ࡱ> %?A"#$%&'()*+,-./0123456789:;<=>DEFGp@ bjbj  i1gi1gV(vv*****d++++D 6 +C8HIII;L k$q'*L|;LL(*(*IIbLz(*RI*IL  z*"I}[^0ܿ$ "*_"___0___LLLL_________vX (:  APPLICATION Application Checklist for PROGRAM AREA ONE (Prevention / ITTS) Please be sure that all of the following items are included in your application. Assemble the application in the following order. Use a binder clip at the top left corner on each copy of the application. Number each page consecutively. Applications must be typed in 12-point font, double-spaced with one-inch margins, single sided. ___Cover Letter: The application must include a cover letter, on agency letterhead (if available), signed and dated by an individual authorized to legally bind the Applicant. Include in the cover letter: The legal name of the Applicant agency The RFA number The Applicant agencys federal tax identification number The Applicant agencys DUNS number The closing date for applications. ___Application Face Sheet ___Completed Application (125-page maximum) ___Attachment F: Project Objectives ___Attachment G: Projection Report ___Attachment H: Physicians Standing Orders ___Attachment I: Memoranda of Agreement (MOA)/Letters of Support (MOAs from each provider, documenting which required and/or optional services each member of the network has agreed to be responsible and how health outcomes and services data will be shared among appropriate network providers. Include MOAs for all agencies providing administration, planning and evaluation.) ___Attachment J: Project Organizational Chart ___Attachment K: Staff Plans/Job Descriptions for Key Personnel ___Attachment L: Project Budgets and Budget Narratives (Only submit the Budget Breakdown Page and Budget Justification Pages for the first 12-month periods in the format provided. Budget Summary Instructions, Estimated Budget Breakdown Page and Estimated Budget Justification examples and blank budget page are included. Reference each program area for contract year.) ___Attachment M: IRS Letter Documenting your Organizations Tax Identification Number (public agencies) or IRS Determination Letter Regarding Your Organizations 501(c)(3) Tax Exempt Status (private non-profit agencies) and Verification of 501(c)(3) Status Form (private non-profits)) ___Attachment N: Confidentiality Policy ___Attachment O: Indirect Cost Rate Approval Letter (if applicable) (See Appendix 26) Application Checklist for PROGRAM AREA TWO & THREE (HIV Care/RW Part B & HOPWA) Please be sure that all of the following items are included in your application. Assemble the application in the following order. Use a binder clip at the top left corner on each copy of the application. Number each page consecutively. Applications must be typed in 12-point font, double-spaced with one-inch margins, single sided. ___Cover Letter: The application must include a cover letter, on agency letterhead (if available), signed and dated by an individual authorized to legally bind the Applicant. Include in the cover letter: The legal name of the Applicant agency The RFA number The Applicant agencys federal tax identification number The Applicant agencys DUNS number The closing date for applications. ___Application Face Sheet ___Completed Application (125-page maximum) ___Attachment P: Memorandum of Agreement (MOA): MOAs from each provider, documenting which required and/or optional services each member of the network has agreed to be responsible and how health outcomes and services data will be shared among appropriate network providers. Include MOAs for all agencies providing administration, planning and evaluation. ___Attachment Q: Letters of Support ___Attachment R: Organizational Chart ___Attachment S: Budgets and Budget Narratives: (Only submit the Budget Breakdown Page and Budget Justification Pages for the first 12-month periods in the format provided. Budget Summary Instructions, Estimated Budget Breakdown Page and Estimated Budget Justification examples and blank budget page are included. Reference each program area for contract year.) ___Attachment T: Indirect Cost Rate Approval Letter (if applicable) (See Appendix 26) ___ Attachment U: IRS Letter Documenting your Organizations Tax Identification Number (public agencies) or IRS Determination Letter Regarding Your Organizations 501(c)(3) Tax Exempt Status (private non-profit agencies) and Verification of 501(c)(3) Status Form (private non-profits) ___Attachment V: Confidentiality Policy ___Attachment W: Resumes of Staff Providing Services Application Face Sheet This form provides basic information about the applicant and the proposed project with DPH, Regional Networks of Care and Prevention, including the signature of the individual authorized to sign official documents for the agency. This form is the applications cover page. Signature affirms that the facts contained in the applicants response to RFA #A-379 are truthful and that the applicant is in compliance with the assurances and certifications that follow this form and acknowledges that continued compliance is a condition for the award of a contract. Please follow the instructions below. Legal Name of Agency: Name of individual with Signature Authority:Mailing Address (include zip code+4): Address to which checks will be mailed:Street Address: Contract Administrator: Name: Title:Telephone Number: Fax Number: E-mail AddressAgency Status (check all that apply):( Public( Private Non-Profit( Local Health DepartmentAgency Federal Tax ID Number:Agency DUNS Number:Agencys URL (website):Agencys Financial Reporting Year: Current Service Delivery Areas (county(ies) and communities):Proposed Area(s) To Be Served with Funding (county(ies) and communities):Amount of Funding RequestedProjected Expenditures: Does applicants state and/or federal expenditures exceed $500,000 for applicants current fiscal year (excluding amount requested in #14) Yes ( No (The facts affirmed by me in this application are truthful and I warrant that the applicant is in compliance with the assurances and certifications contained in NC DHHS/DPH Assurances Certifications. I understand that the truthfulness of the facts affirmed herein and the continuing compliance with these requirements are conditions precedent to the award of a contract. The governing body of the applicant has duly authorized this document and I am authorized to represent the applicant.Signature of Authorized Representative: Date  Appendix 1: North Carolina Regional Networks of Care and Prevention (Map)  SHAPE \* MERGEFORMAT  Appendix 2: List of Counties Per Network Region Region 1: Avery, Buncombe, Cherokee, Clay, Cleveland, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, Yancey Region 2: Alexander, Alleghany, Ashe, Burke, Caldwell, Catawba, Lincoln, Watauga, Wilkes Region 3: Davidson, Davie, Forsyth, Iredell, Rowan, Stokes, Surry, Yadkin Region 4: Alamance, Caswell, Guilford, Montgomery, Randolph, Rockingham, Stanly Region 5: Bladen, Cumberland, Harnett, Hoke, Moore, Richmond, Robeson, Sampson, Scotland Region 6: Chatham, Durham, Franklin, Granville, Johnston, Lee, Orange, Person, Vance, Wake, Warren Region 7: Brunswick, Columbus, Duplin, New Hanover, Onslow, Pender Region 8: Edgecombe, Halifax, Nash, Northampton, Wilson Region 9: Bertie, Camden, Chowan, Currituck, Dare, Gates, Hertford, Hyde, Pasquotank, Perquimans, Tyrrell Region 10: Beaufort, Carteret, Craven, Greene, Jones, Lenoir, Martin, Pamlico, Pitt, Washington, Wayne Charlotte Transitional Grant Area (TGA) Counties Anson, Cabarrus, Gaston, Mecklenburg, Union and York County, South Carolina Appendix 3: North Carolina Branch Regional Offices  Appendix 4: North Carolina PrEP Criteria Please use these guidelines when determining eligibility for PrEP. If a client is eligible based on these criteria, please complete a PrEP Referral and Linkage Form and send to your PrEP Coordinator. ______________________________________________________________________________ PrEP may benefit you if you are HIV-negative and ANY of the following apply to you: You are a gay/bisexual man or a Transgender person and have at least one of the following have an HIV-positive partner. have multiple partners, a partner with multiple partners, or a partner whose HIV status is unknownand you also have anal sex without a condom, or recently had a sexually transmitted disease (STD). You are a heterosexual man or woman and have at least one of the following have an HIV-positive partner. have multiple partners, a partner with multiple partners, or a partner whose HIV status is unknownand you also dont always use a condom for sex with people who inject drugs, or dont always use a condom for sex with bisexual men. You inject drugs and have at least one of the following share needles or equipment to inject drugs. are at risk for getting HIV from sex. NC PrEP Criteria Referral Exceptions: Staff determines that a PrEP referral is appropriate Client requests a PrEP referral NOTE: All PrEP protocols should be followed in these instances Adapted from: https://www.cdc.gov/hiv/pdf/library/factsheets/prep101-consumer-info.pdf Updated 2/20/2020 Appendix 5: Sample ITTS Memorandum of Agreement (MOA) Awesome County Health Department and North Carolina Ending the Epidemic HIV/STD Program This Memorandum of Agreement is entered by and between Awesome County Health Department and North Carolinas Ending the Epidemic HIV/STD Program (hereinafter referred to as Contractor), for the purpose of participating in the Integrated HIV/STD Targeted Testing Sites Project. This MOA is subject to the provisions of all applicable Federal and State laws, regulations, policies and standards. The Administrator for the Awesome County Health Department will be Thom Goodman, Health Director, 135 Outreach Street, Community, North Carolina 01235, (252) 000-0000. The Administrator for the Contractor will be Telly Tubby, Executive Director, 357 Main Street, Hometown, North Carolina 01234, (919) 000-0000. This MOA may be terminated by either party upon at least 30 days written notice or immediately upon notice for cause. This MOA may be amended, if mutually agreed upon, to change scope and terms of the MOA. Such changes shall be incorporated as a written amendment to this MOA. The Awesome County Health Department agrees to provide the following: Certified staff that can provide free pre-and post-test counseling, testing and referrals (trained in the State approved CTR and phlebotomy training) Laboratory and testing supplies, condoms and literature Paperwork and data entry as required by the State Prevention Program and the State Laboratory Continuous quality improvement in accordance with laboratory and procedural guidelines for labeling and processing samples Linkages and referrals to HIV/STD/PrEP treatment/care, and, any other risk reduction or psychosocial needs The Contractor agrees to provide the following: A secure free testing space, which allows for privacy, does not compromise confidentiality and is near a telephone, water source and restrooms for counseling and testing services that are provided at least twice each month Social marketing strategies to actively market the program in an effort to raise community awareness about counseling, testing and referral activities, including the distribution of brochures and posting flyers about planned testing events and activities This MOA shall begin on June 1, 2022 and end on May 31, 2023. Awesome County Health Department North Carolina Ending the Epidemic Program BY: Thom Goodman BY: Theodore Hawkins TITLE: Health Director TITLE: Executive Director DATE: June 1, 2022 DATE: June 1, 2022 Appendix 6: EvaluationWeb for ITTS Evaluation Web HIV Testing Data Form NORTH CAROLINA Data Collection / Data Entry Procedures Use Form for All HIV Testing Events as of 01/01/19 Applies to agencies and health departments funded or supported through the following: Expanded Testing (Community Health Centers, Emergency Departments, Jails) Integrated Targeted Testing (ITTS) Rapid Kits Only when the test event involves the Rapid Kit/s provided by the State Prevention Program Substance Abuse Centers (SAC) Does NOT apply to regular testing in health department clinics If a client declines HIV testing but is tested for other STIs, still use the form to enter the data Use this form to collect your data as of 1/1/2019 Printing and Copying The form can be printed locally and it is fine to photocopy it as well We suggest that you fill in a form with your Agency ID and photocopy that is 2-sided If you are doing any point of care (POC)/Rapid testing for HIV, Syphilis or HCV, you will need all 3 pages of the form because we are using Local Use Fields in Section 8 to track rapid testing If you are NOT doing any POC/Rapid tests, you can use just pages 1-2 Use with Agency Intake Forms Data should ultimately be recorded on the HIV Testing Data Form but if your agency uses a separate client or counselor intake form first, that is fine If so, make sure that all of the necessary data elements are covered on your local intake form and transferred to the HIV Testing Data Form. The HIV Testing Data Form is designed to be filled out by a trained HIV test counselor Please do not give this form to the tested client for them to fill out Any forms that are given to clients to fill out should be designed specifically for that purpose Format The order of the data elements follows the order of data entry in Evaluation Web The order may not make the most sense for client encounters so you will need to skip around a little Oval bubbles mean select only one and square boxes mean check all that apply Note that Name and full Date of Birth are needed by CDB in order to look up the client in the Surveillance system in the event that the person tests positive for HIV. Evaluation Web does not capture name and requires only year of birth Data to Collect at Time of Testing Name and Program information at the top Repeat Client name on page 2 and page 3 Skip Form ID this ID number is created by Evaluation Web at the time of data entry Section 1 Agency and Client Information Program Announcement = PS18-1802 Section 2 Testing Information HIV Test Election = Confidential HIV Test Type For Rapid testing complete CLIA-waived point-of-care (POC)/Rapid test/s For lab testing complete Laboratory-based Test If both Rapid/POC testing and Laboratory-based testing was done Fill out both results sections Complete Local Use Field 1 on page 3 RHIV Section 3 Negative Test Result Collect information for all tested persons Use the Eval Web PrEP Questions Guidance to complete the screened, eligible, referral given questions If the client is eligible for PrEP based on the NC PrEP Criteria, please complete the PrEP Referral and Linkage Form and accompanying guidance Do Not complete the last question Was the client provided with services to assist with linkage to a PrEP provider? as this will be completed only by PrEP Coordinators The HIV Testing and PrEP Data Collection Guide provides an overview of PrEP and HIV Prevention testing Section 5 Additional Tests Fill out which tests were performed and wait for results If Syphilis Rapid Test was done, record results and complete Local Use Field 2 on page 3 RSYPH If HCV Rapid Test was done, record results and complete Local Use Field 3 on page 3 RHCV Section 6 PrEP Awareness & Priority Populations Section 7 Essential Support Services Complete the last 4 rows of questions; this includes health benefits navigation and enrollment, evidence-based risk-reduction intervention, behavioral health services, and social services Section 8 Local Use Fields. As of now, we are using fields 1, 2, 3 to indicate rapid testing for HIV, Syphilis, HCV. Local Use Field 4 is to be completed only by PrEP Coordinators. Local Use Fields 1-4 have been assigned and are not available for any other use. Please refrain from assigning or using Local use Fields 5-8. Fill Out Separate Form(s) to Order HIV and STI Testing from Laboratories For HIV and HCV testing at the State Laboratory of Public Health (SLPH), use the current HIV testing form. You can skip Test1, Test2 and the behavioral risk factors Send Lab form and blood sample to SLPH for testing For Syphilis, Chlamydia, Gonorrhea testing, fill out form(s) for appropriate State, County, or Private Lab Send Lab form and blood sample to appropriate lab for testing Agency Filing System Needed Forms awaiting Laboratory Results Forms with all results complete awaiting data entry Forms that have been entered Forms for HIV-Positives that have been copied and sent to CDB All forms need to be kept in a secure, locked location Preferably a locked cabinet within a locked room Record All Results on HIV Testing Data Form Record POC/Rapid test results immediately Record Lab test results as they come in If HIV-positive, fill out as much of Section 4 Positive Test Result as you are able; it is fine if you dont know all of it, Communicable Disease Branch staff will check the surveillance system for some of these answers Keep forms filed as above until all results have been recorded When ALL HIV/STI test results have been recorded, file separately: HIV Negative, Invalid tests (regardless of results from other STI testing) These forms are now ready for data entry Further sort the forms by Program Funding and Region This will make data entry easier (see below) HIV Positive, Preliminary Positive, Discordant, and Inconclusive HIV tests Make a photocopy and send to us in CDB Place forms in an inner envelope that is sealed and marked Confidential Place that envelope inside an outer envelope and send to: Meghan Furnari, MA Prevention Program 1200 Front St, Suite 104 Raleigh, NC 27609 CDB Staff will check the HIV Case Surveillance system and will fill out the remainder of Section 4 (Positive Test Result) and Section 9 (Health Department Use Only) CDB Staff will then enter the forms in Evaluation Web Entry into Evaluation Web please use Google Chrome as your web browser, Firefox and Microsoft Edge are alternative options as well Agencies will enter the data for the HIV-Negative forms Enter regularly, preferably several times per month. Enter stacks of similar Program/Region together. The first data field chosen will be called Program which is a combination of the CDB Program/Funding and the Region. Many agencies will only have one or two choices. Indicate that each form has been entered. As each form is entered, the Evaluation Web system will generate a Form ID for each form entered. Since EW does not include data on Client Name or full Date of Birth, the Form ID is the only unique identifier that will link a database record to a form. Agency staff must write the Form ID on the HIV Testing Data Form during data entry. If the client has been referred to PrEP the Form ID must be noted on the PrEP Referral and Linkage Form as well. File entered forms. We suggest filing them by date. For now, please keep all forms. We will verify the State records retention policy and advise further. CDB staff will enter the data for the HIV-Positives, Preliminary Positives, Inconclusives, and Discordant HIV results. Rapid Testing Data Procedures - Recap HIV POC Rapid Test(s) only - Negatives Use the POC Rapid Test Result in Section 2 HIV POC Rapid Test(s) only - Positives Make a copy of the form and send the copy to CDB. File your own copy. CDB will enter data. HIV POC Rapid Test(s) AND Laboratory-based test Negatives Fill out information for both types of testing. In Evaluation Web, choose Laboratory-based testing and enter the Lab result. Enter RHIV in Local Use Field 1 on page 3 HIV POC Rapid Test(s) AND Laboratory-based test Positives Fill out information for both types of testing in Section 2. Enter RHIV in Local Use Field 1 on page 3 Make a copy of the form and send the copy to CDB. File your own copy. CDB will enter data. Syphilis POC Rapid Test Enter test result (all results) Enter RSYPH in Local Use Field 2 on page 3 Hepatitis C POC Rapid Test Enter test result (all results) Enter RHCV in Local Use Field 3 on page 3 Eval Web Data Entry Guide (the short version) Your HIV testing data forms should be separated out into different batches waiting on lab results; all results awaiting data entry with HIV results of Negative and Invalid, or no HIV test forms that have already been entered with Form IDs written down forms that need to be double enveloped and mailed to Prevention for all HIV results of Positive, Preliminary Positive, Inconclusive, and Discordant (mail as soon as forms are complete) forms that have been mailed to Prevention Grab the batch of forms ready for data entry (all with HIV testing results of Negative and Invalid, or no HIV test). Make sure they are separated by Program (if your agency participates in multiple programs with Prevention, like ITTS, SAC, ET) and Region (if applicable). Take out your Grid card, open Chrome, and Log into SAMS (SAMS.CDC.GOV) Click through several screens until you make it to the Eval Web Welcome page. Click Data or the arrow beside it, click HIV Testing Form, and begin data entry. Remember to click on every answer, as only that allows the system to populate more questions. Be sure to WRITE DOWN THE FORM ID on HIV Testing Forms Form Id line. If Eval Web asks you for information about HIV medical care, or if the person ever had a positive HIV test PLEASE STOP. This means you chose a Positive result as the result of the HIV. Go back and change the HIV test result to match the paper form. And if your paper form has an HIV result of Positive, Preliminary Positive, Inconclusive or Discordant please put that form to the side as it should not be entered by agency staff (these are the forms must be mailed to Prevention). Please answer all the questions in Eval Web EXCEPT the Section 3 PrEP Linkage question. Please use the Local Use Fields as applicable: if testing event started with a Rapid HIV test followed by a Lab/Blood HIV test then please type RHIV into Local Use Field 1 if a Rapid Syphilis test was used please type RSYPH into Local Use Field 2 if a Rapid Hepatitis C test was used please type RHCV into Local Use Field 3 Before you click to save the test event DOUBLE CHECK that you entered the FORM ID on the upper right side of page 1. Now click SAVE to save the test event. Repeat data entry processes as needed. If you encounter any issues during the data entry process please call the Luther Consulting at 866-517-6570 option 1, and email or call Meghan to fill her in on what the help desk said/did. Once you have completed data entry for all test events in this Program and Region file these forms with the others that have already been entered. Recommendations: Enter HIV Neg., HIV Invalid, and test events that do not involve an HIV test into Eval Web at least weekly. Mail copies of forms for all HIV Positive, Preliminary Positive, Inconclusive and Discordant results to Prevention as soon as the forms are complete. Please do not enter these test events into Eval Web. If you did enter it, please be sure that you wrote down the Form ID on page one of the testing data form before you send a copy to Prevention. Any questions, issues, comments, guidance or help needed call or email Meghan: (919) 755-3147 or  HYPERLINK "mailto:Meghan.Furnari@DHHS.NC.GOV" Meghan.Furnari@DHHS.NC.GOV Appendix 7: ITTS Policy and Procedures Manual Requirements Current contract Required reports (progress reports, monthly calendars, projection reports) Resumes/training certificates for staff person(s) funded on current contract Standing orders for delivery of services State updates Letters of Support, Memoranda of Agreement with testing and condom distribution sites Schedule of testing sites Agency Request for Access to State Laboratory of Public Health Laboratory Form and instructions Exposure Control Plan to protect employees from exposure to bloodborne pathogens, staff training, staff vaccination against HBV, properly disposing of regulated medical waste, hand washing procedures, containing, transporting and mailing specimens, handling exposure of patients/staff to HIV/hepatitis B, post-exposure evaluation and follow-up, incident report form, physicians evaluation form Pre-test counseling, risk reduction form, testing report form and all instructions, consent for testing form Post-test counseling, providing results for both negative and positive off-site clients, communicable disease report form Referral form, patient tracking and confirmation referral logs, list of community resources/referral agencies PrEP to high-risk negatives referral process and forms Condom distribution plan, condom log (site of distribution, target demographics, number and brand distributed) Utilizing Disease Intervention Specialists (DIS), follow-up of positive individuals for partner notification, regional office contact information Patient confidentiality of records, personnel confidentiality statement, confidentiality of patient information, permission to release patient information form Rapid HIV testing, if applicable, CLIA certificate of waiver, HIV testing license number certificate, training records, quality assurance plan, proficiency testing, method used for confirmatory testing, temperature logs for storage of test kits and controls Quality assurance plan, staff training, professional development and evaluation, client satisfaction surveys, file transport and storage, chart audits, records management protocol Grievance policy, managing patient complaints, employee complaints Community outreach activities, outreach log, field safety, transporting specimens N.C. General Statutes 130A and N.C. Administrative Codes (10A NCAD 41A. 0100) Appendix 8: Ryan White and HOPWA Service List RYAN WHITE CORE MEDICAL SERVICES Required:* Outpatient/Ambulatory Health Services (including Treatment Adherence)* Oral Health Care * Health Insurance Premium and Cost-Sharing Assistance * Mental Health Services* Medical Case Management (including Treatment Adherence)* Substance Abuse Services-outpatient *Early Intervention ServicesRYAN WHITE CORE MEDICAL SERVICES Optional:Home and Community-based Health ServicesMedical Nutrition TherapyRYAN WHITE SUPPORT SERVICES Required:* Medical Transportation ServicesRYAN WHITE SUPPORT SERVICES Optional:Emergency Financial AssistanceFood Bank/Home-delivered MealsHousing ServicesLinguistic ServicesPsychosocial Support ServicesSubstance Abuse Services-residential Tenant-Based Rental Assistance * Short-Term Rent, Mortgage, Utilities * Permanent Housing Placement Supportive Services Resource Identification Housing Information Operating Costs (for dedicated housing facility) HOPWA SERVICES Required:* Short-Term Rent, Mortgage, Utilities * Tenant-Based Rental Assistance * Permanent Housing Placement* Resource IdentificationHOPWA SERVICES Optional:Housing InformationSupportive ServicesHotel/Motel AssistanceTransitional HousingEmergency/minor Repair Cost for HOPWA facilities/units HOPWA Service Definitions Emergency Housing the Hotel/Motel (H/M) component of HOPWA funds are designed to provide short-term hotel and motel stays for eligible clients under the leasing line item in the HOPWA program; these units are preferably located within extended stay hotels/motels. Clients can remain in these units for no more than 60 days in a six-month period (90 with an approved waiver), only if no appropriate housing or shelter beds are available and if subsequent rental housing has been identified but is not immediately available for move-in by the program participants.   Short-term rent, mortgage, and utility (STRMU) payments are used to prevent a tenant from becoming homeless. The amount of assistance may vary depending on funds available, tenant needs, and program guidelines. A funding cap per client may be established by the network and is usually equivalent to two monthly rent payments. STRMU cannot be used to pay first month rent or security deposits and assistance is limited to 21 weeks in a 52-week period. Assistance must be paid to a third party such as a mortgage company, landlord or a utility company. Short-term rent, mortgage, and utility (STRMU) Program Cost are cost related to direct program expenses (e.g., costs to operate). Expenses may include the following: completion and tracking of emergency assistance requests for STRMU, eligibility determination, intake/assessment of client needs, documentation of housing needs in the individual service plan (care plan) contacting other resources (HOPWA is payer of last resort), communicating with landlords, utility companies, processing/issuing checks to landlords, utility companies, and staff costs in the form of time. Supportive Services are services that help clients maintain stable housing. These services include mental health and substance use treatment, case management, food assistance and transportation.  Transitional housing is technically called Short-term supportive housing are intended to provide temporary shelter to eligible individuals to prevent homelessness and allow an opportunity to develop an individualized housing and service plan to guide the clients linkage to permanent housing. These facilities provide temporary shelter to persons living with HIV/AIDS (PLWHA) who are homeless. A short-term supportive housing facility may not provide residence for any individual for more than 60 days in any 6-month period. 24 CFR 574.330 (a). A short term supported facility may not provide shelter or housing at any single time for more than 50 families or individuals. A program assisted under this section shall provide each assisted individual with an opportunity to receive case management services from the appropriate social services agencies. Placement in Permanent Housing: Each short-term facility must, to the maximum extent possible, offer individuals residing in such housing the opportunity for placement in permanent housing. Emergency/Minor Repair funding is used for the improvement or repair of an existing structure, or an addition to an existing structure that does not increase the floor area by more than 100 percent. The HOPWA eligible activity repair includes routine maintenance, preventative measures to keep the building in working order, and periodic replacement of fixtures and appliances on an as-needed basis. HOPWA funds spent on repairs in facility-based housing units are categorized as operating funds APR or CAPER. Appendix 9: Verification of 501 (c)(3) Status IRS Tax Exemption Verification Form (Annual) I, _________________________, hereby state that I am ___________________________ of (Printed Name) (Title) _____________________________________ (Organization), and by that authority duly given (Legal Name of Organization) and as the act and deed of the Organization, state that the Organizations status continues to be designated as 501(c)(3) pursuant to U.S. Internal Revenue Code, and the documentation on file with the North Carolina Department of Health and Human Services is current and accurate. I understand that the penalty for perjury is a Class F Felony in North Carolina pursuant to N.C. Gen. Stat. 14-209, and that other state laws, including N.C. Gen. Stat. 143C-10-1, and federal laws may also apply for making perjured and/or false statements or misrepresentations. I declare under penalty of perjury that the foregoing is true and correct. Executed on this the _____ day of ___________, 20_______. ___________________________________ (Signature) Appendix 10: Federal Certifications FEDERAL CERTIFICATIONS The undersigned states that: He or she is the duly authorized representative of the Contractor named below; He or she is authorized to make, and does hereby make, the following certifications on behalf of the Contractor, as set out herein: The Certification Regarding Nondiscrimination; The Certification Regarding Drug-Free Workplace Requirements; The Certification Regarding Environmental Tobacco Smoke; The Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions; and The Certification Regarding Lobbying; He or she has completed the Certification Regarding Drug-Free Workplace Requirements by providing the addresses at which the contract work will be performed; [Check the applicable statement]  FORMCHECKBOX  He or she has completed the attached Disclosure of Lobbying Activities because the Contractor has made, or has an agreement to make, a payment to a lobbying entity for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action; OR  FORMCHECKBOX  He or she has not completed the attached Disclosure of Lobbying Activities because the Contractor has not made, and has no agreement to make, any payment to any lobbying entity for influencing or attempting to influence any officer or employee of any agency, any Member of Congress, any officer or employee of Congress, or any employee of a Member of Congress in connection with a covered Federal action. The Contractor shall require its subcontractors, if any, to make the same certifications and disclosure. ______________________________________________________________________________ Signature Title ______________________________________________________________________________ Contractor [Organizations] Legal Name Date [This Certification must be signed by a representative of the Contractor who is authorized to sign contracts.] I. Certification Regarding Nondiscrimination The Contractor certifies that it will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. 1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. 6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (h) the Food Stamp Act and USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and (i) the requirements of any other nondiscrimination statutes which may apply to this Agreement. II. Certification Regarding Drug-Free Workplace Requirements The Contractor certifies that it will provide a drug-free workplace by: Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the Contractors workplace and specifying the actions that will be taken against employees for violation of such prohibition; Establishing a drug-free awareness program to inform employees about: The dangers of drug abuse in the workplace; The Contractors policy of maintaining a drug-free workplace; Any available drug counseling, rehabilitation, and employee assistance programs; and The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; Making it a requirement that each employee be engaged in the performance of the agreement be given a copy of the statement required by paragraph (a); Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the agreement, the employee will: Abide by the terms of the statement; and Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction; Notifying the Department within ten days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction; Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(2), with respect to any employee who is so convicted: taking appropriate personnel action against such an employee, up to and including termination; or Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; and Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e), and (f). The sites for the performance of work done in connection with the specific agreement are listed below (list all sites; add additional pages if necessary): Street Address No. 1: _____________________________________________________________________________ City, State, Zip Code: ______________________________________________________________________________ Street Address No. 2: ______________________________________________________________________________ City, State, Zip Code: ______________________________________________________________________________ Contractor will inform the Department of any additional sites for performance of work under this agreement. False certification or violation of the certification may be grounds for suspension of payment, suspension or termination of grants, or government-wide Federal suspension or debarment. 45 C.F.R. 82.510. III. Certification Regarding Environmental Tobacco Smoke Public Law 103-227, Part C-Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, education, or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law does not apply to children's services provided in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000.00 per day and/or the imposition of an administrative compliance order on the responsible entity. The Contractor certifies that it will comply with the requirements of the Act. The Contractor further agrees that it will require the language of this certification be included in any subawards that contain provisions for children's services and that all subgrantees shall certify accordingly. IV. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions Instructions [The phrase "prospective lower tier participant" means the Contractor.] By signing and submitting this document, the prospective lower tier participant is providing the certification set out below. The certification in this clause is a material representation of the fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originate may pursue available remedies, including suspension and/or debarment. The prospective lower tier participant will provide immediate written notice to the person to whom this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549, 45 CFR Part 76. You may contact the person to whom this proposal is submitted for assistance in obtaining a copy of those regulations. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter any lower tier covered transaction with a person who is debarred, suspended, determined ineligible or voluntarily excluded from participation in this covered transaction unless authorized by the department or agency with which this transaction originated. The prospective lower tier participant further agrees by submitting this document that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Covered Transaction," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the Nonprocurement List. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. Except for transactions authorized in paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension, and/or debarment. Certification The prospective lower tier participant certifies, by submission of this document, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. V. Certification Regarding Lobbying The Contractor certifies, to the best of his or her knowledge and belief, that: No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federally funded contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form SF-LLL, "Disclosure of Lobbying Activities," in accordance with its instructions. The undersigned shall require that the language of this certification be included in the award document for subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) who receive federal funds of $100,000.00 or more and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000.00 and not more than $100,000.00 for each such failure. VI. Disclosure of Lobbying Activities Instructions This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. Identify the status of the covered Federal action. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or sub-award recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. If the organization filing the report in Item 4 checks "Subawardee", then enter the full name, address, city, state and zip code of the prime Federal recipient. Include Congressional District, if known. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. Enter the Federal program name or description for the covered Federal action (Item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. Enter the most appropriate Federal Identifying number available for the Federal action identified in Item 1 (e.g., Request for Proposal (RFP) number, Invitation for Bid (IFB) number, grant announcement number, the contract grant, or loan award number, the application/proposal control number assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001." For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in Item 4 or 5. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in Item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter Last Name, First Name and Middle Initial (MI). Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (Item 4) to the lobbying entity (Item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made. Check the appropriate boxes. Check all boxes that apply. If payment is made through an in-kind contribution, specify the nature and value of the in-kind payment. Check the appropriate boxes. Check all boxes that apply. If other, specify nature. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to perform, and the date(s) of any services rendered. Include all preparatory and related activity, not just time spent in actual contact with Federal officials. Identify the Federal official(s) or employee(s) contacted or the officer(s), employee(s), or Member(s) of Congress that were contacted. Check whether or not a SF-LLL-A Continuation Sheet(s) is attached. The certifying official shall sign and date the form, print his/her name, title, and telephone number. Disclosure of Lobbying Activities (Approved by OMB 0348-0046) Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 1. Type of Federal Action:  FORMCHECKBOX  a. contract  FORMCHECKBOX  b. grant  FORMCHECKBOX  c. cooperative agreement  FORMCHECKBOX  d. loan  FORMCHECKBOX  e. loan guarantee  FORMCHECKBOX  f. loan insurance2. Status of Federal Action:  FORMCHECKBOX  a. Bid/offer/application  FORMCHECKBOX  b. Initial Award  FORMCHECKBOX  c. Post-Award3. Report Type:  FORMCHECKBOX  a. initial filing  FORMCHECKBOX  b. material change For Material Change Only: Year___________ Quarter____________ Date of Last Report:_________________ 4. Name and Address of Reporting Entity:  FORMCHECKBOX  Prime  FORMCHECKBOX  Subawardee Tier _________, (if known) Congressional District (if known) 5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime: Congressional District (if known) 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number (if applicable) _______________________ 8. Federal Action Number (if known) 9. Award Amount (if known) : $10. a. Name and Address of Lobbying Registrant (if individual, last name, first name, MI): (attach Continuation Sheet(s) SF-LLL-A, if necessary) b. Individuals Performing Services (including address if different from No. 10a.) (last name, first name, MI): (attach Continuation Sheet(s) SF-LLL-A, if necessary)11. Amount of Payment (check all that apply): $ actual planned 13. Type of Payment (check all that apply):  FORMCHECKBOX  a. retainer  FORMCHECKBOX  b. one-time fee  FORMCHECKBOX  c. commission  FORMCHECKBOX  d. contingent fee  FORMCHECKBOX  e. deferred  FORMCHECKBOX  f. other; specify: _____________________________ 12. Form of Payment (check all that apply):  FORMCHECKBOX  a. cash  FORMCHECKBOX  b. In-kind; specify: Nature Value 14. Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11(attach Continuation Sheet(s) SF-LLL-A, if necessary): 15. Continuation Sheet(s) SF-LLL-A attached:  FORMCHECKBOX  Yes  FORMCHECKBOX  No16. Information requested through this form is authorized by title 31 U. S. C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U. S. C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.Signature: Print Name: Title: Telephone No: Date: Federal Use OnlyAuthorized for Local Reproduction Standard Form - LLL Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, D. C. 20503 Appendix 11: Letter to Identify Individuals to Sign Contracts [Delete this note before printing this page on your letterhead] Individuals Authorized to Sign Contracts I, ____________________________________________________, Board President/Chairperson of __________________________________________________________________ [Entitys legal name] hereby identify the following individuals who are authorized to sign Contracts for the entity named above: Printed NameTitle Signature * Title Date Appendix 12: Letter to Identify Individuals to Sign Expenditure Reports [Delete this note before printing this page on your letterhead] Individuals Authorized to Sign Contract Expenditure Reports (CERs) I, ____________________________________________________, Board President/Chairperson of __________________________________________________________________ [Entitys legal name] hereby identify the following individuals who are authorized to sign Contract Expenditure Reports for the entity named above: Printed NameTitle Signature * Title Date Appendix 13: Conflict of Interest Policy Directions for this Conflict of Interest Policy All organizations are to submit two items regarding the Conflict of Interest: 1. A completed Conflict of Interest Acknowledgement and Policy page (which is provided in a separate Microsoft Word file) 2. Your organizations Conflict of Interest Policy If your organization...already has its own Conflict of Interest Policy... please provide a copy of it with the Acknowledgement form. does not have a Conflict of Interest Policy yet... You must adopt a Conflict of Interest Policy before you can submit your forms. Your organization must have a Conflict of Interest Policy in place to be able to contract with DHHS. You may provide your own policy or use the generic policy that DHHS provides (which is included in the following pages). If you are going to use this generic policy, it will need to be adopted by your Board of Directors. This adoption date is one piece of information that you will write on the Acknowledgement form. If your Board of Directors has already adopted this generic COI Policy in the past, then your organization does have its own COI Policy and this generic one is it. Please attach your COI policy to your completed Acknowledgement page and include that prior date that your board adopted it on the Acknowledgement page. CONFLICT OF INTEREST ACKNOWLEDGEMENT AND POLICY State of _________________________________ County __________________________________ I, ____________________________ hereby state that I am the _______________________ (Printed Name) (Title) of _________________________________________ (Organization), and by that authority (Legal Name of Organization) duly given and as the act and deed of the Organization, state that the following Conflict of Interest Policy was adopted by the Board of Directors/Trustees or other governing body in a meeting held on the __________ day of ___________, _______. I understand that the penalty (Day of Month (Month) (Year) for perjury is a Class F Felony in North Carolina pursuant to N.C. Gen. Stat. 14-209, and that other state laws, including N.C. Gen. Stat. 143C-10-1, and federal laws may also apply for making perjured and/or false statements or misrepresentations. I declare under penalty of perjury that the foregoing is true and correct. Executed on this the __________ day of _________ __, 20_______. (Day of Month) (Month) (Year) ___________________________________ (Signature) ****************************************************************************************************************** Instruction for Organization: Sign and attach the following pages after adopted by the Board of Directors/Trustees or other governing body OR replace the following with the current adopted conflict of interest policy. ___________________________________________ Name of Organization ___________________________________________ Signature of Organization Official Conflict of Interest Policy The Board of Directors/Trustees or other governing persons, officers, employees or agents are to avoid any conflict of interest, even the appearance of a conflict of interest. The Organizations Board of Directors, Trustees, or other governing body, officers, staff and agents are obligated to always act in the best interest of the organization. This obligation requires that any Board member or other governing person, officer, employee or agent, in the performance of Organization duties, seek only the furtherance of the Organization mission. At all times, Board members or other governing persons, officers, employees or agents, are prohibited from using their job title, the Organization's name or property, for private profit or benefit. A. The Board members or other governing persons, officers, employees, or agents of the Organization should neither solicit nor accept gratuities, favors, or anything of monetary value from current or potential contractors/vendors, persons receiving benefits from the Organization or persons who may benefit from the actions of any Board member or other governing person, officer, employee or agent. This is not intended to preclude bona-fide Organization fund raising-activities. B. A Board or other governing body member may, with the approval of Board or other governing body, receive honoraria for lectures and other such activities while not acting in any official capacity for the Organization. Officers may, with the approval of the Board or other governing body, receive honoraria for lectures and other such activities while on personal days, compensatory time, annual leave, or leave without pay. Employees may, with the prior written approval of their supervisor, receive honoraria for lectures and other such activities while on personal days, compensatory time, annual leave, or leave without pay. If a Board or other governing body member, officer, employee or agent is acting in any official capacity, honoraria received in connection with activities relating to the Organization are to be paid to the Organization. C. No Board member or other governing person, officer, employee, or agent of the Organization shall participate in the selection, award, or administration of a purchase or contract with a vendor where, to his knowledge, any of the following has a financial interest in that purchase or contract: The Board member or other governing person, officer, employee, or agent; Any member of their family by whole or half blood, step or personal relationship or relative-in-law; An organization in which any of the above is an officer, director, or employee; A person or organization with whom any of the above individuals is negotiating or has any arrangement concerning prospective employment or contracts. D. Duty to Disclosure -- Any conflict of interest, potential conflict of interest, or the appearance of a conflict of interest is to be reported to the Board or other governing body or ones supervisor immediately. E. Board Action -- When a conflict of interest is relevant to a matter requiring action by the Board of Directors/Trustees or other governing body, the Board member or other governing person, officer, employee, or agent (person(s)) must disclose the existence of the conflict of interest and be given the opportunity to disclose all material facts to the Board and members of committees with governing board delegated powers considering the possible conflict of interest. After disclosure of all material facts, and after any discussion with the person, he/she shall leave the governing board or committee meeting while the determination of a conflict of interest is discussed and voted upon. The remaining board or committee members shall decide if a conflict of interest exists. In addition, the person(s) shall not participate in the final deliberation or decision regarding the matter under consideration and shall leave the meeting during the discussion of and vote of the Board of Directors/Trustees or other governing body. F. Violations of the Conflicts of Interest Policy -- If the Board of Directors/Trustees or other governing body has reasonable cause to believe a member, officer, employee or agent has failed to disclose actual or possible conflicts of interest, it shall inform the person of the basis for such belief and afford the person an opportunity to explain the alleged failure to disclose. If, after hearing the person's response and after making further investigation as warranted by the circumstances, the Board of Directors/Trustees or other governing body determines the member, officer, employee or agent has failed to disclose an actual or possible conflict of interest, it shall take appropriate disciplinary and corrective action. G. Record of Conflict -- The minutes of the governing board and all committees with board delegated powers shall contain: The names of the persons who disclosed or otherwise were found to have an actual or possible conflict of interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing board's or committee's decision as to whether a conflict of interest in fact existed. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings. Approved by: _______________________________________ Name of Organization _______________________________________ Signature of Organization Official _______________________________________ Date Conflict of Interest Verification (Annual) We, the undersigned entity, hereby testify that our Organizations Conflict of Interest Acknowledgement and Policy adopted by the Board of Directors/Trustees or other governing body, is on file with the North Carolina Department of Health and Human Services (NCDHHS). If any changes are made to the Conflict of Interest Policy, we will submit a new Conflict of Interest Acknowledgment and Policy to the Department (NCDHHS). Name of OrganizationSignature of Organizations Authorized AgentDatePrinted Name of Organizations Authorized AgentTitleSignature of WitnessDatePrinted Name of WitnessTitle Appendix 14: No Overdue Tax Debts Certification [Delete this note before printing this page on your letterhead] State Grant Certification No Overdue Tax Debts Date of Certification: ____________________________________ To: State Agency Head and Chief Fiscal Officer Certification: We certify that the _____________________________________________________________ [Organizations full legal name] does not have any overdue tax debts, as defined by N.C.G.S. 105243.1 1, at the federal, State, or local level. We further understand that any person who makes a false statement in violation of N.C.G.S. 143C-6-23(c) is guilty of a criminal offense punishable as provided by N.C.G.S. 143C-10-1(b). Sworn Statement: ____________________________________ and _____________________________________ [Names of Board Chair and Second Authorizing Official] being duly sworn, say that we are the Board Chair and __________________________________________ [Title of Second Authorizing Official], respectively, of __________________________________________________________________________________ [Organizations legal name] of ______________________ [City] in the State of ______________________; and that the foregoing certification is true, accurate and complete to the best of our knowledge and was made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for further action. Board ChairSignatureTitleSignature Title of Second Authorizing Official Sworn to and subscribed before me on the day of the date of said certification. ___________________________________ Notary Signature and Seal Notarys commission expires ____________________, 20 ___ Appendix 15: Contractor Certifications State Certifications Contractor Certifications Required by North Carolina Law Instructions: The person who signs this document should read the text of the statutes and Executive Order listed below and consult with counsel and other knowledgeable persons before signing. The text of each North Carolina General Statutes and of the Executive Order can be found online at: Article 2 of Chapter 64:  HYPERLINK "http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/ByArticle/Chapter_64/Article_2.pdf" http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/ByArticle/Chapter_64/Article_2.pdf G.S. 133-32:  HYPERLINK "http://www.ncga.state.nc.us/gascripts/statutes/statutelookup.pl?statute=133-32" http://www.ncga.state.nc.us/gascripts/statutes/statutelookup.pl?statute=133-32 Executive Order No. 24 (Perdue, Gov., Oct. 1, 2009):  HYPERLINK "http://www.ethicscommission.nc.gov/library/pdfs/Laws/EO24.pdf" http://www.ethicscommission.nc.gov/library/pdfs/Laws/EO24.pdf G.S. 105-164.8(b):  HYPERLINK "http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_105/GS_105-164.8.pdf" http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_105/GS_105-164.8.pdf G.S. 143-48.5:  HYPERLINK "http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter_143/GS_143-48.5.html" http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter_143/GS_143-48.5.html G.S. 143-59.1:  HYPERLINK "http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_143/GS_143-59.1.pdf" http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_143/GS_143-59.1.pdf G.S. 143-59.2:  HYPERLINK "http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_143/GS_143-59.2.pdf" http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_143/GS_143-59.2.pdf G.S. 143-133.3:  HYPERLINK "http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter_143/GS_143-133.3.html" http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter_143/GS_143-133.3.html G.S. 143B-139.6C:  HYPERLINK "http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_143B/GS_143B-139.6C.pdf" http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_143B/GS_143B-139.6C.pdf Certifications Pursuant to G.S. 133-32 and Executive Order No. 24 (Perdue, Gov., Oct. 1, 2009), the undersigned hereby certifies that the Contractor named below is in compliance with, and has not violated, the provisions of either said statute or Executive Order. Pursuant to G.S. 143-48.5 and G.S. 143-133.3, the undersigned hereby certifies that the Contractor named below, and the Contractors subcontractors, complies with the requirements of Article 2 of Chapter 64 of the NC General Statutes, including the requirement for each employer with more than 25 employees in North Carolina to verify the work authorization of its employees through the federal E-Verify system." E-Verify System Link:  HYPERLINK "http://www.uscis.gov" www.uscis.gov Pursuant to G.S. 143-59.1(b), the undersigned hereby certifies that the Contractor named below is not an ineligible Contractor as set forth in G.S. 143-59.1(a) because: Neither the Contractor nor any of its affiliates has refused to collect the use tax levied under Article 5 of Chapter 105 of the General Statutes on its sales delivered to North Carolina when the sales met one or more of the conditions of G.S. 105-164.8(b); and [check one of the following boxes] & Neither the Contractor nor any of its affiliates has incorporated or reincorporated in a  tax haven country as set forth in G.S. 143-59.1(c)(2) after December 31, 2001; or & The Contractor or one of its affiliates has incorporated or reincorporated in a tax haven country as set forth in G.S. 143-59.1(c)(2) after December 31, 2001 but the United States is not the principal market for the public trading of the stock of the corporation incorporated in the tax haven country. Pursuant to G.S. 143-59.2(b), the undersigned hereby certifies that none of the Contractors officers, directors, or owners (if the Contractor is an unincorporated business entity) has been convicted of any violation of Chapter 78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 years immediately prior to the date of the bid solicitation. Pursuant to G.S. 143B-139.6C, the undersigned hereby certifies that the Contractor will not use a former employee, as defined by G.S. 143B-139.6C(d)(2), of the North Carolina Department of Health and Human Services in the administration of a contract with the Department in violation of G.S. 143B-139.6C and that a violation of that statute shall void the Agreement. The undersigned hereby certifies further that: He or she is a duly authorized representative of the Contractor named below; He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the Contractor; and He or she understands that any person who knowingly submits a false certification in response to the requirements of G.S. 143-59.1and -59.2 shall be guilty of a Class I felony. Contractors Name: Contractors Authorized Agent:SignatureDate Printed Name Title Witness:SignatureDate Printed Name Title The witness should be present when the Contractors Authorized Agent signs this certification and should sign and date this document immediately thereafter. Appendix 16: FFATA Form Federal Funding Accountability and Transparency Act (FFATA) Data Reporting Requirement NC DHHS, Division of Public Health Subawardee Information Exemptions from Reporting Entities are exempted from the entire FFATA reporting requirement if any of the following are true: The entity has a gross income, from all sources, of less than $300,000 in the previous tax year The entity is an individual If the required reporting would disclose classified information Entities who are not exempted for the FFATA reporting requirement may be exempted from the requirement to provide executive compensation data. This executive compensation data is required only if both are true: More than 80% of the entitys gross revenues are from the federal government and those revenues are more than $25 million in the preceding fiscal year Compensation information is not already available through reporting to the U.S. Securities and Exchange Commission. By signing below, I state that the entity listed below is exempt from: The entire FFATA reporting requirement:  FORMCHECKBOX  as the entitys gross income is less than $300,000 in the previous tax year.  FORMCHECKBOX  as the entity is an individual.  FORMCHECKBOX  as the reporting would disclose classified information. Only executive compensation data reporting:  FORMCHECKBOX  as at least one of the bulleted items in item number 2 above is not true. SignatureName FORMTEXT      Title FORMTEXT      Entity FORMTEXT      Date FORMTEXT      Reporting FFATA Data required by all entities which receive federal funding (except those exempted above) per the reporting requirements of the Federal Funding Accountability and Transparency Act (FFATA). Entity s Legal Name FORMTEXT      Contract Number FORMTEXT        FORMCHECKBOX  Active SAM registration record is attached FORMTEXT       FORMTEXT      An active registration with SAM is requiredEntity s DUNS NumberEntity s Parent s DUNS Nbr (if applicable)Entity s LocationPrimary Place of Performance for specified contract Check here if address is the same as Entity s Location  FORMCHECKBOX street address FORMTEXT      street address FORMTEXT      city/st/zip+4 FORMTEXT      city/st/zip+4 FORMTEXT      county FORMTEXT      county FORMTEXT      Executive Compensation Data for the entity s five most highly compensated officers (unless exempted above): TitleNameTotal Compensation1. FORMTEXT       FORMTEXT       FORMTEXT      2. FORMTEXT       FORMTEXT       FORMTEXT      3. FORMTEXT       FORMTEXT       FORMTEXT      4. FORMTEXT       FORMTEXT       FORMTEXT      5. FORMTEXT       FORMTEXT       FORMTEXT       Appendix 17: Certification of Eligibility Under the Iran Divestment Act  Appendix 18: Sample Ryan White / HOPWA Memorandum of Agreements Sample Memorandum of Agreement (MOA) for Ryan White Part B Services Community Care Services and The Counseling Center This Memorandum of Agreement (MOA) is entered by and between Community Care Services (hereinafter referred to as Program) and The Counseling Center (hereinafter referred to as Sub-Recipient), for the purpose of participating in the Ryan White Part B HIV Care Services program. Through this MOA, The Counseling Center will provide mental health services for persons living with HIV referred by Community Care Services. This MOA is subject to the provisions of all applicable Federal and State laws, regulations, policies and standards. The administrator for the Program will be Joe Blow, HIV Services Director, 123 Main Street, Anytown, North Carolina 12345 (919) 555-5555. The administrator for the Sub-Recipient will be Sally Mae, Executive Director, 321 Prevention Street, Anywhere, North Carolina 54321, (919) 555-5556. This MOA may be terminated by either party upon at least 30 days written notice or immediately upon notice for cause. This MOA may be amended, if mutually agreed upon, to change scope and terms of the MOA. Such changes shall be incorporated as a written amendment to this MOA. The Counseling Center (Sub-Recipient) agrees to provide the following: Work with Community Care Services (Program) to establish a client referral and tracking system in order to have a Counselor available to meet with clients at designated times. Provide outpatient, individual, mental health counseling services for four hours per week. Client appointments will be made within two weeks of referral from the Program to the Sub-Recipient. Maintain record keeping for the provision of mental health services as outlined in the Ryan White Part B National Monitoring Standards. Allow for client record and fiscal review by the Program as required to ensure that all Federal and State laws, regulations, policies and standards are being met. Not refer clients to another mental health provider outside of the Sub-Recipients agency without prior notification to and approval from the Program. Invoice the Program monthly in a mutually agreed upon format. Community Care Services (Program) agrees to provide the following: Work with The Counseling Center (Sub-Recipient) to establish a client referral and tracking system in order to ensure a Counselor is available to meet with clients at designated times. Refer patients with mental health conditions that are beyond the expertise of the Programs staff. Review client and fiscal records for client services provided by the Sub-Recipient to ensure that all Federal and State laws, regulations, policies and standards are being met. Provide reimbursement at $65 per hour (not to exceed Medicaid rates) for payment of services rendered in keeping with the policies of the Ryan White Part B program. Review this agreement with the Sub-Recipient quarterly and make written modifications as necessary. This MOA shall begin on April 1, 2022 and end on March 31, 2023. Community Care Services The Counseling Center BY: Joe Jenkins BY: Sally Mae TITLE: HIV Services Director TITLE: Executive Director DATE: April 1, 2022 DATE: April 1, 2022 Leroy Jones Witness Sample Memorandum of Agreement (MOA) for HOPWA Services Housing Coalition, Inc. and Clifton Housing Services This Memorandum of Agreement (MOA) is entered by and between Housing Coalition, Inc. (hereinafter referred to as Program) and Clifton Housing Services (hereinafter referred to as Sub-Recipient), for the purpose of participating in the Housing Opportunities for Persons with AIDS (HOPWA) program. Through this MOA, Clifton Housing Services will provide Tenant Based Rental Assistance (TBRA) for persons living with HIV/AIDS as referred by Housing Coalition, Inc. This MOA is subject to the provisions of all applicable Federal and State laws, regulations, policies and standards. The administrator for the Program will be Joe Blow, HIV Services Director, 123 Main Street, Anytown, North Carolina 12345 (919) 555-5555. The administrator for the Sub-Recipient will be Sally Mae, Executive Director, 321 Prevention Street, Anywhere, North Carolina 54321, (919) 555-5556. This MOA may be terminated by either party upon at least 30 days written notice or immediately upon notice for cause. This MOA may be amended, if mutually agreed upon, to change scope and terms of the MOA. Such changes shall be incorporated as a written amendment to this MOA. Clifton Housing Services (Sub-Recipient) agrees to provide the following: Administer the TBRA program to referred clients through a voucher system. Conduct all inspections or rental units in accordance with HUD guidelines. Maintain record keeping for the provision of TBRA services as outlined in the North Carolina HOPWA Manual. Allow for client record and fiscal review by the Program as required to ensure that all Federal and State laws, regulations, policies and standards are being met. Notify the program anytime a client wait list must be implemented and provide a plan for how the wait list will be managed and clients will be referred to other available housing resources. Invoice the Program monthly in a mutually agreed upon format. Housing Coalition Inc. (Program) agrees to provide the following: Screen clients for HOPWA eligibility and refer clients needing TBRA services to the Sub-Recipient. Provide TBRA programmatic training and technical assistance as needed to Sub-Recipient staff. Review client and fiscal records for client services provided by the Sub-Recipient to ensure that all Federal and State laws, regulations, policies and standards are being met. Provide reimbursement for TBRA services rendered in keeping with the policies of the HOPWA program. Review this agreement with the Sub-Recipient quarterly and make written modifications as necessary. Any modification will be dated and signed by all parties prior to any changes being performed. This MOA shall begin on January 1, 2022 and end on December 31, 2022. Housing Coalition, Inc. The Counseling Center BY: Joe Jenkins BY: Sally Mae TITLE: HIV Services Director TITLE: Executive Director DATE: January 1, 2022 DATE: January 1, 2022 Leroy Jones Witness Appendix 19: ITTS Project Objectives Please use the template provided below to complete your Goals and Objectives and include it with your application. The objectives should be completed for one year only (June 1, 2022 May 31, 2023.) Agencies providing Integrated Targeted Testing Services (ITTS) are required to conduct HIV and syphilis testing. Hepatitis C testing is required for agencies testing people who currently inject or have a history of injecting drugs. PrEP goals and objectives should follow the NC PrEP Criteria identified in Appendix 4. Agencies must focus other HIV/STD/HCV prevention goals and objectives towards the following priority populations: Men who have Sex with Men (MSM) of all races and ethnicities (with a focus on African American/Black gay and bisexual men) African American and Latino men and women Minority Youth ages 13 to 24 years Persons Who Inject Drugs (PWID) Transgender Persons (with a focus on HIV among African American/Black transgender women) Goal 1: Reduce the incidence of HIV/STDs in (add County/s or Region) by increasing the number of persons aware of their HIV/STD/HCV status.Testing Objective/s:1.By May 31, 2023, (Enter Agency Name) will conduct (#___) HIV tests among N.C. identified priority populations by providing HIV counseling, testing, referral, and linkage to care in (add County/s or Region).2.By May 31, 2023 (Agency Name) will conduct (#__) HIV tests among young African American MSM by providing HIV counseling, testing, referral and linkage to care in (add county/Region). Note: 25% of total tests.3. By May 31, 2023, (Agency Name) will conduct (#___) HIV tests among non-MSM youth by providing by providing HIV counseling, testing, referral and linkage to care in (add county/Region). Note: 20% of total tests.4.By May 31, 2023, (Enter Agency Name) will conduct (#___) syphilis tests among N.C. identified priority populations by providing testing and referral to treatment in (add County/s or Region).5.By May 31, 2023, (Enter Agency Name) will conduct (#___) HCV tests among substance abusers by providing testing and referral to treatment in (add County/s or Region).6.By May 31, 2023, (Enter Agency Name) will conduct (#___) gonorrhea/chlamydia tests among N.C. identified priority populations by providing testing and referral to treatment in (add County/s or Region).Goal 2: Increase condom availability and use among populations at risk for HIV/STD/HCV.Condom Distribution Objective/s:1.By May 31, 2023, (Enter Agency Name) will establish and maintain a minimum of (#__) condom distribution sites and distribute (#_____) condoms among N.C. identified priority populations.Goal 3: Increase PrEP access among populations at risk for HIV. PrEP Objective/s:1.By May 31, 2023, (Enter Agency Name) will conduct (#___) PrEP referrals (make first appointment) using N.C. PrEP criteria in (add County/s or Region).Goal 4: Increase information sharing through social media among populations at risk for HIV/STD/HCV.Social Media Objective/s:1d.By May 31, 2022, (Enter Agency Name) will conduct (#___) social media activities on (Facebook, Grindr, SCRUFF) to boost testing among N.C. identified priority populations in (add County/s or Region).  Appendix 20: ITTS Projection Reports Annual Projection for Funded Testing ProgramAgency Name:Contract Period:Annual Contract Objectives:Number of persons tested for: ______HIV ______Syph ______GC/CT ______HCV Number of persons referred for PrEP: _______Agency StaffCountyDays/HoursNumber of persons testedNumber of persons referred for PrEPQuarterlyAnnuallyQuarterlyAnnuallyEx. Teeples HouseMary K. SoleCumberlandEvery Monday25 HIV100 HIV10501-3pm25 Syphilis100 SyphilisTOTAL (for all sites) Appendix 21: ITTS Physicians Standing Orders {Physician Letterhead} Date {Agency Name and address} To Whom It May Concern: The following are Standing Orders for {Name of Agency} regarding HIV, syphilis, hepatitis C, gonorrhea and chlamydia testing. {Name of Director} is appointed the sole person responsible for ensuring that these standing orders are carried out in full on behalf and in the authority of {Name of Physician}. Designated staff representing {Name of Agency} may collect appropriate specimens for HIV, syphilis, hepatitis C, gonorrhea and chlamydia testing at the specified site and at other nontraditional test sites in {Name of Counties} and during special targeted testing events. Signed by {Name of Director} Signed by {Name of Physician} Appendix 22: Organizational Charts Instructions for Creating an Organizational Chart Using Microsoft Word Please provide an Organizational Chart detailing the hierarchy at your agency. A sample Organizational Chart has been provided along with a template for your convenience. Instructions are provided below for those who wish to develop their own Organizational Chart as opposed to using the template provided. Step 1: Launch Microsoft Word. To add an organizational chart to an existing document, open the file and scroll to the place for the chart. Press Ctrl+Enter to add a new page. Otherwise, Word starts a new blank document upon opening. Step 2: Click the Insert tab. Click the SmartArt button on the ribbon, which opens the Choose a SmartArt graphic pop-up window. Step 3: Click the Hierarchy link in the left side column. Review the different organizational chart options. These are just the Word defaults you will be able to change the colors and add rows and boxes in later steps. Double-click a chart, such as Organization Chart, that best suits your agency. The chart is added to the Word document and a new purple SmartArt Tools tab and ribbon open at the top of the work area. Step 4: Click into the first/top box on the chart, which may show [Text] as the default. Type the name and, if desired, title of the highest-ranking person in your organization, such as the CEO, Health Director, or Executive Director. Step 5: Move to the next box, which branches below the first. Type the name of the next-highest person. Most Word templates have three boxes on this branch. If you only have one or two people on this branch, click the box and press the Delete key. If you have more than three, click any box on the row, then click the Add Shape menu on the ribbon. Click Add Shape After to add another box on the same branch. Continue until all persons or job titles on this level of your organization are represented. Step 6: Click a box on the second row. Click the Add Shape menu and choose Add Shape Below. This creates the next, lower level in the organizational hierarchy. Add boxes, names and titles for each person on this level of your company. Continue to add boxes and rows. Note that as you add boxes, Word will automatically shrink the chart to fit on the page. Step 7: Assign administrative positions to the persons for whom they work by clicking a box, then clicking the Add Shape menu. Click Add Assistant and a link is created from the executive to the assistant. Step 8: Click the Change Colors button on the ribbon. Choose a different set of hues from the default Word blue. You can also change individual colors in the chart. Click a box or click multiple boxes by holding down the Ctrl key and then clicking each box to change. Right-click any of the selected boxes and choose Format Shape. In the Fill window, choose a new color. Step 9: Click the File tab and select Save As. Type a name for the organizational chart and select where to save the file. Click the Save button.   Agency Name  Appendix 23: Sample ITTS Budget Estimated Budget ITTS Narrative - SAMPLE No Limits Health Care, Inc. - Budget Detail Year 1 Category ItemNarrativeAmountSalary/WagesHIV/STD Prevention Program Director, Ruth Chris, 0.50 FTE - Annual Salary = $48,500 x 0.50 FTE = $24,250 The Program Director will be directly responsible for program staff, monitor the ITTS program budget, and develop and institute a quality management plan. She will also process, maintain, and prepare required reports for the State Communicable Disease Branch. HIV/STD Coordinator/Phlebotomist, Rita Cahan, 1.0 FTE - Annual Salary = $28,100 x 1.0 FTE = $28,100 The Coordinator/Phlebotomist will plan, coordinate, and conduct counseling, testing and referrals at targeted sites for high-risk populations, send specimens to the State Laboratory of Public Health (SLPH) and to LabCorp, make referrals for all clients that receive positive test results and make PrEP referrals for HIV negative clients. Data Manager/Phlebotomist, Dolby Grey, 0.25 FTE - Annual Salary = $25,840 x 0.25 FTE = $6,460 The Data Manager/Phlebotomist will assist in planning, coordinating, and conducting counseling, testing and referrals at targeted sites for high-risk populations, send specimens to the State Laboratory of Public Health (SLPH) and to LabCorp, and, conduct post-test counseling and referrals for all clients that receive positive test results. He will also enter all data into EvaluationWeb and review all positive forms for accuracy prior to sending to the Prevention Programs Data Manager. Total FTEs: 0.50 + 1.0 + 0.25 = 1.75 FTEs Total Salary: $24,250 + 28,100 + $6,460 = $58,810$58,810Fringe Benefits HIV/STD Prevention Program Director, Ruth Chris, 0.50 FTE - Annual Health Insurance Premium = $4,235 x 0.50 FTE = $2,117.50; SUI ($22,300 x 3.0% = $669 x 0.50 FTE = $334.50); FICA ($24,250 x 7.65% = $1,855.13); Retirement ($24,250 x 3% = $727.50); Workers Comp ($24,250 x 1.0% = $242.50). Total = $5,277.13 ($5,277) HIV/STD Coordinator/Phlebotomist, Rita Cahan, 1.0 FTE - Annual Health Insurance Premium = $4,235 x 1.0 FTE = $4,235; SUI ($22,300 x 3.0% = $669 x 1.0 FTE = $669); FICA ($28,100 x 7.65% = $2,149.65); Retirement ($28,100 x 3% = $843); Workers Comp ($28,100 x 1.0% = $281). Total = $8,177.65 ($8,178) Data Manager/Phlebotomist, Dolby Grey, 0.25 FTE - Annual Health Insurance Premium = $4,235 x 0.25 FTE = $1,058.75; SUI ($22,300 x 3.0% = $669 x 0.25 FTE = $167.25); FICA ($6,460 x 7.65% = $494.19); Retirement ($6,460 x 3% = $193.80); Workers Comp ($6,460 x 1.0% = $64.60). Total = $1,978.59 ($1,979) Total Fringe: $5,277 + $8,178+ $1,979 = $15,434 $15,434Supplies and MaterialsOtherOffice Supplies: General office supplies needed to support 1.75 FTE ITTS program staff in conducting the day to day program operations: 3 - cases of paper x $35 ea. = $105; 3 - Desk Calendars x $6.50 ea. = $19.50; 8 Printer toner cartridges x $32.05 ea. = $256.40; 1 - pkg. of Sharpie Highlighters at $7.49; 5 - toner cartridges for the copier x $68 each = $340; 20 - boxes of folders x $12.75 each = $255; 1 - case of legal pads at $74.50; 3 pkg. of pens x $11.75 ea. = $35.25. Total Supplies/Materials: $105 + $19.50 + $256.40 + $7.49 + $340 + $255 + $74.50 + $35.25 = $1,093$1,093Supplies and MaterialsOtherMedical Supplies: Medical supplies necessary to conduct the testing requirements of the ITTS Program: 100 - syphilis mailers x $1.76 ea. = $176; 2 - cases of biohazard bags x $100 ea. = $200; 3 - boxes of disposable lab gear x $135 ea. = $405; 5 - cases of latex gloves x $60 ea. = $300; 15 - bottles of disinfectant x $3.28 ea. = $49.20; 4 - Hand Sanitizers x $3.50 ea. = $14; 4 - boxes of Lancets at $20.56 ea. = $82.24; 3 - packs of Tubes x $67.23 ea. = $201.69; 3 - Flexible Fabric Elastic Strips x $29 ea. = $87; 176 OraQuick ADVANCE HCV kits x $19.25 ea. = $3,388. Total Supplies/Materials: $176 + $200 + $405 + $300 + $49.20 + $14 + $82.24 + $201.69 + $87 + $3,388 = $4,903 $4,903Travel Contractor StaffTravel: Reimbursement for staff to travel throughout a five-county region to conduct testing and program activities. Also includes mileage to attend HIV/STD Communicable Disease Branch required trainings and meetings. Program staff travels an estimated 515 miles per month. 528.79 x 12 = 6,345.48 miles x $0.56 per mile = $3,553.46 ($3,553) $3,553Utilities TelephoneTelephone: The telephone lines are used to maintain communication with agency staff, community partners, and clients. 3 Cell Phones at $60 per month each for voice and data package. ITTS Funds are allocated to pay for a portion of the monthly cost, based on 1.75 FTEs. HIV/STD Prevention Program Director 0.50 FTE x $60 = $30 per month x 12 = $360; HIV/STD Coordinator/Phlebotomist, 1.0 FTE x $60 = $60 per month x 12 = $720; Data Manager/Phlebotomist 0.25 FTE x $60 = $15 per month x 12 = $180. $360 + $720 + $180 = $1,260$1,260 Rent Office SpaceRent: Offices for No Limits Health Care, Inc. are located at 1000 Main St., Suite G, Arrow, NC 28000. The ITTS Program occupies 315 sq. ft. (in a building that is 12,235 sq. ft.). The Rent is based on the rate of $2.05 per sq. ft. x 12 mos. (June 1, 2017 to May 31, 2018). 315 x $2.05 = $645.75 per mo. x 12 mos. = $7,749 $7,749Professional Services PayrollPayroll: Automatic Data Processing (ADP) performs payroll and tax filing functions, as well as maintaining 401k accounts. $75 per month x 1.75 FTE = $131.25 x 12 months = $1,575 $1,575 Operational Other Incentives and ParticipantsIncentives: The ITTS Program plans to test 1,000 unduplicated clients. As an incentive to increase test numbers, clients that agree to test will receive a $5 gift card from various local retail stores. 268 gift cards will be purchased and the remaining 732 gift cards will be requested from the Branch and other sources. 268 x $5 = $1,340$1,340Subcontracting/Grants:Operational OtherService PaymentsLabCorp: LabCorp is contracted to process Gonorrhea and Chlamydia tests. 150 tests x $30 ea. = $4,500 $4,500Total Contractual Services:$4,500Total Budget$100,217 Name: No Limits Health Care, Inc.Item DescriptionContract AmountSalary and FringeHIV/STD Prevention Program Director, Ruth Chris$24,250 Fringe - HIV/STD Prevention Program Director$5,277HIV/STD Coordinator/Phlebotomist, Rita Cahan$28,100 Fringe - HIV/STD Coordinator/Phlebotomist$8,178Data Manager/Phlebotomist, Dolby Grey$6,460 Fringe Phlebotomist$1,979Total Salary and Fringe$74,244Operating ExpensesSupplies and Materials Office$1,093Supplies and Materials Medical Supplies$4,903Travel/Contractor Staff$3,553Utilities Telephone$1,260Rent Office Space$7,749Professional Services Payroll $1,575Operational Other Incentives and Participants$1,340Total Operation Expenses$21,473Subcontracting/GrantsOperational Other/Service Payments - LabCorp$4,500Total Contractual Services$4,500Total Budget$ 100,217Estimated Budget ITTS Narrative - SAMPLE Estimated ITTS Detailed Budget Breakdown Page and Estimated Budget Justification Page Instructions Complete the Estimated Budget Breakdown Page and Estimated Budget Justification Page. As shown in Appendix 23. Budget narratives must show calculations for all budget line items and clearly justify/explain the need for these items. Budget costs must be in accordance with State rates, reasonable and justifiable. The budget must support the Scope of Work activities and objectives. All expenses that are shared across multiple programs (e.g., rent, utilities, insurance, etc.) must be prorated for this program and the narrative must include a detailed calculation which demonstrates how the agency prorates the items. Salary and Fringe: Salary/Wages Provide justification of all personnel including staff names, titles and descriptions of job duties as they relate to the program. Note: Narratives for staff in contracts with any State (UNC) Universities MUST include the staff persons university employment status as SPA, EPA, EPA Physician, etc. Justification Sample for Salary/Wages: HIV/STD Coordinator/Phlebotomist, Rita Cahan, 1.0 FTE - Annual Salary = $28,100 x 1.0 FTE = $28,100 The Coordinator/Phlebotomist will plan, coordinate, and conduct counseling, testing and referrals at targeted sites for high-risk populations using both phlebotomy services and rapid HIV and HCV testing methods. She is also responsible for sending specimens to the State Lab and LabCorp. Conducts post-test counseling and referrals for all clients that receive positive test results. Fringe Provide justification narrative for fringe. List each benefit and include percentage for each and show the calculation for each staff person listed. Justification Sample for Fringe: HIV/STD Coordinator/Phlebotomist, Rita Cahan, 1.0 FTE - Annual Health Insurance Premium = $4,235 x 1.0 FTE = $4,235; SUI ($22,300 x 3.0% = $669 x 1.0 FTE = $669); FICA ($28,100 x 7.65% = $2,149.65); Retirement ($28,100 x 3% = $843); Workers Comp ($28,100 x 1.0% = $281). Total = $8,177.65 Supplies and Materials: There are two main categories under Supplies and Materials; Furniture and Other. The one most commonly used is Other. Categories are further described below. Furniture: Desks, Bookshelves, chairs, file cabinets, etc. Other: Additional Supplies and Materials purchased such as Educational items, Curriculums, Videos, Books, Training manuals, Office supplies, Postage, Business cards, etc. Stand alone, purchased software, under $500 (such as Peachtree Accounting or similar) is also considered a supply. Disposable (one-time-use) medical supplies are also considered a supply. Equipment: Equipment is for items that are purchased outright not rented or leased. Typically, an item considered Equipment is a depreciable asset. Office: Copier Machine, Fax Machine. IT: Personal Computers, laptops, iPads, scanners, desk printers, PC speakers. Scientific: Centrifuge, Microscope, Lab equipment. Travel: Please note: Reimbursements for travel should not exceed current State Rates as defined by the State of North Carolina Office of State Budget and Management. Contractor Staff: Include any travels, meals, mileage for staff members listed under the salary and fringe section. Board Members Expense: Includes any travel, meals, mileage for board members Justification Sample for Contractor Staff Travel: Overnight accommodations for Program Coordinator and Program Assistant to attend required XYZ Training: 2 nights x $75.10 = $150.02. 418 miles round trip from Greensboro, NC to Wilmington, NC for training x $0.560/mile = $234.08. 2 staff x (1 breakfast at $8.60 each + 2 lunches at $11.30 each + 2 dinners at $19.50 each) = $140.40. Total travel: $150.02 + $234.08 + $140.40= $524.50. Utilities: (If not included in the rent) Gas: Monthly Gas bill prorated for program share Electric: Monthly Electricity bill prorated for program share Telephone: Monthly Phone or Cell service prorated for program share Water: Monthly Water bill prorated for program share Other: Use this for any utility item that does not fit in one of the defined categories above, such as internet service (unless it combines with telephone), security monthly monitoring cost, etc. Justification Sample for Utilities: Prorated share of electric bill: This contract represents 25% of the combined total of all 4 funding sources and therefore is responsible for 25% of the overall cost. 25% of $100 monthly cost is $25; 12 months x $25 = $300. Repair and Maintenance: Custodial Services or basic Repairs and Maintenance not billed in the Professional Service area. Publications: Items that the Contractor is responsible for designing, producing, and/or printing such as brochures, posters, and fact sheets, related to program activities etc. Reprints: Duplication of an existing publication; photocopies. This is typically done at an office supply business. Websites and Web Materials: Includes the costs to create a website and/or maintain website, etc. This could also be prorated for program share. Justification Sample for Reprints: Program flyers for community program (1,000 @ $.10 = $100); photocopies for use in program sessions (400/month @ $.05 ea. = $20 x 12 mos. = $240); Total = $340. Rent: Office Space: Office Space, Program Meeting Space must include square footage. Calculations must define totals and prorated amounts for the program. Equipment: This category is for equipment that is rented or leased, such as a Copier Machine or Phone System. Furniture: Rented or Leased office furniture. Vehicles: Long-term leases of Cars, Vans or Buses. (Vehicles rented for short-term staff travel belong under Contractor Staff travel. Vehicles rented for short-term participant travel belong under Incentives and Participants.) Professional Services: These are services that are purchased to support the overhead of the agency. Legal: Legal services retained by the Contractor IT: Information Technology or IT-related technical services retained by the Contractor Accounting: Accounting, bookkeeping services retained by the Contractor Payroll: Payroll services retained by the Contractor Security: Security services, in the form of personnel such as a security guard, retained by the Contractor. (Purchase of a security system belongs under Equipment - Other. Monthly security monitoring belongs under Utilities Other.) Dues and Subscriptions: Dues for professional associations/affiliations; Subscriptions to related or required periodicals; Subscriptions to web-based applications such as Survey Monkey or Constant Contact that are leased at a rate per month. Operational Other: Audit Services: Cost associated with annual financial audits preformed. NOTE: Contractors must be a Level 3 Contractor with the State (i.e., receive more than $500,000 in State dollars) for audit costs to be allowable in their budget. Audit costs are NOT allowable at all in Purchase of Service (POS) contracts. Service Payments: Costs associated with a retained service, or medical activity such as the processing of blood work by a lab, physical examination, or the monitoring of a person's blood pressure where the practitioner is paid for the particular service rendered, rather than receiving a salary. Incentives and Participants: Costs associated with: Incentives given to participants or comparison group members (e.g., gift cards, meals, diaper bags, etc.); Participant Costs (field trips, enrichment activities, etc.); Open Houses; Parents Nights, etc. Insurance and Bonding: Liability Insurance to cover staff and participants while field trip or daily activities. Other: Use this for any item that does not fit in any other category. Subcontracting: The Contractor subcontracts work out to another entity. Note: do not include any Professional Services (legal, accounting) as they are captured in the Professional Services category listed above. Example 1: The Contractor is giving a portion of the funds to another entity that will also render services to participants such as providing testing services. Example 2: The contract is for an evaluation and the building of a database to track recipients of service, number of services received, etc. The Contractor hires an IT vendor to build the database. In this instance, the IT vendor is a subcontractor because the work is program-related. Appendix 24: Sample Ryan White Budget Region 12 Network of Care Chelsea Medical Center (CMC) Ryan White Part B BUDGET NARRATIVE April 1, 2022 - March 31, 2023 Fairy Primary Health (FPH) is an Early Intervention Services (EIS) clinic owned and operated Chelsea Medical Center (CMC). Fringe Schedule (8.65% paid by Part B) for all Employees, as indicated, includes: FICA 7.65% Pension 1% Health Insurance - CMC pays $8,920 for traditional PPO plan and $7,691 for Consumer Driven Health Plan Administration $26,200 Administration activities include: Manage CAREWare data collection, data entry, RSR and CLD; Fulfill state and Federal regulations, policies, guidance and all contractual obligations; Compile and submit required fiscal and program reports Salary/Fringe: $26,200 The following staff will have responsibility for all administrative activities: Ryan White Program Coordinator J. Cook - (.1 FTE): $7,479 Annual Salary: $60,626 Part B: $6,063 Total Fringe: $1,416 Annual Health Insurance Premium: $8,920 Part B: $892 Fringe Benefits: 8.65% Part B: $524 Medical Case Management (MCM) Supervisor K. Signal (.18 FTE): $18,721 Annual Salary: $87,513 Part B: $15,752 Total Fringe: $2,969 Annual Health Insurance Premium: $8,920 Part B: $1,606 Fringe Benefits: 8.65% Part B: $1,363 Additional staff members enter client level data (CLD) but are not paid with RW Part B funds. Quality Improvement $18,941 Quality Improvement activities include: Conduct Quality Improvement activities; Collect/report quality improvement performance indicators; and Actively participate in the Regional Quality Council (RQC) and associated National Quality Improvement Projects such as ECHO, etc. Salary/Fringe: $17,631 The following staff will have responsibility for all Quality Improvement activities: Ryan White Program Coordinator J. Cook - (.08 FTE): $5,984 Annual Salary: $60,626 Part B: $4,850 Total Fringe: $1,134 Annual Health Insurance Premium: $8,920 Part B: $714 Fringe Benefits: 8.65% Part B: $420 Nurse Practitioner L. Noles, ANP (.05 FTE): $7,040 Annual Salary: $121,384 Part B: $6,069 Total Fringe: $971 Annual Health Insurance Premium: $8,920 Part B: $446 Fringe Benefits: 8.65% Part B: $525 Clinical Manager D. Harris, RN - (.055 FTE): $4,607 Annual Salary: $70,020 Part B: $3,851 Total Fringe: $756 Annual Health Insurance Premium: $7,691 Part B: $423 Fringe Benefits: 8.65% Part B: $333 Staff Travel: $1,310 Funds are requested for the Program Coordinator to attend Regional Quality Council (RQC) Meetings in Raleigh four times per year. Overnight lodging (Raleigh) $114.50 per RQC meeting x 4 meetings = $458 ($75.10 hotel + $8.60 breakfast + $11.30 lunch + $19.50 dinner) Mileage 1,521.4 miles at $0.560 per mile = $852 Planning and Evaluation $34,264 Planning and Evaluation activities include: Coordinate the Network, convene/facilitate quarterly Network meetings within the contract period; Coordinate Network services; Implement and update an Evaluation Plan for the Network; Annually review and update the Network Grievance Policy; and Annual client satisfaction survey Salary/Fringe: $34,264 The following staff will have responsibility for all P/E activities: Ryan White Program Coordinator J. Cook - (.18 FTE): $13,463 Annual Salary: $60,626 Part B: $10,913 Total Fringe: $2,550 Annual Health Insurance Premium: $8,920 Part B: $1,606 Fringe Benefits: 8.65% Part B: $944 Medical Case Management (MCM) Supervisor K. Signal (.2 FTE): $20,801 Annual Salary: $87,513 Part B: $17,503 Total Fringe: $3,298 Annual Health Insurance Premium: $8,920 Part B: $1,784 Fringe Benefits: 8.65% Part B: $1,514 Note: M. Lucy, Assistant VP is assisting with the update of the Network Client Grievance Policy and facilitation of quarterly Network meetings. However, she is paid with other funding sources. Core Medical Services: $156,542 Outpatient/Ambulatory Medical Care $116,221 Outpatient/Ambulatory Health Services (OA) are diagnostic and therapeutic services provided directly to a client by a licensed healthcare provider in an outpatient medical setting. Outpatient medical settings include clinics, medical offices, and mobile vans where clients do not stay overnight. Allowable activities include: medical history taking; physical examination; diagnostic testing (including laboratory testing); treatment and management of physical and behavioral health conditions; behavioral risk assessment, subsequent counseling, and referral; preventive care and screening; pediatric developmental assessment; prescription, and management of medication therapy; treatment adherence provided during the OA visit; education and counseling on health and prevention issues; and referral to and provision of specialty care related to HIV diagnosis. Clinical Manager position is responsible for ordering of vaccines, OTC medications and medical supplies. This position monitors and discards all out of date supplies and medications on a monthly basis and also serves as clinical support based on patient volume. An estimated 400 Outpatient/Ambulatory services will be provided to 150 clients at Medicaid rates. Salary/Fringe: $71,400 Nurse Practitioner L. Noles, ANP (.40 FTE): $56,322 Annual Salary: $121,384 Part B: $48,554 Total Fringe: $7,768 Annual Health Insurance Premium: $8,920 Part B: $3,568 Fringe Benefits: 8.65% Part B: $4,200 Clinical Manager D. Harris, RN - (.18 FTE): $15,078 Annual Salary: $70,020 Part B: $12,604 Total Fringe: $2,474 Annual Health Insurance Premium: $7,691 Part B: $1,384 Fringe Benefits: 8.65% Part B: $1,090 Operating Expenses: $44,821 Laboratory and Diagnostic Services $31,821 CMC will reimburse laboratories and hospitals to perform all the laboratory and diagnostic tests required to deliver high-quality medical care. The estimated cost of laboratory expense per patient, per test, per year is as listed below. Lab TestUnduplicated PtsUnits/Pt/YearTotal Units per YearCost per UnitTotal CostHIV-1 Antibody40140$30.53$1,221.20HIV VL RNA by PCR622124$29.61$3,671.64CD4 Count602120$33.02$3,962.40HCV Screen60160$40.17 $2,410.20HCV Viral Load602120$30.24$3,628.80HBV Screen60160$14.36 $861.60Metabolic Panel602120$10.42 $1,250.40Lipid Panel60160$16.53 $991.80CBC/Diff602120$9.58 $1,149.60RPR60160$22.18 $1,330.80HIV-1 Genotype60160$96.26 $5,775.60Various radiology tests522104~$53.524$5,566.50Total 6941,048 $31,820.54 (Rounded to $31,821) Medical Supplies $3,000 This line item includes the following consumable supplies: disposable gloves; personal protective equipment (e.g., eyeglasses/face shields); alcohol swabs; disinfectants/ sterilizers, gauze, disposable exam robes, examination table paper, etc. Medical supply costs (partial costs) are based on historical experience and are estimated at $5 patient encounter x 600 patient encounters per year. ($5 x 600 = $3,000) Specialty Medical Services Professional Services (Various Private Practices) $10,000 This line item is budgeted to reimburse medical providers for specialty consultations (e.g., cardiology, gastroenterology, neurology, ophthalmology, etc.). These services are required to provide Part B patients comprehensive outpatient/ambulatory medical care. Reimbursement will be on a fee-for-service basis using the Medicaid fee schedule. Based on prior experience, Part-B patients will need at least 80 specialty consultations during the year at an average cost of $125/visit. ($125 x 80 = $10,000) Oral Health Care $16,000 Oral Health Care services provide outpatient diagnostic, preventive, and therapeutic services (including prosthetics) by dental health care professionals, including general dental practitioners, dental specialists, dental hygienists, and licensed dental assistants. Services provided at Medicaid rates on a fee-for-service basis by dental providers throughout the region. 40 clients @ 2 visit/client = 80 @ $200/visit = $16,000 Mental Health $6,000 Mental Health services are the provision of outpatient psychological and psychiatric screening, assessment, diagnosis, treatment and counseling services offered to clients living with HIV. Services are based on a treatment plan, conducted in an outpatient group or individual session, and provided by a mental health professional licensed or authorized within the state to render such services. Such professionals typically include psychiatrists, psychologists, and licensed clinical social workers. Services are provided at Medicaid rates on a fee-for-service basis. 25 clients @ 3 visit/client = 75 @ $80/visit = $6,000 Substance Abuse Outpatient Care $0 Substance Abuse services are paid with other funding sources such as 340B funds and RW Part C funding based on client need. Medical Case Management $8,321 Medical Case Management is the provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. Activities may be prescribed by an interdisciplinary team that includes other specialty care providers. Medical Case Management includes all types of case management encounters (e.g., face-to-face, phone contact, and any other forms of communication). Key activities include: initial assessment of service needs; development of a comprehensive, individualized care plan; timely and coordinated access to medically appropriate levels of health and support services and continuity of care; client monitoring to assess the efficacy of the care plan; re-evaluation of the care plan at least every six months with adaptations as necessary; ongoing assessment of the clients and other key family members needs and personal support systems; treatment adherence counseling to ensure readiness for and adherence to complex HIV treatments; client-specific advocacy and/or review of utilization of services. CMC will provide medical case management by linking clients with medical care providers and other healthcare services. The MCM Supervisor will conduct intake appointments with clients, which include the initial assessment of service needs. She will provide treatment adherence counseling to ensure readiness for, and adherence to, complex HIV/AIDS treatments. The MCM supervisor will ensure timely access to medically appropriate levels of health and support services and continuity of care through ongoing assessment of the clients needs. She will ensure coordination and follow-up of medical treatments. K. Signal does not perform additional duties under MCM scope as she does not carry a client case load. 85 clients for intake assessments x 1 assessment = 85 visits. **This number of clients was derived following review of actual CAREWare data from FY 2018 and FY 2019 to date. Salary/Fringe: $8,321 Medical Case Management (MCM) Supervisor K. Signal (.08 FTE): $8,321 Annual Salary: $87,513 Part B: $7,001 Total Fringe: $1,320 Annual Health Insurance Premium: $8,920 Part B: $714 Fringe Benefits: 8.65% Part B: $606 Health Insurance Premium & Cost-Sharing Assistance for Low Income Individuals $10,000 Health Insurance Premium and Cost Sharing Assistance provides financial assistance for eligible clients living with HIV to maintain continuity of health insurance or to receive medical and pharmacy benefits under a health care coverage program. (Health Insurance also includes standalone dental insurance). Allowable services include: paying health insurance premiums to provide comprehensive HIV Outpatient/Ambulatory Health Services and pharmacy benefits that provide a full range of HIV medications for eligible clients; paying standalone dental insurance premiums to provide comprehensive oral health care services for eligible clients; and paying cost sharing on behalf of the client. Eligible Ryan White patients will be expected to participate in the opportunities of the Affordable Care Act. A total of 60 clients will be served. 10 clients will receive assistance with cost-sharing assistance for Qualified Health Plans through the Federally Facilitated Marketplace (FFM) and COBRA premiums. 60 will receive assistance with provision of cost sharing assistance. There will be overlap as some clients will need both types of assistance. 50 clients @ 2 payments = 100 @ $100/payment = $10,000 Support Services: $8,361 Psychosocial Support $4,161 Position will provide support and counseling activities, HIV support groups, and bereavement counseling to clients and their families. Psychosocial support is a means of providing information concerning coping with chronic illness and gathering educational resources to lessen anxiety about HIV disease. 180 clients x 2 visits = 360 visits. Salary/Fringe: $4,161 Medical Case Management (MCM) Supervisor K. Signal (.04 FTE): $4,161 Annual Salary: $87,513 Part B: $3,501 Total Fringe: $660 Annual Health Insurance Premium: $8,920 Part B: $357 Fringe Benefits: 8.65% Part B: $303 Medical Transportation $1,200 FPH will provide transportation assistance in the form of mileage reimbursement (at the state rate or below) to volunteers, friends, and family members to transport clients to medical appointments. A total of 25 clients will be served (other transportation assistance). 40 clients @ 100 miles (4 trips per client) = 4,000 @ $0.30/mile = $1,200 Emergency Financial Assistance $3,000 FPH to provide short-term payments on a fee-for-service basis to assist with emergency expenses related to essential utilities, housing, and food, when other resources are not available. The assistance is provided on a short-term basis and is used as payment of last resort. A total of 12 clients will be served (6 clients will receive EFA for utility assistance and 6 clients will receive EFA for general expenses). 12 clients @ $250/payment = $3,000 Contracted Services Fringe Schedule (18.65%) for all Employees includes: FICA - 7.65% Health Insurance 13% Total salary funded by RW Part B = $79,917. Total health insurance billed to RW Part B = $10,896. $10,896/$79,717 = 0.13. Administration $10,158 Administration activities include: CAREWare data collection, data entry, and RSR; Adhere to State and Federal regulations, policies, guidance and all contractual obligations; Compile and submit required fiscal and program reports; Process requests for payment of services; Assist with contract record keeping; Monitor budget and expenditures to assure that contract guidelines are met; Locate and maintain providers and assist in obtaining memoranda of Understanding agreements for the region; Process and paycheck requests from providers; Complete and submit monthly billing and reports; and Monitor budget and maintain contract records. Salary/Fringe: $10,158 The following staff will have responsibility for all administrative activities: HSO Lead Medical Case Manager M. Buttons (.08 FTE): $3,373 Annual Salary: $42,162 Part B: $3,373 HSO Chief Financial Officer Q. Ganny - (.13 FTE): $6,785 Annual Salary: $52,189 Part B: $6,785 Fringe benefits are not being charged to Ryan White Part B for Administration. Total Projected Part B Salary: $10,158 ($3,373 + $6,785) Total Projected Part B Fringe: $0.00 Planning and Evaluation $4,155 Planning and Evaluation activities include: Coordinate Network services; Assist with implementation and updates of an Evaluation Plan for the Network; Annually review and update the Network Grievance Policy; and Annual client satisfaction survey. Salary/Fringe: $4,155 The following staff will have responsibility for all P/E activities: HSO Lead Medical Case Manager M. Buttons (.08 FTE): $4,155 Annual Salary: $42,162 Part B: $3,373 Total Fringe: $782 Annual Health Insurance Premium: $6,547 Part B: $524 Fringe Benefits: 7.65% Part B: $258 Medical Case Management $98,482 HSO Medical Case Managers (MCM) Medical Case Management is the provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. Activities may be prescribed by an interdisciplinary team that includes other specialty care providers. Medical Case Management includes all types of case management encounters (e.g., face-to-face, phone contact, and any other forms of communication). Key activities include: initial assessment of service needs; development of a comprehensive, individualized care plan; timely and coordinated access to medically appropriate levels of health and support services and continuity of care; client monitoring to assess the efficacy of the care plan; re-evaluation of the care plan at least every six months with adaptations as necessary; ongoing assessment of the clients and other key family members needs and personal support systems; treatment adherence counseling to ensure readiness for and adherence to complex HIV treatments; client-specific advocacy and/or review of utilization of services. An estimated 1,010 Medical Case Management services will be provided to 101 clients. Salary/Fringe: $98,482 Case Manager L. Jank (.77 FTE): $35,363 Annual Salary: $37,086 Part B: $28,556 Total Fringe: $6,807 Annual Health Insurance Premium: $6,003 Part B: $4,622 Fringe Benefits: 7.65% Part B: $2,185 Case Manager E. Dubb (.51 FTE): $18,914 Annual Salary: $37,086 Part B: $18,914 Total Fringe: $0.00 Annual Health Insurance Premium: (health insurance is being paid by another funding source for F. Walker) Fringe Benefits: (fringe benefits are being paid by another funding source for F. Walker) Case Manager M. Buttons (.20 FTE): $10,386 Annual Salary: $42,162 Part B: $8,432 Total Fringe: $1,954 Annual Health Insurance Premium: $6,547 Part B: $1,309 Fringe Benefits: 7.65% Part B: $645.00 Case Manager R.Candy (.82 FTE): $33,819 Annual Salary: $33,280 Part B: $27,290 Total Fringe: $6,529 Annual Health Insurance Premium: $5,416 Part B: $4,441 Fringe Benefits: 7.65% Part B: $2,088 Support Services: $40,658 Psychosocial Support Services $2,108 HSO Psychosocial Support Manager (PSM) Position will provide HIV support group facilitation and nutritional counseling by a non-dietician.This will include guidance on nutritional intake and support group facilitation at least 1 x per month.Key activities include: initial assessment of service needs and development of a comprehensive plan for the support group and each individual clients nutritional need, and ongoing assessment of the client's and other key family members' needs and personal support systems. An estimated 64 Psychosocial Support services will be provided to 8 clients. Salary: $2,108 Case Manager M. Buttons (.05 FTE): $2,108 Annual Salary: $42,162 Part B: $2,108 Fringe benefits and health insurance are not being charged to Ryan White Part B for Non-Medical Case Management. Medical Transportation (Support)$15,220 HSO will provide transportation assistance in the form of bus/van tickets and mileage reimbursement (at the state rate or below) to clients, volunteers, or family members and HSO staff members to transport clients to medical appointments. Note: Clients will not be eligible for direct mileage reimbursement. 53 clients x 2.24 medical case managers = 119 transports x 10 visits/services per client = 1,190 A total of 53 clients will be served. 275 trips @ 181.87 miles @ $0.30/mile = $15,004.28 6 clients @ 16 dial a ride bus/van tickets @ $2.25/ticket = $216 Food Bank (Support) $7,980 HSO will purchase food vouchers for clients when clients complete annual and quarterly reviews of their care plan, medication adherence and demographic information, and experience emergency food shortages. 150 clients @ $9.50/voucher @ 5.6 vouchers/client = $7,980 Emergency Financial Assistance (Support) $15,350 HSO will provide short-term payments on a fee-for-service basis to assist with emergency expenses related to essential utilities, housing, food, and medication when other resources are not available. The assistance is provided on a short-term basis and is used as payment of last resort. 139 clients @ $110.43/payment = $15,349.77 (rounded to $15,350) Minority AIDS Initiative: $29,010 Minority AIDS Initiative (MAI) services provide assistance in increasing minority client enrollment in HMAP. This position will also provide vigorous pursuit of healthcare coverage, enrollment services for patients including coverage to care assistance and pharmacy enrollment, especially targeting minorities to ensure that Ryan White is the payor of last resort. An estimated 600 Minority AIDS Initiative services will be provided to 200 clients. Salary/Fringe: $29,010 Enrollment Case Manager R. Gill (.54576 FTE): $29,010 Annual Salary: $53,155 Part B: $29,010 Fringe benefits for MAI salary will be paid by CMC/program income. Health Insurance will be paid from CMC/program income. Total Part B $397,761 Total MAI $29,010 TOTAL RYAN WHITE $426,771  EMBED Acrobat.Document.2017  Appendix 25: Sample HOPWA Budget HIV Care Network (Region 12) Apple Health Services Housing Opportunities for People with AIDS (HOPWA) Budget Narrative January 1, 2022 December 31, 2022 Fringe Schedule (0%) for all Employees includes: All fringe benefits will be paid from operational program income or other grant sources and will not be covered under HOPWA funding. Administration $21,302 Administration activities include: CAREWare data collection CAPER reporting Adhere to State and Federal regulations, policies, guidance Ensure all contractual obligations are fulfilled Compile and submit required fiscal and program reports Ensure HOPWA services are available in all counties of the Network Monitor sub-contracted providers Assess client satisfaction with HOPWA services received and implement programmatic improvements as needed based on results of satisfaction assessments Ensure the Network Grievance Policy is distributed to all HOPWA clients Conduct Quality Improvement (QI) and collect and report QI performance indicators Salary: $21,302 The following staff will have responsibility for all administrative activities: Network Administrator Lisa Selma (.25 FTE): $16,721 Annual Salary: $66,882 HOPWA: $16,721 Total Fringe: $0 Health Information Technician Yvonne Parks (.125 FTE): $4,581 Annual Salary: $36,646 HOPWA: $4,581 Total Fringe: $0 Housing Information $12,349 Housing Information services include, but are not limited to, counseling, information, and referral services to assist an eligible person to locate, acquire, finance, and maintain housing. This may include fair housing guidance for eligible persons who may encounter discrimination on the basis of race, color, religion, sex, age, national origin, familial status, or handicap. It is estimated that 55 households will receive 2 services resulting in 110 services. Salary: $12,349 Housing Specialist Lamar Hager (.25 FTE) $12,349 Annual Salary: $49,394 HOPWA Annual Salary: $12,349 Total Fringe: $0 Resource Identification $3,744 Resource Identification services include the establishment, coordination and development of housing assistance resources for eligible persons, including conducting preliminary research and making expenditures necessary to determine the feasibility of specific housing related initiatives. It is estimated that 55 households will receive 2 services resulting in 110 services. Travel Reimbursement: $3,744 The Housing Specialist will travel throughout the 18 counties of the Network service area to locate housing units, meet with landlords and clients, conduct outreach, and attend housing meetings and trainings to establish, coordinate and develop housing resources for eligible clients. Estimated mileage is 557 miles per month at a rate of $0.56 per mile. (557.1 miles x 12 months x $0.56 per mile = $3,744) Tenant Based Rental Assistance (TBRA): $415,151 TBRA is a rental subsidy used to help participants obtain permanent housing in the private rental housing market that meets housing quality standards and is rent reasonable. TBRA pays the difference between the Fair Market Rent or reasonable rent and the tenants portion of the rent. With TBRA, rental payments are made directly to property owners. The HOPWA subsidy covers a portion of the full rent and the tenant pays a portion based on their adjusted income or gross income. This service includes the completion of client intakes/assessments, verification of client/household income, verification of client medical status, completion of initial and annual housing inspections, conducting annual recertification of eligibility, mediation of client/landlord concerns, preparation of program termination documentation, and the issuance of monthly rental and utility assistance checks. It is estimated that 50 HOPWA beneficiaries will receive approximately 600 units of service. TBRA Program Cost (salary): $41,627 Housing Specialist Lamar Hager (.75 FTE) $37,046 Annual Salary: $49,394 HOPWA Annual Salary: $37,046 Total Fringe: $0 This position completes client intake and service needs assessments, reviews client household income, performs initial and annual housing inspections to ensure housing meets Housing Quality Standards (HQS) and Fair Market Rent (FMR) standards, conducts annual client recertifications, handles client and/or landlord concerns, prepares and maintains TBRA termination documentation, and works with accounting/data staff to prepare monthly rental assistance checks. TBRA Rental Subsidy Payments (WNCCHS): $373,524 Apple Health Services will provide tenant-based rental assistance to clients living throughout the 18 counties of the Network. Based on updated rental costs, the average monthly rent and utilities allowance subsidy per household is $622.54 x 50 households per year. ($622.54 x 12 months x 50 households = $373,524). Support Services $4,266 Permanent Housing Placement (PHP) $4,266 Permanent Housing Placement (PHP) services are used to help eligible persons establish a new residence where ongoing occupancy is expected to continue. Allowable costs include application fees, credit checks, security deposits, fees for housing services or activities designed to assist individuals or families in locating suitable housing, including tenant counseling, assisting individuals and families to understand leases, secure utilities, making moving arrangements, pay for representative payee services for persons who use such services to better manage their own finances, and mediation services related to neighbor/landlord issues that may arise. Placement costs cannot exceed the value of two months rent in the new unit. Funds used must be returned to the program when clients vacate the unit and these returned funds should be recorded as program income and used to further program purposes. 4 unduplicated clients will receive 4 units of service each at $266.62 per service. ($266.62 x 4 clients x 4 services = $4,266). Contracted Services Short-Term Rental/Mortgage and Utility Assistance (STRMU) $27,613 One Step HIV Project STRMU provides sort-term interventions that help maintain stable living environments for households who are experiencing a financial crisis and the potential loss of their housing arrangement. Allowable costs include overdue and ongoing rent, mortgage, or utility payments including late fees associated with overdue rent, mortgage and utility payments intended as a bridge to more permanent housing solutions, such as obtaining long-term rental assistance, increasing household income, or helping a household resolve a short-term crisis. STRMU assistance is limited to 21 weeks of assistance in a 52-week period. Based on prior experience, One Step HIV Project will provide STRMU to at least 40 unduplicated clients (and their household members) per year, resulting in at least 135 units of service. The average amount per household per year is $690.32. ($690.32 x 40 clients = $27,613). Total HOPWA $484,425 Apple Health Services, Inc.HOPWA Region Twelve January 1, 2022 - December 31, 2022 BudgetAdminShort-Term Rent Mortgage & UtilityTenant Based Rental Assistance  RI HITotalPHPSalary and Fringe:Selma, Network Administrator - $66,882 (.25 FTE) 16,721  16,721 Parks, Health Information Technician - $36,646 (.25 FTE) 4,581  4,581  9,162 Hager, Housing Specialist - $49,394 (1.00 FTE) 37,046  12,349  49,395 Operating Expenses:Tenant Based Rental Assistance (TBRA) 373,524  373,524 Resource Identification (Travel) 3,744  3,744 Permanent Housing Placement 4,266  4,266 Contracted Services One Step HIV Project 27,613  27,613 Total  21,302  27,613  415,151  3,744  4,266  12,349  484,425  Appendix 26: Additional Budget Guidance Travel Reimbursement Mileage reimbursement rates must be based on rates determined by the North Carolina Office of State Budget and Management (OSBM). Because mileage rates fluctuate with the price of fuel, the OSBM will release the Change in IRS Mileage Rate memorandum to be found on  HYPERLINK "https://www.osbm.nc.gov/" OSBMs website when there is a change to this rate. The current state mileage reimbursement rate is 56 cents per mile. For other travel related expenses, please refer to the current rates for travel and lodging reimbursement, presented in the chart below. However, please be advised that reimbursement rates periodically change. The Division of Public Health will only reimburse for rates authorized in OSBMs North Carolina Budget Manual or adopted by means of an OSBM Budget Memo. Current Rates for Travel and Lodging MealsIn StateOut of StateBreakfast$8.60$8.60Lunch$11.30$11.30Dinner$19.50$22.20Per Diem$39.40$42.10Lodging(Maximum)$75.10$88.70Total$114.50$130.80Mileage$0.560 cents per mile State rules and guidelines shall take precedence over federal guidelines governing the use of federal grant funds, unless specifically exempted by OSBM in advance. Indirect Cost Indirect cost is the cost incurred for common or joint objectives, which cannot be readily identified but are necessary to the operations of the organization, e.g., the cost of operating and maintaining facilities, depreciation, and administrative salaries. Regulations restricting the allocation of indirect cost vary based on the funding source. Prevention (ITTS) Federally Funded Where the applicant has a Federal Negotiated Indirect Cost Rate (FNICR) and there are no funding source restrictions, the applicant organization may request up to the federally negotiated rate. The total modified direct cost identified in the applicants FNICR shall be applied. A copy of the FNICR must be included with the applicants budget. If the applicant does not have an FNICR, a 10% indirect cost rate (known as the de minimis rate) may be used on the total, modified direct cost as defined in 2 CFR 200.68, Modified Total Direct Cost (MTDC), with no additional documentation required, per the U.S. Office of Management and Budget (OMB) Omni-Circular. Applicants must indicate in the budget narrative that they wish to use the de minimis rate, or some part thereof. Applicants who do not wish to claim any indirect cost should enter No indirect cost requested in the indirect cost line item of the budget narrative. Prevention (ITTS) State Funded NC Division of Public Health policy limits indirect cost to 10%. HIV Care/ R Part B and HOPWA Per Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (commonly referred to as the Omni-circular), Indirect [facilities & administrative (F&A)] costs means those costs incurred for a common or joint purpose benefitting more than one cost objective, and not readily assignable to the cost objectives specifically benefitted, without effort disproportionate to the results achieved. To facilitate equitable distribution of indirect expenses to the cost objectives served, it may be necessary to establish a number of pools of indirect (F&A) costs. Indirect (F&A) cost pools must be distributed to benefitted cost objectives on bases that will produce an equitable result in consideration of relative benefits derived. [78 FR 78608, Dec. 26, 2013, as amended at 79 FR 75880, Dec. 19, 2014.] To simplify, Indirect Costs (IDCs) are those costs incurred by the project in support of general business operations, but which are not attributable to a specific funded project. Indirect Costs + Direct Costs = Total Project Costs. For all HCP Programs who choose to include IDCs in their contract, the Indirect Cost Rate MUST be calculated on a Modified Total Direct Cost (MTDC) basis, meaning some unallowable costs are exempted when the Indirect Costs are calculated. Modified Total Direct Cost (MTDC) is determined by adding together all direct costs (-) minus any items which are exempt from IDC costs. If an HCP grantee has a federally approved Indirect Cost Rate, these projects may charge their federally approved Indirect Cost Rate on all Ryan White and HOPWA contracts up to the respective allowable aggregate administrative cap. (Currently, the Ryan White administrative cap is 10% and the HOPWA administrative cap is 7%.) (MTDC) x (Federally Negotiated Indirect Cost Rate) = Total Indirect Costs. A portion of the Total Indirect Costs (calculated using the formula above) may be charged to Ryan White Contracts up to 10% of expenditures. A portion of the Total Indirect Costs (calculated using the formula above) may be charged to HOPWA Contracts up to 7% of expenditures. Appendix 27: Acronyms and Abbreviations  AA Agreement AddendumACA Affordable Care ActACS AIDS Care ServicesADAP AIDS Drug Assistance ProgramAED Academy for Educational DevelopmentAHEC Area Health Education CenterAIDS Acquired Immune Deficiency SyndromeAMI Area Median IncomeAPA AIDS Pharmaceutical AssistanceAPP ADAP Pharmacy Program (part of ADAP)ART Anti-retroviral TherapyARV Anti-retroviral medicationsASO AIDS Service OrganizationBranch Communicable Disease BranchBRAT Behavioral Risk Assessment ToolCADR CARE Act Data ReportCAF Contract Approval FormCAPER Consolidated Annual Performance and Evaluation Report (for HOPWA)CARE Act - Ryan White Treatment Modernization Act of 2009CBA Capacity Building AssistanceCBO Community Based OrganizationCCME Carolinas Center for Medical ExcellenceCDB Communicable Disease Branch CDC Centers for Disease Control and Prevention (occasionally, CDCP)CEO Chief Elected OfficialCEO Chief Executive OfficerCER Contract Expenditure ReportCFO Chief Financial OfficerCFR Code of Federal RegulationsCGI Continuous Quality ImprovementCHIP Childrens Health Insurance ProgramCIF Common Intake FormCLI Community Level InterventionCMS Centers for Medicare and Medicaid Services (formerly HCFA)CMV CytomegalovirusCOBRA Consolidated Omnibus Budget Reconciliation ActCOE Centers of ExcellenceCPG Community Planning GroupCSW Commercial Sex WorkerCTR Counseling, Testing and ReferralCTRPN Counseling, Testing, Referral & Partner NotificationCTS Counseling and Testing Sites CW CAREWareCY Calendar YearDEBI Diffusion of Evidence-Based Interventions DHHS Department of Health and Human ServicesDIS Disease Intervention ServiceDMA N.C. Division of Medical AssistanceDOC N.C. Department of CorrectionsDPH Division of Public HealthDPI Department of Public InstructionDSS Division of Service Systems (within HRSA)DSS Division of Social ServicesEBIS Evidence-Based Intervention ServicesEC Emerging CommunityED Executive DirectorEDSS Electronic Disease Surveillance SystemEFA Emergency Financial AssistanceeHARS Electronic HIV/AIDS Reporting SystemEIIHA Early Identification of Individuals with HIV/AIDSEIN Employer Identification NumberEIS Early Intervention ServicesEMA Eligible Metropolitan AreaEMSA Eligible Metropolitan Statistical AreaEPI Epidemiological Profile EtE Ending the EpidemicFAW Federal Award WorksheetFDA Food and Drug AdministrationFPL Federal Poverty LevelFSR Financial Status Report - Form 269FY Fiscal YearGAO Government Accounting Office GAGAS Generally Accepted Government Auditing StandardsHAART Highly Active Antiretroviral TherapyHAB HIV/AIDS Bureau HCBC Home and Community Based CareHCFA Health Care Financing Administration (now CMS) HCP HIV Care Program HCV Hepatitis CHep A Hepatitis Virus AHep B Hepatitis Virus BHep C Hepatitis Virus C HETC HIV Education and Training CenterHIHP High-Impact HIV PreventionHIPAA Health Insurance Portability and Accountability ActHIPCSA Health Insurance Premium and Cost-Sharing AssistanceHIV Human Immunodeficiency VirusHMA High Morbidity Area HMAP HIV Medication Assistance ProgramHMO Health Maintenance OrganizationHOPWA Housing Opportunities for People with AIDSHPCAC HIV/AIDS Prevention and Care Advisory CommitteeHRSA Health Resources and Services AdministrationHSC- Heterosexual ContactHUD Housing and Urban DevelopmentICAP Insurance Copayment Assistance Program (part of ADAP)IDC Indirect Cost ITTS Integrated HIV/STD Targeted Testing SitesKS Kaposis sarcomaLER Local Expense ReportLGBTQ Lesbian, Gay, Bisexual, Transgender, and QuestioningLHD Local Health DepartmentMAI Minority AIDS InitiativeMCM Medical Case ManagementMER Monthly Expenditure ReportMFR Monthly Financial ReportMMWR Morbidity and Mortality Weekly ReportMOA Memorandum of AgreementMOU Memorandum of UnderstandingMSM Men who have Sex with Men MTDC Modified Total Direct CostNA Needs AssessmentNAESM National AIDS Education Services for MinoritiesNAPWA National Association of People With AIDSNASTAD National Alliance of State and Territorial AIDS DirectorsNC DHHS - North Carolina Department of Health and Human ServicesNC - North CarolinaNCAS North Carolina Accounting SystemNGA Notice of Grant AwardNGO Non-governmental OrganizationNHAS National HIV/AIDS Strategy NMAC National Minority AIDS CouncilNNRTI Non-Nucleoside Reverse Transcriptase InhibitorNRTI Nucleoside Analog Reverse Transcriptase InhibitorOA Outpatient/AmbulatoryOI Opportunistic InfectionOMB Office of Management and BudgetOW Open Window PCAP Premium and Copayment Assistance ProgramPCIP Pre-existing Conditions Insurance ProgramPCP Pneumocystis PneumoniaPCRS - Partner Counseling and Referral ServicesPEP Post-exposure ProphylaxisPfP Prevention For Positives (now Prevention With Positives) PHP Permanent Housing PlacementPHS U.S. Public Health ServicePI Protease InhibitorPIRR Parity, Inclusion, Representation and RetentionPLWH People Living with HIV DiseasePLWHA People Living with HIV/AIDSPMDC Primary Medical and Dental CarePN Partner NotificationPOMCS Purchase of Medical Care ServicesPPO Preferred Provider OrganizationPrEP Pre-Exposure ProphylaxisPSA Public Service AnnouncementPWID People Who Inject DrugsPwP Prevention With Positives (was Prevention for Positives)QA Quality AssuranceQATD - Quality Assurance and Training DevelopmentQI Quality ImprovementREM Racial and Ethnic MinoritiesRFA Request for ApplicationRFP Request for Proposal RI Resource Identification RNCP Regional Networks of Care and PreventionRSR Ryan White Program Services Report Ryan White CARE Act CARE - Comprehensive AIDS Resources Emergency ActSAMHSA Substance Abuse and Mental Health Services AdministrationSAS Substance Abuse ServicesS-CHIP State Childrens Health Insurance ProgramSCPG Statewide Community Planning GroupSCSN Statewide Coordinated Statement of NeedSES Socioeconomic status SHIIP Seniors Health Information Insurance ProgramSMART - Specific, Measurable, Appropriate, Realistic and Time phasedSOW Scope of WorkSPAP State Pharmaceutical Assistance Program (part of ADAP)SPNS Special Projects of National SignificanceSSDI Social Security Disability InsuranceSSI Supplemental Security Income (from Social Security) SSP Syringe Services Program STA Short Term AssistanceSTD Sexually transmitted diseaseSTI Sexually Transmitted InfectionSTRMU Short Term Rent, Mortgage, and Utility (assistance)TA Technical AssistanceTAC Treatment Adherence CounselingTB TuberculosisTBRA Tenant Based Rental AssistanceTGA Transitional Grant AreaTrOOP True Out Of Pocket (Expenditures) Unit HIV/STD Prevention, Care and Viral Hepatitis Unit UMAP Uninsured/Underinsured Medication Assistance ProgramWIRM Web Identity Role Management Appendix 28: Glossary of Terms Acquired Immune Deficiency Syndrome (AIDS): a medical condition where the immune system cannot function properly and protect the body from disease. As a result, the body cannot defend itself against infections (like pneumonia). AIDS is caused by the Human Immunodeficiency Virus (HIV). This virus is spread through direct contact with the blood and body fluids of an infected individual. High risk activities include unprotected sexual intercourse and intravenous drug use (sharing needles). There is no cure for AIDS; however, research efforts are on-going to develop a vaccine. AIDS Drug Assistance Program (ADAP): ADAP was created as part of the Ryan White CARE Act and is administered under Title II. ADAP provides medications to low-income people living with HIV/AIDS that are uninsured or under-insured and lack coverage for medications. AIDS Service Organization (ASO): ASO is an organization which provides a variety of services to the community, for example health and prevention services, housing, and advocacy. Allocations: refers to the distribution of dollar amounts or percentages of funding to established priorities service categories, geographic areas, populations, or subpopulations. Antibody: a protein found in the blood that is produced in response to foreign substances (e.g., bacteria or viruses) invading the body. Antibodies protect the body from disease by binding to these organisms and destroying them. Barrier: a factor or circumstance that prohibits or inhibits access and/or use of services. Baseline: measures of the dependent variable taken prior to the introduction of the treatment in a time-series experimental design and used as the standard of comparison. Behavioral Intervention: programs that aim to change individual behaviors only, without explicit or direct attempts to change the norms (social or peer) of the community, e.g., geographically defined area, or the target population, e.g., drug users or men having sex with men. Typical examples of these interventions include health education, risk reduction counseling, and other individual-level interventions. Behavioral Science: an area of social sciences research that examines individuals behaviors in depth; it explores what people do and why they do it. Bridge Counselor: a field service interventionist who provides brief (1-2 contacts) for linkage of newly diagnosed persons with HIV and reengagement of persons living with HIV (PLWH) who were not in care. Bylaws: standing rules written by a group to govern business processes. Capacity Building: one or more activities that contribute to an increase in the quality, quantity, and efficiency of program services and the infrastructure and organizational systems that support these program services. In the case of HIV prevention capacity building, the activities are associated with the core competencies of an organization that contribute to its ability to develop and implement an effective HIV prevention intervention and to sustain the infrastructure and resource base necessary to support and maintain the intervention. Case Management: a system for assuring effective delivery of services and maintaining access to resources for individuals with multiple, changing service needs. Centers for Disease Control and Prevention (CDC): the lead federal agency for protecting the health and safety of people, providing credible information to enhance health decisions, and promoting health through strong partnerships. Based in Atlanta, Georgia., this agency of the U.S. Department of Health and Human Services serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and education activities designed to improve the health of the people of the United States. Client Level Data: data that is derived from individual clients. Close-ended Questions: questions in an interview or survey format that provide a limited set of predefined alterative responses; for example, a survey might ask respondents if they are receiving case management services, and if they say yes, ask About how often have you been in contact with your case manager for services during the past six months, either in person or by telephone? and provide the following response options: Once a week or more, two to three times a month, approximately once a month, three to five times, one to two times, not at all. Collaboration: working with another person, organization, or group for mutual benefit by exchanging information, sharing resources, or enhancing the others capacity, often to achieve a common goal or purpose. Community-based Organization (CBO): a structured group offering services to a specific group of people in a defined area. These groups may include minority groups, housing for the homeless, and AIDS service organizations. Community Forum (or Public Meeting): a small-group method of collecting information from community members in which a community meeting is used to provide a directed and highly interactive discussion. Community-Level Interventions (CLI): an intervention that seeks to improve the risk conditions and behaviors in a community through a focus on the community as a whole, rather than by intervening only with individuals or small groups. This is often done by attempting to alter social norms, policies, or characteristics of the environment. Examples of CLI include community mobilizations, social marketing campaigns, community-wide events, policy interventions, and structural interventions. Community Mobilization: the process by which community citizens take an active role in defining, prioritizing, and addressing issues in their community. This process focuses on identifying and activating the skills and resources of residents and organizations while developing linkages and relationships within and beyond the community for the purpose of expanding the current scope and effectiveness of HIV/STD prevention. Community Planning: a term used to describe a community-based planning process, whereby a plan is developed based on data of a defined community (geographic or population specific). Community Planning Co-Chairs: persons assigned by the Network and elected from community members to particular community planning areas. They are responsible for organizing, covering, and leading the HIV Prevention Groups. Community Planning Groups (CPGs): the official HIV prevention planning body that follows the HIV Prevention Community Planning Guidance to develop a comprehensive HIV prevention plan for a project area. CPGs are composed of community representatives and other technical experts, and staff of non-governmental organizations; also, departments of health, education, and substance abuse prevention. Community Planning Leadership Orientation & Training (CPLOT): a national program sponsored by the National Minority AIDS Council (NMAC) that provides training in community planning processes for HIV prevention. Comparison Group: individuals whose characteristics (such as race/ethnicity, gender, and age) are similar to those of the program participants. These individuals may not receive any services, or they may receive a different set of services, activities, or products. As part of the evaluation process, the experimental (or treatment) group and the comparison group are assessed to determine which type of services, activities, or products provided by the program produced the expected changes. Comprehensive HIV prevention plan: a plan that identifies prioritized target populations and describes what interventions will best meet the needs of each prioritized target population. The primary task of the community planning process is developing a comprehensive HIV prevention plan through a participatory, science-based planning process. The contents of the plan are described in the HIV Prevention Community Planning Guidance, and key information necessary to develop the comprehensive HIV prevention plan is found in the epidemiologic profile and the community services assessment. Comprehensive Planning: refers to the consideration and inclusion of all priority needs in HIV prevention and services in a written plan, although some of the needs may not be funded. Comprehensive Risk Counseling and Services (CRCS, formerly PCM): CRCS is an intensive, individualized client-centered counseling for adopting and maintaining HIV risk-reduction behaviors. CRCS is designed for HIV-positive and HIV-negative individuals who are at high risk for acquiring or transmitting HIV and STDs and struggle with issues such as substance use and abuse, physical and mental health, and social and cultural factors that affect HIV risk. Confidentiality: pertains to the disclosure of personal information in a relationship of trust and with the expectation that it will not be divulged to others in ways that are inconsistent with the original disclosure. Must be maintained for persons who are recommended and/or who receive HIV counseling, testing, and referral (CTR) services. Conflict of Interest: conflict between the private interests and public obligations of a person in an official position. Consensus: an agreement or decision that all parties can support. Contemplation: one of the stages of the Stages of Change behavioral theory; person is aware that a problem exists, is seriously thinking about overcoming it, but has not yet made a commitment to act. Continuum of Care: a set of services and linkages that responds to an individual or a familys changing needs for HIV prevention and care. A continuum of care is the complete system of providers and available resources for people at risk for, or living with HIV, and their families within a particular geographic service area. Core Group: subgroups within a larger planning area. For prevention planning, the prioritizing of subpopulations and the selection of interventions occurs at the core group level. Correlation: a statistical measure of the degree of relationship/association between variables. Cost Effectiveness Analysis: a type of analysis that involves comparing the relative costs of operating a program with the extent to which the program met its goals and objectives; for example, a program to reduce HIV transmission would estimate the dollars that had to be expended for prevention efforts compared to dollars expended for HIV related treatment and services. Counseling and Testing: the voluntary process of client-centered, interactive information sharing in which an individual is made aware of the basic information about HIV/AIDS, testing procedures, how to prevent the transmission and acquisition of HIV infection and given tailored support on how to adapt this information to their life. Counseling, Testing, Referral, and Partner Notification: CTRPN refers to voluntary HIV/AIDS counseling and testing, referral to appropriate medical and social services, and anonymous or confidential partner notification of sex or needle-sharing partners by health department staff when accompanied by testing; includes pre-test counseling, for example, when it is clear that testing is being offered as an option for the individual to consider. Cultural Competence: capacity and skill to function effectively in culturally diverse environments that are composed of distinct elements and qualities. Culture: the learned patterns of behavior with traits characteristic of large, autonomous, or semi-autonomous, human social groups. These patterns prescribe the acceptable values, norms, attitudes, social roles and statuses, etiquette, interpersonal and familial relationships, and personal conduct of the members of the culture. They also define the behavior expected of other people. Culture is expressed and reinforced through shared language, group identity, religion/belief system, folklore, social and legal institutions, traditions, customs, history, and arts. Data: specific information or facts that are collected. A data element is usually a discrete or single measure. Examples of client-level data elements are sex, race/ethnicity, age, and neighborhood. Data Analysis: the process of systematically applying statistical and logical techniques to describe, summarize, and compare data collected. Data System: a systematic structure that contains and tracks data. Database: an accumulation of information that has been systematically organized for easy access and analysis. Databases are typically computerized. Demographics: the statistical characteristics of human populations such as age, race, ethnicity, and sex that can provide insight into the development, culture, and sex specific issues that the intervention will need to account for. Determinants of Behavior: the external and internal factors that determine or influence individuals actions. Drop-off Site: locations that volunteer to distribute HIV prevention materials. Typically outreach workers keep these sites supplied. Eligible Metropolitan Area (EMA): a designation used by the Ryan White CARE Act to identify an area eligible for funds under Title I. Ending the Epidemic: A plan under development by the North Carolina Communicable Disease Branch with community participation to end the HIV epidemic in North Carolina. Epidemic: a disease that spreads rapidly through a demographic segment of the human population, such as everyone in a given geographic area; a military base, or similar population unit; or everyone of a certain age or sex, such as the children or women of a region. Epidemic diseases can be spread from person to person or from a contaminated source such as food or water. Epidemiologic Profile: a description of the current status, distribution, and impact of an infectious disease or other health-related condition in a specified geographic area. Epidemiology: the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems. Evaluation: a process for determining how well health systems, either public or private, deliver or improve services and for demonstrating the results of resource investments. Evidence-based: based on evidence that is collected from scientific data. Some examples of evidence-based decisions in HIV/STD prevention planning are the prioritization of subpopulations based on epidemiological and needs assessments data, and the selection of interventions that have been demonstrated to be effective in research studies. Reduction Interventions (HE/RR): organized efforts to reach persons at increased risk of becoming HIV-infected or, if already infected, of transmitting the virus to others, with the goal of reducing the risk of these events occurring; activities range from individual case management to broad community-based interventions. Factors Influencing Behaviors (FIB) or Influencing Factors: the underlying reasons that individuals exhibit certain behaviors. FIBs are an important consideration in selecting appropriate HIV/STD interventions as part of the prevention planning process. Fidelity, also accuracy: the exact adherence to established protocols, procedures, and content in implementation or replication of a program. Fixed-site Outreach: activities conducted at a specific place, e.g., setting up a table at a corner or working out of a mobile van or store front. Focus Group: a method of information collection involving a facilitated discussion among a small group and led by a trained moderator. Formative Evaluation: a systematic determination of a subject's merit, worth and significance, using criteria governed by a set of standards, undertaken during the design and pretesting of programs to guide the design process. Emphasizes questions related to how the program is operating. Used to assist planners, managers and staff to develop a new program or improve an on-going program. Generalizability: the extent to which findings or conclusions from a sample can be assumed to be true for the entire population from which the sample was drawn; findings can be generalized only when the sampling procedure and the data meet certain methodological standards. Group-Level Interventions (GLI): health education and risk-reduction counseling that shifts the delivery of service from the individual to groups of varying sizes. Group-level interventions use peer and non-peer models involving a range of skills, information, education, and support. Goals: broad aims/statements that describe what the proposed project hopes to accomplish. Health Disparity: a higher burden of illness, injury, disability, or mortality experienced by one group relative to another Health Equity: Everyone has a fair and just opportunity to be as healthy as possible. Health Resources and Services Administration (HRSA): HRSA directs national health programs that improve the Nations health by assuring equitable access to comprehensive, quality health care for all. HRSA works to improve and extend life for people living with HIV, provide primary health care to medically underserved people, serve women and children through State programs, and train a health workforce that is both diverse and motivated to work in underserved communities. HRSA is the Federal agency responsible for administering the Ryan White CARE Act. Hepatitis B: a liver disease caused by the Hepatitis B virus (HBV). HBV is found in the blood of infected persons and is most commonly transmitted through unprotected sex. Hepatitis C: a liver disease caused by the Hepatitis C virus (HCV), which is found in the blood of persons who have the disease. HCV is spread by contact with the blood of an infected person, most commonly through injection drug use. High-Impact HIV Prevention: CDC initiative that seeks to use a combination of scientifically proven, cost-effective, and scalable interventions targeted to the right populations in the right geographic areas; this approach promises to increase the impact of HIV prevention efforts an essential step in achieving the goals of NHAS. High Morbidity Analysis Zone (HMAZ): a term used in the TDH 2000 Area Epidemic Profiles to denote clusters of counties that show higher numbers of reported cases of HIV/AIDS and/or STDs. HIV Education and Training Center (HETC): HETC was created as part of the Ryan White CARE Act and is administered under Part F. The HETC program is a network of regional centers that conduct targeted, multi-disciplinary education and training programs for health care providers. HIV (Human Immunodeficiency Virus): the virus that causes AIDS. Several types of HIV exist, with HIV-1 being the most common in the United States. HIV Prevention Community Planning: the cyclical, evidence-based planning process in which authority for identifying priorities for funding HIV prevention programs is vested in one or more planning groups in a state or local health department that receives HIV prevention funds from CDC. HIV Services Delivery Area, also known as Health Service Delivery Area: a designation used by the Ryan White CARE Act to identify an area eligible for funds under Title II (formula funding to States and territories). HIV Test: more correctly referred to as an HIV antibody test, the HIV test is a laboratory procedure that detects antibodies to HIV, rather than the virus itself. Housing Opportunities for People with AIDS (HOPWA): is a Federal program of the Department of Housing and Urban Development that provides housing assistance and supportive services for low-income people with HIV/AIDS and their families. Human Immunodeficiency Virus (HIV): see HIV. Inclusion: the assurance that the views, perspectives, and needs of all affected communities are included and involved in a meaningful manner in the community planning process. Implementation: to put into effect according to or by means of a definite plan or procedure, e.g., collecting information about the interventions identified in the HIV prevention comprehensive plan. Incidence: the number of new cases in a defined population within a certain time period, often a year that can be used to measure disease frequency. It is important to understand the difference between HIV incidence, which refers to new cases, and new HIV diagnosis, which does not reflect when a person was infected. Information: in the context of HIV counseling, information encompasses the topics HIV transmission and prevention and the meaning of HIV test results. Informed Consent: permission granted by a participant in a research study after he/she has received comprehensive information about the study. This is a statement of trust between the institution performing the research procedure and the person on whom the research procedures are to be performed. Intervention: a specific activity (or set of related activities) intended to bring about HIV risk reduction in a particular target population using a common strategy of delivering the prevention message. An intervention has distinct process and outcome objectives and a protocol outlining the steps for implementation. Intervention Plan: a type of plan for setting forth the goals, expectations, and implementation procedures for an intervention. It should describe the evidence or theory basis for the intervention, justification for application to the target population and setting, and the service delivery plan. Justification: a judgment about whether the intervention plan does or does not explain how the intervention will lead to the specified outcomes. Linkage: the connection between the comprehensive HIV prevention plan and resource allocation in order to determine if the resources allocated in the previous year (meaning the year that has just ended) corresponded with recommendations in the plan from the previous year. Men who have Sex with Men (MSM): men who report sexual contact with other men, e.g., homosexual contact, or men who report sexual contact with both men and women, e.g., bisexual contact. MSM/IDU: men who report both sexual contact with other men and injection drug use. Mass Media: the use of print, radio, and television, to communicate with specific populations. It includes public service announcements, news broadcasts, infomercials, magazines, newspapers, billboards, etc., which reach a large-scale audience in a short period of time. Methodology: a plan that defines outcome measures, the choice of a research design, sampling, sample size, and choice of data systems. Monitoring: routine documentation of characteristics of the people served, the services that were provided, and the resources used to provide those services. National Association of State and Territorial AIDS Directors (NASTAD): the national association that supports health department AIDS directors and coordinates peer technical assistance for prevention planning processes. NHAS (National HIV/AIDS Strategy): created by the White House; a more coordinated national response to the HIV epidemic that seeks to accomplish three primary goals: 1) reducing the number of people who become infected with HIV, 2) increasing access to care and optimizing health outcomes for people living with HIV, and 3) reducing HIV-related health disparities. This Strategy is intended to be a concise plan that will identify a set of priorities and strategic action steps tied to measurable outcomes. National Minority AIDS Council (NMAC): a national agency that focuses on the provision of technical assistance to prevention planning groups. Needs Assessment: the process of obtaining and analyzing information from a variety of sources in order to determine the needs of a particular client, population, or community. Non-occupational HIV Exposure: a reported sexual, injection-drug--use, or other non-occupational HIV exposure that might put a patient at high risk for acquiring HIV infection. Objectives: specific statements which describe what is intended to be done with the proposed program within a given period. Open-ended Questions: an interview or survey format that allow those responding to answer as they choose, rather than having to select one of a limited set of predefined alternative responses. Opt-Out HIV Counseling and Testing: at the time pre-test counseling is provided, and, after informed consent is obtained, the counselor shall test the client for HIV infection, unless the client refuses the HIV test. Outcome Evaluation: the application of rigorous methods to assess whether the prevention program has an effect on the predetermined set of goals; the use of rigorous methods allows one to rule out factors that might otherwise appear responsible for the changes seen; for example outcome evaluation determines whether a particular intervention had a desired effect on the targeted populations behavior; whether the intervention provided made a difference in knowledge, skills, attitudes, beliefs, behaviors, or health outcomes. Outcome Monitoring: the procedures for assessing whether providers are meeting the outcome objectives that they set for themselves and efforts to track the programs of clients in a program based upon outcome measures set forth in program goals. In many cases - especially for individual and group level counseling interventions - this may simply require administering a brief questionnaire before the intervention begins and then again after it is finished. Outcome Objectives: the overall intended effects of the intervention, specifying its purpose and mission. These might include increasing knowledge about HIV, changing risk-related behaviors, promoting community norms for safer sex, or reducing HIV transmission. Outreach: HIV/AIDS educational interventions generally conducted by peer or paraprofessional educators face-to-face with high-risk individuals in the clients neighborhoods or other areas where clients typically congregate. Usually includes distribution of condoms, bleach, sexual responsibility kits, and educational materials. Parity: a situation in which all members of the planning group are provided opportunities for orientation and skills building to participate in the planning process and to have an equal voice in voting and other decision-making activities. Parity, Inclusion and Representation (PIR): a principle applied to CPG membership to assure that planning for HIV prevention needs is done by the individuals most affected or by those who can represent the viewpoints of those most affected. Partner Services: a public health strategy to identify, contact, and provide HIV prevention services to the sex and needle sharing partners of Persons Living with HIV, formerly referred to as Partner Counseling and Referral Services. Peer Navigator: Role models who provide reliable and relevant information to help clients overcome barriers that may prevent engagement, retention, or re-engagement in treatment. People who Inject Drugs (PWID): people who are at risk for HIV infection through the use of equipment used to inject drugs, e.g., syringes, needles, cookers, spoons, etc. Pilot Test: a trial run with a few subjects to assess the appropriateness and practicality of the procedures and data collecting instruments. Planning Council: volunteer planning groups composed of community members who prioritize services and allocate funds under Title I of the Ryan White CARE Act. PLWH/A: people (or person) living with HIV/AIDS. PLWH and PLWA also are used. Policy Intervention: an aim to change/influence policies that serve as barriers to behavior change. These interventions include, for example, decisions such as those that permit advertising and social marketing of condoms, allow for pharmacy sales of needles, and decriminalize prostitution. Population: a population is any entire collection of people, animals, plants or things from which data may be collected. Positive Test: for HIV, a specimen sample that is reactive on an initial ELISA test, repeatedly reactive on a second ELISA run on the same specimen and confirmed positive on Western blot or other supplemental test indicates that the client is infected. Pre-Exposure Prophylaxis (PrEP): a daily medication taken to prevent HIV infection. Pretest: test of planned public information strategies, messages, materials or measurement tools before completion or release to allow for feedback and revision to help assure effectiveness. Prevalence: the total number of persons living with a specific disease or condition during a given time period. Prevention Case Management (PCM): See CRCS Prevention Counseling and Partner Elicitation (PCPE): a set of program activities widely used to counsel and test persons and their sex and/or needle -sharing partners who are at risk for acquiring or transmitting HIV infection. Prevention Programs: interventions, strategies, programs, and structures designed to reduce risk behaviors that may lead to HIV infection or other disease. Successful HIV prevention programs include outreach to the populations at highest risk and the subsequent referral into prevention counseling, testing, and other targeted, intensive interventions. Primary Prevention: intervention and education activities that are intended to help people reduce risk behaviors that may lead to infection with HIV. Examples of primary prevention include skills building for condom use, counseling that focuses on the reduction of the number of sex partners and HIV and STD testing. Priority population: a population identified through the epidemiologic profile and community services assessment that requires prevention efforts due to high rates of HIV infection and the presence of risky behavior. Priority Setting: a system used to determine numerical priorities of categories, such as subpopulations for prevention planning or service categories for services planning. Process Evaluation: a descriptive assessment of the implementation of program activities; what was done, to whom, and how, when, and where, e.g., assessing such things as an interventions conformity to program design, how it was implemented, and the extent to which it reaches the intended audience. Process Monitoring: the collection of data to describe and assess intervention implementation; for example, routine documentation of characteristics describing the target population served, the services that were provided, and the resources used to deliver those services. Process Objectives: the specific intervention activities, the projected level of effort needed to carry them out, the people responsible for carrying them out, and when they will be completed. Program: a program is an organized effort to attain a set of predetermined goals; a program is a distinction often used by an agency to describe a related set of interventions serving a particular population. Program Evaluation: the systematic assessment of the means and ends of some or all of the action program stages, including program planning, implementation, and outcomes, in order to determine the value of and to improve the program. Public Health Surveillance: an ongoing, systematic process of collecting, analyzing and using data on specific health conditions and diseases, in order to monitor these health problems, such as the Centers for Disease Control and Preventions (CDC) surveillance system for AIDS. Qualitative Data: data presented in narrative form that generally are not expressed numerically, such as the information collected from focus groups or key informant interviews. Quality Assurance: an ongoing process for ensuring that the CTR program effectively delivers a consistently high level of service to the clients. Quantitative Data: data presented in numerical terms, such as survey data and data from epidemiologic reports. Rapid ART: Initiation of HIV medication therapy within seven days of diagnosis. Rapid HIV Test: a test to detect antibodies to HIV that can be collected and processed within a short interval of time (e.g., approximately 10--60 minutes). Referral: a process by which an individual or client who has a need is connected with a provider who can serve that need (usually in a different agency); for example, individuals with high-risk behaviors and those infected with HIV are guided towards prevention, psychosocial, and medical resources needed to meet their primary and secondary HIV prevention needs. Relevance: the extent to which an intervention plan addresses the needs of affected populations in the jurisdiction and of other community stakeholders. As described in the CDC Guidance, relevance is the extent to which the population targeted in the intervention plan is consistent with the target population in the comprehensive HIV prevention plan. Reliability: the consistency of a measure or question, in obtaining very similar or identical results when used repeatedly; for example, if a test was done on the same blood sample several times, it would be reliable if it generated the same results each time. Representation: the assurance that the persons representing a specific community truly reflect that communitys values, norms, and behaviors. Representative: the term used to indicate that a sample is similar to the population from which it was drawn, and therefore can be used to draw conclusions about that population. Request for Proposals (RFP): public announcements regarding the availability of grant funding. Risk Behavior: behavior or other factor that increases the chance that a person may acquire disease. For HIV/AIDS, includes such factors as sharing of injection drug use equipment, unprotected male-to-male sexual contact, and commercial sex work without the use of condoms. Ryan White CARE Act: on August 18, 1990, Congress enacted the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. Reauthorized in 1996 and 2000, the CARE Act is designed to improve the quality and availability of care for individuals and families affected by HIV/AIDS. The CARE Act includes the following major programs: Title II, Title III, Title IV, Part F, and I. The CARE Act is now the largest sole source of HIV funding in the nation. Sample: a group of subjects selected from a total population or universe with the expectation that studying the group will provide important information about the total population. Sampling Frame: the list from which the sample population is drawn, i.e., the telephone directory is often used for general population surveys. Sample Size: the number of people from whom data are collected. Scientific Soundness: the application of behavioral and social science theories developed or adapted by the provider agency or agreement of principles of a program with accepted scientific findings or theories. Screening Test: an initial test, usually designed to be sensitive, to identify all persons with a given condition or infection (e.g., enzyme immunoassay [EIA] or enzyme-linked immunosorbent assay [ELISA]). Secondary Prevention: prevention programs that serve the needs of people infected with HIV, the goals of which are to prevent further transmission and to link the infected person to early intervention services in order to minimize the disease progression. Secondary Source Data: existing information that was collected by someone else, but which can be analyzed or re-analyzed to use. Such data may be in raw (unanalyzed) or analyzed form. Self-efficacy: belief in ones ability to perform the desired behavior. Semi-structured Questionnaires: referring to questionnaires that combine structured questions with open-ended questions. Seroprevalence: HIV seroprevalence refers to the number of persons in a population who test HIV+ based on serology (blood serum) specimens; often presented as a percent of the total specimens tested or as a ratio per 1,000 persons tested. Seroprevalence Reports: reports which provide information about the percent or rate of people in specific testing groups and populations who have tested positive for HIV. Sexually transmitted infections (STD) or Sexually Transmitted Infection (STI): an infection that is spread through intimate sexual contact. HIV, herpes, syphilis, and gonorrhea are commonly known STDs. Stakeholders (federal, state and local community): those who have an interest in and can affect implementation of an intervention or program; key players; influential. Statewide Coordinated Statement of Need (SCSN): the Ryan White CARE Act requires all CARE Act Networks to participate in this representative process. The purposes of the SCSN are to provide a mechanism to collaborate in identifying and addressing significant HIV care issues related to the needs of people and families living with HIV and to maximize coordination, integration, and effective linkages across the CARE Act Titles. Stigma: negative attitudes and beliefs about people living with HIV Street Outreach: HIV/AIDS educational interventions generally conducted by peer or paraprofessional educators face-to-face with high-risk individuals in the clients neighborhoods or other areas where clients typically congregate. Usually includes distribution of condoms, bleach, safer sex kits and educational materials. Structural Intervention: interventions designed to remove barriers and incorporate facilitators of an individuals HIV prevention behaviors. These barriers or facilitators include physical, social, cultural, organizational, community, economic, legal, or policy circumstances or actions that directly or indirectly affect an individuals ability to avoid exposure to HIV. Structured Survey/Questionnaire: questionnaires or surveys that are pre-determined and standardized that include close-ended responses that are easily quantifiable and typically pre-coded to facilitate the transfer of data to the computer. Summative Evaluation: evaluation designed to present conclusions about the merit or worth of an intervention and recommendations about whether it should be retained, altered, or eliminated. Sufficiency of the Service Plan: in reference to the CDCs evaluation guidance, the SSP provides details about whether the resources and operational plan for the intervention will allow it to be executed given its current context within the jurisdiction. Surveillance: the ongoing and systematic collection, analysis, and interpretation of data about a disease or health condition. As part of a surveillance system to monitor the HIV epidemic in the United States, the Centers for Disease Control and Prevention (CDC), in collaboration with state and local health departments, other federal agencies, blood collection agencies, and medical research institutions, conducts standardized HIV seroprevalence surveys in designated subgroups of the U.S. population. Collecting blood samples for the purpose of surveillance is called serosurveillance. Surveillance Data: statistics representing people with HIV or AIDS in a particular area. Statistics are reported to the Centers for Disease Control and Prevention from the public health officials who collect them from testing sites, treatment facilities, and other groups, and analyze them to produce a full picture of trends in the epidemic. Surveillance Report: reports providing information on the number of reported AIDS and HIV cases nationally and for specific locations and subpopulations; the Centers for Disease Control and Prevention (CDC) issues such a report twice a year, providing both cumulative cases and new cases reported during specific time periods. Syringe Services Program: community-based prevention programs that can provide a range of services, including linkage to substance use disorder treatment; access to and disposal of sterile syringes and injection equipment; and vaccination, testing, and linkage to care and treatment for infectious diseases. Target Populations: determined groups of people to be reached through some action or intervention. In HIV prevention community planning, refers to populations that are the focus of HIV prevention efforts due to high rates of HIV infection, usually defined based on a review of the HIV epidemiologic profile, and high levels of risky behavior. Groups often defined based on a combination of characteristics such as race or ethnicity, age, gender, risk factor/behavior, and geographic location. Technical Assistance: the delivery of expert programmatic, scientific, and technical support to organizations and communities in the design, implementation and evaluation of HIV prevention interventions and programs. Title I: under the Ryan White CARE Act, funding is given to eligible metropolitan areas hardest hit by the HIV epidemic. Title II: under the Ryan White CARE Act, assists states and territories in improving the quality, availability, and organization of health care and support services for individuals and families with HIV disease and provides access to needed pharmaceuticals through the AIDS Drug Assistance Program (ADAP). Title III: under the Ryan White CARE Act, provides support for early intervention and primary care services for people with HIV/AIDS. Title IV: under the Ryan White CARE Act, provides coordinated HIV services and access to research for women, infants, children, youth, and families with, or at risk for, HIV/AIDS, focusing on the development and operation of family-centered systems of primary health care and social services that benefit these population groups. Transitional Grant Area (TGA): an area reporting 1,000 to 1,999 AIDS cases in the most recent five years with a population of at least 50,000. Ryan White Part A grants to TGAs include formula and supplemental components as well as (MAI) funds, which support services targeting minority populations. Transmission Categories: in describing HIV/AIDS cases, same as exposure categories; how an individual may have been exposed to HIV, such as injecting drug use, Men who have Sex with Men, and heterosexual contact. Universe: the total population from which a sample is drawn. 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Variable: a characteristic of finding that can change or vary among different people or in the same person over time; for example, race or ethnicity varies among individuals, and income varies for the same individual over time. Viral Suppression: the amount of HIV in the body is reduced to a very low level, which keeps the immune system working, prevents illness, and helps prevent transmission to others. Voluntary HIV testing: HIV testing that is offered free of coercion. With voluntary HIV testing, participants can accept or refuse HIV testing.  Office of State Budget and Management Budget Manual. Current travel rates can be found in this document:  HYPERLINK "https://ncosbm.s3.amazonaws.com/s3fs-public/documents/files/BudgetManual.pdf" https://ncosbm.s3.amazonaws.com/s3fs-public/documents/files/BudgetManual.pdf     N.C. Division of Public Health v.01-22-2020 Page  PAGE \* MERGEFORMAT 10 of  NUMPAGES \* MERGEFORMAT 47 RFA # ________ Date N.C. Division of Public Health v.01-22-2020 Page  PAGE \* MERGEFORMAT 1 of  NUMPAGES \* MERGEFORMAT 1 RFA # A-379 Date: May 3, 2021 N.C. Division of Public Health v.01-22-2020 Page  PAGE \* MERGEFORMAT 10 of  NUMPAGES \* MERGEFORMAT 47 RFA # ________ Date N.C. 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