drug abuse in the workplace; 

b. The Applicant/Grantee's policy of maintaining a drug‐free workplace; 

c. Any available drug counseling, rehabilitation, and employee assistance programs; and 

d. The penalties that may be imposed upon employees for drug abuse violations occurring in the 

workplace; and  

(3)  Provide all employees engaged in performance of the grant with a copy of the statement required by the law;  

17. Assurance of Nondiscrimination and Equal Opportunity, found in 29 CFR 34.20; 

18. District of Columbia Human Rights Act of 1977 (D.C. Official Code § 2‐1401.01 et  seq.); 

19. Title VI of the Civil Rights Act of 1964; 

20. District of Columbia Language Access Act of 2004, DC Law 15 ‐ 414 (D.C. Official Code § 2‐1931 et seq.); 

21.  Lobbying Disclosure Act of 1995, Pub. L. 104‐65, Dec 19, 1995; 109 Stat. 693, (31 U.S.C. 1352); and 

22. Child and Youth, Safety and Health Omnibus Amendment Act of 2004, effective April 13, 2005 (D.C. Law 

§15‐353; D.C. Official Code § 4‐1501.01 et  seq.)(CYSHA). In accordance with the CYSHA any person who 

may, pursuant to the grant, potentially work directly with any child (meaning a person younger than age 

thirteen (13)), or any youth (meaning a person between the ages of thirteen (13) and seventeen (17) 

years, inclusive) shall complete a background check that meets the requirements of the District's 

Department of Human Resources and HIPAA. 

 

C.  Mandatory Disclosures 

1. The Applicant/Grantee certifies  that  the  information disclosed  in  the  table below  is  true at  the  time of 

submission of the application for funding and at the time of award if funded.  If the information changes, 

the Grantee shall notify the Grant Administrator within 24 hours of the change in status. A duly authorized 

representative must sign the disclosure certification   

2. Applicant/Grantee Mandatory Disclosures  

A. Per OMB 2 CFR §200.501– any recipient that expends $750,000 or more in federal funds 

within the recipient’s last fiscal, must have an annual audit conducted by a third – party.  In 

the Applicant/Grantee’s last fiscal year, were you required to conduct a third‐party audit? 

  YES 

  NO 

B. Covered Entity Disclosure During the two‐year period preceding the execution of the attached    YES 

Agreement, were any principals or key personnel of the Applicant/Grantee / Recipient 

organization or any of its agents who will participate directly, extensively and substantially in 

the request for funding (i.e. application), pre‐award negotiation or the administration or 

management of the funding, nor any agent of the above,  is or will be a candidate for public 

office or a contributor to a campaign of a person who is a candidate for public office, as 

prohibited by local law. 

  NO 

C. Executive Compensation: For an award issued at $25,000 or above, do Applicant/Grantee’s 

top five executives  do not receive more than 80% of their annual gross revenues from the 

federal government, Applicant/Grantee’s revenues are greater than $25 million dollars 

annually AND compensation information is not already available through reporting to the 

Security and Exchange Commission. 

If No, the Applicant, if funded shall provide the names and salaries of the top five executives, per the requirements of the Federal Funding Accountability and Transparency Act – P.L. 109‐282. 

  YES 

  NO 

 

D. The Applicant/Grantee organization has a federally‐negotiated Indirect Cost Rate Agreement.   

If yes, insert issue date for the IDCR: ___________ If yes, insert the name of the cognizant 

federal agency? _____________ 

  YES 

  NO 

E. No key personnel or agent of the Applicant/Grantee organization who will participate directly, 

extensively and substantially in the request for funding (i.e. application), pre‐award 

negotiation or the administration or management of the funding is currently in violation of 

federal and local criminal laws involving fraud, bribery or gratuity violations potentially 

affecting the DOH award. 

  YES 

  NO 

ACCEPTANCE OF ASSURANCES, CERTIFICATIONS AND DISCLOSURES I am authorized to submit this application for funding and if considered for funding by DOH, to negotiate and accept terms of Agreement on behalf of the Applicant/Grantee organization; and  I have read and accept the terms, requirements and conditions outlined in all sections of the RFA, and understand that the acceptance will be incorporated by reference into any agreements with the Department of Health, if funded; and     I, as the authorized representative of the Grantee organization, certify that to the best of my knowledge the information disclosed in the Table: Mandatory Disclosures is accurate and true as of the date of the submission of the application for funding or at the time of issuance of award, whichever is the latter.  Sign: 

  Date: 

NAME: INSERT NAME  TITLE:  INSERT TITLE     AGENCY NAME: