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