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Part IV

By Evelyn Clark,2014-05-17 10:26
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Part IV

    Cancer, Cardiovascular Disease and Pulmonary Disease Competitive Grants Program | Part III: Budget, Budget

    Narrative and Financial Assessment Questionnaire

    Part III.

    ? Financial

    Assessment

    Questionnaire

    ? Budget

    ? Budget Narrative

    The CCPD Application Guidelines are available on the CCPD website (http://www.cdphe.state.co.us/pp/ccpd/).

    The Application Guidelines include instructions and guidance about funding areas, the application process (including

    an Application Checklist), formatting guidelines and additional requirements for new and sunsetting projects.

    Cancer, Cardiovascular Disease and Pulmonary Disease Competitive Grants Program | Part III: Budget, Budget Narrative and

    Financial Assessment Questionnaire

    Instructions

Part III of the application should include the required cover page, the completed Financial Assessment Questionnaire,

    operating budgets for years one, two and three (if applicable), and a budget narrative for year one. The budget

    narrative must be single-spaced with one-inch margins, written in 12-point font. Please include page numbers in the

    bottom right hand corner of the page. For a complete list of formatting guidelines, refer to the CCPD Application

    Guidelines.

This section should include an operating budget, using the Budget Spreadsheet provided on the CCPD Website, and

    a budget narrative (see sample on page 5) describing how costs were determined and are related to the project.

    Proposals for two or three-year projects must include a detailed budget (budget narratives are not required) for years

    two and three using a separate Excel spreadsheet for each year. The Review Committee will rely on planned annual

    budgets to set future funding ranges. Please make annual budgets as accurate as possible.

Indirect costs up to but not exceeding 20% of total direct costs as indicated in the budget line items in the

    spreadsheet provided are allowed. The indirect rate cannot be applied to capital equipment costs greater than

    $5,000.00. A flow through rate no greater than 2% is allowable on subcontracting costs. If an applicant does not

    have an established indirect rate, justification for the administrative costs of providing the proposed services must be

    provided.

Include costs for key personnel on the project to travel to the Denver Metropolitan Area for at least four trainings or

    meetings per year in the “in-state” travel line item. Applicants outside the Denver Metropolitan area may include

    lodging costs. Mileage may be budgeted at the current State rate of $.53/mile (80% of the current federal rate in

    accordance with the State of Colorado Fiscal Rules). However, mileage will be reimbursed at the rate established by

    the State of Colorado at the time of award. Airfare for in-state travel will be reimbursed at the coach rate.

If other sources of funding will be used for the project, indicate the source of funding and the funding amount on the

    budget spreadsheet and describe in the budget narrative how the other sources of funding will be used within the

    scope of work, and how the funds will be tracked.

The Review Committee reserves the right to deny requests for any item listed in the budget that is deemed to be

    unnecessary for the implementation of the project. Requests for out-of-state/national/international travel and

    conference registrations and requests for equipment are at the discretion of the Review Committee and CCPD staff.

    Cell phones, rent and equipment maintenance expenses are discouraged, but will be considered on a case-by-case

    basis. Meeting expenses must be detailed in the budget narrative and include any planned expenses for food and

    beverage.

Signature of Director or Authorized Representative and Date: The agency’s director or authorized representative

    must sign the Budget Request and date their signature prior to submitting the grant application.

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    Cancer, Cardiovascular Disease and Pulmonary Disease Competitive Grants Program | Part III: Budget, Budget Narrative and

    Financial Assessment Questionnaire

1. APPLICATION FINANCIAL ASSESSMENT QUESTIONS

Note: Local public health departments, county nursing services and Indian tribes applying for CCPD funds

    do not need to complete this questionnaire.

Name of organization:

Name and title of person completing this form:

1) Please complete the following chart (add lines, as necessary) or attach your own document

    detailing your organization’s current sources of funding (including CDPHE grants) by

    providing the funding agency, the program name, the types of funds (i.e., Federal, State,

    local, private, etc.), and the contract budget amount:

    Contract

    Grantor Agency Program Type of Funds Budget Amount Contract Period

     -

     -

     -

     -

2) Are you currently seeking any other funds from the CDPHE through grant applications,

    proposals in response to requests for proposals, purchase orders, other contracts, or any

    other financial arrangement? If yes, please list and explain.

3) Has your organization administered programs similar to your current grant proposal?

    < Select > If so, please list and explain.

    4) How many years has your organization been in existence?

5) How many total FTE are there in your organization?

    6) How many total FTE perform accounting functions within your organization?

7) When is your organization’s fiscal year end?

8) Does your organization receive an annual financial statement audit under the Single Audit

    Act/OMB Circular A-133 (Government Auditing Standards) <Select> OR

     Generally Accepted Auditing Standards (GAAS) <Select>

    If yes, please provide a copy ( electronic preferred) of your most recent audit report

    and STOP HERE AND SIGN/DATE BELOW. IF NO, PLEASE ANSWER ALL

    THE REMAINING QUESTIONS (9 18) AND SIGN/DATE BELOW.

9) Are your organization’s financial records maintained in accordance with Generally

    Accepted Accounting Principles (GAAP)? <Select>

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    Cancer, Cardiovascular Disease and Pulmonary Disease Competitive Grants Program | Part III: Budget, Budget Narrative and

    Financial Assessment Questionnaire

10) How are the financial records maintained to identify the source/revenue and

    application/expenditure of funds?

11) How are contract funds separately accounted for and allocated in your organizations

    accounting records?

12) Are accounting records supported by source documentation? If so, please provide

    examples of source documentation that is maintained and retained?

13) What controls are followed to ensure all of the following:

    a) the reasonableness of cost;

    b) the allowability of costs; and

    c) the allocability of costs to a contract?

14) Please describe your organization’s overall fiscal controls and structure to sufficiently

    a) permit the preparation of financial reports required by this contract and preparation of

    financial statements;

    b) allow the organization’s staff, in the normal course of performing their assigned

    functions, to prevent or detect misstatements in financial reporting or the loss of assets

    in a timely basis;

    c) allow for accurate, current, and complete disclosure of the financial results of financial

    activities in accordance with the financial reporting requirements of the contract;

    d) permit the tracing of funds to a level of expenditures adequate to establish that such

    funds have not been used in violation of the restrictions and prohibitions of applicable

    statutes, regulations, and contracts; and

    e) maintain and safeguard all organization cash, real and personal property, and other

    assets.

15) This contract will be a cost reimbursement basis. What will be your organization’s source

    of cash and how will your organization manage its cash flow between the time costs are

    incurred and reimbursed?

16) What is the accounting experience and qualifications of the person that is charge of

    maintaining your accounting and financial records?

17) Does your organization have employee fidelity bond/insurance coverage for all its

    employees that handle cash? <Select> If so, what is the coverage amount?

18) Does your organization have an active oversight committee/board and are they provided

    financial reports and information on a regular basis? <Select> If so, please elaborate.

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    Cancer, Cardiovascular Disease and Pulmonary Disease Competitive Grants Program | Part III: Budget, Budget Narrative and

    Financial Assessment Questionnaire

Please Sign and Date Below:

______________________________________ _________________

    (a) Signature Date

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    Cancer, Cardiovascular Disease and Pulmonary Disease Competitive Grants Program | Part III: Budget, Budget Narrative and

    Financial Assessment Questionnaire

    (Budget Template and Sample Budget available at: http://www.cdphe.state.co.us/pp/ccpd/) 2. Budget Template

     (sample)3. Budget Narrative

Year 1: July 1, 2009 through June 30, 2010

    RN Case Manager Charles Butler will provide general project oversight and 1.0 FT coordination

     between the project and staff full-time during the project (12 months for first

     year). Salary calculation is (mid-range) $25.75/hr or $53,560/yr, which is

     $4,463/mo.

Administrative Assistant Susan Smith will provide general administrative support 1.0 FTE for the program.

     Salary calculation is $11.50/hr or $23,920/yr, which is $1,993/mo.

Benefits Benefits are calculated at negotiated fringe benefits rate of 28%.

Printing/Copying 10,000 copies for program brochures @ .20/copy for $2,000; Printing of 75 posters for

    clinics @ $25/each for $1,875. Printing estimates for outreach/educational pamphlets, 300

    @ $1.00/ea for $300.

Meeting Expenses Colorado Health Association will host two trainings @ $750 per training ($300 site fee per

     training; $150 equipment rental per training; food/beverage for 20 people per training @

     $15 per person).

Testing Supplies Glucometer Testing Strips, 20 bottles @ $80/btl for a total of $1,600.

RN Case Manager Estimated mileage for home visits/outreach 2000 miles per year @ .53/mile for a

     total of $1,060.

Subcontractor Innovative Solutions - for database development with John Doe - 1040 hrs @ $10/hr for

     a total of $10,400.

    Evaluation is calculated @ $50/hour for data collection, analysis, and reports. (Estimated

     80 hours during initial 12 month period x $50/hr = $4,000)

Marketing/Media Focus group costs, 10 focus groups @ $600 for a total of $6,000.

Health Screenings 100 people @ $25 each for a total of $2,500

     Indirect cost is calculated @ 2% of subcontracts and 20% of all other total direct costs.

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