Section 970.340  Application Procedures for Services for Breast Cancer Victims

The Department will provide written application instructions and forms to potential applicants upon request.  Information concerning the grant will be available on the Department's website, http://www.idph.state.il.us/fundop.htm.

a)         All applications shall include the following:

1)         The applicant's name, address, and telephone and FAX and teletypewriter (TTY) numbers, if available;

2)         The name, address, and telephone and FAX and TTY numbers, if available, of the entity (such as a local health department, not-for-profit organization, governmental entity, licensed hospital, or community health center) through which the application is being submitted;

3)         A one-page abstract, which describes the significance of the applicant's method to provide services for breast cancer victims;

4)         A summary statement of the applicant's proposed plan of action to address the need for this service described in the Department's request for proposals;

5)         A description of the geographic area or special population group to be served by the applicant's service, a statement of the special needs of the area or groups, and a thorough explanation of the manner in which the proposed services would meet those needs;

6)         A statement of the measurable and relevant objectives the applicant proposes to achieve in the grant year;

7)         An evaluation plan that will allow documentation of the applicant's progress in meeting the particular needs of the area or group and a plan for monitoring the overall project;

8)         The TIN;

9)         The signature of agency official authorized to certify the application;

10)         A detailed budget for the funding period, documenting sufficient resources to carry out the project. The budget shall be by line item category and shall provide sufficient detail to justify the use of grant funds to support project activities.  The applicant shall indicate the total cost of conducting the projects, the anticipated funding request for years two and three of the project (if applicable), the source of other funds supporting the projects, and the amount of support requested from the Department;

11)         A signed Statement of Assurances indicating compliance with applicable State and federal requirements, such as the Fiscal Control and Internal Auditing Act, Office of Management and Budget (OMB) Circular A-128 (local governments), OMB Circular A-133 (not-for-profit organizations), bribery certification, contract debarment, unlawful discrimination, Illinois Human Rights Act, The Civil Rights Act of 1964, The Drug-Free Workplace Act of 1988, The Davis-Bacon Act of 1931, conflict of interest as specified in the Illinois Procurement Code [30 ILCS 500], and protection of the confidentiality of services.

(Source:  Added at 30 Ill. Reg. 17924, effective October 27, 2006)