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 CenterRoom 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

Transcript of Chicago Department of Public Health

Page 1: Chicago Department of Public Health

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.

pdf

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.