Application: WARM

1

Legal organization name

2

Common name (doing business as [DBA])

3

Address line 1

4

Address line 2

5

City

6

State

7

ZIP

8

County

9

Public health region

• Bellwood
• West Chicago
• Champaign
• Marion
• Metro East
• Peoria
• Rockford
• Multiple [logic, answer 9a]

Select the public health region (s) where you primarily provide services or that pertains to this application per the IDPH Health Regions map.

9a

If you chose multiple, please briefly describe which regions will be served by the strategies funded under this award.

Text

10

Organization phone

11

Organization website address (optional)

12

Type of organization

• Nonprofit
• For profit
• Tax exempt

Select your organization type.

13

Year founded/incorporated

14

IDHS /SUPR licenses, if any

15

Primary contact name

16

Primary contact title

17

Primary contact email address

18

Primary contact phone

19

Alternative contact name

20

Alternative contact title

21

Alternative contact email address

22

Alternative contact phone

23

Indirect cost election

• Federally negotiated rate
• 10% de minimis
• No indirect costs election

Select your indirect cost election.

If you select “Federally negotiated rate,” continue to item 24.

If you select “10% de minimis” or “No indirect costs election,” skip item 24 and continue with item 25.

24

Negotiated Indirect Cost Rate Agreement (NICRA) letter

Document upload (if applicable)

Upload as Attachment A (if applicable).

25

Current or planned organizational chart

Document upload (required)

Upload as Attachment B.

26

Current fiscal year organizational budget or, if you are a new organization, your planned budget for the upcoming fiscal year

Document upload (required)

Upload as Attachment C.

27

Federal or State Employer Identification Number (FEIN/EIN)

Indicate your FEIN/EIN.

28

Form W-9, Request for Taxpayer Identification Number and Certification

Document upload (required)

Upload as Attachment D.

29

Unique Entity Identifier (UEI)

Indicate your UEI.

30

Illinois Secretary of State File ID

Indicate your File ID.

31

Do you attest that your organization is not on the Federal Excluded Parties List?

Yes

No

32

Do you attest that your organization is not on the Illinois Stop Payment list? 

Yes

No

33

Do you attest that your organization is not on the Department of Healthcare and Family Services Provider Sanctions list? 

Yes

No

34

Do you attest that your organization is in good standing with the Illinois Secretary of State?

Yes

No

35

What type of accounting system does the organization use? (2.01)

• Manual and/or spreadsheet-driven
• Automated - off the shelf
• Automated - written in-house or by consulting firm
• Not Applicable

Select the response that best describes your accounting system.

36

Does the accounting system require users to have separate sign in/log on credentials for access and approval? (2.02)

• Yes
• No

37

Have any new accounting systems been implemented during the last fiscal year? (2.03)

• Yes
• No

38

Does the accounting system or 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

Select the response that best describes how receipt and expenditure of grant funds are tracked.

39

Does the accounting system or 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

40

How often are the general ledger accounts reconciled? (2.06)

• Monthly
• Quarterly
• Semi-annually
• Annually
• Not applicable

Select the response that best describes how often the general ledger accounts are reconciled.

41

Does the organization require monthly bank reconciliations? (2.07)

• Yes
• No

42

Does 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

43

Does the organization have written review and approval processes for financial and program-related reporting? (3.01)

• Yes
• No

44

Are 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

45

Does the organization have written policies and procedures to ensure program performance measures and deliverables align with the program spending plan? (3.03)

• Yes
• No

46

Has 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

47

Who prepares the organization’s financial statements? (3.05)

• Trained staff who work for the organization
• Financial consultants who are not part of the organization’s audit firm
• Independent auditors who conduct the financial statement audit

Select the response that best describes who prepares the organization’s financial statements.

48

Who 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

Select the response that best describes who prepares the organization’s performance reports.

49

Does the organization have written policies and procedures that support compliance with cost principles? (4.01)

• Yes
• No

50

Does the organization have written policies and procedures for allocating costs? (4.02)

• Yes
• No

51

Are 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

52

Does the organization charge indirect costs? (4.04)

• Yes
• No

53

Does the organization keep adequate documentation to support all costs charged to its grant awards? (4.06)

• Yes
• No

54

Does 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

55

Is financial information, including budget to actual revenue and expenditure reports, provided to leadership or the governing body members? (4.08)

• Always
• Sometimes
• Never

Select the response that best describes how often financial information is provided to leadership or governing body members

56

Is 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)

• Engaged in all audit function activities
• Engaged in some audit function activities
• Not involved in audit activities

Select the response that best describes how often the governing body is engaged with audit function activities.

57

Does the organization make purchases of equipment of $5,000 or more with grant funding? (4.10)

• Yes
• No

58

Is a control system in place with adequate safeguards to prevent loss, damage, theft, or unauthorized use of property? (4.13)

• Yes
• No

59

Does the organization have written policies and procedures for proper authorization of property disposals? (4.14)

• Yes
• No
• Not applicable

60

Does the organization have written policies and procedures for purchasing goods and services with grant funds? (4.15)

• Yes
• No

61

Does 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

62

Does 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

63

Does the organization have written policies and procedures that document subrecipient and contractor determinations? (4.18)

• Yes
• No

64

In those determinations, has the organization identified any subrecipients? (4.19)

• Yes
• No

65

Does the organization have written policies and procedures for assessing subrecipient risk and monitoring program implementation? (4.20)

• Yes
• No

66

Does the accounting system or do related written policies and procedures identify expenses in excess of available budget? (4.21)

• Yes
• No

67

Are adequate controls in place to ensure that necessary budget revisions receive prior approval from the grantor when applicable? (4.22)

• Yes
• No

68

Does the organization have written policies and procedures for allocating personnel time and effort by funding source? (4.23)

• Yes
• No

69

Does 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

70

Does the organization have written policies and procedures to ensure accurate tracking of grant deliverables and performance measures? (4.25)

• Yes
• No

71

Does 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

72

Are the terms of the executed agreement and budget shared with the performance or program management staff? (4.28)

• Yes
• No

73

Does the organization have written policies and procedures for documenting participant eligibility determinations? (4.29)

• Yes
• No

74

Have 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

75

Has a financial statement audit of the organization been conducted in the past year? (5.02)

• Yes
• No

If “no” is selected, skip items 77–80, continuing with item 81.

76

What 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

Select the response that best describes the type of audit conducted within the past year.

77

Did the audit find significant deficiencies or material weaknesses? (5.04)

• Yes
• No

78

Financial Audit Report (most recent)

Document upload (optional, if available)

Upload as Attachment E, if available.

79

Has the organization submitted financial and program-related reporting in a timely manner and as required for prior grant awards?

• Always
• Sometimes
• Rarely

80

By 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.

81

I attest that my organization is committed to processing a subaward within six (6) weeks from the Notice of Award.

• Yes
• No

82

I attest that my organization is responsible for performance and monitoring of external partners, subcontractors, and subrecipients (as allowed by the grant agreement).

• Yes
• No

83

I attest that I have reviewed the terms and conditions within this Notice of Funding Opportunity in its entirety. My organization meets the eligibility criteria and has the capacity to fulfill the scope of services described.

• Yes
• No

84

I 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

85

Conflict of Interest Disclosure

Document upload (required)

Upload as Attachment F.

Please list the relevant zip codes (required), Chicago Community Area(s), and/or municipalities where you will primarily provide services funded with this award.

Enter zip codes OR

Not applicable

Summarize the following:

• The population of focus to be served, including geographic, demographic, and other relevant characteristics.
• The reason why this population was selected.
• An overview of the services to be provided.
• 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 explains the need for the proposed program for the population of focus, and justifies the need.
• The population of focus described in the response aligns with the program requirements.
• The services described in the response align with the program requirements.
• The response demonstrates an understanding of the expertise needed to deliver  the program,

What population do you serve, and how has the opioid crisis impacted your service area?

Describe

• The geographic area and population you currently serve.
• Demographic information (age, gender, race, ethnicity, language spoken, etc.) about the population you serve.
• Other characteristics (housing situation, trauma history, etc.) about the population you serve.
• Information about opioid use disorder, fatal and nonfatal overdoses, and other relevant information for the service area

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 has an established track record of serving a clearly defined population that is affected by health, economic, and other health disparities.
• The geographic service area is disproportionately affected by the opioid crisis, defined as including at least one of the following:
  • High opioid fatality rates per 100,000 capita
  • Concentrated poverty
  • Concentrated firearm violence
  • Other conditions that hinder the communities reaching their full potential for health and well-being
• The response includes relevant data, including sources.

What is the population of focus for the proposed program and what is their need for warm handoff and recovery support services?

• Describe the setting in which outreach and warm handoffs will be initiated.
• Describe the specific geographic area to be served by the program. 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.
• Explain what needs will be met by the proposed program, including barriers to access for the population of focus, such as social determinants of health, lack of coverage, etc.
• Explain why the community and population to be served were chosen and how they will benefit from the proposed program.

Please cite the source of any data included.

(15 points)

• The response addresses all elements of the question.
• The specific population to be served is clearly defined and in accordance with the priority population.
• The specific population experiences barriers to accessing warm handoff and recovery services.
• The proposed program fills an unmet need.
• The response includes relevant data, including sources.

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.

Identify the staff who will deliver services and describe their experience and qualifications.

For new staff, describe your plan to hire people with the necessary qualifications and characteristics (including people with lived and living experience).

Up to 1,000 words

(5 points)

• The response addresses all elements of the question.
• The applicant understands the experience and expertise required to implement the proposed program.
• The applicant demonstrates an ability to provide qualified staff.
• The applicant demonstrates a commitment to hiring people with lived and living experience

Up to 1,000 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.

93

Provide 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’s grants align with one or more of the following:
  • Providing services like the proposed program.
  • Addressing health disparities.
  • Working with the priority populations.

How 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. Discuss your experience supporting peer support workers in the workforce.

(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.

Describe how you will make sure services are culturally and linguistically appropriate based on the diversity of the population to be served.

• What types of policies and procedures exist to ensure you are identifying the service needs of your service population?
• How do you incorporate the the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care into your organization’s practice and procedures?

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 related to cultural and linguistic barriers.
• 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.

200 characters

200 characters

[Drop Down choices—federal, state, local government, other]

Currency, whole dollar only

200 characters

Date

Date

[same]

[same]

[same]

[same]

Describe how your organization will implement  each task.

In your answer, include the following information:

• How you will establish community partnerships,
• How you will identify and engage the priority population,
• How you will tailor services to the individual needs of the priority population, and
• How your organization will support peer support workers (PSWs) and/or persons with lived experience (PLEs).

For each relevant task, specify quantities (e.g., number of partnerships or number of people to be served).

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.

(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.

(10 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.

• Advance Payment and Reconcile Method
• Reimbursement Method
• Working Capital Advance Method

The budget and narrative tie fiscal activity to program objectives and deliverables and 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.

(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.
• All line items correspond to elements of the proposed program.