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Transcript of Chicago Department of Public Health
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City of Chicago Department of Public Health
Request for Proposals (RFP)
REACH Demonstration Grant
RFP# DA-41-000J-07-2012-001
Key Dates
RFP Release Date 7/25/12 Bidders Conference 7/27/12 Proposal Due 7/31/12 Contract Start Date 11/30/12
Submit one (1) original, five (5) complete copies, and a complete electronic copy on a CD of the
Proposal
All Proposals must be addressed and delivered to:
Department of Public Health
DePaul Center—Room 200
333 South State Street
Chicago, Illinois, 60604
PROPOSALS MUST BE RECEIVED NO LATER THAN 5:00 P.M. CENTRAL TIME
_____________Tuesday, July 31, 2012__________________
NO PROPOSALS WILL BE ACCEPTED FOR ANY REASON AFTER THIS DEADLINE.
City of Chicago
Department of Public Health
Division of Community Affairs
Rahm Emanuel Bechara Choucair, M.D. Mayor Commissioner
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TABLE OF CONTENTS
City of Chicago
Department of Public Health, Division of Policy, Planning and Legislative Affairs
I. Program Authority ................................................................................................................... 3
II. Purpose .................................................................................................................................... 3
A. Overview ....................................................................................................................... 3
B. Definitions ..................................................................................................................... 3
III. Background ............................................................................................................................ 4
IV. Eligibility Requirements for Delegate Agencies .................................................................... 4
VI. Available Funding .................................................................................................................. 4
VII. Eligible Program Activities and Priorities .............................................................................. 5
A. Program Activities ............................................................................................................. 5
B. Funding Requirements and Priorities. ............................................................................... 5
C. Scopes of Services ............................................................................................................. 5
VIII. Instructions for Completing an Application ............................................................................ 5
A. Application Components. ............................................................................................. 5
B. Application Guidelines ................................................................................................. 5
C. Application Checklist ............................................................................................ ….10
IX. Submission Guidelines ......................................................................................................... 10
A. Format Instructions ..................................................................................................... 11
X. Evaluation of Proposals .......................................................................................................... 11
XI. Reporting and Other Requirements for Successful Delegate Agencies ................................. 12
XII. Compliance with Laws, Statutes, Ordinances and Executive Orders ................................... 12
Appendices
A. PSE example………………………………………………………………………. 15
B. Proof of Insurance/Insurance Requirements .............................................................. 19
C. Title Page .................................................................................................................... 22
D. Collaborating Partners. .............................................................................................. 23
E. Program Work Plan ................................................................................................... 24
F. Budget Template ........................................................................................................ 25
G. Application Checklist ................................................................................................. 31
H. Examples of Strategic Intervention activities………………………………………32
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I. Program Authority
The City of Chicago, Department of Public Health (CDPH) plans to apply for funds from the Centers for
Disease Control (CDC) for the implementation of Racial and Ethnic Approaches to Community Health
(REACH) demonstration project. CDPH has not yet received a grant award from CDC.
II. Purpose
A. Overview
Chicago Department of Public Health (CDPH) if it receives a REACH grant award from CDC, intends to
provide funding, if awarded, for two delegate agencies through this RFP for the implementation of the
REACH demonstration project in target communities in Chicago from October 1, 2012 through
September 30, 2015. REACH is focused on decreasing obesity and hypertension health disparities by
implementing policy, environmental and systems (PES)improvements, as well as, and evidence-based
interventions.
This funding opportunity focuses on two major drivers of chronic disease disparities—obesity and
hypertension. Reduction in disparities in the burdens of obesity and hypertension can help to reduce
disparities in heart disease, stroke, cancer, diabetes, arthritis and other chronic conditions. Improving
nutrition and increasing physical activity to reduce obesity can have an added benefit of reducing
hypertension.
This project builds upon previous Racial and Ethnic Approaches to Community Health (REACH)
programs (www.cdc.gov/reach) and other health equity-related community health programs and serves as
a focused complement to programs working to make population-wide, place-based improvements.
The goal of the REACH project is to promote health and wellness among Chicago residents by
increasing; 1) smoke free environments; 2) availability and access to healthy foods, and 3) access to safe
places to be physically active.
CDPH will fund 1-2 delegate agencies to implement the project through comprehensive and integrated
strategies focused on reaching communities that have disproportional rates of obesity and hypertension
(see Appendix A- for examples of PSE improvements and related activities).
B. Definitions
CDPH
The CDPH refers to the Chicago Department of Public Health, the grantee organization.
Delegate Agency
The delegate agency is the organization that applies and is awarded an agreement under the REACH RFP.
The delegate agency contracts with the CDPH to perform the scopes of services outlined below.
The target communities for this RFP are African American and Hispanic neighborhoods in the city with
substantial numbers of residents with risk factors for obesity and hypertension, as well as, neighborhoods
with limited or no access to healthy food options, and/or limited environmental resources that can
promote physical activity.
National studies have found that obesity prevalence is higher among Hispanic/Latino and African
Americans than among Whites. These trends are mirrored among adults in Chicago, with higher rates of
self-reported obesity in adults being associated with low socio-economic status. For these reasons, the
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target communities for this RFP are neighborhoods in the city with substantial numbers of residents with
these demographic risk factors for obesity, and hypertension.
III. Background
The mission of the CDPH is to make Chicago a safer and healthier place by working with community
partners to promote health, prevent disease, reduce environmental hazards, and ensure access to health
care for all Chicagoans. The goal of the REACH project aligns with the mission of the CDPH by
promoting health and wellness through the creation of healthier, safer environments, as priority outlined
in the Healthy Chicago public health agenda released in August 2011. The REACH project will involve
multiple partners, including community-based organizations and various city Departments and Agencies,
such as the Chicago Department of Transportation, and Chicago Park District.
IV. Eligibility Requirements for Delegate Agencies
In order to be eligible for these funds, an applicant must meet the following criteria:
Be a non-profit community-based organization with 501(c)3 status.
Be located in the City of Chicago.
Have two years of organizational experience collaborating with targeted communities on health
disparities.
Have fiscal responsibility and capability to manage funds.
Successful respondents will be required to participate in evaluation and quality assurance
activities coordinated by CDPH.
VI. Available Funding
A total of $400,000 to $750,000.00 may be available for funding applications for the implementation of
REACH in the City of Chicago. Funding will be determined by the number of community based
organizations that the delegate agency will collaborate with, and the number of residents that will be
reached by intervention activities. CDPH may make appropriate changes to the allocations and amounts
in this RFP as necessary. Funding maximum request is $400,000 per delegate agency.
If The CDC awards a REACH grant to the City, then the City intends to award grants to selected delegate
agencies for the project period beginning October 30, 2012 and ending September 30, 2015.
VII. Eligible Program Activities and Priorities
A. Program Activities
Proposal must include at least one or more activities in two of the following strategic areas:
o Tobacco-Free Living
o Active Living and Healthy Eating, and
o Healthy and Safe Environment
(See Appendix H for recommended evidence based strategies)
Proposal may focus on one or both target populations (African American and/or Hispanic)
Program activities should be culturally and linguistically appropriate for targeted population
B. Funding Requirements and Priorities
Funds will be used to plan and implement REACH intervention strategies in targeted African American
and Hispanic Chicago communities. The target communities for this RFP are areas of the City of Chicago
that are underserved, have high rates of obesity and hypertension. The target communities for this RFP
are neighborhoods in the city with substantial numbers of residents with risk factors for obesity and
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hypertension, as well as, neighborhoods with limited or no access to healthy food options, and/or limited
environmental resources that promote physical activity.
Any grantee found to be non-compliant with the REACH grant agreement at any time, will be held
responsible and required by the City of Chicago to restore any damages and/or costs associated with
grantee non-compliance.
C. Scopes of Services
The delegate agency will:
1. Implement approved REACH intervention strategic activities per contract agreement.
2. Identify a minimum of 4 or more CBOs or similar entities that will collaborate with delegate agency
to implement activities in their community/neighborhood (provide letter of support). These CBOs
may receive REACH funding from the delegate agency to support intervention activities.
3. Develop work plan and timeline for CDPH approval.
4. Provide activities to target population in geographic area.
5. Participate in program evaluation plan as required.
6. Participate in monthly coalition meetings.
7. Provide monthly progress reports.
VIII. Instructions for Completing an Application
A. Application Components
Please see Application Guidelines below for additional information and page limits.
B. Application Guidelines
This section provides information on proposal requirements and submission guidelines. Page limits for
each section are included. (See the section on Submission Guidelines for formatting instructions.) Include
a table of contents reflecting major categories and corresponding page numbers. Use headings and
subheadings to ensure that your proposal covers all the required elements. Use the Application Checklist
in Appendix G to create the Table of Contents and to ensure that your proposal is complete. Only
documents requested in this RFP or directly related to the RFP should be submitted. Any unsolicited
material submitted with a proposal will be discarded before review.
If awarded the grant, Respondents must:
- Complete the City’s On-Line Economic Disclosure Statement (EDS) and Affidavit, at
http://www.cityofchicago.org/city/en/depts/dps/provdrs/comp/svcs/economic_disclosurestatement
seds.html.
Note: this does not have to be submitted with the proposal.
Required Documentation
Internal Revenue Service 501(c)3 tax exempt determination letter
Copy of delegate agency’s Articles of Incorporation
Copy of the delegate agency’s most recent Financial Statement and OMB Circular A-133 Audit
List of Board of Directors (must include place of employment for each member)
Proof of Insurance – See Appendix B
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Include a minimum of 4 Letters of Support from agencies or partners in the intended target
communities to demonstrate previous experience within the target communities.
A Letter of Commitment is required from any outside resource cited in the proposal who will be
working with the applicant organization and whose role is essential to the program.
Title Page
This page must be the first page of your proposal. This is Appendix C.
Project Abstract (1/2 to 1 page)
The Project Abstract provides a brief description of the applicant organization and its experience relevant
to this proposal. The Project Abstract should summarize the project proposal and include the following
information:
Name of organization and address
Description of the organization’s history and experience
Description of the project for which funds are being requested
Description of the geographical area(s) to be served
Description of the target population(s) to be served
Description of the project’s measurable objectives (can be included with work plan)
Proposed impact (number of residents) activities will reach
Agency Mission and Experience (1/2 to 1 page)
Provide a narrative describing your organization’s mission and experience in providing the service
category in this proposal. Discuss how the proposed program may be supported by other programs offered
by your organization. Provide a brief description of the following, as it relates to the organization:
Prior experience or demonstrated ability working with disadvantaged, underserved communities
Prior experience or demonstrated ability to work with issues of health disparities and wellness
and/or other public health issues
Prior experience or demonstrated ability to work with community-based organizations
Prior experience or demonstrated ability to organize programs involving community-based
organizations
Target Population(s) and Collaborations (1/2 to 1 page) Note: graphs and tables can be attached as
supporting documentation and will not count towards allotted page limit.
Justify the community or communities (i.e., geographic community areas or region(s) of Chicago)
in which your organization is proposing to work. In doing so, answer the following question:
o Describe the barriers to healthy eating, tobacco free living, or physical activity in the
community/communities in which you are proposing to work. Use data (for example,
obesity, violence, and/or access to public parks and recreational spaces such as
Chicago Park District parks and YMCAs) to justify your answer.
The racial or ethnic group of the selected intervention population within the defined
geographic area, which represents the population experiencing disparities in
overweight/obesity and hypertension.
The percentage and number of individuals that the intervention population(s) represents
among the total population. For example: The selected intervention population is 420,000
African American residents in Community X, which represents 56% of the total African
American population of approximately 750,000 individuals.
The estimated reach of program activities within the selected intervention population(s).
For example: Proposed program activities will be designed to reach approximately 80% of
the intervention population in Community X (the 420,000 African American residents), for
an estimated reach of 336,000 individuals.
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Identify and describe the demographic and social/environmental characteristics of the target
communities this project will serve.
Describe your organization’s experience in and capability to providing services to the target
population(s).
Describe any prior work, linkages, or collaborations formed in the target community or
geographic area, or, if relevant, outside of the target community or geographic area.
Include a minimum of 3 Letters of Support from agencies or partners in the intended target
communities with the required attachments. (Note: Letters of Support are not included in the page
limit.)
Complete Appendix D to indicate partner community-based organizations you propose to work
with, and in which community areas of Chicago they work.
Cultural and Linguistic Capacity (1/2 to 1 page)
Describe the agency’s history of involvement and relationship with its target population(s) and within its
geographic area.
Discuss any cultural and linguistic barriers anticipated in the implementation of this initiative, and
how your organization will address those barriers.
Technical Capabilities (1 page or less)
Discuss resources both inside and outside the organization that will enhance its ability to carry out the
proposed program objectives. Provide examples that demonstrate the organization’s abilities and
experience in the following areas:
Data collection and reporting
Performing evaluations or studies (for example, program evaluations or needs assessments),
including the ability to evaluate the quality of services provided
Budget/fiscal management/capability to manage funds
Continuous quality improvement activities
Staffing planning groups including meeting preparation and logistics
Communication (oral ,written, electronic, translation)
Description of Proposed Project and Work Plan (3 pages or less for the narrative; no page limit for the
Program Work Plan form)
This section describes the proposed project in detail, including the geographic area, target population, and
activities that will be involved in program implementation. This section explains how these elements
come together to create the proposed project.
Be specific about how the project will meet the needs of the target population.
Develop a detailed work plan using the template in Appendix E to demonstrate how your organization
will carry out the activities listed in the Scopes of Services. Describe the roles and responsibilities of
staff as it relates to these activities.
Personnel
Provide qualifications of individuals who will be involved in the project and the percentage of their time
they will spend on the project. Include résumés or curriculum vitae of Project/Program Director and all
staff associated with program. Include supporting documentation that supports the agency’s programmatic
and administrative abilities such as management staff resumes, certifications, licenses, in-house training,
or other evidence.
Budget and Justification (1 page or less for budget justification; no page limit for budget forms)
Provide a narrative description of the proposed project budget.
Describe the agency’s fiscal capacity and stability to manage the proposed project.
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All contracts will be paid on a reimbursement basis. Describe your agency’s demonstrated capacity
to operate on a reimbursement basis.
Describe and justify all costs proposed in the budget. The budget and narrative must meet all
requirements set forth below.
Provide a budget using the template in Appendix F. The maximum amount of the bid may not be
increased after the proposal is received. The proposed budget is subject to change during contract
award negotiation.
This section provides the format for the required budget explaining how each line item will be expended.
Delegate agencies may request funds through this RFP to support the following costs:
Personnel Salaries
Stipends
Operating Costs
Professional/Technical Costs
Materials and Supplies
Equipment
Transportation and Travel Expense
Administrative Expenses
A description of each expense category is presented below.
Personnel: For these costs, provide the following information: the name of the employee and job title,
number of positions, annual salary, and percentage of time to be spent on this project, and the
share/amount of the salary to be paid for by this CDPH grant. Provide a brief budget justification
explaining the duties of each employee assigned to the project. If the delegate agency has not yet
identified individuals to fill salaried positions, indicate that these individuals are yet to be hired (TBH).
Make sure to show your calculations and indicate if staff is paid weekly, biweekly, or monthly.
Example
Position/Title No. Annual
Salary ($) % of
Time Spent CDPH Share
($) Brief Summary of Job
Responsibilities
Project Director
1
$40,000
50 $20,000 (Remaining
salary will
come from
delegate
agency.)
Will oversee the implementation of the
project. Will serve as the liaison and
contact person on behalf of the delegate
agency for the Chicago Department of
Public Health (CDPH).
Fringe Benefits: For these costs, provide the following information: the amount of fringe benefits
requested (which should also include the percentage rate for FICA); medical insurance; including dental
and vision coverage, if applicable; worker's compensation and disability insurance; life insurance, if
applicable; and, vacation and sick pay benefits, etc. Please include elements that are included in the fringe
benefit amount. Fringe benefits must be based on the delegate agency's established personnel policies.
Show all calculations (formula used to determine final cost). Note: If a fringe benefit is not listed, you
cannot be reimbursed for it.
Operating Costs: Delegate agencies must delineate expenditures for items related to any programmatic
activities integral to this project (e.g., telephone, advertising, printing, duplication, equipment
leasing/maintenance, insurance premiums, facility maintenance, and postage).
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Note: Agencies funded through this RFP will be required to comply with various insurance specifications
established by the City of Chicago: these include workers' compensation, auto liability, commercial
liability and professional liability. These requirements also apply to all subcontractors and consultants.
(See Appendix B for details.)
Professional/Technical Costs: List and justify all fees to be paid to consultants and subcontractors,
noting the number of hours to be devoted to the project and specific responsibilities. Consultant fees will
be allowed on a limited basis only, and should not to be used in place of staff support. This category may
include sub-contractual services that facilitate program delivery, as well as services that increase client
access or to assess client satisfaction. However, regardless of the function, the consultant must not have
been a member of the delegate agency's Board of Directors during the 12-month period preceding the date
of the delegate agency's request for funding. Additionally, the consultant may not serve as a Board
member during the 12-month period following the completion of the funded project period.
Note: The City of Chicago will require all successful delegate agencies to identify any consultants and
subcontractors that will be part of the proposed program. If they have not yet been identified, indicate
that in the budget and budget justification. They must be identified and pre-approved by the project
officer before they begin any services to be funded through this proposal.
Materials and Supplies: Itemize and justify programmatic materials, including office supplies that will
be used by program staff in service delivery.
Equipment: Itemize and justify programmatic equipment (e.g., play equipment, street closure barriers).
Note: CDPH must approve and catalogue all equipment purchases of $5,000 or greater.
Transportation and Travel Expenses: Funding for transportation should be requested only as
appropriate for program needs. Program-specific transportation expenses may include transit passes,
vouchers, or expenses incurred in operating agency-leased/owned vehicles. Out of town travel is not an
allowable expense.
Local Travel: Delineate amounts for public transportation and mileage reimbursement at the rate
established in the agency’s policies. If the agency does not have a mileage reimbursement rate
established, use the current federal rate available at http://www.gsa.gov/mileage. Include expenses to
operate agency-owned vehicles that are used in program delivery. All drivers and vehicles used for this
program must have valid licenses and insurance. If an agency employee would like to request
reimbursement for mileage, then the City of Chicago must be listed as an additional insured party.
Administrative Expenses: Administrative expenses of up to 10% of direct costs are allowable. These
must be specifically delineated and justified. The delegate agency must provide a brief narrative
justification for the amount requested. Example of administrative and indirect costs include rental costs
for administrative office space, office utilities, insurance, payroll, personnel, voucher processing and
financial reporting and audit expenses. Administrative costs may also include partial salaries of
administrative staff (e.g. executive director or office manager). Providers must retain records of the
expenses actually charged against any contract that is awarded as a result of the RFP. Agencies with a
limited capacity to administer the fiscal responsibilities associated with their programs are encouraged to
sub-contract with a third-party agent.
C. Application Checklist
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The Application Checklist should be used to ensure that the proposal is complete. Include the Checklist
with the proposal. Proposals that do not contain each of the items indicated in the checklist will be
considered incomplete. (See Appendix G for a copy of the Checklist).
IX. Submission Guidelines
Failure to follow any of the instructions related to content will result in the application being eliminated
from consideration. Other than late delivery, the most common reasons that applications are rejected
include inadequate number of copies, missing sections, and failure to include requested documents.
It is the responsibility of the delegate agency to ensure delivery of the application to CDPH by the
deadline. All applications will be date and time stamped upon receipt, and the receipt will be given to the
person delivering the package at the time of receipts. Delegate agencies using a messenger service to
deliver their proposals should advise the messenger service of the deadline and make sure the messenger
knows to wait for a receipt. Delegate agencies wishing to drop off completed proposals prior to the
deadline should contact Herminia Vanna (contact information below) to arrange for a drop off time.
All programmatic questions regarding this RFP (i.e., objectives, review criteria, work plan, budget
components, etc.), and assistance with the application guidelines should be referred to:
Berenice Tow
Chicago Department of Public Health
Telephone: 312-745-0590
E-mail: [email protected]
Submit one (1) original and five (5) complete copies (six (6) in total), and a CD with an electronic version
of the application to:
Department of Public Health
DePaul Center—Room 200
333 South State Street
Chicago, Illinois, 60604
Applications must be received by 5:00 p.m. Central Standard Time on Friday 27, 2012. No extensions
will be permitted. No late applications will be accepted.
A. Format Instructions
Follow these instructions in completing your proposal:
Use at least 1.5 line spacing and at 11-point font size.
Proposals should have margins of at least ¾ inch on all sides.
Submit only unbound proposals (i.e., no staples, ring binders, covers)
All documents should be on 8 ½‖x11‖ paper
Print only on the front of each page (if any of your supporting documents are two-sided, photocopy
them to meet this requirement)
Include a table of contents reflecting major categories and corresponding page numbers
Attach only supporting documentation requested or directly related to the proposal
Sequentially number the entire proposal including all the attachments
No faxes will be accepted
X. Evaluation of Proposals
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All proposals that are received on time will undergo a technical review to determine whether all required
components have been addressed and included. Proposals that are determined by the City to be
incomplete will not be further considered. The City reserves the right to waive irregularities that, within
its sole discretion, it determines to be minor. If such irregularities are waived, similar irregularities in all
proposals will be waived. Proposals that are determined to be complete will be forwarded to a Review
Panel.
The Review Panel will evaluate and rate all remaining proposals based on the Evaluation Criteria listed
below. The Review Panel forwards its recommendations and comments to the Program
Manager/Assistant Commissioner of Chicago Department of Public Health. Past contractual performance
may also be considered for delegate agencies that have previously received funding. Final funding
decisions are made by the CDPH and Commissioner of Public Health. All delegate agencies will be
notified of the results in writing.
Evaluation Criteria:
Respondent’s relevant experience in providing the proposed service
Documented coordination and collaboration with other providers
Identification and description of the socio-demographic characteristics of the target population and
physical activity needs of the target population
Respondent’s cultural capability and linguistic capacity and technical capabilities (e.g., data
collection and reporting abilities)
Comprehensiveness and soundness of proposed program approach and work plan
Soundness of proposed budget and delegate agency’s financial capacity and stability to manage a
program of the size and scopes contemplated
The City of Chicago reserves the right to recommend qualified funding proposals out of rank in order to
ensure adequate geographic distribution. If an insufficient number of qualified proposals are submitted,
the City reserves the right to directly solicit and select appropriate community-based providers to fill in
the gaps.
XI. Reporting and Other Requirements for Successful Delegate Agencies
All successful delegate agencies will be required to submit monthly program reports, vouchers on a
monthly basis, and participate in all CDPH-sponsored site visits, evaluation and quality assurance
activities. Vouchers must be accompanied by appropriate documentation and contain adequate details for
all expenses for which reimbursement is requested.
XII. Compliance with Laws, Statutes, Ordinances and Executive Orders
Grant awards will not be final until the City and the respondent have fully negotiated and executed a
grant agreement. All payments under grant agreements are subject to annual appropriation and
availability of funds. The City assumes no liability for costs incurred in responding to this RFP or for
costs incurred by the respondent in anticipation of a grant agreement. As a condition of a grant award,
respondents must comply with the following and with each provision of the grant agreement:
1. Conflict of Interest Clause: No member of the governing body of the City of Chicago or other unit of
government and no other officer, employee, or agent of the City of Chicago or other government unit
who exercises any functions or responsibilities in connection with the carrying out of the project
shall have any personal interest, direct or indirect, in the grant agreement.
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The respondent covenants that he/she presently has no interest, and shall not acquire any interest,
direct, or indirect, in the project to which the grant agreement pertains which would conflict in any
manner or degree with the performance of his/her work hereunder. The respondent further covenants
that in the performance of the grant agreement no person having any such interest shall be employed.
2. Governmental Ethics Ordinance, Chapter 2-156: All respondents agree to comply with the
Governmental Ethics Ordinance, Chapter 2-156 which includes the following provisions: a) a
representation by the respondent that he/she has not procured the grant agreement in violation of this
order; and b) a provision that any grant agreement which the respondent has negotiated, entered into,
or performed in violation of any of the provisions of this Ordinance shall be voidable by the City.
3. Selected respondents shall establish procedures and policies to promote a Drug-free Workplace. The
selected respondent shall notify employees of its policy for maintaining a drug-free workplace, and
the penalties that may be imposed for drug abuse violations occurring in the workplace. The
selected respondent shall notify the City if any of its employees are convicted of a criminal offense
in the workplace no later than ten days after such conviction.
4. Business Relationships with Elected Officials - Pursuant to Section 2-156-030(b) of the Municipal
Code of Chicago, as amended (the "Municipal Code") it is illegal for any elected official of the
City, or any person acting at the direction of such official, to contact, either orally or in writing, any
other City official or employee with respect to any matter involving any person with whom the
elected official has a business relationship, or to participate in any discussion in any City Council
committee hearing or in any City Council meeting or to vote on any matter involving the person with
whom an elected official has a business relationship. Violation of Section 2-156-030(b) by any
elected official with respect to the grant agreement shall be grounds for termination of the
grant agreement. The term business relationship is defined as set forth in Section 2-156-080 of the
Municipal Code.
Section 2-156-080 defines a ― business relationship‖ as any contractual or other private business
dealing of an official, or his or her spouse or domestic partner, or of any entity in which an official or
his or her spouse or domestic partner has a financial interest, with a person or entity which entitles
an official to compensation or payment in the amount of $2,500 or more in a calendar year;
provided, however, a financial interest shall not include: (i) any ownership through purchase at fair
market value or inheritance of less than one percent of the share of a corporation, or any corporate
subsidiary, parent or affiliate thereof, regardless of the value of or dividends on such shares, if such
shares are registered on a securities exchange pursuant to the Securities Exchange Act of 1934, as
amended; (ii) the authorized compensation paid to an official or employee for his office or
employment; (iii) any economic benefit provided equally to all residents of the City; (iv) a time or
demand deposit in a financial institution; or (v) an endowment or insurance policy or annuity
contract purchased from an insurance company. A ―contractual or other private business dealing‖
shall not include any employment relationship of an official’s spouse or domestic partner with an
entity when such spouse or domestic partner has no discretion concerning or input relating to the
relationship between that entity and the City.
5. Compliance with Federal, State of Illinois and City of Chicago regulations, ordinances, policies,
procedures, rules, executive orders and requirements, including Disclosure of Ownership Interests
Ordinance (Chapter 2-154 of the Municipal Code); the State of Illinois - Certification Affidavit
Statute (Illinois Criminal Code); State Tax Delinquencies (65ILCS 5/11-42.1-1); Governmental
Ethics Ordinance (Chapter 2-156 of the Municipal Code); Office of the Inspector General Ordinance
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(Chapter 2-56 of the Municipal Code); Child Support Arrearage Ordinance (Section 2-92-380 of the
Municipal Code); and Landscape Ordinance (Chapters 32 and 194A of the Municipal Code).
6. If selected for grant award, respondents are required to (a) execute the City’s On-Line Economic
Disclosure Statement (EDS) and Affidavit, and (b) indemnify the City as described in the grant
agreement between the City and the successful respondents.
7. Prohibition on Certain Contributions, Mayoral Executive Order 2011-4. No person or entity
responding to this request for proposals (the ―Respondent‖) or any person or entity who directly or
indirectly has an ownership or beneficial interest in Respondent of more than 7.5 percent
("Owners"), spouses and domestic partners of such Owners, Respondent’s proposed subcontractors,
any person or entity who directly or indirectly has an ownership or beneficial interest in any
proposed subcontractor of more than 7.5 percent ("Sub-owners") and spouses and domestic partners
of such Sub-owners (Respondent and all the other preceding classes of persons and entities are
together, the "Identified Parties"), shall make a contribution of any amount to the Mayor of the City
of Chicago (the "Mayor") or to his political fundraising committee during (i) the bid or other
solicitation process for the Contract or Other Contract, including while the Contract or Other
Contract is executory, (ii) the term of the Contract or any Other Contract between City and
Respondent, and/or (iii) any period in which an extension of the Contract or Other Contract with the
City is being sought or negotiated.
Respondent represents and warrants that since the date of public advertisement of the specification,
request for qualifications, request for proposals or request for information (or any combination of
those requests) or, if not competitively procured, from the date the City approached the Respondent
or the date the Respondent approached the City, as applicable, regarding the formulation of the
Contract, no Identified Parties have made a contribution of any amount to the Mayor or to his
political fundraising committee.
Respondent shall not: (a) coerce, compel or intimidate its employees to make a contribution of any
amount to the Mayor or to the Mayor’s political fundraising committee; (b) reimburse its employees
for a contribution of any amount made to the Mayor or to the Mayor’s political fundraising
committee; or (c) bundle or solicit others to bundle contributions to the Mayor or to his political
fundraising committee.
The Identified Parties must not engage in any conduct whatsoever designed to intentionally violate
this provision or Mayoral Executive Order No. 2011-4 or to entice, direct or solicit others to
intentionally violate this provision or Mayoral Executive Order No. 2011-4.
Violation of, non-compliance with, misrepresentation with respect to, or breach of any covenant or
warranty under this provision or violation of Mayoral Executive Order No. 2011-4 will constitute a
breach and default under the Contract, and under any Other Contract for which no opportunity to
cure will be granted. Such breach and default will entitles the City to all remedies (including
without limitation termination for default) under the Contract, under Other Contract, at law and in
equity. This provision amends any Other Contract and supersedes any inconsistent provision
contained therein.
If Respondent violates this provision or Mayoral Executive Order No. 2011-4 prior to the award of
the Contract, the Commissioner may reject Respondent’s proposal.
For purposes of this provision:
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―Bundle‖ means to collect contributions from more than one source which are then delivered by
one person to the Mayor or to his political fundraising committee.
―Contract‖ means an agreement resulting from this request for qualifications/proposals/
information.
"Contribution" means a "political contribution" as defined in Chapter 2-156 of the Municipal
Code.
For purposes of this provision only, individuals are ―Domestic Partners‖ if they satisfy the
following criteria: (A) they are each other's sole domestic partner, responsible for each
other's common welfare; and (B) neither party is married, as marriage is defined under
Illinois law; and (C) the partners are not related by blood closer than would bar marriage
in the State of Illinois; and (D) each partner is at least 18 years of age, and the partners are
the same sex, and the partners reside at the same residence; and (E) two of the following
four conditions exist for the partners: (1) the partners have been residing together for at
least 12 months; (2) the partners have common or joint ownership of a residence; (3) the
partners have at least two of the following arrangements: (a) joint ownership of a motor
vehicle, (b) a joint credit account, (c) a joint checking account, or (d) a lease for a residence
identifying both domestic partners as tenants; and (4) each partner identifies the other
partner as a primary beneficiary in a will.
"Other Contract" means any agreement entered into between the Respondent and the City that is
(i) formed under the authority of Chapter 2-92 of the Municipal Code; (ii) for the purchase, sale
or lease of real or personal property; or (iii) for materials, supplies, equipment or services which
are approved and/or authorized by the City Council.
"Political fundraising committee" means a "political fundraising committee" as defined in
Chapter 2-156 of the Municipal Code.
Any Contract will be subject to and contain provisions requiring continued compliance with
Executive Order 2011-4.
8. False Statements
(a) 1-21-010 False Statements
Any person who knowingly makes a false statement of material fact to the city in violation of any
statute, ordinance or regulation, or who knowingly falsifies any statement of material fact made in
connection with an proposal, report, affidavit, oath, or attestation, including a statement of
material fact made in connection with a bid, proposal, contract or economic disclosure statement
or affidavit, is liable to the city for a civil penalty of not less than $500.00 and not more than
$1,000.00, plus up to three times the amount of damages which the city sustains because of the
person's violation of this section. A person who violates this section shall also be liable for the
city's litigation and collection costs and attorney's fees.
The penalties imposed by this section shall be in addition to any other penalty provided for in the
municipal code. (Added Coun. J. 12-15-04, p. 39915, § 1)
(b) 1-21-020 Aiding and Abetting.
Any person who aids, abets, incites, compels or coerces the doing of any act prohibited by this
chapter shall be liable to the city for the same penalties for the violation.(Added Coun. J. 12-15-
04, p. 39915, § 1)
(c) 1-21-030 Enforcement.
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In addition to any other means authorized by law, the corporation counsel may enforce this
chapter by instituting an action with the department of administrative hearings. (Added Coun. J.
12-15-04, p. 39915, § 1)
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Appendix A
Sample Policy, Systems, and Environmental (PSE) Strategies
for Prevention of Obesity and Hypertension
Department of Public Health
This list is meant to provide a starting point for community assessments to determine what strategies are
in place. It is not meant to be a menu of approaches from which applicants should select, but rather a list
of strategies that could be strengthened to better reduce health disparities through activities proposed by
applicants.
Applicants should determine barriers that might limit full benefit to these strategies, and opportunities to
leverage strategies so that health equity is achieved, as experienced by the selected intervention
population(s).
Community Retail Venues: Increase availability, accessibility, affordability, and identification of
healthier foods and beverages through community retail venues (including supermarkets, grocery
stores, small stores, and farmers markets).
o Recommended ways to implement this strategy include but are not limited to:
locating new full-service grocery stores in underserved areas
increasing healthier food and beverage offerings at existing stores
increasing the number of stores that are compliant with the Special Supplemental
Nutrition Program for Women, Infants and Children (WIC) Program
implementing Community Supported Agriculture and/or farmers markets on
worksite and community grounds
increasing the number of farmers markets that are approved and equipped (i.e.
Electronic Benefit Transfer) to accept Supplemental Nutrition Assistance
Program (SNAP) benefits and WIC and Senior Farmers Market Nutrition
Program coupons
Food Service Guidelines: Adopt and implement food service guidelines that include food and
beverage standards for cafeterias, vending machines, meetings, and conferences, and any other
place where food and beverages are served or available, particularly in public service venues and
venues that serve or employ disparate racial or ethnic groups.
o Recommended ways to implement this strategy include but are not limited to:
adopting and implementing the Health and Sustainability Guidelines for Federal
Concessions and Vending Operations
adopting and implementing farm-to-institution practices
Youth Setting-Based Healthier Foods and Beverages: Increase availability, accessibility,
affordability, and identification of healthier foods and beverages in school, after school, and early
care and education settings, particularly those environments that serve disparate racial or ethnic
groups.
o Recommended ways to implement this strategy include but are not limited to:
establishing and maintaining salad bars in schools
establishing and maintaining farm to school and farm to preschool practices
offering fruits, vegetables, and water any time that competitive foods or any
foods and beverages are available to students
establishing onsite gardens for garden-based education and food production for
schools and ECE facilities
ensuring ready access to potable drinking water and other healthful alternatives
to sugar-sweetened beverages
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Sodium Reduction: Improving the health content of food by reducing sodium intake.
o Recommended ways to implement this strategy include but are not limited to:
adopting and implementing sodium guidelines for menu items in restaurants
frequented by seniors
increasing local school wellness practices which incorporate sodium reduction
guidelines
increasing the availability, sales and point of purchase labeling of lower-sodium
products in grocery stores and convenience stores
Breastfeeding Support: Increase implementation of policies and practices to support breastfeeding
in health care, community, and workplaces.
o Recommended ways to implement this strategy include but are not limited to:
increasing implementation of the Baby-Friendly Hospital Initiative, particularly
in hospitals predominantly serving disparate racial or ethnic groups
using community-based organizations to promote and support breastfeeding,
such as by providing all-hours access to breastfeeding assistance
ensuring that employers establish and maintain comprehensive, high-quality
lactation support programs for their employees
Early Care and Education Best Practices: Implement evidence-based/practice-tested facility-level
early care and education (ECE) best practices particularly in ECE centers and family day care
homes serving minority racial or ethnic and low-income communities.
o Recommended ways to implement this strategy include but are not limited to:
implementing nationally recognized ECE interventions and resources such as
Let’s Move Child Care; NAP SACC; Eat Well/Play Hard in Child Care; Grow it,
Try it, Like it; and Color Me Healthy
improving child care standards for nutrition, physical activity, screen time and
breastfeeding support if the community is in a state that does not pre-empt local
jurisdictions from strengthening child care standards
ensuring that ECE facilities that serve infants meet guidelines for supporting
breastfeeding mothers
Multi-Component Physical Activity Interventions: Conduct broad-based, multi-component
interventions to increase physical activity.
o Recommended ways to implement this strategy include but are not limited to:
media or social marketing campaigns directed at large audiences through a
variety of channels (including television, radio, mailings, billboards, posters,
PSA’s, etc.) in conjunction with additional components such as support and self-
help groups, physical activity counseling, risk factor screening and education at
worksites, schools, and health care settings, and community events (e.g., fun
walks or runs). Stand-alone mass media campaigns are not recommended.
School-Based Physical Education: Increase and enhance school-based physical education.
o Recommended ways to implement this strategy include but are not limited to:
implementing daily physical education (PE) as optimal
increasing more time spent moving during PE class
providing other opportunities for youth to be active (e.g., recess, afterschool
programs, safe routes- or walk-to-school programs)
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Physical Activity Access and Outreach: Create or enhance access to places for physical activity
combined with informational outreach.
o Recommended ways to implement this strategy include but are not limited to:
Providing access by:
promoting walking trails at green spaces or school fields
adapting strength and aerobic fitness equipment to be accessible to people with
disabilities
providing access to school grounds during after school hours (such as joint use
agreements)
promoting parks trail maintenance, equipment maintenance and cleanup of
grounds
creating bicycle share programs
improving accessibility to stairs
Combined with:
using signage or other outreach promoting use of places for physical activity
using point-of-decision-prompts to create spontaneous moments for persons to be
active, such as using signs to encourage people to take stairs rather than
escalators or elevators.
Street and Community Design: Increase street- and community-scale urban design and land use
practices to promote increases in physical activity, including active transit.
o Recommended ways to implement this strategy include but are not limited to:
Street-scale design interventions for enhancing street lighting to increase
visibility and reduce crime, improving cross walk safety (e.g., install crosswalk
flag systems), making sidewalk repairs, and using traffic calming devices.
Community-scale design interventions for improving side walk connectivity (i.e.,
sidewalks go to destinations rather than dead ends or unkept foot paths;
placement of residential, business, and shopping sitings that allow for walking
and bicycling to purposeful destinations), preserving green spaces for play and
recreation, and improving safety measures for ALL users (motorized vehicles,
pedestrians, bicyclists, persons with disabilities or mobility limitations, i.e.,
complete streets).
The following two strategies may be used to enhance the above physical activity
strategies.
Physical activity individual health behavior change interventions
o Recommended ways to implement this strategy include but are not
limited to:
using goal setting and self-monitoring progress through physical
activity logs, diaries, or pedometers for feedback and putting
plans in place to overcome barriers and rewards for successful
achievement of goals
Social support interventions for physical activity
o Recommended ways to implement this strategy include but are not
limited to:
using walking groups, worksite fitness classes, buddy systems,
or behavioral contracting where one person contracts with
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another person to hold him or her accountable for achieving
goals
Tobacco Exposure- decrease prevalence of smoking and exposure to secondhand smoke.
o Recommended ways to implement this strategy include but are not limited to:
Implement evidence-based strategies to protect people from secondhand smoke.
Increase smoke-free multi-unit housing.
Implement evidence-based strategies to prevent and reduce tobacco use among
youth and adults.
Increase types of outdoor venues where tobacco use is prohibited (smoke-free
parks, smoke-free schools and campuses).
Alcohol –Interventions directed to the general population will have the added benefit of reducing
excessive alcohol consumption in populations with or at risk of hypertension
Recommended ways to implement this strategy include but are not limited to:
Maintaining limits on days and hours of alcohol sale in on-premises settings
Using regulatory authority ( e.g., through licensing and zoning) to limit alcohol
outlet density.
Worksite Wellness- A comprehensive health promotion program that includes sustained
individual risk reduction counseling for employees and lower-cost policy and environmental
interventions is the most effective approach for supporting cardiovascular health.
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Appendix B
PROOF OF INSURANCE/INSURANCE REQUIREMENTS
Department of Public Health
Grantee must provide and maintain at Grantee's own expense or cause to be provided, during the term of
the Agreement, the insurance coverage and requirements specified below, insuring all operations related
to the Agreement.
A. INSURANCE TO BE PROVIDED
1) Workers Compensation and Employers Liability
Workers Compensation Insurance, as prescribed by applicable law covering all employees who
are to provide work or a service under this Agreement and Employers Liability coverage with
limits of not less than $500,000 each accident, illness or disease.
2) Commercial General Liability (Primary and Umbrella)
Commercial General Liability Insurance or equivalent with limits of not less than
$2,000,000 per occurrence for bodily injury, personal injury, and property damage liability.
Coverages must include the following: All premises and operations, products/completed
operations, separation of insureds, defense, and contractual liability (not to include Endorsement
CG 21 39 or equivalent). The City of Chicago is to be named as an additional insured on a
primary, non-contributory basis for any liability arising directly or indirectly from the work or
services.
Sub-Grantees performing work for the Grantee must maintain limits of not less than $1,000,000
with the same terms herein.
3) Automobile Liability (Primary and Umbrella)
When any motor vehicles (owned, non-owned and hired) are used in connection with work to be
performed, Grantee must provide Automobile Liability Insurance with limits of not less than
$1,000,000 per occurrence for bodily injury and property damage. The City of Chicago is to be
named as an additional insured on a primary, non-contributory basis.
5) Blanket Crime
Grantee must provide Blanket Crime Insurance or equivalent covering all persons handling funds
under this Agreement, against loss by dishonesty, robbery, destruction or disappearance,
computer fraud, credit card forgery, and other related crime risks. The policy limit shall be
written to cover losses in the amount of the maximum monies collected or received and in the
possession of Grantee at any given time.
6) Professional Liability
When any program or project managers/administrators or other consultants perform work or
services in connection with this Agreement, Professional Liability Insurance covering acts, errors,
or omissions must be maintained with limits of not less than $ 1,000,000 . When policies are
renewed or replaced, the policy retroactive date must coincide with, or precede, start of work or
services on the Agreement. A claims-made policy which is not renewed or replaced must have an
extended reporting period of two (2) years.
7) Valuable Papers
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When any plans, records, reports, media, data, files and other documents are produced or used
under this Agreement, Valuable Papers Insurance must be maintained in an amount to insure
against any loss whatsoever, and must have limits sufficient to pay for the re-creation and
reconstruction of such records.
8) Directors and Officers Liability
Directors and Officers Liability Insurance must be maintained in connection with this Agreement
with limits of not less than $ 1,000,000. Coverage must include any actual or alleged act, error or
omission by directors or officers while acting in their individual or collective capacities. When
policies are renewed or replaced, the policy retroactive date must coincide with or precede
commencement of services by the Grantee under this Agreement. A claims-made policy which is
not renewed or replaced must have an extended reporting period of two (2) years.
B. ADDITIONAL REQUIREMENTS
Grantee must furnish the City of Chicago, Department of Public Health, Room 200, 333 South State
Street, Chicago IL. 60604, original Certificates of Insurance, or such similar evidence, to be in force on
the date of this Agreement, and Renewal Certificates of Insurance, or such similar evidence, if the
coverages have an expiration or renewal date occurring during the term of this Agreement. Grantee must
submit evidence of insurance on the City of Chicago Insurance Certificate Form (copy attached as
Exhibit-) or equivalent prior to execution of Agreement. The receipt of any certificate does not constitute
agreement by the City that the insurance requirements in the Agreement have been fully met or that the
insurance policies indicated on the certificate are in compliance with all requirements of Agreement. The
failure of the City to obtain certificates or other insurance evidence from Grantee is not a waiver by the
City of any requirements for the Grantee to obtain and maintain the specified coverages. Grantee must
advise all insurers of the Agreement provisions regarding insurance. Non-conforming insurance does not
relieve Grantee of the obligation to provide insurance as specified in this Agreement. Nonfulfillment of
the insurance conditions may constitute a violation of the Agreement, and the City retains the right to
suspend this Agreement until proper evidence of insurance is provided, or the Agreement may be
terminated.
The insurance must provide for 60 days prior written notice to be given to the City in the event coverage
is substantially changed, canceled or non-renewed.
Any deductibles or self-insured retentions on referenced insurance coverages must be borne by Grantee.
Grantee hereby waives and agrees to require their insurers to waive their rights of subrogation against the
City of Chicago, its employees, elected officials, agents or representatives.
The coverages and limits furnished by Grantee in no way limit the Grantee's liabilities and responsibilities
specified within the Agreement or by law.
Any insurance or self-insurance programs maintained by the City of Chicago do not contribute with
insurance provided by Grantee under this Agreement.
The required insurance to be carried is not limited by any limitations expressed in the indemnification
language in this Agreement or any limitation placed on the indemnity in this Agreement given as a matter
of law.
If Grantee is a joint venture or limited liability company, the insurance policies must name the joint
venture or limited liability company as a named insured.
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Grantee must require Sub-Grantees to provide the insurance required herein, or Grantee may provide the
coverage for Sub-Grantees. Sub-Grantees are subject to the same insurance requirements of Grantee
unless otherwise specified in this Agreement.
If Grantee or Sub-Grantees desire additional coverages, the party desiring the additional coverage is
responsible for the acquisition and cost.
Notwithstanding any provisions in the Agreement to the contrary, the City of Chicago Risk Management
Department maintains the right to modify, delete, alter or change these requirements.
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Appendix C
Title Page
City of Chicago City of Chicago
Department of Public Health, Division of Policy, Planning and Legislative Affair
Agency Name:
Agency Administrative Mailing Address:
Agency Service Site Address:
Agency Tax Identification Number:
Service Category Applying for:
Total Amount Requested:
Executive Director:
President of the Board of Directors:
Executive Director’s Phone Number:
Executive Director’s Email Address:
Primary Program Contact Person:
Primary Program Contact’s Phone
Number:
Primary Program Contact’s Fax
Number:
Primary Program Contact’s Email Address:
Fiscal Agent Name (if applicable):
Fiscal Organization Mailing Address:
Fiscal Agent’s Phone Number: Fiscal Agent’s Fax Number:
Fiscal Agent’s Email Address:
Signature of the Executive Director: Date:
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Appendix D
Collaborating Partners
City of Chicago
Department of Public Health, Division of Policy, Planning and Legislative Affairs
Name of Community-Based Organization CBO Contact CBO Address Chicago Community Areas Currently Served
by CBO
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Appendix E
Program Work Plan
City of Chicago
(If additional space is needed, this page can be copied)
SCOPES OF SERVICES RESOURCES ACTIVITIES TIMELINE Population Impact
What are we going to do? Who will do this?
What inputs are needed?
How are we going to do this? Include start and end dates,
specified to the week and
month. Year is assumed to be
2012, unless otherwise
specified.
How many people to you anticipate
reaching through specific activity?
Specify percent of target population
Example 1: Conduct trainers in 10
underserved community areas in
Chicago.
10 community-based
organizations will be
identified to implement
PlayStreets in Community
Areas 57, 59, 61, 62, and
63.
Reach out to 10 or more community-
based organizations to conduct
PlayStreets.
Select at least 10 CBOs to
implement PlayStreets in
their neighborhood in May.
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Appendix F- Budget Template
CITY OF CHICAGO
CHICAGO DEPARTMENT OF PUBLIC HEALTH DELEGATE AGENCY FINAL BUDGET SUMMARY
Form 1
A. Delegate Agency Name: G. Funding Strip:
B. Purchase Order Number: H. Contract Period:
C. Release Number: I. Maximum Amount of Contract:
D. Vendor Code: J. Budget (or Release) Amount:
E. Department Program: K. Budget (or Release) Period:
F. IRS Number: L. (C. F. D. A. Number) :
PROJECT BUDGET SUMMARY
Item of Expenditure Account CDPH Share Other Share Total Budget
# ($) ($) ($)
Personnel 220005
Fringes 220044
Stipends 220050
Operating Expenses 220100
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Professional/Technical Services 220140
Transportation 220200
Materials and Supplies 220300
Equipment 220400
Administrative Cost/Indirect Cost (_____%) 220801
Other 220999
TOTAL
Authorization City Authorization
Signatory of Agency Official Date Signature of Department or Official Date
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CHICAGO DEPARTMENT OF PUBLIC HEALTH
CONTRACTS UNIT
FINAL PERSONNEL BUDGET
Form 2
Agency Name:
Purchase Order Number:
Release Number:
Department Program:
PERSONNEL BUDGET ALLOCATION
(1) (2) (3) (4) (5)
Brief Summary of Job Responsibilities
Position/Title No. Annual Salary % of
CDPH Share
($) Time ($)
Spent
(6) Totals
Totals must match Budget Summary Form, account 220005
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FRINGE BENEFITS AND TOTAL PERSONNEL COSTS
Type of Fringe Benefit
CDPH Share
Please show Calculations below.
($)
(7) FICA and Medicare
(8) State Unemployment Insurance
(9) State Workers Compensations
(10) Other (please list)
(11) Other (please list)
(12) TOTAL FRINGE BENEFITS (Add lines 7-11) Totals must match Budget Summary Form, account 220005
(13) TOTAL PERSONNEL AND FRINGE COSTS (Add lines 6 and 12)
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CHICAGO DEPARTMENT OF PUBLIC HEALTH
CONTRACTS UNIT
FINAL NON-PERSONNEL BUDGET Form 3
Agency Name:
Purchase Order Number:
Release Number:
Department Program:
Item of Expenditure Account # CDPH Share Description & Justification
Of Cost ($)
Stipends 220050
Operating Expenses 220100
Professional and Technical Services 220140
Transportation Expenses 220200
Materials and Supplies 220300
Equipment 220400
Administrative/Indirect Costs (_____%) 220801
Other 220999
TOTAL NON PERSONNEL COSTS Total of this page
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Appendix G
Application Checklist
City of Chicago
Department of Public Health, Division of Policy, Planning and Legislative Affairs
The application checklist should be used to ensure that the application is complete. Include the checklist with the application. Applications that do
not contain each of the items below will be considered incomplete.
Title Page using Appendix C
Application Checklist
Table of Contents
Proposal Narrative
Project Abstract (1 page limit)
Agency Mission and Experience (1 page limit)
Target Populations and Collaborations (1 page limit)
Cultural and Linguistic Capacity (1 page limit)
Technical Capabilities (1 page limit)
Description of Proposed Project and Work Plan (3 page limit on narrative; no page limit for Work Plan form)
Personnel
Budget and Justification (1 page limit for budget justification; no page limit for budget forms)
Required Documentation
Internal Revenue Service 501(c)3 tax exempt determination letter
Copy of delegate agency’s Articles of Incorporation
Copy of the delegate agency’s most recent Financial Statement and OMB Circular A-133 Audit
List of Board of Directors (must include place of employment for each member)
Proof of Insurance – Appendix B
At least 3 Letters of Support from agencies or partners in the intended target communities
A Letter of Commitment is required from any outside resource cited in the proposal who will be
working with the applicant organization and whose role is essential to the program.
One (1) original, five (5) complete copies (total of six copies) and one (1) electronic copy of the proposal are submitted
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Appendix H:
Examples of CDC-Recommended Evidence- and Practice-Based
Strategies Table
Tobacco-Free Living Goal: Prevent and Reduce Tobacco Use
CDC-Recommended
Evidence- and Practice-Based
Strategies
Implement evidence-based
strategies to reduce exposure to
secondhand smoke.
Evaluation Toolkit for Smoke-Free Policies (2008).
http://www.cdc.gov/tobacco/basic_information/secondhand_smoke/evalu
ation_toolkit/index.htm CDC Resources on Secondhand Smoke http://www.cdc.gov/tobacco/basic_information/secondhand_smoke/index
.htm
Community Guide Findings on Effective Approaches to Reducing
Secondhand Smoke Exposure
http://www.thecommunityguide.org/tobacco/environmental/index.html
Tobacco-Free Workplace Campus Initiative This toolkit provides guidance for assessing, planning, implementing,
and evaluating a tobacco-free campus (TFC) initiative that includes a
policy and comprehensive cessation services for employees.
http://www.cdc.gov/nccdphp/dnpao/hwi/toolkits/tobacco/index.htm Healthy Homes Manual: Smoke-Free Policies in Mulitunit Housing http://www.cdc.gov/healthyhomes/Healthy_Homes_Manual_WEB.pdf U.S. Department of Housing and Urban Development (HUD):
Implement evidence-based
strategies to prevent and reduce
tobacco use among youth and
adults.
Overview of Key Findings from 2012 Surgeon General’s Report http://www.surgeongeneral.gov/library/reports/preventing-youth-
tobacco-use/factsheet.html
Community Guide Findings on Effective Approaches to Reducing
Tobacco Use Initiation http://www.thecommunityguide.org/tobacco/initiation/index.html
Institute of Medicine 2007 Report on Ending the Tobacco Epidemic http://www.iom.edu/Reports/2007/Ending-the-Tobacco-Problem-A-
Blueprint-for-the-Nation.aspx
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Tobacco-Free Living Innovative
Proposals Recipient will provide evidence behind their proposal.
Active Living and Healthy Eating Goals: Prevent and Reduce Obesity, Increase Physical Activity, and
Improve Nutrition in Accordance with the Dietary Guidelines for American, 2010
Improve jurisdiction-wide
nutrition, physical activity, and
screen time policies and
practices in early childcare
settings.
HRSA Early Childhood Resources Including 3rd Edition of Caring
for Our Children. Includes resources including the 3rd edition of Caring for Our Children:
National Health and Safety Performance Standards; Guidelines for Early
Care and Education Programs. These national standards developed with
funding from the Health Resources and Services Administration
represent the best evidence, expertise, and experience in the country on
quality health and safety practices and policies that should be followed in
today’s early care and education settings.
http://mchb.hrsa.gov/programs/earlychildhood/index.html
Let’s Move! Child Care Fact Sheet http://www.letsmove.gov/sites/letsmove.gov/files/Let_s_Move_Child_Ca
re_Fact_Sheet.pdf
Increase the number of
designated baby-friendly
hospitals.
CDC Vital Signs: Hospital Support for Breastfeeding Includes information about current hospital support for breastfeeding, the
Baby-Friendly Ten Steps to Successful Breastfeeding, actions that
various sectors can take to support mothers to breastfeed, and links to
resources. http://www.cdc.gov/vitalsigns/BreastFeeding/ http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6030a4.htm?s_cid=m
m6030a4_w
Educate communities about
policies and practices to support
breastfeeding in health care,
community, workplaces, and
learning and childcare settings.
The Surgeon General’s Call to Action to Support Breastfeeding Provides evidence-based actions for families, communities, health care,
employment, public health, and research to support breastfeeding. http://www.surgeongeneral.gov/library/calls/breastfeeding/calltoactiontos
upportbreastfeeding.pdf
Purchaser’s Guide to Clinical Preventive Services Provides summary plan description language that benefits managers to
use to purchase recommended breastfeeding counseling coverage
(USPSTF B Recommendation).
http://www.cdc.gov/pcd/issues/2008/apr/07_0220.htm
Investing in Workplace Breastfeeding Program and Policies: An
Employer’s Tool Kit The CDC and the National Business Group on Health developed this
health toolkit that provides information for assessing, planning,
promoting, implementing, and evaluating a worksite lactation support
program.
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http://www.cdc.gov/workplacehealthpromotion/implementation/topics/nu
trition.html
Improve nutrition quality of
foods and beverages served or
available in schools.
Increase access to fruits and
vegetables in schools.
Decrease amount of sodium
in foods in schools.
Ensure availability of plain,
cold drinking water
throughout the day at no
cost to students.
Sodium Procurement Guide
http://www.cdc.gov/salt/pdfs/DHDSP_Procurement_Guide.pdf
CDC Resource center – Schools: Model Wellness Policy Language
for Water Access in Schools
http://www.cdc.gov/CommunitiesPuttingPreventiontoWork/resources/sch
ools.htm
USDA’s Be Salt Savvy—Cut Back on Sodium for Healthier School
Meals Fact Sheet
http://www.fns.usda.gov/tn/Resources/DGfactsheet_sodium.pdf
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Improve the quality and amount
of physical education and
physical activity in schools.
Increase the amount of
time students spend in
moderate or vigorous
physical activity during
physical education
class.
Increase the total
number of physical
activity opportunities
implemented at school
facilities, including
daily recess,
intramurals/physical
activity clubs, and walk
or bicycle to and from
school.
Increase number of
public places (e.g.
schools) accessible to
the public for physical
activity.
The Community Guide Physical Activity Chapter
www.thecommunityguide.org
CDC’s Physical Education Curriculum Analysis Tool
http://www.cdc.gov/healthyyouth/pecat
CDC’s Strategies to Improve the Quality of Physical Education
http://www.cdc.gov/healthyyouth/physicalactivity/pdf/quality_pe.pdf
Physical Activity Guidelines for Children and Adolescents:
The Role of Schools in Promoting Youth Physical Activity
http://www.cdc.gov/healthyyouth/physicalactivity/toolkit/youth_pa_guid
elines_schools.pdf
CDC’s Youth Physical Activity Guidelines Toolkit
http://www.cdc.gov/HealthyYouth/physicalactivity/guidelines.htm#1
CDC Joint Use Agreement Resources
www.cdc.gov/CommunitiesPuttingPreventiontoWork/resources/schools.h
tm#joint_use_agreements
Kids Walk-to-School: A Guide to Promote Walking to School
http://www.cdc.gov/nccdphp/dnpa/kidswalk/resources.htm#guide
CDC Resources for Safe Routes to School Guide, Toolkit, and Other
Resources
http://www.cdc.gov/Features/PedestrianSafety/
DHHS Physical Activity Guidelines
http://www.health.gov/paguidelines/
Increase accessibility,
availability, affordability and
identification of healthy foods in
Equitable Development Toolkit:
Healthy Food Retailing Policy Link
An online tool that focuses on increasing access to retail outlets that sell
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communities, including
provision of full service grocery
stores, farmers markets, small
store initiatives, mobile vending
carts, and restaurant initiatives. Carry more low-sodium
and no-sodium options.
Promote healthy food
and beverage
availability and
identification.
Placement and
promotion strategies.
Incentivize new grocery
store development.
nutritious, affordable food in underserved communities.
http://www.cdc.gov/obesity/downloads/Healthier_Food_Retail.pdf
Recommended Community Strategies and Measurements to Prevent
Obesity in the United States http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5807a1.htm
USDA Food Desert Locator http://www.ers.usda.gov/data/fooddesert/
Increase availability and
affordability of healthful foods
in institutional settings,
workplaces, senior centers, and
government facilities.
Farm to institution
strategies.
Increase availability of
fruits and vegetables to
employees in their
workplaces.
CDC’s Lean Works! Offers interactive tools and evidence-based resources to design effective
worksite obesity prevention and control programs.
http://www.cdc.gov/leanworks/index.html Health and Sustainability Guidelines for Federal Concessions and
Vending Operations
http://www.cdc.gov/chronicdisease/resources/guidelines/food-service-
guidelines.htm Sodium Procurement Guide
http://www.cdc.gov/salt/pdfs/DHDSP_Procurement_Guide.pdf
CDC Workplace Health Promotion, North Carolina Organizational
Health Eating Policy Template
http://www.cdc.gov/workplacehealthpromotion/implementation/topics/ph
ysical-activity.html
CDC's LEAN Works! A Workplace Obesity Prevention Program,
California Fit Business Kit Helps employers develop and implement a
culture and environment at their workplaces that support healthy eating
and physical activity among workers.
http://www.cdc.gov/leanworks/resources/stateresources.html
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Promote purchase of fruits,
vegetables, and other healthy
foods through incentives
associated with food assistance
programs.
Supplemental Nutrition Assistance Program (SNAP) at Farmers
Markets:
A How To Handbook.
http://www.ams.usda.gov/AMSv1.0/getfile?dDocName=STELPRDC508
5298&acct=wdmgeninfo
Increase access to food retail
outlets offering healthier
choices; encourage retail venues
to provide access and
availability to healthier foods. Provide incentives to
encourage existing
stores or restaurants to
provide healthier food
options or to encourage
the development of new
retail venues that offer
healthier foods.
Recommended Community Strategies and Measurements to Prevent
Obesity in the United States http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5807a1.htm
Increase opportunities for
physical activity in communities
and workplaces. Community-wide
campaigns.
Access to facilities and
places.
Joint use agreements.
Flextime.
Stairwell modification.
Incentives
CDC Workplace Health Promotion Tools and Resources Utah Department of Health Exercise and Health Activity Time Policy
http://www.cdc.gov/workplacehealthpromotion/implementation/topics/ph
ysical-activity.html
Workplace Stairwell Modification and Promotion to Increase Daily
Physical Activity
This toolkit provides information for implementing and promoting
changes to workplace stairwells to encourage physical activity at work.
www.cdc.gov/nccdphp/dnpao/hwi/toolkits/stairwell/index.htm
Kids Walk-to-School: A Guide to Promote Walking to School
http://www.cdc.gov/nccdphp/dnpa/kidswalk/pdf/kidswalk.pdf
Discount Fitness Club Network
This toolkit provides guidance on identifying and establishing a
relationship with a nationwide discount fitness club network (DFCN) for
employees of multi-site organizations.
http://www.cdc.gov/nccdphp/dnpao/hwi/toolkits/fitnessclub/
Recommended Community Strategies and Measurements to Prevent
Obesity in the United States http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5807a1.htm
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Active Living and Healthy
Eating Innovative Strategies. Recipient will provide evidence supporting their proposal.
Increased Use of High-Impact Quality Clinical Preventive Services Goals: Increase control of high blood pressure and high cholesterol; increase access to and demand for high-
impact quality preventive services.
Provide training and technical
assistance to health care
institutions, providers and
provider organizations to
effectively implement systems
to improve delivery of clinical
preventive services, consistent
with USPSTF
recommendations.
Implement strategies to
translate known
interventions into usual
clinical care to increase
control of high blood
pressure and high
cholesterol.
Provide training and
technical assistance to
health care institutions,
providers and provider
organizations to
effectively implement
systems to increase
delivery and use of
treatment for tobacco
use and dependence.
Provide training and
technical assistance to
health care institutions,
providers and provider
organizations to
effectively implement
systems to increase
delivery and use brief
intervention to reduce
excessive alcohol use.
Provide training and
technical assistance to
health care institutions,
Vital Signs: Prevalence, Treatment, and Control of Hypertension, United States, 1999–2002 and 2005–2008 MMWR, February 4, 2011 / 60(04);103-108
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6004a4.htm?s_cid=m
m6004a4_w
Purchaser’s Guide to Increase Use of Clinical Preventive Services
Among Employees
http://www.cdc.gov/pcd/issues/2008/apr/07_0220.htm
United States Preventive Services Task Force
http://www.ahrq.gov/clinic/uspstfix.htm
Better Diabetes Care
www.betterdiabetescare.nih.gov
Project CHOICES A brief motivational intervention for reducing alcohol-exposed
pregnancies among women who are at high risk for such pregnancies.
http://www.cdc.gov/ncbddd/fasd/research-preventing.html
Drinking and Reproductive Health: A Fetal Alcohol Spectrum
Disorders Prevention Tool Kit
http://www.cdc.gov/ncbddd/fasd/acog_toolkit.html
NCI Patient Navigator Research Program Manual http://ncipoetqa.cancer.gov/PatientNavigator/documents/Patient%20Navi
gator%20Binder.pdf Community Health Workers’ Sourcebook
A training manual for preventing heart disease and stroke.
http://www.cdc.gov/dhdsp/library/chw_sourcebook/pdfs/sourcebook.pdf
CDC Recommendation for Routine HIV Testing for Persons Aged
13-64 Years http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm National Chlamydia Coalition Testing Implementation Guidance.
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providers and provider
organizations to
effectively implement
systems to increase
delivery and use of
cancer screening
services.
Provide training and
technical assistance to
health care institutions,
providers and provider
organizations to
effectively implement
systems to increase
appropriate testing of
HIV and STDs and links
to care and prevention
with people who test
positive.
Provide training and
technical assistance to
health care institutions,
providers and provider
organizations to
effectively implement
systems to increase
recognition and enhance
secondary prevention of
chronic Hepatitis B and
Hepatitis C infection.
Why Screen for Chlamydia: An Implementation Guide for
Healthcare Providers. Comprehensive guidance on Chlamydia testing
and screening algorithms and assistance for clinical providers in dealing
with test providers, as well as discussing sexual health and testing with
patients www.cdc.gov/stopsyphilis/dear-coord/SEECoordinators-June-2009.pdf Centers for Disease Control and Prevention. Recommendations for
Identification and Public Health Management of Persons with
Chronic Hepatitis B Virus Infection. MMWR 2008; 57 (No. RR- 8): 1-
20. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5708a1.htm
American Association for the Study of Liver Diseases. Management,
and Treatment of Hepatitis C: Practice Guidelines, 2009 Update (pp 1335-1339, sections on Testing, Counseling, and Test Interpretation) http://www.guidelines.gov/content.aspx?id=14708
Provide outreach, including paid
and earned media, to increase
use of clinical preventive
services by the population or
population subgroups.
CDC Sexually Transmitted Diseases, Resources http://www.cdc.gov/std/program/resources.htm
Prevent diabetes, especially in
high-risk populations. Increase coverage,
availability and use of the
National Diabetes
Prevention Program.
Increase preventive services
for pregnant women with
gestational diabetes or a
history of gestational
diabetes.
Diabetes Training and Technical Assistance Center – **This site
provides information on the Diabetes Prevention Program (DPP)
including the standards that must be met in order to become a recognized
provider of the DPP lifestyle intervention.
http://www.cdc.gov/diabetes/prevention/dttac.htm
Increase access to and use of
school-based dental sealant Preventing Dental Caries Through School-Based Sealant Programs:
Updated Recommendations and Review of Evidence
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programs. http://www.cdc.gov/OralHealth/topics/dental_sealant_programs.htm
Community Guide Recommendation for School-based Sealant
Delivery Programs
http://www.thecommunityguide.org/oral/schoolsealants.html
Improve arthritis, asthma,
cardiovascular disease, and
diabetes outcomes with chronic
disease self management
training programs.
Arthritis Evidence-based Self-Management Programs
http://www.cdc.gov/arthritis/interventions/self_manage.htm
Guidelines for the Diagnosis and Management of Asthma
www.nhlbi.nih.gov/guidelines/asthma/ Asthma: A Business Case for Employers and Health Care Purchasers http://www.cdc.gov/niosh/topics/asthma/OccAsthmaPrevention.html The Asheville Project http://www.ncbi.nlm.nih.gov/pubmed/12688435
Implement Viral Hepatitis
Action Plan HHS Viral Hepatitis Action Plan http://www.hhs.gov/ash/initiatives/hepatitis/
Clinical Preventive Services
Innovative Interventions.
Recipient will provide evidence supporting their proposal.
Social and Emotional Wellness Goals: Increase child and adolescent health and wellness, including social and emotional wellness.
Educate communities about
child development and health
outcomes.
Bright Futures http://www.cdc.gov/ncbddd/childdevelopment/links.html Adverse Childhood Experiences Study http://www.cdc.gov/ace/index.htm School Connectedness: Strategies for Increasing Protective Factors
among Youth
http://www.cdc.gov/HealthyYouth/AdolescentHealth/pdf/connectedness.
Implement effective positive
youth development and risk
reduction approaches to improve
adolescent health.
Raising Healthy Children http://www.cdc.gov/parents/children/healthy_children.html
Social and Emotional Wellness
Innovative Interventions. Recipient will provide evidence supporting their proposal.
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Healthy and Safe Physical Environment Goals: Increase bicycling and walking; improve the community environment to support health.
Educate communities about
comprehensive approaches to improve
community design to enhance walking and
bicycling and active transportation.
CDC Recommendations for Improving Health through
Transportation Policy
http://www.cdc.gov/transportation/recommendation.htm
Kids Walk-to-School: A Guide to Promote Walking to
School
http://www.cdc.gov/nccdphp/dnpa/kidswalk/resources.htm#gui
de
National Center for Safe Routes to School guide, Toolkit,
and Other Resources
http://www.cdc.gov/Features/SafeSchools/
Educate communities about community
design standards to make streets safe for
all users, including pedestrians, bicyclists
and users of public transit.
Increasing Physical Activity Through Community Design:
A Guide for Public Health Practitioners
www.cdc.gov/CommunitiesPuttingPreventiontoWork/resources
/physical_activity.htm
How to Develop a Pedestrian Safety Action Plan
http://safety.fhwa.dot.gov/ped_bike/pssp/
Educate communities about the effect of
increasing mixed use land use and transit-
oriented development.
Creating Safe, Healthy and Active Living Communities: A
Public Health Professional's Guide to Key Land Use and
Transportation Planning Policies and Processes
http://www.cdc.gov/healthyplaces/publications/landuseNALBO
H.pdf
Establish community protocols to assess
the effect of community changes on
community health and well-being.
CDC Resources—Health Impact Assessment/Practice
Standards
http://www.cdc.gov/healthyplaces/hia.htm
Increase access to safe and healthy homes.
Promote radon-resistant construction
in communities.
Implement community-wide
Healthy Housing Reference Manual www.cdc.gov/nceh/publications/books/housing/housing.htm Surgeon General’s Call to Action to Promote Healthy
Homes www.surgeongeneral.gov/topics/healthyhomes/calltoactiontopr
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*Complete Healthy People 2020 Objectives can be found at:
http://www.healthypeople.gov/hp2020/Objectives/TopicAreas.aspx
campaigns that promote safe and
healthy homes.
omotehealthyhomes.pdf Asthma Community Guide www.thecommunityguide.org/asthma/index.html HUD’s Strategic Plan www.hud.gov/offices/lead/library/hhi/hh_strategic_plan.pdf www.cdc.gov/lead
Educate communities about the effect of
community water fluoridation
CDC - Community Water Fluoridation: Questions and
Answers
http://www.cdc.gov/fluoridation/fact_sheets/cwf_qa.htm
Educate communities about the effect of
illegal beverage sales on community
health.
Community Guide
http://www.thecommunityguide.org/alcohol/outletdensity.html
Community Guide
http://www.thecommunityguide.org/alcohol/dramshop.html
Healthy and Safe Physical Environment
Innovative Interventions. Recipient will provide evidence supporting their proposal.