Box 3, Folder 2, Document 5

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Box 3, Folder 2, Document 5

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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







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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.

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