Box 3, Folder 2, Document 5

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DEPARTMENT OF
HEALTH, EDUCATION, AND WELFARE
PUBLIC HEALTH SERVICE

OFFICE OF COMPREHENSIVE HEALTH PLANNING
BETHESDA, MARYLAND 20014

APPLICATION FOR HEALTH PLANNING OR HEALTH SERVICES



TO BE COMPLETED BY PHS



DATE RECEIVED



PHS ACCOUNT NUMBER



GRANT NUMBER

PROJECT GRANT





1. GRANT PROGRAM:

(Section 314 (e) (1)
Health Services Special Project Grant

3. PROJECT TITLE:

Community Development Aide Project

2. TYPE OF ORGANIZATION

PUBLIC [_]STATE LJ INTERSTATE
[x] LocaL [_] AREAWIDE
PRIVATE [_] NATIONAL (J REGIONAL

NONPROFIT

(| state [_] Local





5A. PROJECT DIRECTOR(Name, Title, and Address, including Zip Code)

4. TYPE OF APPLICATION

[ag] INITIAL

[_] CONTINUATION

[_] RENEWAL [_] REVISION





6. PROJECT PERIOD REQUESTED OR APPROVED

































AREA CODE NUMBER FROM THROUGH
TELEPHONE
5B. DEGREE 5C. SOCIAL SECURITY NUMBER 7s GRANT SUPPORT REQUESTED BY BUDGET PERIOD
FROM THROUGH AMOUNT
9. APPLICANT ORGANIZATION (Name, Address-Street, City, State, o1 s
Zip Code)
02
03
o4
os
TOTAL - $





COUNTY

Fulton and Dekalb

CONGRESSIONAL DISTRICT

5





10. WHERE WILL THE PROJECT BE CONDUCTED?

City of Atlanta

8. INDIRECT CoOsTs
(_] Not REQUESTED

[_] REQUESTED: RATE UNDER NEGOTIATION

[ ] REQUESTED: RATE % OF

APPROVED BY



FOR PERIOD





11. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION (Name, Title,
Address, include Zip Code)

12. FINANCIAL OFFICER ( Name, Title and Address, include Zip Code)



AREA CODE NUMBER

TELEPHONE



AREA CODE NUMBER

TELEPHONE





AGREEMENT: The undersigned accept as to any grant awarded, the obligation to comply with the applicable Public Health Service grant informa-

tion and policies pertinent to this program in effect at the time of the award and any special conditions that may be made a part of the award. The
undersigned also certify that personnel associated with the project have no commitments or obligations, including those with respect to inventions,
inconsistent with Department Regulations (42 C.F.R., Part 8). The undersigned further agree to comply with Title VI of the Civil Rights Act of
1964, (P.L. 88-352, and the Regulations issued pursuant thereto and state that the foqmally filed, or attached Assurance of Compliance with such

Regulations (Form HEW 441) applies to this project.



SIGNATURES:

SIGN ORIGINAL ONLY.

AUTHORIZED OFFICIAL (NAMED IN ITEM 11)

DATE



USE INK.
“*per"’ signatures not
acceptable.



PROJECT DIRECTOR (NAMED IN ITEM 5A)

DATE





PHS-5028-1
7-67

(PAGE 1)

Form Approved
Budget Bureau No. 68-RO0981









































APPLICANT ORGANIZATION / APPLICATION/GRANT NO,
14. DETAILED BUDGET FOR THIS PERIOD % TIME TOTAL AMOUNT
(DIRECT COSTS ONLY) SRN er OR REQUESTED sa i REQUESTED
FROM THROUGH BALERS EFFORT FOR PROJECT SHARE FROM PHS
(1) (2) (3) (4) (5) '
A. PERSONNEL $ s s s
Project Director (1) 10,000 | Full 10,000 10,000
Vector Control Specialist (1) 9,000 | Full 9,000 9,000
Evaluation Officer (1) 9,000 | Full 9,000 9,000
Operations Officer (1) 9,000 Full 9,000 9,000
Budget and Financial Officer (1) ‘ 8,000 | Full 8,000 8,000
Community Health Specialist (2) 7,000 Full 14,000 14,000
Housing Inspector (2) 7,000 5 7,000 7,000
Sanitary Supervisor (6) 6,000 | Full 36,000 36,000
Community Organizer (3) 6,000 | Full 18,000 18,000
‘150 Aides @ $1.65 per hour - 40 hours
per week 514,500 |14 wks. 138,600 138,600
100 Aides @ $1.65 per hour - 15 hours
per week 128,700 |38 wks. 94,050 94,050
50 Aides @ $1.65 per hour - 40 hours
per week 173,166 |38 wks. 126,540 126,540
FRINGE BENEFITS 5 %. 23,960 23,960
CATEGORY TOTAL |$ 603 419 S $ 503,149
B. CONSULTANT SERVICES (include fees and travel) .
Consultation Fees 3,000 | 1,000 2,000
CATEGORY TOTAL |§$ 3,000 S 1,000 $ 2.000
Cc. EQUIPMENT
2 Movie Projectors @ $200 each 400 200 200
2 Slide Projectors @ $50 each 100 50 50
2 Typewriters (Rental or Purchase) @ $300 each 600 300 300
1 Duplicating Machine (Used, Rent or Purchase) 2,000 2,000
6 Desks and Chairs @ $150 900 450 450
1 Mixing Machine (L-800) 1,885 1,885
1 Mixing Bowl (80 Quart Capacity) 7 71
1 Packaging Machine ; 2,000 2,000
1 Auto Bus 3,000 3,000
50 Uniforms @ $15 each ‘ 750 350 400
10 Model D Dusters @ $5.20 each 52 52
CATEGORY TOTAL |$ 1758 53.3501 $ 10,408 __
SUB-TOTAL THIS PAGE (carried forward to page 3) $ 517,907 5 2,350 |°515,557_









PHS-5028-1 (PAGE 2) —- BUDGET PAGE 1 OF 2
7-67




APPLICANT ORGANIZATION

APPLICATION/G

RAN TNO.



14. DETAILED BUDGET FOR THIS PERIOD (Continued)













































TOTAL ag
REQUESTED APPLICANT Beguie cee
FOR SHARE eal eke
FROM THROUGH PROJECT 1
(3) (4) (5) j
SUB-TOTAL (Brought forward from page 2) s 517,907 $9 350 s 515,557
D. SUPPLIES
Supplies (See Detailed Explanation on Page 4A) 26,818 26,818
CATEGORY TOTAL |S 96.818 s S 26,818
E. TRAVEL
Auto Expense for Staff 2,500 500 2,000
Travel Out of Town for PHS and Other Types of
2,000 500 1,500
Meetings ’
CATEGORY TOTAL [5 4.500 $ 1.000 5 3.500
F., OTHER EXPENSES ri
Office Rental 4,200 2,100 2,100
Printing and Training and Cirriculum Material 2,000 500 1,500
Other Program Supplies (Poisons, Traps, Tools, etc.) 2,000 2,000
Six Dump Trucks, one year (Rent) 8,000 8,000
CATEGORY TOTAL $ 16.200 5 9.600 $ 13,600
1, FINANCIAL ASSISTANCE (CASH AWARD)
G. REQUESTED
FROM PHS
2. DIRECT ASSISTANCE
s $s $
H. TOTAL DIRECT COSTS OF PROJECT 565,425 5.951 559,475
FOR PHS USE ONLY
1. INDIRECT COST ALLOWANCE
Ss $s Ss
J. TOTAL PROJECT COSTS s s $
15. SOURCES OF FUNDS FOR APPLICANT SHARE OF DIRECT PROJECT COSTS
A, APPLICANT’S OWN FUNDS
B. FEES TO BE EARNED BY PROJECT
C. GRANTS FROM NON-FEDERAL FUNDS
D. PARTICIPATION BY OTHER AGENCIES OR ORGANIZATIONS (IDENTIFY)
E, OTHER SOURCE (EXPLAIN)
= | TOTAL APPLICANT SHARE Ss













PHS-5028-1 (PAGE 3)
7-67

BUDGET PAGE 2 OF 2


APPLICANT ORGANIZATION



APPLICATION NUMBER



16. ESTIMATES FOR FUTURE YEARS OF PROJECT SUPPORT (nIRECT COSTS ONLY)







































= ADDITIONAL YEARS SUPPORT REQUESTED
1ST BUDGET
YEAR 2ND BUDGET 3RD BUDGET 4TH BUDGET STH BUDGET
YEAR YEAR YEAR YEAR
$ $ $
A. FINANCIAL ASSISTANCE
(1) PERSONNEL
503,149
(2) CONSULTANT
SERVICES 3,000
(3) EQUIPMENT
11,758
(4) SUPPLIES 26,818
(5)
TRAVEL 4,500
(6) OTHER EXPENSES
16,200
(7) SUBTOTAL, FINANCIAL S$ Ss s §
ASSISTANCE 565,425
$s Ss $ $
B. DIRECT ASSISTANCE
$ Ss $s $
C. TOTAL PHS COSTS
559,475
D. APPLICANT SHARE F C 2 v
i 595%
E. TOTAL PROJECT COST . *. e
565,425
REMARKS:
Line 14, D, items 3, 4 and 5
SUPPLIES TOTAL APPLICANT AMOUNT
REQUESTED SHARE REQUESTED
FOR FROM PHS
PROJECT
Warfarin (.05) 6,000 lbs. @ 70¢
per pound; $ 4,200 $ 4,200
D. D. T. (10% Dust) 6,000 lbs.
@ 8¢ per pound; 480 480
Red Squill (500 mg. per kg.
Fortified) 6,000 lbs. @ $2.00
per pound; 12,000 12,000
Yellow Corn Meal (Coarse Ground)
180,000 ibs. @ 5¢ per pound; 9,000 9,000
Fish (Cheap Grade) 100 Cases @
$8.16 per case; 816 816
Masking Compound (Emulsifiable
Concentrate) 50 gallon drum; 122 122
Ten First Aid Kits; 100 100
Fifty 2-cell flashlights and.
batteries; 100 100
‘$26,818 $26,818



*PHS-S028-1 (PAGE 4A) — FUTURE ESTIMATES
7-67






(PAGE 4B)

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,




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