Application: IMNH

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About the Application

The application is organized into 9 sections. The information in Sections 1–4 is about the organization overall and will be saved for future applications, so these questions must be completed only once (and reviewed annually for updates).

Section 1. Organization Information

Questions 1-26 ask for basic administrative and fiscal information about your organization.

#	Data Item	Field Options	Instructions
1	Legal organization name
2	Common name (doing business as [DBA])
3	Address line 1
4	Address line 2
5	City
6	State
7	ZIP
8	County
9	Public health region	Bellwood West Chicago Champaign Marion Metro East Peoria Rockford	Select the public health region where you primarily provide services or that pertains to this application per the Illinois Department of Public Health (IDPH) Health Regions map.
10	Organization phone
11	Organization website address (optional)
12	Type of organization	Nonprofit For profit Tax exempt
13	Year founded/incorporated
14	Illinois Department of Human Services/Division of Substance Use Prevention and Recovery (IDHS/SUPR) licenses, if any
15	Primary contact name
16	Primary contact title
17	Primary contact email address
18	Primary contact phone
19	Alternative contact name
20	Alternative contact title
21	Alternative contact email address
22	Alternative contact phone
23	Indirect cost election	Federally negotiated rate 10% de minimis No indirect costs election	Select your indirect cost election. If you select “Federally negotiated rate,” complete the next question.
24	Negotiated Indirect Cost Rate Agreement (NICRA) letter	Document upload (if applicable)	Upload as Attachment A (if applicable).
25	Current or planned organizational chart	Document upload (required)	Upload as Attachment B.
26	Current fiscal year organizational budget	Document upload (required)	Upload as Attachment C.

Section 2. Pre-Qualification Information

Questions 27-35 ask for organizational information and attestations to verify eligibility to receive an award.

#	Data Item	Field Information	Instructions
27	Federal or State Employer Identification Number (FEIN/EIN)
28	Form W-9, Request for Taxpayer Identification Number and Certification	Document upload (required)	Upload as Attachment D.
29	System for Award Management (SAM.gov) account number
30	Unique Entity Identifier (UEI)
31	Illinois Secretary of State File ID
32	Do you attest that your organization is not on the Federal Excluded Parties List?	Yes No
33	Do you attest that your organization is not on the Illinois Stop Payment list?	Yes No
34	Do you attest that your organization is not on the Department of Healthcare and Family Services Provider Sanctions list?	Yes No
35	Do you attest that your organization is in good standing with the Illinois Secretary of State?	Yes No

Section 3. Internal Controls

Questions 36-81 ask about administrative and management controls within the organization. These questions are used to assess organizational risk.

#	Data Item	Field Options	Instructions
36	Describe the organization’s accounting system. (2.01)	Manual and/or Spreadsheet Driven Automated - Off the shelf Automated - Written in-house or by consulting firm Not Applicable
37	Does the accounting system require users to have separate sign in/log on credentials for access and approval? (2.02)	Yes No
38	Have any new accounting systems been implemented during the last fiscal year? (2.03)	Yes No
39	Does the accounting system or do related written policies and procedures separate the receipt and expenditure of grant funds at the grant level? (2.04)	Tracked outside of the accounting system with spreadsheets Tracked in the accounting system
40	Does the accounting system or do written policies and procedures include a formal chart of accounts that allows users to record transactions by the categories of the approved budget? (2.05)	Yes No
41	How often are the general ledger accounts reconciled? (2.06)	Monthly Quarterly Semi-annually Annually Not applicable
42	Does the organization require monthly bank reconciliations? (2.07)	Yes No
43	Does the organization have written policies and procedures regarding proper segregation of duties for fiscal activities that include, but are not limited to, a) authorization of transactions, b) recordkeeping for receipts and payments, and c) cash management? (2.08)	Yes No
44	Does the organization have written review and approval processes for financial and program-related reporting? (3.01)	Yes No
45	Are the annual financial statements prepared in accordance with Generally Accepted Accounting Principles (GAAP) or on a basis acceptable by the regulatory agency? (3.02)	Yes No
46	Does the organization have written policies and procedures to ensure program performance measures and deliverables align with the program spending plan? (3.03)	Yes No
47	Has the organization taken steps to ensure the individuals who prepare, review, and approve reports have the financial and/or program-related required knowledge, skills, and abilities? (3.04)	Always Sometimes Never Not applicable
48	Who prepares the organization’s financial statements? (3.05)	Trained staff who work for the organization Financial consultants who are not from the organization’s audit firm Independent auditors who conduct the financial statement audit
49	Who prepares the organization’s program performance reports? (3.06)	Trained staff who work in the specific program Grant Managers or Program Directors Organizational management outside of the program
50	Does the organization have written policies and procedures that support compliance with cost principles? (4.01)	Yes No
51	Does the organization have written policies and procedures for allocating costs? (4.02)	Yes No
52	Are costs recorded consistently with regulations and written policies and procedures to address uniformity both in grant awards and in the organization’s other activities? (4.03)	Yes No
53	Does the organization charge indirect costs? (4.04)	Yes No
54	Does the organization keep adequate documentation to support all costs charged to its grant awards? (4.06)	Yes No
55	Does the organization have a governing body (for example, Board of Directors, Board of Trustees, City Council, County Board, Leadership, Legislature, Governor’s Office)? (4.07)	Yes No
56	Is financial information, including budget to actual revenue and expenditure reports, provided to leadership or the governing body members? (4.08)	Always Sometimes Never
57	Is the governing body engaged in audit function activities such as selection of an audit firm, the audit firm’s presentation of audit results, or follow-up on corrective action of audit findings? (4.09)	All audit function activities Some audit function activities Not involved in audit activities
58	Does the organization make purchases of equipment of $5,000 or more with grant funding? (4.10)	Yes No
59	Is a control system in place with adequate safeguards to prevent loss, damage, theft, or unauthorized use of property? (4.13)	Yes No
60	Does the organization have written policies and procedures for proper authorization of property disposals? (4.14)	Yes No
61	Does the organization have written policies and procedures for purchasing goods and services with grant funds? (4.15)	Yes No
62	Does the organization have written policies and procedures that forbid employees, management officers, or agents from participating in the selection, award or administration of a contract supported by a grant award if there is a real or apparent conflict of interest? (4.16)	Yes No
63	Does the organization have written policies and procedures that forbid contractors who develop or draft specifications, requirements, statements of work (scope of services) or requests for proposals from competing for such procurements? (4.17)	Yes No
64	Does the organization have written policies and procedures that document subrecipient and contractor determinations? (4.18)	Yes No
65	In those determinations, has the organization identified any subrecipients? (4.19)	Yes No
66	Does the organization have written policies and procedures for assessing subrecipient risk and monitoring program implementation? (4.20)	Yes No
67	Does the accounting system or do related written policies and procedures identify expenses in excess of available budget? (4.21)	Yes No
68	Are adequate controls in place to ensure that necessary budget revisions receive prior approval from the grantor when applicable? (4.22)	Yes No
69	Does the organization have written policies and procedures for allocating personnel time and effort by funding source? (4.23)	Yes No
70	Does the organization have written policies and procedures to ensure that all salaries and wages charged to grants accurately reflect work performed (i.e., time and effort or after-the-fact payroll verification)? (4.24)	Yes No
71	Does the organization have written policies and procedures to ensure accurate tracking of grant deliverables and performance measures? (4.25)	Yes No
72	Does the organization have written policies and procedures to make sure program activities are allowable under the grant agreement and state and federal regulations? (4.26)	Yes No
73	Are the terms of the executed agreement and budget shared with the performance or program management staff? (4.28)	Yes No
74	Does the organization have written policies and procedures for keeping documentation of participant eligibility determinations? (4.29)	Yes No
75	Have there been any changes in key organizational personnel since the last audit, such as changes to Fiscal and Administrative Management, the Executive Director, and/or Program Management? (5.01)	Yes No
76	Has the organization had a financial statement audit conducted in the past year? (5.02)	Yes No
77	What type of audit was conducted? (5.03)	Financial audit conducted in accordance with Generally Accepted Auditing Standards Financial audit conducted in accordance with Generally Accepted Government Auditing Standards Single Audit/Program Specific Audit in accordance with CFR2 200.501
78	Did the audit find significant deficiencies or material weaknesses? (5.04)	Yes No
79	When was the audit conducted?	[date]
80	Financial Audit Report for the current fiscal year	Document upload (optional, if available)	Upload as Attachment E, if available.
81	Has the organization submitted financial and program-related reporting in a timely manner and as required for prior grant awards?	• Always • Sometimes • Rarely

Section 4. Organization Attestations

Questions 82-87 ask for verification of capacity and truthfulness of information in the application.

#	Data Item	Field Information	Instructions
82	By entering my name, title, and date, I attest that I am authorized to submit the application on my organization’s behalf.	[Name] [Title] [Date]	Enter requested information in fields.
83	I attest that my organization is committed to processing a subaward within six (6) weeks from the Notice of Award.
84	I attest that my organization is responsible for performance and monitoring of external partners, subcontractors, and subrecipients (as allowed by the grant agreement).	Yes No
85	I attest that I have reviewed the terms and conditions within this Notice of Funding Opportunity in its entirety and my organization meets the eligibility criteria and has the capacity to fulfill the scope of services described.	Yes No
86	I certify that the statements herein are true, complete, and accurate to the best of my knowledge. I agree to comply, on behalf of my organization, with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)	Yes No
87	Conflict of Interest Disclosure Upload Conflict of Interest Form as Attachment F.	Yes No

Section 5. Executive Summary

Question 88 seeks an overview of your organization and the services you plan to deliver if awarded funding.

#	Data Item	Field Information	Evaluation Criteria
88	Summarize the following: The activities and outcomes to be achieved by the project The challenges in distributing naloxone to communities disproportionately affected by the opioid crisis and how those challenges would be met Your organization’s experience providing similar services, including timeframes The relevant expertise of the staff bid in the proposal	Up to 1,000 words	(5 points) The response addresses all elements of the question. The response provides a specific description of a population of focus and explains the need for the proposed program for that population. The response demonstrates that the organization has the experience and expertise to successfully implement the proposed program.

Section 6. Need and Opportunity

Question 89 asks how the proposed work will contribute to the purpose of the project.

#	Data Item	Field Information	Evaluation Criteria
89	How does your proposal support the grant program purpose? Describe how the proposed project will increase public access to naloxone, address inequities, and reduce harms from OUD and opioid overdose. Please cite the source of any data included.	Up to 1,500 words	(20 points) The response addresses all elements of the question. The response demonstrates a clear understanding of the purpose of the funding need. The response includes relevant data, including sources.

Section 7. Capacity

Questions 90-95 ask how your organization’s work, approach, and experience are aligned with the intent of the opioid settlement funds and the project requirements.

#	Data Item	Field Information	Evaluation Criteria
90	What is your organization’s experience implementing the tasks described in the scope of work? Describe experience with conducting local, regional, and statewide harm reduction or other public health activities.	Up to 500 words	(10 points) The response addresses all elements of the question. The applicant has relevant experience, including but not limited to: Conducting public health needs assessments Developing public health solutions Conducting harm reduction activities Purchasing and distributing naloxone Tracking health outcomes
91	Provide up to five examples of grants or contracts that your organization has successfully managed in the past 5 years, with awarding agencies, dates, and dollar amounts. Include any current fiscal year funding from IDHS/SUPR or IDPH. Select “not applicable” if you have not received previous grants or contracts.	Not applicable or list up to 5 grants in the table within the online application tool	(5 points) The response addresses all elements of the question. The applicant demonstrates experience with grants management. The applicant demonstrates experience with services that address the opioid epidemic. The applicant demonstrates experience providing services like the proposed program. The applicant demonstrates experience addressing health disparities.
92	Identify staff leadership and describe their experience and qualifications. For new staff, describe your plan to hire people with the necessary qualifications and characteristics (including people with lived and living experience).	Up to 2,000 words Upload project lead and project deputy lead resumes as Attachment G.	(5 points) The response addresses all elements of the question. The applicant understands the experience and expertise required to implement the proposed program. The applicant demonstrates an ability to provide qualified staff. The applicant demonstrates a commitment to hiring people with lived and living experience.
93	How does your hiring approach ensure your staffing reflects the populations you serve? Discuss how your current staff demographics are reflective of the racial/ethnic community served, your approach to hiring persons with lived and living experience, and any changes to hiring processes that will need to be made to ensure cultural and linguistic needs are met.	Up to 1,000 words	(5 points) The response addresses all elements of the question. The applicant understands the experience and expertise required to implement the proposed program. The applicant demonstrates an ability to provide qualified staff. The applicant demonstrates a commitment to hiring people with lived and living experience.
94	Identify the community partnerships needed to ensure kits are distributed where they are most needed and your organization’s experience with these partners.	Up to 1,000 words	(5 points) The response addresses all elements of the question. The response identifies a sufficient range of partners, including those who serve communities disproportionately affected by the opioid crisis. The applicant has existing connections to community partners. The applicant will leverage partnerships to support equitable and culturally responsive distribution practices.
95	Describe how you will make sure that the distribution of naloxone injection kits, including educational materials, is done in a culturally and linguistically appropriate manner, so as to serve all Illinois communities.	Up to 1,000 words	(5 points) The response addresses all elements of the question. The applicant is committed to equitable and culturally responsive distribution practices. The applicant is prepared to provide interpreters and other accommodations.

Section 8. Quality

Questions 96-97 ask for an explanation of the implementation approach and anticipated outcomes of the proposed activities to be funded.

#	Data Item	Field Information	Instructions
96	Provide a task-by-task description of how your organization will implement the evaluation.	Up to 2,500 words	(20 points) The response addresses all elements of the question. The response indicates a sound methodology for a needs assessment. The response reflects an understanding of the Standardized Procedure and best practices in harm reduction. The response explains how outreach will be conducted through OENDs, SSPs, harm reduction organizations, and other ongoing efforts to reduce overdose deaths. Specific details are provided as to how naloxone will be obtained and how kits will be assembled, stored, and distributed. The response specifies how many kits will be distributed in bulk to organizations and how many will be distributed individually to people who misuse opioids. The response reflects a commitment to equitable and culturally responsive distribution practices.
97	Provide a detailed timeline for your proposed approach that includes hiring of staff, anticipated linkage agreements, and other coordination activities necessary to accomplish the goals and objectives.	Upload Project Plan as Attachment H (required)	(15 points) The response addresses all elements of the question. The timeline proposed includes all required program elements. The timeline includes realistic milestones. The response includes relevant data, including sources.

Section 9. Budget

Questions 98-100 request information about the project budget.

#	Data Item	Field Information	Evaluation Criteria
98	Total funding requested for the period of performance	[currency]	0 points
99	Please select your preferred payment term as described in Section G.2. of this document.	Advance Payment and Reconcile Method Reimbursement Method Working Capital Advance Method	0 points
100	The budget and narrative must tie fiscal activity to program objectives and deliverables and must demonstrate that all proposed costs are Reasonable and necessary, Allocable, and Allowable as defined by program regulatory requirements and Uniform Guidance (2 CFR 200), as applicable.	Upload the Budget Workbook as Attachment I to submit your project budget and advance payment request. (required)	(5 points) The budget is filled out completely. Salaries, benefits, and other expenditures appear reasonable for the community in which the proposed program will take place. Indirect costs meet guidelines (attach NICRA agreement letter if applicable). All line items correspond to elements of the proposed program.