application checklist - indiana · smokefree air model ordinance agreement brand use ... does the...

APPLICATION CHECKLIST

APPLICATION SECTION COMPONENTS INCLUDED

Administration

Cover Sheet and Lead Agency ProfileLead Agency Responsibility ChecklistContract Requirements ChecklistWork Plan Progress and Goals FormSmokefree Air Model Ordinance AgreementBrand Use AgreementAttachments:

• Organizational chart - include staff that would be paid for by grant

• Lead Agency’s Tobacco-Free Grounds Policy

Coalition Assessment

Coalition Assessment FormSummary of Coalition PartnersAttachments

• Five Letters of Support from Committed Coalition Partners• Copy of Tool Used to Recruit Prospective Coalition Partners

2019-2021 Work Plan Completed Work Plan Forms

Budget

TPC Declarations FormAttachments:

• Provided Excel Budget Template which includes:• Budget Worksheet Form• Budget Narrative Form

• Provided Scope of Work Form • Job Description of Program Coordinator (and any other

employee paid by the TPC grant)• Audited Financial Statements, if applicable• Subcontract Forms, if applicable

Disclaimer: By completing a “Signature” or “Initials” box on any form with your typed name or initals you are, for all legal purposes, signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on any form submitted.

Application Forms

Section 1: Administration

This section outlines the accomplishments of the coalition during the 2017-2019 grant period. Be succinct but demonstrate success. The applicant should focus on the work toward indicators in the four priority areas and any policy and social norm changes that have occurred. Also included in this section is an opportunity for the coalition to identify goals it would like to achieve during 2019-2021 grant cycle. Forms to complete in this section:

• Application Cover Sheet and Lead Agency Profile o Note: at least three different signatures from the organization are required on

Application Cover Sheet

• Lead Agency Responsibilities checklist • Contract Requirements checklist • Work Plan Progress and Goals Form

• Smokefree Air Model Ordinance Agreement • Brand Use Agreement

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Tobacco Prevention and Cessation ProgramJuly 2019–June 2021

Application for Local Community-Based or Minority-Based Partnerships

Lead Agency Name County

First Name Last Name Title

Address City Zip Code

Phone Number Fax

Email Federal Identification Number (Please only include on original application)

Signature


Address (If different from above) City Zip Code

Phone Number Fax

Email

Signature

Lead Agency Contact

Primary Contact to TPC



Phone Number Fax

Email

Signature

Primary Contact Supervisor



Phone Number Fax

Email

Signature

Lead Agency Financial Contact

Proposal Information

Specify indicators selected in this application (beyond required indicators)

1 2 3 4 5 7 8 9 11 12 13 14 15 16

Total Funding Requested 3

1. Describe the rationale for the selection of the Lead Agency. This description should include the Lead Agency’s abilityand flexibility in serving as an effective leader for policy-focused interventions.

2. Provide a brief history of the agency, including the agency’s role in the community and its role with the coalition.

3. Describe the Lead Agency’s role in coordinating the development of the proposed work plans. Include informationon the means by which the Lead Agency will assure that the activities and outcomes of the program will beaccomplished, and any areas of anticipated difficulty for the Lead Agency.

4. Is there a coordinator for this program? ____ Yes ____ NoIf no, please describe the process by which the agency will hire a coordinator for this grant project.

5. Describe how the program is to be organized, staffed and managed. Include the following:

a. To whom does the coordinator report within the Lead Agency

b. List the normal working hours for the coordinator and any other staff paid through this grant.

6. Does the Lead Agency accept funds or other resources from any tobacco company, any of its subsidiaries or parentcompany? ____ No ____ YesIf yes, please describe.

7. Does the Lead Agency provide insurance coverage or other support for tobacco dependence treatment (smokingcessation) for employees? ____ No ____ YesIf yes, please describe.

Lead Agency Profile

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Lead Agency ResponsibilitiesPlease acknowledge each of the Lead Agency responsibilities listed below by marking the boxes below. As fiscal agent, the Lead Agency must:

Financial Capabilities ѣServe as the fiscal officer for the grant ѣHave a Federal Identification Number registered to the Lead Agency ѣSubmit Monthly or Quarterly Invoices by due dates ѣRespond timely to periodic information requests ѣBe registered with the Indiana Secretary of State ѣBe a registered Bidder with the State ѣFulfill the terms of the contract ѣEstablish a separate account or ledger for grant funds to ensure that TPC funds are not comingled with other funds ѣParticipate in monitoring engagements to review fiscal compliance ѣConduct an audit to be paid by grant recipient (if required by law) ѣProvide additional financial information if requested

Programmatic Responsibilities ѣParticipate actively in the preparation of the work plan ѣEnsure that the Lead Agency is educated on tobacco control best practices ѣActively participate in the coalition, with representation from the Lead Agency other than the coalition coordinator ѣDemonstrate collaboration with other key partners in the preparation of the work plan ѣAgree to serve as the key point of contact for required reporting to TPC ѣSubmit Monthly Program Reports by due dates ѣRespond timely to periodic information requests ѣIn the temporary absence of a coalition coordinator, ensure that the Lead Agency is represented at coalition meetings and TPC required trainings such as training events, conference calls and regional cluster meetings ѣAssure that all grant related staff (coalition coordinator) participate in all TPC training events ѣParticipate in all evaluation and accountability activities including monitoring of subcontracts ѣPromote and conduct the Youth Tobacco Survey data collection. Disseminate results to school administrators ѣDesignate an in-house Lead Agency staff person to serve as the Supervisor for the Coordinator. Coordinator will report directly to the Lead Agency staff person.

Coalition Responsibilitiesѣ Assure that a qualified coalition coordinator is employed full or part time to this grant program. Additional staff may be hired based

on the needs of the coalition and the work plan.ѣ Assure that hours billed to this grant for staff time are devoted solely to working on the approved work plan.ѣ Assure that resources are available for the coalition that may include meeting accommodations and notices, logistical assistance,

and other necessary support.ѣ Assure that a communication mechanism is developed and maintained to keep coalition members informed of activities and events ѣ Assure that the coalition’s member organizations are provided opportunities to develop specific experience in tobacco prevention

and cessation interventions

Director of the Lead Agency

Signature Date

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Contract Requirements The following are requirements for funding for all TPC community-based and minority-based grants. Please acknowledge each of the contract requirements listed below by checking the corresponding boxes. The Coalition Coordinator and Lead Agency must:

ѣ Work on Indicators their corresponding contract deliverables• Point-of-Sale: Extent of broad-based community support for tobacco point-of-sale strategies at the local level.• Tobacco-free Worksites: Proportion of local smoke-free air ordinances for all worksites, including restaurants,

bars, membership clubs, and gaming facilities.• Multi-Unit Housing: Proportion of comprehensive smoke-free policies in multi-unit housing. • Quitline: Extent of utilization of the Indiana Tobacco Quitline throughout the community.• Employers: Extent of tobacco cessation benefits provided by employers.• Coalition: Extent of participation by partners within the broad-based coalition.• Priority Populations: Extent of participation by groups serving priority populations in the community. • Tobacco-free Families: Extent of organizations serving priority populations that have received training on the

Breathe: Healthy Steps to Living Tobacco Free education program

ѣSubmit complete and accurate invoices and monthly program reports by the due date. ѣAdminister the 2020 Youth Tobacco Survey in local or surrounding schools, if selected. This may include schools in neighboring counties. ѣParticipate in all required TPC trainings. Program staff agree to accept technical assistance from TPC throughout the course of the grant period to implement their respective work plan. All new coordinators are required to participate in the TPC New Coordinator Training Program. ѣCollaborate with TPC statewide and national partners on initiatives when appropriate and as directed. For a list of current statewide partners and description of projects, visit http://www.in.gov/itpc/2349.htm. ѣWhen working with organizations such as school districts, hospital systems, behavioral health centers, college and university campuses, and other workplaces on tobacco-related policy change in addition to city and county ordinances, current model policies provided by TPC must be used. ѣProvide TPC with a copy of all newly-passed tobacco-free policies, including but not limited to the following settings: school districts, university/college and other post-high school training institutions, behavioral health centers, public housing and other multi-family housing, hospital campuses, and community health centers. When a local smoke-free air ordinance passes or is amended, provide TPC with a copy of the signed and filed (“official”) community smoke-free air ordinance. ѣAdhere to TPC communication requirements, which includes completing and maintaining a communications plan (see Recommended Communication Outreach reference page as a guide) and using all media materials (i.e. swiss cheese press releases and media advisories) that TPC instructs partners to customize and distribute to local media outlets. ѣIdentify and educate state and local policymakers about the burden of tobacco use and how tobacco companies target disparately affected populations. ѣDemonstrate collaboration throughout the work plan between the TPC funded minority-based and community-based partnership(s) in your community, if applicable. ѣRespond in a timely manner to ALL information and data requests from TPC throughout the duration of the grant cycle.

Director of the Lead AgencySignature ___________________________________Date___________

Name and Title _____________________________________

CoordinatorSignature ___________________________________Date___________ Name _____________________________________

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Work Plan Progress and Goals FormTPC is interested in understanding the coalition’s success and vision by Priority Area:

• Decrease youth smoking rates• Increase proportion of Hoosiers not exposed to secondhand smoke• Decrease adult smoking rates• Protect and maintain a state and local infrastructure necessary to lower tobacco use rates

List progress made by the local coalition toward reducing tobacco use during the 2017-2019 grant period (currently TPC funded applicants only). Provide facts to support success. Include at least three goals for the Priority Area that are well documented and explained in the 2019-2021 Work Plan.If this is the first year for application, please complete the goal sections for each Priority Area.

Start with the Priority Area that is most important to the coalition.

Priority Area:

List success/progress during 2017-2019:

Include at least three realistic goals in this Priority Area that are more detailed in the 2019-2021 Work Plan:

Priority Area: List success/progress during 2017-2019:


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Smokefree Air Model Ordinance Agreement

TPC, along with other state and national public health organizations, has adopted a model Smokefree Air ordinance to be used in state and local smokefree air campaigns throughout Indiana. This model ordinance provides fair and sound language that clearly states the intent and specific points of smokefree policy, fosters clear implementation and enforcement, stands up to legal challenges, and achieves the health goal of protecting people from secondhand smoke (ANR, 2014).

All TPC grantees must agree to use the model ordinance in their local smokefree air campaigns recognizing its importance as a comprehensive policy that protects all workers from secondhand smoke.

Coordinator

Signature _____________________________________

Date ___________

Coalition Chairperson

Signature _____________________________________

Date ___________

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Brand Use Agreement

The Tobacco Prevention and Cessation Commission hopes its partners will promote media messages. However, to ensure appropriate use of messages and campaign brands, TPC has guidelines for use of its campaign brands. These include the following:

• Indiana Tobacco Quitline• 1.800.QUIT.NOW• Quit Now Indiana• Breathe Easy Indiana• Indiana Smoke-free Housing• VOICE

All grantees must agree to seek written approval from TPC prior to using any of these brands. Grantees must contact their Regional Director for written approval and appropriate brand distribution on the following elements, but not limited to:

Advertising (print, radio, TV, digital)WebsitesBrochures, ManualsPalm Cards, FlyersDisplays, SignageLetterhead, EnvelopesForms, LabelsSpecialty Items

Coordinator

Signature _____________________________________

Date ___________

Coalition Chairperson

Signature _____________________________________

Date ___________

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Section 2: Coalition Assessment The Coalition Assessment section addresses how the coalition plans to build and maintain partnerships across diverse sectors of the community in order to sustain a broad-based coalition of support for social norm changes related to tobacco prevention and cessation. Applicants are required to provide five (5) unique letters of support. If the coalition is comprised of multiple lead agencies, applicants should provide letters of support that are specific to their own lead agency. A significant portion of this section is devoted to identifying and assessing the population groups in the community that are disparately affected by tobacco and describing the collaboration between the community and minority-based partnerships, where applicable. Forms to be completed in this section:

• Coalition Assessment • Summary of Coalition Partners

Attachments to be included with this section:

• A copy of the tool used to recruit prospective coalition partners

• Five (5) unique letters of support from a variety of committed coalition partners outside of the lead agency. Included in each letter should be the role of the coalition partner, what resources they will dedicate to the coalition and how their work with the coalition fits within their organizational mission.

_ Note: Three (3) of the letters should be from the following sectors: Health Care (e.g. physician, dentist, nurse, hospital, community health center,

health care administration) Business (e.g. economic development corporation, chamber of commerce,

business professional association) Civic (e.g. city council member, mayor, local policymaker)

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Coalition AssessmentThis section of the application addresses how the coalition plans to build and maintain a partnership across diverse sectors of the community in order to sustain a broad-based coalition of support for social norm changes related to tobacco control.

Membership• Describe the coalition’s structure including leadership and the responsibilities of each level of membership (please include total

number in coalition, number in database, frequency of meetings, approximate number of partners that attend coalition meetings, formalleadership positions – chair, vice-chair, etc. and the primary organizations represented).

• Provide a list of the standing committees or work groups and how often they meet.

Diversity of Coalition• Describe the area of greatest growth in the diversity of the coalition during the 2017-2019 grant period.

• What gaps exist in current coalition membership that must be filled to impact tobacco control in the community? Identify the plan foraddressing these gaps.

Reaching Disparately Affected Populations• Summarize your top three work plan accomplishments in reaching disparately affected populations during the 2017-2019 grant period.

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Coalition Assessment (continued)

Tobacco Control Advocacy Database SectionThis is a group of individuals that are interested in tobacco control issues, but are not regular members of your coalition.

• How many advocates are currently in your database?

• How do you recruit for this database? Please be specific and describe how often recruitment occurs.

• How many times in the last year did you communicate with your database? What were the topics?

Online media presence. Provide a link, if applicable.

Does the coalition have:

• A Facebook page? Yes No

• A Twitter account? Yes No

• Other social media accounts or blogs? Yes No

• A website specific to the coalition? Yes No

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BUSINESS CIVIC

EDUCATION FAITH

HEALTH CARE YOUTH

OTHER

Summary of Coalition Partners

Please provide a list of partner organizations by sector

TOTAL NUMBER OF PARTNER ORGANIZATIONS

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Section 3: 2019-2021 Work Plan

Please complete at least one work plan form for each Community Indicator your coalition will work on. The coalition may choose to write more than one work plan for the same Community Indicator if they have more than one SMART Objective they want to address for the Community Indicator. Use as many forms as needed. Reference sample work plans section. Reference pages xxx for a complete listing of the Priority Areas, Community Indicators, and Contract Deliverables.

Instructions for completing the Work Plan Form:

1. Priority Area – Select the Priority Area associated with the Community Indicator coveredby the work plan.

2. Community Indicator – Select the Community Indicator for the work plan.

3. SMART Objective – Create one SMART Objective for the Community Indicator. A SMARTObjective is Specific, Measureable, Achievable, Results-oriented, and Time-limited. Itstates where you started, where you are going, when you plan to arrive, and how you willknow you have arrived. Reference SMART Objective resource page xxx.

4. Baseline Measurement – Provide baseline data for the Community Indicator. This sectionshould include one or two sentences describing the current status of the CommunityIndicator in your community and cite sources for the data listed. Examples of data sourcesinclude the coalition’s tracking mechanisms and databases, community surveys, coalitionassessment, monthly program reports, etc.

5. Deliverable - Copy and paste each deliverable for your selected Community Indicator intoits corresponding box on the work plan form.

6. Strategies - Select one or more strategy categories that apply to the coalition’s work foreach deliverable. The different categories include: Data, Education, Media andCommunication, Partnership Building, Policy Implementation and Maintenance

It may be easier to select the strategy/strategies once you complete your list of activities.

7. Activities – Write a brief list of activities that the coalition will need to complete in order tofulfill the corresponding deliverable. All of your activities for each deliverable should worktowards completing your SMART objective for the selected Community Indicator on thatwork plan.

8. Partners and Timeframe - List coalition partners who will work on each deliverable, andindicate a timeframe or activity frequency for completion of the deliverable.

Signatures – All work plan forms must be reviewed by a representative of the Lead Agency, the Coordinator, and a representative of the coalition. There is an electronic signature page at the end of the work plan section for signees to indicate that they have reviewed all work plans.

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Work Plan Form Priority Area: Community Indicator:SMART Objective for indicator:

Baseline measurement for this indicator:

Data source for baseline measurement:

DELIVERABLE STRATEGIES ACTIVITIES (LIST) PARTNERS TIMEFRAME

Data

Education

Media & Communication

Partnership Building

Policy Implementation & Maintenance

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I have read and commit to all work plans submitted with this RFA:

Lead Agency Representative: _________________________

Coordinator: _________________________

Coalition Representative: ___________________________

Work Plan Approval

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Section 4: Budget

The section describes the operation costs to continue tobacco control programming through June 30, 2021.

Forms to be completed in this section:

• Budget Worksheet Form• Budget Narrative Form• Scope of Work Form

Attachments included in this section:

• Audited financial statements (required for all non-governmental entities).• Subcontract forms for all subcontracts to be executed, if applicable.• Job Description(s)

Reminder: Provide a written Job Description for all positions funded through this grant. Submission of a resume does not replace the job description requirement.

If the coalition is selecting the YOUTH EMPOWERMENT/VOICE (Indicator 2), personnel must be added to the budget and budget narrative. A job description must be included with the application.

NOTE: The submitted budget is not the final budget. The final budget, including proposed subcontracts, must be approved by the Regional Director.

Budget Form Download Instructions:

Visit https://www.in.gov/isdh/tpc/2348.htm and look for the heading: Local Community/Minority Based Partnership Grant

Download the Excel file that contains the Budget Worksheet and Budget Narrative formsDownload the Scope of Work file (Word document)

Complete these forms and submit them with your full application. Please refer to the Instructions for Electronic Submission document (located on the same webpage) for more information.

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Upon approval of the grant application, new Lead Agencies will be required to submit the IRS W-9, Direct Deposit Authorization, and complete an online Bidder Registration prior to receiving a contract from the State of Indiana.In

Upon approval of the grant application, existing Lead Agencies will be required to confirm their Employer Identification Number (EIN) and submit a Direct Deposit Authorization if the signatory has changed since the last grant cycle prior to receiving a contract from the State of Indiana.

TPC Declarations Form•

https://www.in.gov/isdh/tpc/2348.htm

Tobacco Prevention and Cessation Commission (TPC) Declarations

Must be initialed and signed by the signatory authority of the Lead Agency

ѩ The TPC may seek additional information from an applicant prior to or during the review of the application.

ѩ The TPC reserves the right to negotiate a modification of the proposed work plan and will award funds after agreement has been reached.

ѩ The TPC reserves the right to examine the physical location, all books, documents, papers, accounting records, and other evidence (Records) pertaining to the administration of the community program upon request and copies thereof shall be furnished at no cost to the Tobacco Prevention and Cessation Commission.

ѩ The signatory for this Organization represents that he/she has been duly authorized to executive agreements on behalf of the organization and has obtained all necessary or applicable approvals from the home office of the organization.

ѩ It is policy of the TPC that any organization or individual receiving funding from TPC must agree as a condition of receiving funds that they will not accept any funding from the tobacco industry. By entering into this grant agreement the grantee agrees to abide by this policy during the term of this agreement. Any violation of this clause by the grantee could lead to termination of this agreement by the State.

ѩ It is policy of the TPC that any organization or individual receiving funding from TPC must agree as a condition of receiving funds that they will adopt a tobacco-free campus policy. By entering into this agreement the grantee agrees to abide by this policy during the term of this agreement. Any violation of this clause by the grantee could lead to termination of this agreement by the State.

By initialing above and signing below you indicate that you have read and understand these declarations. For questions and assistance please call: Tobacco Prevention and Cessation Commission at (317) 234-1787

__________________________________ ____________________ Signature Date

__________________________________ Printed Name

________________________________________________________ Lead Agency Name

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Community-Minority Grant Agreement Lead Agency Sub-Contract Template

County:______________________ Lead Agency:__________________________________

Grant number:_________________ Lead Agency Fax:______________________________

Name of person with Lead Agency that will supervise or manage the sub-contractor: _____________________________________ Name of sub-contracting agency (or individual): _____________________________________

Name of responsible person with sub-contractor: _____________________________________ Address: _____________________________________________________________________

City: ________________________________ State: _____ Zip___________________________ Telephone: _________________Fax:______________________

Email: _________________________

Time period of sub-contract: to

Cost of performing sub-contract: $_____________________

** Funds received by the sub-contractor pursuant to this Agreement shall be used only to institute services described in the Grant Agreement between TPC/ISDH and the Lead Agency. Should it be determined by TPC/ISDH that the sub-contractor has used funds inconsistent with the Grant Agreement then the Lead Agency could be required to reimburse TPC/ISDH. Should the Lead Agency be required to make such reimbursement, the sub-contractor may be required to reimburse the Lead Agency.

Required attachments:

Attach a sheet that describes the scope of work to be performed through this sub-contract, including tasks and deliverables.

Attach a description of how this sub-contract will further the goals of your county’s work plan which is on file with ITPC including the indicator(s) it represents.

Attach the Budget Worksheet and the Budget Narrative form to show the distribution of funds for the sub-contract.

Signature of primary contact with Lead Agency:_______________________________________Date:_____________

Signature of responsible person with the sub-contractor:________________________________Date: _____________

TPC Office Use Only: Signature of Regional Director upon approval of the Subcontract___________________________________

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application checklist - indiana · smokefree air model ordinance agreement brand use ... does the...

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