E Application and Plan for Public Health

Section 630.APPENDIX E   Application and Plan for Public Health ILLINOIS DEPARTMENT OF PUBLIC HEALTH 535 WEST JEFFERSON STREET SPRINGFIELD, ILLINOIS 62761 APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT 1. PROGRAM TITLE: BRIEF SUMMARY: 2. APPLICATION ORGANIZATION: NAME: ADRESS: TELEPHONE: (___) FEIN NUMBER: PROJECT DIRECTOR: FINANCE OFFICER: 3. APPLICANT CERTIFICATION: To the best of my knowledge, the data and statements in this application are true and correct. The applicant agrees to comply with all State/Federal statutes and Rules/Regulations applicable to the program AUTHORIZED OFFICIAL: Date Signature 4. TYPE OF ORGANIZATION: LOCAL HEALTH DEPARTMENT PRIVATE NON-PROFIT AGENCY OTHER 5. GRANT SUPPORT REQUESTED: BEGINNING ENDING AMOUNT 6. TYPE OF APPLICATION: INITIAL CONTINUATION REVISION 7. LEGISLATIVE DISTRICT: CONGRESSIONAL LEGISLATIVE (State Senate) REPRESENTATIVE (State Representative) 8. DATE OF SUBMISSION: Month Date Year 9. IMPORTANT NOTICE: This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 30 ILCS 105. Failure to provide this information may prevent this form from being processed. This form has been approved by the Forms Management Center. ILLINOIS DEPARTMENT OF PUBLIC HEALTH APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT PROGRAM NARRATIVE OR PROGRESS REPORT INSTRUCTIONS:  Please complete a narrative in accordance with the instructions found in "Rules and Regulations" for the specific project for which you are requesting funds. If this is a continuation application, please use this page as a progress report in accordance with instructions in the "Rules and Regulations". Following the narrative, please attach a listing of all sites of service and their addresses for this project. ILLINOIS DEPARTMENT OF PUBLIC HEALTH APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT DATE FROM: THROUGH: SUMMARY BUDGET FOR THIS PERIOD SOURCE OF FUNDS Budget Total For Program Applicant And Other Amount Assistance Requested 1. PERSONAL SERVICES 2. CONTRACTUAL SERVICES 3. SUPPLIES 4. TRAVEL 5. PATIENT CARE 6. EQUIPMENT 7. TOTAL DIRECT COSTS SOURCE OF FUNDS – APPLICANT & CODE MATCHING OR COST OTHER OTHER CATEGORY ONLY PARTICIPATION REQUIREMENTS $ $ TOTAL $ $ USE ADDITIONAL SHEETS IF NECESSARY ILLINOIS DEPARTMENT OF PUBLIC HEALTH APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT DATE FROM:11219 THROUGH: DETAILED BUDGET FOR THIS PERIOD (TOTAL COST) MONTHLY SALARY RATE NUMBERMONTHS BUDGET- ED PER- CENT TIME BUDGET TOTAL FOR PROGRAM C O APPLICANT D AND OTHER E SOURCE OF FUNDS AMOUNT ASSISTANCE REQUESTED (1) (2) (3) (4) (5) (6) 1. PERSONAL SERVICES (Position Title & Name of Incumbent) FRINGE BENEFITS (Rate                          ) CATEGORY TOTAL USE ADDITIONAL SHEETS IF NECESSARY ILLINOIS DEPARTMENT OF PUBLIC HEALTH APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT DATE FROM: THROUGH: DETAILED BUDGET BUDGET TOTAL C APPLICANT AMOUNT FOR THIS PERIOD: FOR O AND ASSISTANCE PROGRAM D OTHER REQUESTED (3) E (4) (5) 2. CONTRACTUAL SERVICES: Itemize CATEGORY TOTAL $ $ $ 3. SUPPLIES Itemize CATEGORY TOTAL $ $ $ 4. TRAVEL: Itemize Mileage (Rate per mile:      ¢) Lodging Meals/Per Diem Commercial Transportation Other: CATEGORY TOTAL $ $ $ USE ADDITIONAL SHEETS IF NECESSARY ILLINOIS DEPARTMENT OF PUBLIC HEALTH APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT DATE FROM: THROUGH: DETAILED BUDGET BUDGET TOTAL C APPLICANT AMOUNT FOR THIS PERIOD: FOR O AND ASSISTANCE PROGRAM D OTHER REQUESTED (3) E (4) (5) 5. PATIENT CARE: Itemize CATEGORY TOTAL $ $ $ 6. EQUIPMENT Itemize CATEGORY TOTAL $ $ $ 7. TOTAL COSTS $ $ $ USE ADDITIONAL SHEETS IF NECESSARY ILLINOIS DEPARTMEN OF PUBLIC HEALTH APPLICATION AND PLAN FOR HEALTH SERVICES GRANT DATE FROM:11219THROUGH: BUDGET JUSTIFICATION INSTRUCTIONS: Show justification for specific items or categories listed in the detailed budget for which the need is not self-evident. Justifications should clearly indicate that the times being requested are essential to the achievement of the stated project objectives and the conduct of the proposed procedures. USE ADDITIONAL SHEET IF NECESSARY