Tennessee Home Visitation Program Grant Application Guidelines

7/31/2019 Tennessee Home Visitation Program Grant Application Guidelines

1/28

Tennessee Community Home Visiting Grant Application

Application Guidelines

State of Tennessee

Department of Health

RFS 34347-34112

One (1) original, four (4) complete hard copies, and one (1) electronic copy of your applicationmust be received in the Department of Health office designated below by 2:00 PM CDT onMarch 29, 2011. Incomplete or late applications will not be accepted. Applications may behand-carried or mailed to the address below. Faxed submissions will not be accepted.

Lea PhelpsApplication Coordinator

Bureau of Health ServicesDepartment of HealthCordell Hull Building 4th Floor

425 5th Avenue NorthNashville, TN 37243

Telephone: 615-532-2214Facsimile: 615- 532-2286

Email: [email protected]
mailto:[email protected]:[email protected]


2/28

Table of Contents

I. Proposal Instructions............................................................................................................3II. List of High-Risk Communities...........................................................................................5III. List of Evidence-Based Models Considered for Proposals..................................................5IV. Budget Guidelines................................................................................................................6

APPENDICESA. Attachment 1: Community Home Visiting Program Application..........................7B. Attachment 2: Proposed Grant Budget............................................................11-12

EXHIBITS

A. Pro Forma Contract for cost-reimbursement grants to an individual,business, non-profit, or governmental entity of another state ....13-33

2


3/28

Community Proposal for Implementation of Evidence-Based Home Visiting Program

Maternal, Infant, and Early Childhood Home Visiting Program

Please complete Attachment 1, the Community Home Visiting Program Application. Limit yourresponse to these questions to no more than 15 pages, single-spaced, using 12-point Times New

Roman font, with 1 margin on all sides. Applications that are longer than 15 pages or donot meet the formatting requirements listed above may not be considered. These questionscome directly from the federal Maternal, Infant, and Early Childhood Home Visiting ProgramSupplemental Information Request (SIR), available at:http://www.hrsa.gov/grants/manage/homevisiting/sir02082011.pdfreleased on February 8, 2011.

In addition to your Application, please attach the items listed below. Formatting should be

the same as listed above for the Application. Do not attach additional documents not listed

below; doing so may result in the proposal not being considered.

A budget, not to exceed $350,000 (using Attachment 2) for the project period (July 1,

2011 through September 30, 2012) and a budget narrative. Budget guidelines areprovided on page 6 of these instructions. (Budget and budget narrative not to exceed 10pages)

A list of collaborative public and private partners (not to exceed one page).

A logic model for the proposed home visiting program as a whole. May build on modeldevelopers logic model but should not duplicate it. Logic model should identify inputs,outputs and short-term and long-term outcomes (not to exceed one page).

Documentation of approval by the home visiting model developer to implement theevidence based model as proposed. The documentation, in letter format, should includeverification that the model developer has reviewed and agreed to your community plan assubmitted. Information on the developers of the approved home visiting models can be

found at http://homvee.acf.hhs.gov/implementations.aspx

Proposal Submission Requirements Summary

Attachment 1: Community Home Visiting Program Application (15 page limit)

Attachment 2: Budget and Budget Narrative (10 page limit)

Additional attachments:o List of partners (1 page limit)

o Logic model (1 page limit)

o Letter from model developer with approval for implementation

One (1) original, four (4) complete hard copies, and one (1) electronic copy of your

proposal must be received by the Department of Health office by 2:00 PM CDT onMarch 29, 2011 Incomplete or late proposals will not be accepted. Proposal may behand-carried or mailed to: Lea Phelps, Application Coordinator, Tennessee Departmentof Health, Cordell Hull Building4th Floor, 425 Fifth Avenue North, Nashville, TN,37243. Email address: [email protected]. Telephone: 615-532-2214 Faxedsubmissions will not be accepted.

A Pro Forma Grant Contract is attached as Application Exhibit A. The Pro Forma Grant

Contract substantially represents the grant document applicants selected by the State for

3
http://www.hrsa.gov/grants/manage/homevisiting/sir02082011.pdfhttp://www.hrsa.gov/grants/manage/homevisiting/sir02082011.pdfhttp://homvee.acf.hhs.gov/implementations.aspxmailto:[email protected]://www.hrsa.gov/grants/manage/homevisiting/sir02082011.pdfhttp://homvee.acf.hhs.gov/implementations.aspxmailto:[email protected]


4/28

grant award must agree to and sign, if awarded. The blanks will be completed by the State

with appropriate information in the final grant.

If a grant is awarded to a governmental entity established pursuant to Tennessee Code

Annotated(such as a human resource agency, a developmental district, the University of

Tennessee, or a Board of Regents school), the standard terms and conditions of the grantshall be revised accordingly; however, significant performance requirements shall not be

revised.

4


5/28

List of High-Risk Communities

Tennessee submitted a statewide home visiting needs assessment to HRSA on September 20,2010. Included in that assessment was an outline of community risk. Note: for purposes of theneeds assessment and this proposal, the term community refers to county(ies) . The

communities identified as being at highest risk in that assessment are listed below and are thecommunities in which evidence-based home visiting programs may be implemented for thisproposal. Proposals must be implemented in one (or more) of these communities. Proposalswhich plan for implementation in other communities will not be considered.

Community (County) Risk Score Rank

Shelby 1150 95

Lauderdale 1106 94

Haywood 1067 93

Rhea 1008 92

Hardeman 984 91

Campbell 947 90Maury 936 89

Davidson 934 88

Hardin 929 87

Hamilton 919 86

Henderson 908 85

Madison 904 84

Sequatchie 898 83

Coffee 892 82

Dyer 884 81

List of Evidence-Based Models Considered for Proposals

Seven home visiting models were designated as evidence-based in the Supplemental InformationRequest released on February 8, 2011. Those models are listed below. Additional informationon each model is available in Appendix B of the SIR. Proposals for models other than thoselisted below will not be considered. Note: Models are listed in alphabetical order as they arelisted in the federal SIR.

Early Head StartHome Based Option

Family Check Up Healthy Families America (HFA)

Healthy Steps

Home Instruction Program for Preschool Youngsters (HIPPY)

Nurse-Family Partnership (NFP)

Parents as Teachers

5


6/28

Budget Guidelines for Evidence-Based Home Visiting Proposals

Budgets shall not exceed $350,000 for the period from July 1, 2011 through September 30, 2012.Budgets exceeding the maximum amount will not be considered.

Provide a narrative that explains the amounts requested for each line in the budget. The budgetjustification must describe how each item will support the achievement of proposed objectives.

Refer to Department of Finance and Administration Policy 03, Uniform Reporting Requirementsand Cost Allocation Plans for Subrecipients of Federal and State Grant Monies, Appendix A forfurther definition of each expense object line-item in the model budget format. Policy 03 can befound on the Internet at: http://www.state.tn.us/finance/act/documents/policy3.pdf.

6
http://www.state.tn.us/finance/act/documents/policy3.pdfhttp://www.state.tn.us/finance/act/documents/policy3.pdfhttp://www.state.tn.us/finance/act/documents/policy3.pdf


7/28

Attachment 1: Community Home Visiting Program Application

Implementing Agency Information

Date of Submission

Name of Agency

High-risk county(ies) proposed to

be served (see list in instructions)Evidence-Based model proposedto be implemented (must choosemodel from list in instructionsadditional information availablein Appendix B of Federal SIR)

___ Early Head StartHome Based Option___ Family Check Up___ Healthy Families America (HFA)___ Healthy Steps___ Home Instruction Program for Preschool Youngsters

(HIPPY)___ Nurse-Family Partnership (NFP)___ Parents as Teachers

Name of Primary Agency Contact

Mailing Address

PhoneEmail address for PrimaryAgency Contact

Please respond to the items below in the space at right. There are no space limits to

individual responses; however, this total document should not exceed fifteen pages in

length.

Identify community strengths andrisk factors.

Describe the characteristics andneeds of community participants.

Identify existing home visitingservices in community, currentlyoperating or discontinued since3/23/2010 (number and type ofhome visiting programs andinitiatives, models that are usedby identified home visitingprograms).

Describe existing mechanismsand partnerships for screening,identifying, and referring families

and children to your homevisiting program.

Briefly describe referral resourcescurrently available to supportfamilies residing in thecommunity(ies).

Describe plan for coordinationamong existing programs andresources in your community(ies),

7


8/28


especially regarding health,mental health, early childhooddevelopment, substance abuse,domestic violence prevention,child maltreatment prevention,

child welfare, education, andother social and health services.Include how this program willaddress existing service gaps.

Articulate the goals andobjectives for your home visitingprogram.

Describe how the selectedprogram model meets the needsof the community(ies) proposed.

Describe your agencys current

and prior experience withimplementing the model(s)selected and current capacity tosupport the model.

Outline timeline for obtaining thecurriculum or other materialsneeded.

Describe training for homevisitors and supervisors, includingwhether initial training iscompleted and ongoing training

and professional developmentactivities are provided by theimplementing local agencies, orobtained from the national modeldeveloper.

Describe your plan for providinghigh-quality clinical supervisionand reflective practice for allhome visitors and supervisors.

Estimate the number of familiesto be served.

Outline a plan for identifying andrecruiting participants.

Outline a plan for minimizing theattrition rates for participantsenrolled in the program.

Describe your plan for recruiting,hiring, and retaining appropriatestaff for all positions.

Provide an estimated timeline to

8


9/28


reach maximum caseload in eachcommunity identified.

Outline a plan for obtaining,modifying or continuing a datasystem for ongoing internal

continuous quality improvement(CQI).

Describe local capacity tointegrate the proposed homevisiting services into an earlychildhood system, includingexisting efforts or resources todevelop a coordinated earlychildhood system at thecommunity level, such as agovernance structure or

coordinated system of planning.Describe the current communityinvolvement in programimplementation and note thatcommunity involvement isexpected to continue on anongoing basis throughout theduration of this program.

Outline a plan for ensuringimplementation, with fidelity tothe model, and include a

description of the following: theoverall approach to home visitingquality assurance; the approach toprogram assessment and supportof model fidelity; anticipatedchallenges and risks tomaintaining quality and fidelity,and the proposed response to theissues identified.

Describe your plan for workingwith the national model

developer(s) and include adescription of the technicalassistance and support to beprovided through the nationalmodel.

List anticipated technicalassistance needs such asdeveloping a countywide earlychildhood system, implementing

9


10/28


models with fidelity, planning andconducting CQI activities,identifying benchmarks, or othertopics. Identify areas or topics forwhich technical assistance is

available or will be provided byexisting resources, such asthrough technical assistanceprovided by model developers, ifapplicable.

10


11/28

Tennessee Community Program Proposal

Attachment 2: Proposed Budget

ADDITIONAL IDENTIFICATION INFORMATION AS NECESSARY

APPLICABLE PERIOD: The grant budget line-item amounts below shall be applicable only to expense incurred during the periodbeginning July 1, 2011, and ending September 30, 2012.

POLICY 03Object

Line-itemReference

EXPENSE OBJECT LINE-ITEMCATEGORY

1

(detail schedule(s) attached as applicable)GRANT CONTRACT

GRANTEEPARTICIPATION TOTAL PROJECT

1 Salaries 2$0.00 $0.00 $0.00

2 Benefits & Taxes$0.00 $0.00 $0.00

4, 15 Professional Fee/ Grant & Award 2$0.00 $0.00 $0.00

5 Supplies$0.00 $0.00 $0.00

6 Telephone$0.00 $0.00 $0.00

7 Postage & Shipping

$0.00 $0.00 $0.00

8 Occupancy$0.00 $0.00 $0.00

9 Equipment Rental & Maintenance$0.00 $0.00 $0.00

10 Printing & Publications$0.00 $0.00 $0.00

11, 12 Travel/ Conferences & Meetings2$0.00 $0.00 $0.00

13 Interest 2$0.00 $0.00 $0.00

14 Insurance$0.00 $0.00 $0.00

16 Specific Assistance To Individuals2

$0.00 $0.00 $0.0017 Depreciation 2

$0.00 $0.00 $0.00

18 Other Non-Personnel 2$0.00 $0.00 $0.00

20 Capital Purchase 2$0.00 $0.00 $0.00

22 Indirect Cost (% and method)$0.00 $0.00 $0.00

24 In-Kind Expense$0.00 $0.00 $0.00

25 GRAND TOTAL$0.00 $0.00 $0.00

1

Each expense object line-item shall be defined by the Department of Finance and Administration Policy 03, Uniform Reporting Requirements and CostAllocation Plans for Subrecipients of Federal and State Grant Monies, Appendix A. (posted on the Internet at:http://www.state.tn.us/finance/act/documents/policy3.pdf).

2Applicable detail attached if line-item is funded.

11


12/28


Attachment 2: Proposed Budget

GRANT BUDGET LINE-ITEM DETAIL

(BUDGET PAGE NUMBER)

SALARIESAMOUNT

SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00

TOTAL $0.00

PROFESSIONAL FEE / GRANT & AWARDAMOUNT


TOTAL $0.00

TRAVEL / CONFERENCES & MEETINGSAMOUNT


TOTAL $0.00

SPECIFIC ASSISTANCE TO INDIVIDUALSAMOUNT

SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) AMOUNT

TOTAL

AMOUNT

OTHER NON-PERSONNEL (INCLUDES SUPPLIES)AMOUNT


TOTALAMOUNT

CAPITAL PURCHASEAMOUNT


TOTALAMOUNT

12


13/28


Exhibit A. SAMPLE GRANT CONTRACT-NON PROFIT AGENCY

GRANT CONTRACTBETWEEN THE STATE OF TENNESSEE,

STATE AGENCY NAME

ANDGRANTEE NAME

This Grant Contract, by and between the State of Tennessee, State Agency Name, hereinafter referred toas the State and Contractor Legal Entity Name, hereinafter referred to as the Grantee, is for theprovision of Community Home Visiting, as further defined in the "SCOPE OF SERVICES."

The Grantee is a/an Individual, For-Profit Corporation, Non-Profit Corporation, Special PurposeCorporation Or Association, Partnership, Joint Venture, Or Limited Liability Company.Grantee Federal Employer Identification or Edison Vendor ID # NumberPlace of Incorporation or Organization: Location

A. SCOPE OF SERVICES:

A.1. The Grantee shall provide all service and deliverables as required, described, and detailed hereinand shall meet all service and delivery timelines as specified by this Grant Contract.

A.2. The Grantee shall provide evidence-based home visiting services as outlined in the federalMaternal, Infant, and Early Childhood Home Visiting Program Supplemental Information Request(SIR), available at: http://www.hrsa.gov/grants/manage/homevisiting/sir02082011.pdf.

A.3. The Grantee shall provide evidence-based home visiting services in __________ county(ies).

A.4. The Grantee shall provide evidence-based home visiting services using the ______________model, maintain fidelity to the model throughout the contract period, and maintain certification asrequired by the model developer throughout the grant period.

A.5. The Grantee shall report all process and outcome data, as outlined in A.7 and A.8, to the State ona quarterly basis.

A.6. The Grantee will ensure that priority for evidence-based home visiting services is provided forclients meeting one of more of the following criteria:

a. Have low incomes;b. Are pregnant women who have not attained age 21;c. Have a history of child abuse or neglect or have had interactions with child welfare

services;d. Have a history of substance abuse or need substance abuse treatment;e. Are users of tobacco products in the home;f. Have, or have children with, low student achievement;

g. Have children with developmental delays or disabilities;h. Are in families that include individuals who are serving or have formerly served in the

armed forces, including such families that have members of the armed forces who havehad multiple deployments outside of the United States.

A.7. The Grantee will provide initial and ongoing data collection in a manner designed by the State foreach of the six benchmark areas and constructs listed in the SIR. Data reporting shall follow theform and content outlined in Appendix D of the SIR.

A.8. The Grantee must collect data referenced in A.7 in accordance with the following guidelines: 1)the data must be collected for eligible families that have been enrolled in the program; 2) the

13
http://www.hrsa.gov/grants/manage/homevisiting/sir02082011.pdfhttp://www.hrsa.gov/grants/manage/homevisiting/sir02082011.pdf


14/28


Grantee must collect individual-level demographic and service-utilization data on the participantsin their program as necessary to analyze and understand the progress children and families aremaking. Individual-level demographic and service-utilization data include, but are not limited to,the following:

a. Familys participation rate in the home visiting program (e.g., number of sessions/numberof possible sessions, duration of sessions);

b. Demographic data for the participant child(ren), pregnant woman, expectant father,parent(s), or primary caregiver(s) receiving home visiting services including: childsgender, age of all (including age in months for child) at each data collection point andracial and ethnic background of all participants in the family;

c. Participant childs exposure to languages other than English; andd. Family socioeconomic indicators (e.g., family income, employment status).

A.9. Incorporation of Additional Documents. Each of the following documents is included as a part ofthis Grant Contract by reference or attachment. In the event of a discrepancy or ambiguityregarding the Grantee's duties, responsibilities, and performance hereunder, these items shallgovern in order of precedence below.

a. this Grant Contract document with any attachments or exhibits (excluding the items listed

at subsections b. and c., below);

b. the State grant application solicitation as may be amended, if any;

c. the Grantees application (Attachment1) incorporated to elaborate supplementary scopeof services specifications.

B. CONTRACT PERIOD:

This Grant Contract shall be effective for the period beginning July 1, 2011, and ending on June30, 2012. The Grantee hereby acknowledges and affirms that the State shall have no obligationfor Grantee services or expenditures that were not completed within this specified contract period.

C. PAYMENT TERMS AND CONDITIONS:

C.1. Maximum Liability. In no event shall the maximum liability of the State under this Grant Contractexceed Written Dollar Amount ($Number). The Grant Budget, attached and incorporated heretoas Attachment 2, shall constitute the maximum amount due the Grantee for all service andGrantee obligations hereunder. The Grant Budget line-items include, but are not limited to, allapplicable taxes, fees, overhead, and all other direct and indirect costs incurred or to be incurredby the Grantee.

C.2. Compensation Firm. The maximum liability of the State is not subject to escalation for anyreason unless amended. The Grant Budget amounts are firm for the duration of the GrantContract and are not subject to escalation for any reason unless amended, except as provided insection C.6.

C.3. Payment Methodology. The Grantee shall be reimbursed for actual, reasonable, and necessarycosts based upon the Grant Budget, not to exceed the maximum liability established in sectionC.1. Upon progress toward the completion of the work, as described in section A of this GrantContract, the Grantee shall submit invoices (Attachment 3) prior to any reimbursement ofallowable costs.

C.4. Travel Compensation. Reimbursement to the Grantee for travel, meals, or lodging shall besubject to amounts and limitations specified in the "State Comprehensive Travel Regulations," asthey are amended from time to time, and shall be contingent upon and limited by the GrantBudget funding for said reimbursement.

14


15/28


C.5. Invoice Requirements. The Grantee shall invoice the State no more often than monthly, with allnecessary supporting documentation, and present such to:

___________________, Program DirectorTennessee Department of HealthMaternal and Child HealthCommunity Home Visiting ProgramCordell Hull Building, 4th Floor425 5th Avenue, NorthNashville, TN 37243

a. Each invoice shall clearly and accurately detail all of the following required information(calculations must be extended and totaled correctly).

(1) Invoice/Reference Number (assigned by the Grantee).(2) Invoice Date.(3) Invoice Period (to which the reimbursement request is applicable).(4) Grant Contract Number (assigned by the State).(5) Grantor: Department of Health, Community Home Visiting Program.

(6) Grantor Number (assigned by the Grantee to the above-referenced Grantor).(7) Grantee Name.(8) Grantee Federal Employer Identification, Social Security, or Tennessee Edison

Registration ID Number Referenced in Preamble of this Grant Contract.(9) Grantee Remittance Address.(10) Grantee Contact for Invoice Questions (name, phone, and/or fax).(11) Itemization of Reimbursement Requested for the Invoice Period it must detail,

at minimum, all of the following:

i. The amount requested by Grant Budget line-item (including any travelexpenditure reimbursement requested and for which documentation andreceipts, as required by "State Comprehensive Travel Regulations," areattached to the invoice).

ii. The amount reimbursed by Grant Budget line-item to date.iii. The total amount reimbursed under the Grant Contract to date.iv. The total amount requested (all line-items) for the Invoice Period.

b. The Grantee understands and agrees to all of the following.

(1) An invoice under this Grant Contract shall include only reimbursement requestsfor actual, reasonable, and necessary expenditures required in the delivery ofservice described by this Grant Contract and shall be subject to the Grant Budgetand any other provision of this Grant Contract relating to allowablereimbursements.

(2) An invoice under this Grant Contract shall not include any reimbursementrequest for future expenditures.

(3) An invoice under this Grant Contract shall initiate the timeframe forreimbursement only when the State is in receipt of the invoice, and the invoicemeets the minimum requirements of this section C.5.

(4) An invoice under this Grant Contract shall be presented to the State within sixty(60) days after the end of the calendar month in which the subject costs wereincurred or services were rendered by the Grantee. An invoice submitted morethan sixty (60) days after such date will NOT be paid. The State will not deemsuch Grantee costs to be allowable and reimbursable by the State unless, at thesole discretion of the State, the failure to submit a timely invoice is warranted.The Grantee shall submit a special, written request for reimbursement with anysuch untimely invoice. The request must detail the reason the invoice is untimely

15


16/28


as well as the Grantees plan for submitting future invoices as required, and itmust be signed by a Grantee agent that would be authorized to sign this GrantContract.

C.6. Budget Line-items. Expenditures, reimbursements, and payments under this Grant Contract shalladhere to the Grant Budget. The Grantee may vary from a Grant Budget line-item amount by upto twenty percent (20%) of the line-item amount, provided that any increase is off-set by an equalreduction of other line-item amount(s) such that the net result of variances shall not increase thetotal Grant Contract amount detailed by the Grant Budget. Any increase in the Grant Budget,grand total amounts shall require an amendment of this Grant Contract.

C.7. Disbursement Reconciliation and Close Out. The Grantee shall submit a grant disbursementreconciliation report within sixty (60) days following the end of each quarter and a final invoiceand final grant disbursement reconciliation report within ninety (90) days of the Grant Contractend date and in form and substance acceptable to the State (Attachment 4).

a. If total disbursements by the State pursuant to this Grant Contract exceed the amountspermitted by the section C, payment terms and conditions of this Grant Contract, theGrantee shall refund the difference to the State. The Grantee shall submit said refundwith the final grant disbursement reconciliation report.

b. The State shall not be responsible for the payment of any invoice submitted to the stateafter the grant disbursement reconciliation report. The State will not deem any Granteecosts submitted for reimbursement after the grant disbursement reconciliation report tobe allowable and reimbursable by the State, and such invoices will NOT be paid.

c. The Grantees failure to provide a final grant disbursement reconciliation report to thestate as required shall result in the Grantee being deemed ineligible for reimbursementunder this Grant Contract, and the Grantee shall be required to refund any and allpayments by the state pursuant to this Grant Contract.

d. The Grantee must close out its accounting records at the end of the contract periodinsuch a way that reimbursable expenditures and revenue collections are NOT carried

forward.

C.8. Indirect Cost. Should the Grantee request reimbursement for indirect cost, the Grantee mustsubmit to the State a copy of the indirect cost rate approved by the cognizant federal agency andthe State. The Grantee will be reimbursed for indirect cost in accordance with the approvedindirect cost rate to amounts and limitations specified in the attached Grant Budget. Once theGrantee makes an election and treats a given cost as direct or indirect, it must apply thattreatment consistently and may not change during the contract period. Any changes in theapproved indirect cost rate must have prior approval of the cognizant federal agency and theState. If the indirect cost rate is provisional during the period of this agreement, once the ratebecomes final, the Grantee agrees to remit any overpayment of funds to the State, and subject tothe availability of funds the State agrees to remit any underpayment to the Grantee.

C.9. Cost Allocation. If any part of the costs to be reimbursed under this Grant Contract are joint costsinvolving allocation to more than one program or activity, such costs shall be allocated andreported in accordance with the provisions of Department of Finance and Administration PolicyStatement 03 or any amendments or revisions made to this policy statement during the contractperiod.

C.10. Payment of Invoice. A payment by the State shall not prejudice the State's right to object to orquestion any reimbursement, invoice, or matter in relation thereto. A payment by the State shallnot be construed as acceptance of any part of the work or service provided or as approval of anyamount as an allowable cost.

16


17/28


C.11. Unallowable Costs. Any amounts payable to the Grantee shall be subject to reduction foramounts included in any invoice or payment theretofore made, which are determined by theState, on the basis of audits or monitoring conducted in accordance with the terms of this GrantContract, not to constitute allowable costs.

C.12. Deductions. The State reserves the right to deduct from amounts, which are or shall become dueand payable to the Grantee under this or any contract between the Grantee and the State ofTennessee any amounts, which are or shall become due and payable to the State of Tennesseeby the Grantee.

C.13. Prerequisite Documentation. The Grantee shall not invoice the State under this Grant Contractuntil the State has received the following documentation properly completed.

a. The Grantee shall complete, sign, and present to the State an "Authorization Agreementfor Automatic Deposit (ACH Credits) Form" provided by the State. By doing so, theGrantee acknowledges and agrees that, once said form is received by the State, allpayments to the Grantee, under this or any other contract the Grantee has with the Stateof Tennessee shall be made by Automated Clearing House (ACH).

b. The Grantee shall complete, sign, and present to the State a "Substitute W-9 Form

provided by the State. The taxpayer identification number detailed by said form mustagree with the Federal Employer Identification Number or Social Security Numberreferenced in this Grant Contract or the Grantee's Tennessee Edison Registration.

D. STANDARD TERMS AND CONDITIONS:

D.1. Required Approvals. The State is not bound by this Grant Contract until it is signed by thecontract parties and approved by appropriate officials in accordance with applicable Tennesseelaws and regulations (depending upon the specifics of this contract, said officials may include, butare not limited to, the Commissioner of Finance and Administration, the Commissioner of HumanResources, and the Comptroller of the Treasury).

D.2. Modification and Amendment. Except as specifically provided herein, this Grant Contract may be

modified only by a written amendment signed by all parties hereto and approved by both theofficials who approved the base contract and, depending upon the specifics of the contract asamended, any additional officials required by Tennessee laws and regulations (said officials mayinclude, but are not limited to, the Commissioner of Finance and Administration, theCommissioner of Human Resources, and the Comptroller of the Treasury).

D.3. Termination for Convenience. The State may terminate this Grant Contract without cause for anyreason. Said termination shall not be deemed a breach of contract by the State. The State shallgive the Grantee at least thirty (30) days written notice before the effective termination date. TheGrantee shall be entitled to compensation for authorized expenditures and satisfactory servicescompleted as of the termination date, but in no event shall the State be liable to the Grantee forcompensation for any service which has not been rendered. The final decision as to the amount,for which the State is liable, shall be determined by the State. Should the State exercise this

provision, the Grantee shall not have any right to any actual general, special, incidental,consequential, or any other damages whatsoever of any description or amount.

D.4. Termination for Cause. If the Grantee fails to properly perform its obligations under this GrantContract in a timely or proper manner, or if the Grantee violates any terms of this Grant Contract,the State shall have the right to immediately terminate the Grant Contract and withhold paymentsin excess of fair compensation for completed services. Notwithstanding the above, the Granteeshall not be relieved of liability to the State for damages sustained by virtue of any breach of thisGrant Contract by the Grantee.

17


18/28


D.5. Subcontracting. The Grantee shall not assign this Grant Contract or enter into a subcontract forany of the services performed under this Grant Contract without obtaining the prior writtenapproval of the State. If such subcontracts are approved by the State, each shall contain, at aminimum, sections of this contract pertaining to "Conflicts of Interest," Lobbying,"Nondiscrimination," Public Accountability, Public Notice, and Records" (as identified by thesection headings). Notwithstanding any use of approved subcontractors, the Grantee shall be theprime contractor and shall be responsible for all work performed.

D.6. Conflicts of Interest. The Grantee warrants that no part of the total Grant Amount shall be paiddirectly or indirectly to an employee or official of the State of Tennessee as wages,compensation, or gifts in exchange for acting as an officer, agent, employee, subcontractor, orconsultant to the Grantee in connection with any work contemplated or performed relative to thisGrant Contract.

The Grantee acknowledges, understands, and agrees that this Grant Contract shall be null andvoid if the Grantee is, or within the past six months has been, an employee of the State ofTennessee or if the Grantee is an entity in which a controlling interest is held by an individual whois, or within the past six months has been, an employee of the State of Tennessee.

D.7. Lobbying. The Grantee certifies, to the best of its knowledge and belief, that:

a. No federally appropriated funds have been paid or will be paid, by or on behalf of theundersigned, to any person for influencing or attempting to influence an officer oremployee of an agency, a Member of Congress, an officer or employee of Congress, oran employee of a Member of Congress in connection with the awarding of any Federalcontract, the making of any Federal grant, the making of any federal loan, the enteringinto of any cooperative agreement, and the extension, continuation, renewal,amendment, or modification of any federal contract, grant, loan, or cooperativeagreement.

b. If any funds other than federally appropriated funds have been paid or will be paid to anyperson for influencing or attempting to influence an officer or employee of any agency, aMember of Congress, an officer or employee of Congress, or an employee of a Member

of Congress in connection with this contract, grant, loan, or cooperative agreement, theGrantee shall complete and submit Standard Form-LLL, ``Disclosure Form to ReportLobbying,'' in accordance with its instructions.

c. The Grantee shall require that the language of this certification be included in the awarddocuments for all sub-awards at all tiers (including subcontracts, sub-grants, andcontracts under grants, loans, and cooperative agreements) and that all subrecipientsshall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when thistransaction was made or entered into and is a prerequisite for making or entering into thistransaction imposed by section 1352, title 31, U.S. Code.

D.8. Nondiscrimination. The Grantee hereby agrees, warrants, and assures that no person shall beexcluded from participation in, be denied benefits of, or be otherwise subjected to discriminationin the performance of this Grant Contract or in the employment practices of the Grantee on thegrounds of handicap or disability, age, race, color, religion, sex, national origin, or any otherclassification protected by Federal, Tennessee State constitutional, or statutory law. The Granteeshall, upon request, show proof of such nondiscrimination and shall post in conspicuous places,available to all employees and applicants, notices of nondiscrimination.

D.9. Public Accountability. If the Grantee is subject to Tennessee Code Annotated, Title 8, Chapter 4,Part 4, or if this Grant Contract involves the provision of services to citizens by the Grantee onbehalf of the State, the Grantee agrees to establish a system through which recipients of services

18


19/28


may present grievances about the operation of the service program, and the Grantee shalldisplay in a prominent place, located near the passageway through which the public enters inorder to receive Grant supported services, a sign at least twelve inches (12") in height andeighteen inches (18") in width stating:

NOTICE: THIS AGENCY IS A RECIPIENT OF TAXPAYER FUNDING. IF YOU OBSERVE ANAGENCY DIRECTOR OR EMPLOYEE ENGAGING IN ANY ACTIVITY WHICH YOU CONSIDERTO BE ILLEGAL, IMPROPER, OR WASTEFUL, PLEASE CALL THE STATE COMPTROLLERSTOLL-FREE HOTLINE: 1-800-232-5454

D.10. Public Notice. All notices, informational pamphlets, press releases, research reports, signs, andsimilar public notices prepared and released by the Grantee shall include the statement, Thisproject is funded under an agreement with the State of Tennessee. Any such notices by theGrantee shall be approved by the State.

D.11. Licensure. The Grantee and its employees and all sub-grantees shall be licensed pursuant to allapplicable federal, state, and local laws, ordinances, rules, and regulations and shall uponrequest provide proof of all licenses.

D.12. Records. The Grantee (and any approved subcontractor) shall maintain documentation for all

charges under this Contract. The books, records, and documents of the Grantee (and anyapproved subcontractor), insofar as they relate to work performed or money received under thisContract, shall be maintained for a period of three (3) full years from the date of the final paymentand shall be subject to audit at any reasonable time and upon reasonable notice by the stateagency, the Comptroller of the Treasury, or their duly appointed representatives. The records ofnot-for-profit entities shall be maintained in accordance with theAccounting Manual for theRecipients of Grant Funds in the State of Tennessee , published by the Tennessee Comptroller ofthe Treasury (available at http://comptroller.state.tn.us/ma/nonprofit/nonprofit1.pdf). The financialstatements shall be prepared in accordance with generally accepted accounting principles.

D.13. Monitoring. The Grantees activities conducted and records maintained pursuant to this GrantContract shall be subject to monitoring and evaluation by the State, the Comptroller of theTreasury, or their duly appointed representatives.

D.14. Progress Reports. The Grantee shall submit brief, periodic, progress reports to the State asrequested.

D.15. Annual Report and Audit. The Grantee shall prepare and submit, within nine (9) months after theclose of the reporting period, an annual report of its activities funded under this Grant Contract tothe commissioner or head of the Granting agency, the Tennessee Comptroller of the Treasury,and the Commissioner of Finance and Administration. The annual report for any Grantee thatreceives five hundred thousand dollars ($500,000) or more in aggregate federal and state fundingfor all its programs shall include audited financial statements. All books of account and financialrecords shall be subject to annual audit by the Tennessee Comptroller of the Treasury or theComptrollers duly appointed representative. When an audit is required, the Grantee may, withthe prior approval of the Comptroller, engage a licensed independent public accountant to

perform the audit. The audit contract between the Grantee and the licensed independent publicaccountant shall be on a contract form prescribed by the Tennessee Comptroller of the Treasury.Any such audit shall be performed in accordance with generally accepted government auditingstandards, the provisions of OMB Circular A-133, if applicable, and theAudit Manual forGovernmental Units and Recipients of Grant Funds published by the Tennessee Comptroller ofthe Treasury. The Grantee shall be responsible for reimbursement of the cost of the auditprepared by the Tennessee Comptroller of the Treasury, and payment of fees for the auditprepared by the licensed independent public accountant. Payment of the audit fees of thelicensed independent public accountant by the Grantee shall be subject to the provisions relatingto such fees contained in the prescribed contract form noted above. Copies of such audits shallbe provided to the designated cognizant state agency, the State Granting Department, the

19


20/28


Tennessee Comptroller of the Treasury, and the Department of Finance and Administration andshall be made available to the public.

D.16. Procurement. If other terms of this Grant Contract allow reimbursement for the cost of goods,materials, supplies, equipment, and/or contracted services, such procurement(s) shall be madeon a competitive basis, including the use of competitive bidding procedures, where practical. TheGrantee shall maintain documentation for the basis of each procurement for whichreimbursement is paid pursuant to this Grant Contract. In each instance where it is determinedthat use of a competitive procurement method is not practical, supporting documentation shallinclude a written justification for such decision and non-competitive procurement. Further, andnotwithstanding the foregoing, if such reimbursement is to be made with funds derived wholly orpartially from federal sources, the determination of cost shall be governed by and reimbursementshall be subject to the Grantee's compliance with applicable federal procurement requirements.

The Grantee shall obtain prior approval from the State before purchasing any equipment underthis Grant Contract.

D.17. Strict Performance. Failure by any party to this Grant Contract to insist in any one or more casesupon the strict performance of any of the terms, covenants, conditions, or provisions of thisagreement shall not be construed as a waiver or relinquishment of any such term, covenant,

condition, or provision. No term or condition of this Grant Contract shall be held to be waived,modified, or deleted except by a written amendment signed by the parties hereto.

D.18. Independent Contractor. The parties hereto, in the performance of this Grant Contract, shall notact as employees, partners, joint venturers, or associates of one another. It is expresslyacknowledged by the parties hereto that such parties are independent contracting entities andthat nothing in this Grant Contract shall be construed to create an employer/employeerelationship or to allow either to exercise control or direction over the manner or method by whichthe other transacts its business affairs or provides its usual services. The employees or agents ofone party shall not be deemed or construed to be the employees or agents of the other party forany purpose whatsoever.

The Grantee, being an independent contractor and not an employee of the State, agrees to carry

adequate public liability and other appropriate forms of insurance, including adequate publicliability and other appropriate forms of insurance on the Grantees employees, and to pay allapplicable taxes incident to this Grant Contract.

D.19. State Liability. The State shall have no liability except as specifically provided in this GrantContract.

D.20. Force Majeure. The obligations of the parties to this Grant Contract are subject to prevention bycauses beyond the parties control that could not be avoided by the exercise of due careincluding, but not limited to, natural disasters, riots, wars, epidemics, or any other similar cause.

D.21. State and Federal Compliance. The Grantee shall comply with all applicable state and federallaws and regulations in the performance of this Grant Contract.

D.22. Governing Law. This Grant Contract shall be governed by and construed in accordance with thelaws of the State of Tennessee. The Grantee agrees that it will be subject to the exclusive

jurisdiction of the courts of the State of Tennessee in actions that may arise under this GrantContract. The Grantee acknowledges and agrees that any rights or claims against the State ofTennessee or its employees hereunder, and any remedies arising there from, shall be subject toand limited to those rights and remedies, if any, available underTennessee Code Annotated,Sections 9-8-101 through 9-8-407.

D.23. Completeness. This Grant Contract is complete and contains the entire understanding betweenthe parties relating to the subject matter contained herein, including all the terms and conditions

20


21/28


of the parties agreement. This Grant Contract supersedes any and all prior understandings,representations, negotiations, and agreements between the parties relating hereto, whetherwritten or oral.

D.24. Severability. If any terms and conditions of this Grant Contract are held to be invalid orunenforceable as a matter of law, the other terms and conditions hereof shall not be affectedthereby and shall remain in full force and effect. To this end, the terms and conditions of thisGrant Contract are declared severable.

D.25. Headings. Section headings are for reference purposes only and shall not be construed as partof this Grant Contract.

E. SPECIAL TERMS AND CONDITIONS:

E.1. Conflicting Terms and Conditions. Should any of these special terms and conditions conflict withany other terms and conditions of this Grant Contract, these special terms and conditions shallcontrol.

E.2. Communications and Contacts. All instructions, notices, consents, demands, or othercommunications required or contemplated by this Grant Contract shall be in writing and shall be

made by certified, first class mail, return receipt requested and postage prepaid, by overnightcourier service with an asset tracking system, or by EMAIL or facsimile transmission withrecipient confirmation. Any such communications, regardless of method of transmission, shall beaddressed to the respective party at the appropriate mailing address, facsimile number, or EMAILaddress as set forth below or to that of such other party or address, as may be hereafter specifiedby written notice.

The State:

_________________, Program DirectorTennessee Department of HealthMaternal and Child HealthCommunity Home Visiting Program

Cordell Hull Building, 4th Floor425 5th Avenue, NorthNashville, TN 37243Telephone # 615-___-____FAX # 615-___-____

The Grantee:

Grantee Contact Name & TitleGrantee Name

AddressEmail AddressTelephone # Number

FAX # Number

All instructions, notices, consents, demands, or other communications shall be consideredeffectively given upon receipt or recipient confirmation as may be required.

E.3. Subject to Funds Availability. The Grant Contract is subject to the appropriation and availability ofState and/or Federal funds. In the event that the funds are not appropriated or are otherwiseunavailable, the State reserves the right to terminate the Grant Contract upon written notice to theGrantee. Said termination shall not be deemed a breach of contract by the State. Upon receiptof the written notice, the Grantee shall cease all work associated with the Grant Contract. Shouldsuch an event occur, the Grantee shall be entitled to compensation for all satisfactory and

21


22/28


authorized services completed as of the termination date. Upon such termination, the Granteeshall have no right to recover from the State any actual, general, special, incidental,consequential, or any other damages whatsoever of any description or amount.

E.4. Insurance. The Grantee shall carry adequate liability and other appropriate forms of insurance.

a. The Grantee shall maintain, at minimum, the following insurance coverage:

(1) Workers' Compensation/ Employers' Liability (including all states coverage) witha limit not less than the relevant statutory amount or one million dollars($1,000,000) per occurrence for employers liability whichever is greater.

(2) Comprehensive Commercial General Liability (including personal injury &property damage, premises/operations, independent contractor, contractualliability and completed operations/products) with a bodily injury/property damagecombined single limit not less than one million dollars ($1,000,000) peroccurrence and two million dollars ($2,000,000) aggregate.

(3) Automobile Coverage (including owned, leased, hired, and non-owned vehicles)with a bodily injury/property damage combined single limit not less than one

million dollars ($1,000,000) per occurrence.

(4) Professional Malpractice Liability with a limit of not less than one million dollars($1,000,000) per claim and two million dollars ($2,000,000) aggregate.

b. At any time State may require the Grantee to provide a valid Certificate of Insurancedetailing Coverage Description; Insurance Company & Policy Number; Exceptions andExclusions; Policy Effective Date; Policy Expiration Date; Limit(s) of Liability; and Nameand Address of Insured. Failure to provide required evidence of insurance coverage shallbe a material breach of this Grant Contract.

E.5. Charges to Service Recipients Prohibited. The Grantee shall not collect any amount in the formof fees or reimbursements from the recipients of any service provided pursuant to this Grant

Contract.

E.6. No Equipment Acquisition. This Grant Contract does not involve the acquisition and dispositionof equipment acquired with funds provided under this Grant Contract.

E.7. Confidentiality of Records. Strict standards of confidentiality of records and information shall bemaintained in accordance with applicable state and federal law. All material and information,regardless of form, medium or method of communication, provided to the Grantee by the State oracquired by the Grantee on behalf of the State shall be regarded as confidential information inaccordance with the provisions of applicable state and federal law, state and federal rules andregulations, departmental policy, and ethical standards. Such confidential information shall notbe disclosed, and all necessary steps shall be taken by the Grantee to safeguard theconfidentiality of such material or information in conformance with applicable state and federal

law, state and federal rules and regulations, departmental policy, and ethical standards.

The Grantees obligations under this section do not apply to information in the public domain;entering the public domain but not from a breach by the Grantee of this Grant Contract;previously possessed by the Grantee without written obligations to the State to protect it; acquiredby the Grantee without written restrictions against disclosure from a third party which, to theGrantees knowledge, is free to disclose the information; independently developed by the Granteewithout the use of the States information; or, disclosed by the State to others without restrictionsagainst disclosure. Nothing in this paragraph shall permit Grantee to disclose any information thatis confidential under federal or state law or regulations, regardless of whether it has beendisclosed or made available to the Grantee due to intentional or negligent actions or inactions of

22


23/28


agents of the State or third parties.

It is expressly understood and agreed the obligations set forth in this section shall survive thetermination of this Grant Contract.

E.8. HIPAA Compliance. The State and the Grantee shall comply with obligations under the HealthInsurance Portability and Accountability Act of 1996 (HIPAA) and its accompanying regulations.

a. The Grantee warrants to the State that it is familiar with the requirements of HIPAA andits accompanying regulations, and will comply with all applicable HIPAA requirements inthe course of this contract.

b. The Grantee warrants that it will cooperate with the State, including cooperation andcoordination with State privacy officials and other compliance officers required by HIPAAand its regulations, in the course of performance of the grant so that both parties will bein compliance with HIPAA.

c. The State and the Grantee will sign documents, including but not limited to businessassociate agreements, as required by HIPAA and that are reasonably necessary to keepthe State and the Grantee in compliance with HIPAA. This provision shall not apply if

information received by the State under this grant is NOT protected health informationas defined by HIPAA, or if HIPAA permits the State to receive such information withoutentering into a business associate agreement or signing another such document.

E.9. Printing Authorization. The Grantee agrees that no publication coming within the jurisdiction ofTennessee Code Annotated, Section 12-7-101, et seq., shall be printed pursuant to this contractunless a printing authorization number has been obtained and affixed as required by TennesseeCode Annotated, Section 12-7-103 (d).

E.10. Environmental Tobacco Smoke. Pursuant to the provisions of the federal Pro-Children Act of1994 and the Tennessee Childrens Act for Clean Indoor Air of 1995, the Grantee shall prohibitsmoking of tobacco products within any indoor premises in which services are provided toindividuals under the age of eighteen (18) years. The Grantee shall post no smoking signs in

appropriate, permanent sites within such premises. This prohibition shall be applicable during allhours, not just the hours in which children are present. Violators of the prohibition may be subjectto civil penalties and fines. This prohibition shall apply to and be made part of any subcontractrelated to this Grant Contract.

E.11. Debarment and Suspension. The Grantee certifies, to the best of its knowledge and belief, that it,its current and future principals, its current and future subcontractors and their principals:

a. are not presently debarred, suspended, proposed for debarment, declared ineligible, orvoluntarily excluded from covered transactions by any federal or state department oragency;

b. have not within a three (3) year period preceding this Grant Contract been convicted of,

or had a civil judgment rendered against them from commission of fraud, or a criminaloffence in connection with obtaining, attempting to obtain, or performing a public (federal,state, or local) transaction or grant under a public transaction; violation of federal or stateantitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification, ordestruction of records, making false statements, or receiving stolen property;

c. are not presently indicted or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses detailed in section b. ofthis certification; and

23


24/28


d. have not within a three (3) year period preceding this Grant Contract had one or morepublic transactions (federal, state, or local) terminated for cause or default.

The Grantee shall provide immediate written notice to the State if at any time it learns that therewas an earlier failure to disclose information or that due to changed circumstances, its principalsor the principals of its subcontractors are excluded or disqualified.

E.12. Federal Funding Accountability and Transparency Act (FFATA). This Grant requires the Granteeto provide supplies and/or services that are funded in whole or in part by federal funds that aresubject to FFATA. The Grantee is responsible for ensuring that all applicable requirements,including but not limited to those set forth herein, of FFATA are met and that the Granteeprovides information to the State as required.

The Grantee shall comply with the following:

a. Reporting of Total Compensation of the Grantees Executives.

(1) The Grantee shall report the names and total compensation of each of its fivemost highly compensated executives for the Grantees preceding completedfiscal year, if in the Grantees preceding fiscal year it received:

i. 80 percent or more of the Grantees annual gross revenues from Federalprocurement contracts and Federal financial assistance subject to theTransparency Act, as defined at 2 CFR 170.320 (and subawards); and

ii. $25,000,000 or more in annual gross revenues from Federalprocurement contracts (and subcontracts), and Federal financialassistance subject to the Transparency Act (and subawards); and

iii. The public does not have access to information about the compensationof the executives through periodic reports filed under section 13(a) or15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d))or section 6104 of the Internal Revenue Code of 1986. (To determine ifthe public has access to the compensation information, see the U.S.Security and Exchange Commission total compensation filings at

http://www.sec.gov/answers/execomp.htm.).

Executive means officers, managing partners, or any other employees inmanagement positions.

(2) Total compensation means the cash and noncash dollar value earned by theexecutive during the Grantees preceding fiscal year and includes the following(for more information see 17 CFR 229.402(c)(2)):

i. Salary and bonus.ii. Awards of stock, stock options, and stock appreciation rights. Use the

dollar amount recognized for financial statement reporting purposes withrespect to the fiscal year in accordance with the Statement of Financial

Accounting Standards No. 123 (Revised 2004) (FAS 123R), SharedBased Payments.iii. Earnings for services under non-equity incentive plans. This does not

include group life, health, hospitalization or medical reimbursement plansthat do not discriminate in favor of executives, and are availablegenerally to all salaried employees.

iv. Change in pension value. This is the change in present value of definedbenefit and actuarial pension plans.

v. Above-market earnings on deferred compensation which is not taxqualified.

24


25/28


vi. Other compensation, if the aggregate value of all such othercompensation (e.g. severance, termination payments, value of lifeinsurance paid on behalf of the employee, perquisites or property) for theexecutive exceeds $10,000.

b. The Grantee must report executive total compensation described above to the State bythe end of the month during which this Grant is awarded.

c. If this Grant is amended to extend its term, the Grantee must submit an executive totalcompensation report to the State by the end of the month in which the amendment to thisGrant becomes effective.

d. The Grantee will obtain a Data Universal Numbering System (DUNS) number andmaintain its DUNS number for the term of this Grant. More information about obtaining aDUNS Number can be found at: http://fedgov.dnb.com/webform/

The Grantees failure to comply with the above requirements is a material breach of this Grant forwhich the State may terminate this Grant for cause. The State will not be obligated to pay anyoutstanding invoice received from the Grantee unless and until the Grantee is in full compliancewith the above requirements.

E.12. CFDA Number(s). When applicable, the Grantee shall inform its licensed independent publicaccountant of the federal regulations that are to be complied with in performance of an audit.This information shall consist of the following Catalog of Federal Domestic Assistance Numbers:

93.505 AFFORDABLE CARE ACT (ACA) MATERNAL, INFANT AND EARLY CHILDHOODHOME VISITING PROGRAM

IN WITNESS WHEREOF,

GRANTEE LEGAL ENTITY NAME:

GRANTEESIGNATURE DATE

PRINTED NAME AND TITLE OF GRANTEESIGNATORY (above)

DEPARTMENT OF HEALTH:

SUSAN R. COOPER, COMMISSIONER, RN, MSN DATE

25
http://fedgov.dnb.com/webform/http://fedgov.dnb.com/webform/


26/28


ATTACHMENT 1

GRANTEES PROPOSAL

26


27/28


ATTACHMENT 2

GRANT BUDGET

(BUDGET PAGE 1

ADDITIONAL IDENTIFICATION INFORMATION AS NECESSARY

APPLICABLE PERIOD: The grant budget line-item amounts below shall be applicable only to expense incurred during the periodbeginning July 1, 2011, and ending September 30, 2012.

POLICY 03Object

Line-itemReference

EXPENSE OBJECT LINE-ITEM

CATEGORY1

(detail schedule(s) attached as applicable)GRANT CONTRACT

GRANTEEPARTICIPATION TOTAL PROJECT

1 Salaries 2$0.00 $0.00 $0.00

2 Benefits & Taxes$0.00 $0.00 $0.00

4, 15 Professional Fee/ Grant & Award 2$0.00 $0.00 $0.00

5 Supplies

$0.00 $0.00 $0.006 Telephone

$0.00 $0.00 $0.00

7 Postage & Shipping$0.00 $0.00 $0.00

8 Occupancy$0.00 $0.00 $0.00

9 Equipment Rental & Maintenance$0.00 $0.00 $0.00

10 Printing & Publications$0.00 $0.00 $0.00

11, 12 Travel/ Conferences & Meetings2$0.00 $0.00 $0.00

13 Interest 2

$0.00 $0.00 $0.0014 Insurance

$0.00 $0.00 $0.00

16 Specific Assistance To Individuals2$0.00 $0.00 $0.00

17 Depreciation 2$0.00 $0.00 $0.00

18 Other Non-Personnel 2$0.00 $0.00 $0.00

20 Capital Purchase 2$0.00 $0.00 $0.00

22 Indirect Cost (% and method)$0.00 $0.00 $0.00

24 In-Kind Expense$0.00 $0.00 $0.00

25 GRAND TOTAL$0.00 $0.00 $0.00

1 Each expense object line-item shall be defined by the Department of Finance and Administration Policy 03, Uniform Reporting Requirements and Cost

Allocation Plans for Subrecipients of Federal and State Grant Monies, Appendix A. (posted on the Internet at:http://www.state.tn.us/finance/act/documents/policy3.pdf).

2Applicable detail attached if line-item is funded.

27


28/28


ATTACHMENT 2 (continued)

GRANT BUDGET LINE-ITEM DETAIL

(BUDGET PAGE 2)

SALARIESAMOUNT


TOTAL $0.00

PROFESSIONAL FEE / GRANT & AWARDAMOUNT


TOTAL $0.00

TRAVEL / CONFERENCES & MEETINGS AMOUNT


TOTAL $0.00

INTERESTAMOUNT


TOTALAMOUNT

SPECIFIC ASSISTANCE TO INDIVIDUALSAMOUNT


TOTALAMOUNT

OTHER NON-PERSONNELAMOUNT


TOTALAMOUNT

CAPITAL PURCHASEAMOUNT


TOTALAMOUNT

Tennessee Home Visitation Program Grant Application Guidelines

Documents

Transcript of Tennessee Home Visitation Program Grant Application Guidelines