TITLE 77: PUBLIC HEALTH
CHAPTER X: DEPARTMENT OF HUMAN SERVICES
SUBCHAPTER i: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.APPENDIX C FAMILY PLANNING SERVICES APPLICATION PACKET


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:

 

4.

TYPE OF ORGANIZATION:

 

NAME:

 

 

 

LOCAL HEALTH DEPARTMENT

 

ADDRESS:

 

 

PRIVATE NON-PROFIT AGENCY

OTHER ___________________________

 

 

 

5.

GRANT SUPPORT REQUESTED:

 

TELEPHONE:

(

 

)

 

 

BEGINNING

ENDING

AMOUNT

 

FEIN NUMBER:

 

 

 

 

PROJECT DIRECTOR:

 

 

6.

TYPE OF APPLICATION:

 

 

 

 

 

  INITIAL

  CONTINUATION

  REVISION

 

7.

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.

 

 

8.

DATE OF SUBMISSION:

 

 

 

 

 

 

 

 

Month

Date

Year

 

AUTHORIZED OFFICIAL:

 

 

9.

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

10.

HEALTH CARE PLANS

 

INSTRUCTIONS:

Complete a narrative summarizing the major features of the project including: 1. statement of need, 2. characteristics of the target area including other Family Planning Resources, 3. methods used to conduct program and 4. measure its success.

 

 

USE ADDITIONAL SHEETS IF NECESSARY

3/89

 

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

Budget

Budget

Budget

Budget

1.

Personal Services

 

 

 

 

 

2.

Contractual Services

 

 

 

 

 

3.

Supplies

 

 

 

 

 

4.

Travel

 

 

 

 

 

5.

Patient Care

 

 

 

 

 

6.

Equipment

*

 

 

 

 

7.

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

 

IV      Travel

 

1.      Lodging

 

2.      Per diem

 

3.      Travel expense (mileage, train, or air fare)

 

 

V      Patient Care

 

1.      Lab Work

 

2.      Nurse practitioner for patient care (contracted out)

 

3.      Physicians for patient care (contracted out)

 

VI      Equipment

 

1.      All equipment that is purchased

 

IDPH  (1987)

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

 

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

 

 

 

 

Extended

 

30.00

 

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

 

 

 

 

IUD Insertion

 

30.00

 

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

 

 

 

 

Diaphragm Fit

 

15.00

 

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

 

 

 

 

Sonography

 

30.00

 

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

 

 

 

 

X-ray/Lost IUD

 

24.00

 

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

 

 

 

 

TOTAL

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

/////////

 

 

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

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

///////

 

Laboratory Cost Ctr.

HGB/HCT

 

3.00

 

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

 

 

 

 

U/A

 

4.00

 

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

 

 

 

 

Pregnancy Test

 

10.00

 

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

 

 

 

 

VDRL

 

6.00

 

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

 

 

 

 

Pap Smear

 

8.00

 

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

 

 

 

 

Gonococcal

 

6.00

 

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

 

 

 

 

Misc. Culture

 

6.00

 

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

 

 

 

 

Bact.Sm./Wet Mount

 

5.00

 

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

 

 

 

 

Sickle Cell

 

5.00

 

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

 

 

 

 

PP Blood Gluc.

 

6.00

 

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

 

 

 

 

Cholesterol Level

 

6.00

 

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

 

 

 

 

SMA-12

 

16.00

 

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

 

 

 

 

Colposcopy

 

30.00

 

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

 

 

 

 

Colp./Biopsy

 

40.00

 

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

 

 

 

 

Chlamydia Test

 

7.00

 

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

 

 

 

 

TOTAL

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

/////////

 

 

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

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

///////

 

Pharmacy Cost Ctr.

Orals

 

1.20

 

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

 

 

 

 

Creams

 

2.65

 

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

 

 

 

 

Jellies

 

2.65

 

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

 

 

 

 

Suppositories (ea.)

 

0.15

 

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

 

 

 

 

Foams

 

3.00

 

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

 

 

 

 

Diaphrams

 

4.00

 

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

 

 

 

 

IUD's

 

50.00

 

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

 

 

 

 

Basal T&C

 

10.00

 

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

 

 

 

 

Sponges (ea.)

 

1.50

 

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

 

 

 

 

Condoms (ea.)

 

0.22

 

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

 

 

 

 

Meds/Vag.Inf.

 

5.00

 

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

 

 

 

 

Meds/STD

 

5.00

 

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

 

 

 

 

Contracep Film

 

2.00

 

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

 

 

 

 

TOTAL

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

/////////

 

 

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

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

///////

 

Ed./Couns. Cost Ctr.

1 hr. Indepth

 

30.00

 

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

 

 

 

 

Couns./15min.-1hr.

 

5.50

 

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

 

 

 

 

TOTAL

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

/////////

 

 

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

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

///////

 

 

 

 

 

 

 

 

 

 

 

 

 

-5-

3/89

 

 

 

 

 

 

 

 

Date Cost Analysis Completed

 

 

 

 

 

 

 

BCRR DATA FROM CY 1989

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTACH SCHEDULE OF DISCOUNTS AND SLIDING FEE SCALE

 

WITH CHARGES UTILIZED BY YOUR AGENCY

 

BASED UPON 1990 REVISED POVERTY GUIDELINES

 

Agency Name

 

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT (cont’d.)  DATE FROM:      THROUGH         

15.  OBJECTIVES

INSTRUCTIONS:      Complete the objectives below by inserting the numbers that are

 

appropriate for your agency. Agencies must complete objectives #1 and

#2 by inserting the numbers that are appropriate for their agency. #3

must be an individual agency objective. Also complete the attached

Plans to Achieve Objectives/Program Progress Report forms using these

numbers and listing the tasks necessary to meet the objectives.

1.   Provide family planning services to _____________unduplicated users in need of subsidized

#

 

family planning services during State Fiscal Year 1991.  At least 85% of users will be

 

in the group with income equal to or less than 150% of poverty; ________% of all users will

#

 

be teenagers.

 

 

2.   Provide________ information and education programs for an estimated__________ individuals

#

 

#

in communities served during State Fiscal Year 19___.

 

3.   Individual Agency Objective

 

USE ADDITIONAL SHEETS IF NECESSARY

3/89

 

 

FAMILY PLANNING SERVICES

PLANS TO ACHIEVE OBJECTIVES

PROGRAM PROGRESS REPORT

 

Agency____________________________

 

Project Period  July 1, 1990 – June 30, 1991

 

Objective

#1  Provide family planning services           users in need of subsidized family planning services

 

 

during State Fiscal Year 1991.  At least 85% of users will be in the group with income equal to

 

 

or less than 150% of poverty:              % of all users will be teenagers.

 

 

 

 

 

S C H E D U L E

 

Tasks to Meet Objective 

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

Status of Task 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAMILY PLANNING SERVICES

PLANS TO ACHIEVE OBJECTIVES

PROGRAM PROGRESS REPORT

 

Agency____________________________

 

Project Period  July 1, 1990 – June 30, 1991

 

Objective

#2  Provide             Information and education programs for an estimated            individuals in

 

communities served during State Fiscal Year 1991.

 

 

 

 

 

S C H E D U L E

 

Tasks to Meet Objective 

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

Status of Task 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAMILY PLANNING SERVICES

PLANS TO ACHIEVE OBJECTIVES

PROGRAM PROGRESS REPORT

Agency____________________________

 

Project Period  July 1, 1990 – June 30, 1991

 

 

Objective

#3

 

 

 

 

 

 

 

S C H E D U L E

Tasks to Meet Objective 

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

Status of Task