Online Application
Set up your SurveyMonkey Apply account early so you have time to address any technical concerns. It is CRITICAL that you set up your account early in the application period to avoid any last minute technical challenges.
Set up your SurveyMonkey Apply account early so you have time to address any technical concerns. It is CRITICAL that you set up your account early in the application period to avoid any last minute technical challenges.
About the Application
This page lists all the questions you will be asked to respond to in the SurveyMonkey Apply platform. The application is organized into 9 sections. The information in Sections 1–4 is about the organization overall. The information in sections 5-9 is specific to this funding notice and scored as part of the merit-based review. In sections 5-9, please carefully note the associated criteria for each question. These criteria are used to score each question.
In questions 1-26, provide general information and documentation related to your organization and relevant contact information.
| # | Data Item | Field Options | Instructions |
| 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 | · Cook County (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.
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| 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
· 15% de minimis · No indirect costs election
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Select your indirect cost election.
If you select “Federally negotiated rate,” continue to item 24. If you select “15% 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. |
In questions 27-34, enter information that demonstrates your organization’s eligibility for receiving grant funds.
| # | Data Item | Field Information | Instructions |
| 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 |
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| 32 | Do you attest that your organization is not on the Illinois Stop Payment list? | Yes
No |
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| 33 | Do you attest that your organization is not on the Department of Healthcare and Family Services Provider Sanctions list? | Yes
No |
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| 34 | Do you attest that your organization is in good standing with the Illinois Secretary of State? | Yes
No |
Items 35-79 pose questions about administrative and management controls within the organization to assess organizational risk. These questions align with the Illinois Internal Controls Questionnaire (ICQ).
| # | Data Item | Field Information | Instructions |
| 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 · |
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 |
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| 37 | Have any new accounting systems been implemented during the last fiscal year? (2.03) | · Yes
· No |
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| 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 |
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| 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 |
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| 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 |
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| 43 | Does the organization have written review and approval processes for financial and program-related reporting? (3.01) | · Yes
· No |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 50 | Does the organization have written policies and procedures for allocating costs? (4.02) | · Yes
· No |
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| 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 |
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| 52 | Does the organization charge indirect costs? (4.04) | · Yes
· No |
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| 53 | Does the organization keep adequate documentation to support all costs charged to its grant awards? (4.06) | · Yes
· No |
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| 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 |
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| 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 |
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| 58 | Is a control system in place with adequate safeguards to prevent loss, damage, theft, or unauthorized use of property? (4.13) | · Yes
· No |
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| 59 | Does the organization have written policies and procedures for proper authorization of property disposals? (4.14) | · Yes
· No · Not applicable |
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| 60 | Does the organization have written policies and procedures for purchasing goods and services with grant funds? (4.15) | · Yes
· No |
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| 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 |
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| 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
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| 63 | Does the organization have written policies and procedures that document subrecipient and contractor determinations? (4.18) | · Yes
· No |
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| 64 | In those determinations, has the organization identified any subrecipients? (4.19) | · Yes
· No |
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| 65 | Does the organization have written policies and procedures for assessing subrecipient risk and monitoring program implementation? (4.20) | · Yes
· No |
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| 66 | Does the accounting system or do related written policies and procedures identify expenses in excess of available budget? (4.21) | · Yes
· No |
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| 67 | Are adequate controls in place to ensure that necessary budget revisions receive prior approval from the grantor when applicable? (4.22) | · Yes
· No |
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| 68 | Does the organization have written policies and procedures for allocating personnel time and effort by funding source? (4.23) | · Yes
· No |
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| 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 |
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| 70 | Does the organization have written policies and procedures to ensure accurate tracking of grant deliverables and performance measures? (4.25) | · Yes
· No |
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| 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 |
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| 72 | Are the terms of the executed agreement and budget shared with the performance or program management staff? (4.28) | · Yes
· No |
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| 73 | Does the organization have written policies and procedures for documenting participant eligibility determinations? (4.29) | · Yes
· No |
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| 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 |
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| 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 76–78, continuing with item 79. |
| 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 |
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| 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 |
Section 80-86 asks for verification of capacity and truthfulness of information in the application, as well as disclosure of conflicts of interest.
| # | Data Item | Field Information | Instructions |
| 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 Intent to Award. | · Yes
· No |
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| 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 |
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| 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 |
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| 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 |
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| 85 | I attest that my organization will adhere to applicable standards within Administrative Rule, Part 2060 pertaining to treatment off-site. | · Yes
· No |
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| 86 | Conflict of Interest Disclosure | Document upload (required) | Upload as Attachment F. |
Question 87 asks for an overview of your organization and the services you plan to deliver if awarded funding.
| # | Data Item | Field | Evaluation Criteria |
| 87 | Summarize the following:
· Mission and vision of your organization · The proposed activities and anticipated outcomes of the project · 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)
1) The services described in the response align with the program requirements. 2) The response demonstrates an understanding of the expertise needed to deliver the program. 3) The response addresses all elements of the question.
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Section 6 asks you to detail the need for the program for the population of focus.
| # | Data Item | Field | Evaluation Criteria |
| 88 | How does your proposal support the purpose of the project?
Explain the current need and supported by data, describe how the proposed project will strengthen Illinois’ healthcare and behavioral health workforce across the continuum of care, expand professional development opportunities, enhance programmatic collaboration, and diversify the workforce.
Describe how you will prioritize priority populations.
Please cite the source of any data included. |
Up to 2,000 words | (25 points)
1) The response demonstrates a clear understanding of the program purpose and priority populations. 2) The response describes how project activities will contribute to positive outcomes. 3) The response addresses all elements of the question. 4) The response includes relevant data, including sources. |
| # | Data Item | Field | Evaluation Criteria |
| 89 | What is your organization’s experience implementing the tasks described in the scope of work?
Describe experience with needs assessment, developing and delivering TTA, and providing professional workforce development opportunities statewide.
Provide detailed descriptions of relevant prior work.
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Up to 1,500 words
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(10 points)
1) The r esponse demonstrates that the applicant has experience in each of the following: · Needs assessment, TTA development, delivery, and documentation in content areas defined in the scope of services. · Facilitating and monitoring clinical supervision for licensure or certification · Supporting and monitoring internships, fellowships, and other paid training experiences. 2) The applicant demonstrates relevant experience with examples of prior work. 3) The response addresses all elements of the question. |
| 90 | 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 and awards of similar size and services.
In description, note whether services relate to the services proposed for this award.
Select “not applicable” if you have not received previous grants or contracts. |
Checkbox for not applicable
or
Table below |
(10 points)
1) The applicant demonstrates experience with grants management of comparable size awards. 2) The applicant demonstrates experience with grants that management for comparable services.
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| 91 | Identify proposed program leadership 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 and those who live and work in the community.
Additionally, describe the organizational departments and resources who will support the program team.
Upload resumes of project leadership or, if to be hired, the organizational leadership who will serve in the interim. |
Up to 1,000 words
Upload resumes as Attachment G. |
(5 points)
1) The applicant understands the experience and expertise required to implement the proposed program. 2) The applicant demonstrates an ability to provide qualified staff. 3) The applicant demonstrates a commitment to hiring people with lived and living experience. 4) The response addresses all elements of the question.
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| 92 | Identify the community and educational partnerships that will contribute to the success of the project and describe your organization’s experience with these partners. | Up to 1,000 words
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(5 points)
1) The response identifies a sufficient range of partners to support the proposed program. 2) The applicant has existing connections to community and educational partners. 3) The response addresses all elements of the question. |
| 93 | How does your organization ensure services advance equity and racial and social justice?
Describe policies, procedures, and practices related to: · Diversity, equity, inclusion and racial justice · Equitable access to support and services · Implicit bias · Culturally responsive, culturally humble, and trauma-sensitive services, including providing interpreters and other accommodations
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Up to 1,000 words | (5 points)
1) The response demonstrates organizational commitment, through policy and practice, to advancing equity, racial, and social justice. 2) The applicant is prepared to provide interpreters and other accommodation in response to cultural and linguistic needs. 3) The response addresses all elements of the question.
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Entry table
| Name and Brief Description of Program | Funder Name | Funder Type | Dollar Amount | Population Served | Start Date (MM/DD) | End Date (MM/DD) |
| 200 characters | 200 characters | [Drop Down choices—federal, state, local government, other] | Currency, whole dollar only | 200 characters | Date | Date |
| [same] | ||||||
| [same] | ||||||
| [same] | ||||||
| [same] |
| # | Data Item | Field | Evaluation Criteria |
| 94 | Provide a task-by-task description of how your organization will administer the OTTAC program.
Describe required activities to fulfill process measures and achieve program outcomes. |
Up to 2,500 words | (15 points)
1) The response provides sufficient detail to understand how the applicant will carry out program activities. 2) The response addresses all required tasks. |
| 95 | Upload a detailed project plan for your proposed approach that includes hiring of staff, anticipated linkage agreements, and other coordination activities necessary to accomplish the goals and objectives. | Upload Project Plan as Attachment H. | (10 points)
1) The project plan includes all required program elements. 2) The timeline includes realistic milestones. |
| 96 | Upload a website concept plan.
The website concept plan should include a description of key elements and a visual representation of the OTTAC website. |
Upload Website Concept Plan as Attachment I. | (10 points)
1) The concept plan addresses all elements of the question. 2) The concept plan demonstrates an understanding of the deliverable requirements. |
Questions 97-99 request information about the project budget.
| # | Data Item | Field Information | Evaluation Criteria |
| 97 | Total funding requested for the period of performance | [currency] | (0 points)
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| 98 | Please select your preferred payment term as described in Section G.5. of this document.
Please note, if you are awarded and your preferred payment method is advanced payment and reconciliation, you will be asked to send documents that demonstrate your eligibility per 2 CFR 200.302 and 2 CFR 200.305. Illinois requires that the following conditions must be met to receive advanced payment.
You must maintain or demonstrate the willingness to maintain both:
i. written procedures that minimize the time elapsing between the transfer of funds and disbursement by the awardee; and ii. financial management systems that meet the standards for fund control and accountability as established in 2 CFR 200.302.) |
· Reimbursement Method
· Advance Payment and Reconcile Method · Working Capital Advance Method |
(0 points) |
| 99 | Upload the project budget and narrative. This workbook must tie fiscal activity to program objectives and deliverables.
The budget must demonstrate that all proposed costs are · Reasonable and necessary, · Allocable, and · Allowable as defined by program regulatory requirements and Uniform Guidance (2 CFR 200), as applicable. |
Upload the Budget Workbook as Attachment J to submit your project budget and advance payment request. (required) | (5 points)
1) The budget is filled out completely. 2) Salaries, benefits, and other expenditures appear reasonable for the community in which the proposed program will take place. 3) All line items correspond to elements of the proposed program.
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