Ill. Admin. Code tit. 77, pt. 630, subpt. D, app E
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: _____________________________________________________
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______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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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: ____________________________________
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DateSignature
4. TYPE OF ORGANIZATION:
_______________ LOCAL HEALTH DEPARTMENT
_______________ PRIVATE NON-PROFIT AGENCY
_______________ OTHER
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5. GRANT SUPPORT REQUESTED:
BEGINNINGENDINGAMOUNT
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6. TYPE OF APPLICATION:
INITIALCONTINUATIONREVISION
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7. LEGISLATIVE DISTRICT:
CONGRESSIONAL ________________________________________
LEGISLATIVE ________________________________
(State Senate)
REPRESENTATIVE _____________________
(State Representative)
__________________________________________________________
8. DATE OF SUBMISSION:
__________________________________________________________
MonthDateYear
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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.
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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:
DATE FROM: | THROUGH: | |
SUMMARY BUDGET FOR THIS PERIOD | SOURCE OF FUNDS | |
Budget | Applicant | Amount |
Total | And | Assistance |
For | Other | Requested |
Program | ||
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1. PERSONAL SERVICES
__________________________________________________________
2. CONTRACTUAL SERVICES
__________________________________________________________
3. SUPPLIES
__________________________________________________________
4. TRAVEL
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5. PATIENT CARE
__________________________________________________________
6. EQUIPMENT
__________________________________________________________
7. TOTAL DIRECT COSTS
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SOURCE OF FUNDS - APPLICANT &CODE MATCHING OR COSTOTHER
OTHER CATEGORY ONLYPARTICIPATION
_____________ $ REQUIREMENTS _ $ ____________
TOTAL_____________ $ ________________ _ $ ____________
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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 BUDGETED | PERCENT TIME | BUDGET TOTAL FOR PROGRAM | CODE APPLICANT AND OTHER | 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
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USE ADDITIONAL SHEETS IF NECESSARY
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT
DATE FROM: | THROUGH: | |||||
DETAILED BUDGET FOR THIS PERIOD: | BUDGET TOTAL FOR PROGRAM | CODE | APPLICANT AND OTHER | AMOUNT ASSISTANCE REQUESTED | ||
________ | _____ | ________ | ________ | |||
(3) | (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 FOR THIS PERIOD: | BUDGET TOTAL FOR PROGRAM | CODE | APPLICANT AND OTHER | AMOUNT ASSISTANCE REQUESTED | ||
________ | _____ | ________ | ________ | |||
(3) | (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. |
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USE ADDITIONAL SHEET IF NECESSARY
Ill. Admin. Code tit. 77, pt. 630, subpt. D, app E