.NzUy.NzUy

T O BE COMPLETED BY P H S D EPAR T ME NT OF H EA L TH , EDUC A T I ON , A ND WE LF AR E P U B L IC HE A L TH SE RV I C E D AT E R E CE I V E D OFFI CE OF CO M PREH.ENS I VE H E A L T H P L ANNING 200 1 4 B ETH ESD A , MARY L A ND PH S A C C O U NT NUMB E R GRA NT N U MBER APPLICATION FO R HE AL TH PL ANN ING OR H EA L T H SER V I CES PRO J ECT GRANT I. G RA NT P R O GRAM : 2. T YP E OF O RGA N I Z A T I ON (Se ct i on 3g ( e) (1) l-l.oa 1 t h Services Speci a l Proi e ct Grant [xj LOCAL D D P RIV A TE D D REGIO NA L NONPROFIT OST A T E D L O C AL P U BLIC OsTAT E 3 . P R OJECT T I T L E : , Connnunity Deve lopme nt Aide _Project NAT I O NA L I NTERST A TE ARE AW IDE 4 . TYPE O F AP P LI C A T IO N 5A . P RO J ECT D I RECTO R (Namc, Title , and Address, inc ludin(I Z ip C o d e) [xj IN I T I AL D CONT I NUATION D D REVISION RENEWAL - I I AREA COD E TELEPHON E I SB . DEGREE SC . 9 . AP P L IC ANT OR G AN I z A TION 6 . P R OJ E C T P E R IO D R E QU ES T E D OR A PPR OV i': D F ROM NUMBER SOC I A L S E CU R I TY NU MBER 7. THR OLI GH GR ANT SUPPORT REQUE S TED BY BUD G ET P E R I OD ' · F RO M ( N ame, A d d re s s -Str e e t, C it y, St a te, Zip C o d e) THROU GH AM OUN T s 01 02 03 04 05 - TOTAL s 8 . I ND I R E CT CO ST S I CO UNTY Fu lton and De ka l b CONGR ESS~ON A L D I S T R I C T 1 0 . WH ER E WILL T H E PROJE CT B E CO ND UCTED? D N_O T REQ U ES T ED D R E Q U E ST E D: D R E QUE S T E D : RATE RAT E U N D E R N EG OT I A T I ON % OF AP PR OVED B Y City o f At l anta F O R P E R IO D 11. O FF I C I AL SI GN I NG F O R APP LI C A NT ORG AN I ZAT I O N ( N ame, T i tl e , 12 . F I NA N CI A L O F F I C E R ( N am e, T it l e a nd Addre s s , includ e Z i p Co d e) A d dress, inc l ude Zip C od<l) ·T E L E PHO N E 13 . A R E A COD E I NU M B E R T E L E PHON E I AR E A COD E N UMB E R I AG R EEME NT : Th e u nder s i g n e d ac c ep t as to an y gran t a ward e d, th e obl i gati on t o co mpl y w ith t h e appli cabl e P u bl i c H ea l th Se rvi ce gran t info rm ation a n d p o l i c i es pertin e n t to t h i s pro g r a m in e ffect a t th e t im e o f th e awa r d and a n y speci a l condit io n s t h a t may b e m a d e a p art o f th e awa rd. Th e u n d e r si g n e d al so cer tify th a t pe r sonn e l asso ci a t ed w ith tlie pro j ect h a v e no commitm ent s o r o b li g a ti o n s , in clu di n g those w ith re spect t o in v e n ti ons, i n c on s i s t e n t with D ep a rtm ent R egul a ti o n s ( 42 C.F.R. , P art 8 ) . T h e u nd e r s i g n ed fu rth e r agr ee to co mpl y w ith T i tl e VI o f th e C i v i l Ri g ht s A c t o f 196 4, ( P.L. 8 8 - 352, a nd th e Regula ti o n s i ssu e d pursu a nt th e r e to a nd s t a t e th a t t h e fo , ma l l y fi l ed , or a tt a c h ed A s su ran ce o f Compli a n ce with s u c h R egul a ti o n s (Form H E W 44 1) app l i es t o thi s p ro j ect. S I G NAT U R E S : AUTHO R I ZED O F F I C I A L (NA MED I N I TEM 1 1) DA T E SI GN OR I G I N A L ONLY. P RO J EC T D I RECTOR (N AM E D IN IT EM SA ) U SE I NK. DAT E " pe r" s ig nat ures no t a cc e pt ab le . PH S- 5 0 28- 1 7-6 7 ( P A GE 1) F o rm Ap p ro v e d Budge t B u re n u No. 68- R 098 l -~--- �APP LIC AT I ON/GRANT APP LIC ANT O RGAN I Z AT I ON 14. DE TAIL ED BU DG ET FOR TH IS P ER 10D ANNUAL (DI RE CT COS TS ONLY) · SA L ARY I THROUGH FR OM (1) T OTA L OR REQUESTED EFFO R T FOR PROJECT s Proj ect Director ( 1) Vector Control Spe c ia lis t (1) Eva lua tion Off icer ( 1) Oper a tions Offi c er (1) Budget and Financia l Of f i c er (1) Community Hea l t h Special ist ( 2) · Housing Inspector (2) Sanitary Supervisor (6) Commun ity Organizer (3) · 150 Ai des@ $1.65 per hour - 40 hours per week 100 Aides @ $1-. 65 per hour - 15 hours per week 50 Aid es @ $1.65 per hour - 40 hours per week . 10,000 9,000 9 , 000 9,000 8,000 7,000 7,000 6,000 6,000 Full Fu ll Full Full Full Full AMOUNT APPLICANT REQUESTED SH ARE (3 ) (2 ) s A . PERSONNE L , % TI ME NO. FRO M PHS (4 ) (5) s s Full Full 10,000 9,000 9 , 000 9,000 8,000 14,000 7,000 36,000 18,000 10,000 9,000 9 , 000 9, 000 8,000 14 ,000 7,000 36 , 000 18,000 5 14,500 14 wks . 138 , 600 138 , 600 128 ,700 38 wks . 94, 050 94 ,050 173,166 38 wks . 126,540 126 ,s1~0 % '· - FR I N GE BENEF I TS 5% CA TEGO R Y TOTA L B. C ONS U LT A N T SERV I CES S c; n ~ ll..Q 23. 960 S503.149 s ( i nclude fees and travel) 3 , 000 Consu ltat ion Fees CAT E GORY TOTAL S 3 000 · 2,000 1,000 s 1. 000 s 2. 000 C . EQUIPMENT Movie Projectors@ $200 each Slide Pro j ectors@ $50 each Typewriters (Rental or Purcha se) @ $300 e a ch Duplicating Ma chine (Us ed, Rent or Purchase) De sks and Cha irs @ $150 1 Mixing Machine (L-800) 1 Mixing Bowl (80 Qua rt Capacity) 1 Packaging Machine 1 Auto Bus 50 Uni forms @ $15 each 10 Mode l D Duste rs@ $5 .20 each CA T E GOR Y TOTA L S U B- T OTA L TH I S PAGE PH S·S028· 1 7 •67 ( PAGE 2 ) - ( carrie d forward t o page 3) B U DGET PAGE 1 OF 2 S s 200 50 300 2,000 450 1,885 200 50 300 400 100 600 2,000 900 1,885 2 2 2 1 6 450 71 71 2,000 3,000 750 52 2,000 3,000 400 52 11 i~A 517.907 350 s 1 s ~ "o 2,350 s 10 s ?t:08 515.557 r �APP LI CANT ORG A NIZAolON AP P LIC A T I ON/GR A NT NO . 14. DETA ILED BUDGET FO R THIS PER IOD (Continued) I FROM T OTA L REQUESTED FO R PROJEC T THROUGH APP LI CANT SH ARE A MO U M T R E QU ESTED FRO M PHS (4) (5) ( 3) s SU B-T O T A L (B r ou ght for wa rd fr o m p::i gc 2) 5 517 . 907 s 2.350 515 . 557 D . SU PPL I ES C A T EGORY TOTAL 26 ,818 26,818 Su_ppl ies (S ee De t ai l ed Exp l anation on Page 4A) s A18 ?h s s 26 -81 8 E. TRAVE L Au t o Expense fo r Staff 2, 500 500 2,000 Travel Ou t of Town fo r PHS and Other Types of Meetings 2,000 500 1 ,500 -. CA T EGORY TOTA L s I, r;. no s , 1 non s 3 500 F. OTHER EXPENSES CATEGORY TOTAL 11 - ?.( ')

 ::::::: ,:::::: :::? ::::;:: Z I?

·:-:•:· -:-;.;,

. -:-:-:-:-:

H. TOTAL DIRECT COSTS OF PROJE CT r: ,: : :, : :;-;: :=::,:::: ;::::::: ,::::::: s -:-:-: -:-::-:-: \i \i? :; .:-:-:, -:-:-:.: ;;;:::::::::::i :::::::: ?) ?)(? ? ?Y

 :::::: :;;;: ;:;:::: ;:;:::: ::/ )i

i? }) }: ::\ () s 5 565-425 5 . 951 s F OR PHS USE ONLY I. IND IRECT COST ALLOWANCE J. TOTAL PROJECT COSTS s s s s s s 15 . SOURCES OF FUNDS FOR AP P LICANT SHARE OF DIRECT PROJECT COSTS A . APPLI CAN T ' S O WN FU N DS B . FEES T O BE E ARN E D° BY PROJE CT C. GR AN TS F R O M NO N- FEDE RA L FU N D S D . PART ICIP A TI ON B Y OT H ER A G E NC IES OR OR GA NIZATIO N S (IDENTIFY) E. OTHER SOURCE (EXPLAIN ) PHS-5028 • 1 (PA GE 3) 7-67 BUDGET PAGE 2 OF 2 13 . 600

 : : : :': : :/: : : ::: : : : : ; ,: : : /: })

-:-:-:

'/ ::, ,> I 2. DIRECT ASSIS T ANCE s 2 600 s ?i ii :r: ;:; : ; 1. FI NANC I AL ASSISTA N CE ( CASH AWARD) G. REQUESTED FR OM PHS 2 ,100 1, 500 2 ,000 8, 000 2 , 100 500 4 ,2 00 2 , 000 2 , 000 8, 000 Office Rental Printing and Training and Cirr i culum Material Other Pr ogram Supplies (Poisons , Traps, Tools, etc .) Six Dump Trucks, one year (Rent ) 559.475 �APPL I CANT ORGAN I ZATION APPLIC ATION NUMBER 16. ESTIMAT ES FOR FUTU RE YE ARS OF PROJ ECT SU PP ORT . (DI REC T co sTs ONLY) A D DI T IONAL YEARS SU PPORT REQUEST ED 1ST BUDGET YEAR ' s 3RD BUDGET YEAR 2ND BUDG ET YEAR 4TH BUDGET Y E AR 5TH BUDGET YEAR s s s s s s s s s s s s s s s s s s s $ s $ s s A. FINANCIA L ASSISTANCE (1) PERSONN EL 503,149 (2) CO NSUL T AN T SERVICE S 3 ,000 ( 3 ) EQ UI PM E NT 11 . 758 (4) SUPP LI ES 26,818 (5) T RA VEL 4. 500 (6) OTHER E XPENSES 16.200 s (7) SUB T OTAL , FI NANCIAL ASSISTANCE s B. DI RECT ASSI ST ANCE . C. TO T AL PHS COST S s -. s D. APPLICANT SHARE E. TOTAL PRO J ECT COST 565 .425 s 559.475 5.951 565.425 REMARK S: Line 14, D, items 3 , 4 and 5 SUPPLIES TOTAL REQUESTED FOR APPLICANT SHARE AMOUNT REQUESTED FROM PHS PROJECT Warfar in ( . 05) 6,000 lbs. @ 70¢ per pound; D. D. T. {10% Dust) 6,000 lbs. @ 8¢ per pound; Red Squill (500 mg . per kg. Fortified) 6,000 lbs . @ $2.00 per pound; Yellow Corn Meal (Coarse Ground) 180,000 lbs.@ 5¢ per pound; Fish (Cheap Grade) 100 Cases @ $8.16 pe r ca se; Masking Compound (Emulsifiable Concentrate) 50 gallon drum; Ten First Aid Kits; Fifty 2- cell flashligh t s and ba tte ries; $ 4,200 $ 4,200 480 480 12,000 12,000 9,000 9,000 816 816 122 100 122 100 100 100 · $26,818 , PHS- 5028- 1 ( PAGE 4A ) - FUTU RE ES TI MATES 7 -67 $26,818 · ' �(PAGE 4B) ,I 1 Line 14, A, Items 11, 12 and 13 One of the major objectives of this project is to provide employment for indigenous, unemployed youth and'adults in all phases of this project. The primary personnel request is to achieve that objective. Employment of 150 aides at $1.65 an hour provides a significant number of unemployed persons with a job. It also enhances the success of this project. Line 14, B, Consultation This project is requesting only $2,000 support for consultation. Many organizations and departments have agreed to provide consultation services and technical assistance as in kind contributions. �