Section 635.APPENDIX C Family Planning Services Application Packet

Checklist for Completing the FY90

Family Planning Services Application

Check ( ) the following item for completeness before submitting your application for processing. Each must be addressed, filled in or attached as indicated. CHECKLIST MUST BE SUBMITTED WITH APPLICATION.

Cover Sheet Attachment A
	Complete Sections	2	Applicant Organization
		3	Applicant Certification
		4	Type of Organization
		5	Grant Support Requested
		6	Type of Application
		7	Legislative District
		8	Date of Submission
Health Care Plan
	#10 complete narrative
	#11 define target area
	#12 list clinic(s) names(s)
	and days/hours of operation
	#13 complete budget in accordance
	with the attached budget and
	expenditures category definitions
Checklist – FY 90
	#14 complete cost analysis by IDPH methodology
	Between Page 5 & 6 attach schedule of discounts
	and sliding fee scale with charges based upon
	1989 Poverty Guidelines.
	#15 complete three (3) objectives
	Complete attached Plans to Achieve
	Objective/Program Progress Report
	Forms three (3)

Attachment A

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

535 WEST JEFFERSON STREET

SPRINGFIELD, ILLINOIS 62761

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT

PROGRAM TITLE:

Family Planning Services

BRIEF SUMMARY:

To provide comprehensive family planning services pursuant to the application and assurances

submitted by the grantee. Such services will be delivered in accordance with the Department's applicable rules

entitled Title 77: Public Health, Chapter I: Department of Public Health, Sub Chapter: Maternal and Child Health

Part 635 Program Content and Guidelines for Title X Family Planning Services

APPLICANT ORGANIZATION:

TYPE OF ORGANIZATION:

NAME:

LOCAL HEALTH DEPARTMENT

ADDRESS:

PRIVATE NON-PROFIT AGENCY

OTHER ___________________________

GRANT SUPPORT REQUESTED:

TELEPHONE:

(

)

BEGINNING

ENDING

AMOUNT

FEIN NUMBER:

PROJECT DIRECTOR:

TYPE OF APPLICATION:

INITIAL

CONTINUATION

REVISION

LEGISLATIVE DISTRICT

FINANCE OFFICER:

CONGRESSIONAL

LEGISLATIVE

(State Senate)

REPRESENTATIVE

APPLICANT CERTIFICATION:

(State Representative)

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.

DATE OF SUBMISSION:

Month

Date

Year

AUTHORIZED OFFICIAL:

IMPORTANT NOTICE:

This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under Illinois Revised Statutes, Ch. 127, Par. 137 et. seq. Failure to provide this information may prevent this form from being processed. This form has been approved by the Forms Management Center.

Date

Signature

4/88

					Agency Name
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT (cont'd.)						DATE FROM: THROUGH
11.	GEOGRAPHIC SERVICE AREA
INSTRUCTIONS:			Define your target service area by listing county(ies) or community(ies) served.


12.	CLINIC(S) SCHEDULE(S)
INSTRUCTIONS:		List all clinics by name, address and days/hours of operation.
Clinic(s) Names(s)/Address(es)				Days/Hours of Operation












USE ADDITIONAL SHEETS IF NECESSARY							3/89

Agency Name

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT - (continued)

DATE FROM: THROUGH

13.

BUDGET

INSTRUCTIONS:

All funds must be identified and assigned to categories in accordance with the budget and expenditures category definitions.

CATEGORY

Family Planning Award

Title XIX

Patient Fees

Other Funds

TOTAL

Budget

Personal Services

Contractual Services

Supplies

Travel

Patient Care

Equipment

Total

*Details must be provided below. Use additional sheets if necessary.

3/89

Illinois Department of Public Health

Division of Family Health

Budget Category Definitions

Personal Services

“The item ‘personal services', means the reward or recompense made for personal services rendered by an employee of the delegate agency in support of this project, or any amount required or authorized to be deducted from the salary of any such person or any retirement or tax law, or both, or deductions from the salary of any such person under the Social Security Enabling Act, or deductions from the salary of such person. Any employee is anyone who receives the fringe benefits offered by the delegate agency.

Contractual Services

“The item ‘contractual services’, means and includes: (a) Expenditures, incident to the current conduct and operation of an office, department, or agency in direct support of this project for postage and postal charges, telephone expenses, printing, office conveniences and services, exclusive of supplies as herein defined: (b) Expenditures of $5,000 or less for repair or maintenance of property or equipment, utility services, professional or technical services; (c) Expenditures pursuant to multi-year lease, lease-purchase or installment purchase contracts for duplicating equipment authorized by the contract.”

Travel

“The item ‘travel’, shall include any expenditure directly incident to official travel by employees of the project, involving reimbursement to travelers or direct payment to private agencies providing transportation or related services.”

Supplies

“The item ‘supplies’ means and includes expenditures in connection with current operation and maintenance for the purchase of articles of a consumable nature which show a material change or appreciable depreciation with first usage, repair parts, and including tools and equipment having a unit value not in any instance exceeding $50, but does not include any expenditure for library books or expenditure included in 'permanent improvements’.”

Equipment

(purchase exceeding $100)

“The item ‘equipment’, shall mean and include all expenditures for library books, and expenditures, having a unit value exceeding $100, for the acquisition, replacement or increase of visible tangible personal property of a non-consumable nature.”

Patient Care

“The item ‘patient care’ means services necessary for the care of patients that the delegate can not provide other than by an outside vendor. This includes medical and social service contracts.

IDPH (1987)

Illinois Department of Public Health

Division of Family Health

Expenditures per Category

Listed below are examples of the most common charges shown under their appropriate category. If you have any other type of expense, please do not hesitate to call for assistance in placing it in the correct category.

I. Personal Services

1. Fringe benefits

2. Salaries

II. Contractual Services

1. Advertising costs

2. Building and ground maintenance

3. Conference and registration fees

4. Contractual employees

5. Copy machine rental

6. Insurance (building, fire, theft and malpractice)

7. Legal services and accounting fees

8. Postage (including stamps)

9. Printing

10. Rent or lease of space of property

11. Repair and maintenance of furniture and equipment

12. Statistical and tabulation services (data processing)

13. Subscriptions

14. Telephone

15. Utility cost

III. Supplies

1. Contraceptives

2. Educational and instructional materials

3. Medical supplies

4. Office supplies

5. Pamphlets

Agency Name

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT (continued)

DATE FROM: THROUGH

14. COST ANALYSIS AND FEES

INSTRUCTIONS: Complete the cost analysis following the cost analysis manual instructions. Attach a copy of your agency's Schedule of Discounts and sliding fee schedule with charges based upon the 1990 federal poverty guidelines.

(a)

Service/Procedure

(b)

Serv. Util.

(c)

RVS

(d)

Total Serv. Units

(e)

Total Cost/Cost Ctr.

(f)

Avg. Cost/Serv. Unit

(g)

Cost/Serv.

(h)

Fee

Medical Cost Center

Minimal

5.00

/////////////////////////////////

Brief/Intermediate

18.00

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Extended

30.00

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IUD Insertion

30.00

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