Application: PACSS

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About the Application

The application is organized into 9 sections. The information in Sections 1–4 is about the organization overall.

Section 1. Organization Information

In questions 1-26, provide general information and documentation related to your organization and relevant contact information

#	Data Item	Field Options	Instructions
1	Legal organization name
2	Common name (doing business as [DBA])
3	Address line 1
4	Address line 2
5	City
6	State
7	ZIP
8	County
9	Public health region	Cook County (Bellwood) West Chicago Champaign Marion Metro East Peoria Rockford Statewide Multiple [logic, answer 9a]	Select the public health region (s) where you primarily provide services or that pertains to this application per the IDPH Health Regions map.
9a	If you chose multiple, please briefly describe which regions will be served under this award.	Text
10	Organization phone
11	Organization website address (optional)
12	Type of organization	Nonprofit For profit Tax exempt	Select your organization type.
13	Year founded/incorporated
14	IDHS /SUPR licenses, if any
15	Primary contact name
16	Primary contact title
17	Primary contact email address
18	Primary contact phone
19	Alternative contact name
20	Alternative contact title
21	Alternative contact email address
22	Alternative contact phone
23	Indirect cost election	Federally negotiated rate 10% de minimis No indirect costs election	Select your indirect cost election. If you select “Federally negotiated rate,” continue to item 24. If you select “10% de minimis” or “No indirect costs election,” skip item 24 and continue with item 25.
24	Negotiated Indirect Cost Rate Agreement (NICRA) letter	Document upload (if applicable)	Upload as Attachment A (if applicable).
25	Current or planned organizational chart	Document upload (required)	Upload as Attachment B.
26	Current fiscal year organizational budget or, if you are a new organization, your planned budget for the upcoming fiscal year	Document upload (required)	Upload as Attachment C.

Section 2. Pre-Qualification Information

In questions 27-34, enter information that demonstrates your organization’s eligibility for receiving grant funds.

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

Section 3. Internal Controls

Items 35-79 pose questions about administrative and management controls within the organization to assess organizational risk. These questions align with the Illinois Internal Controls Questionnaire (ICQ).

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

Section 4. Organization Attestations

Questions 80-85 ask for verification of capacity and truthfulness of information in the application.

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

Section 5. Executive Summary

Questions 86-87 ask for an overview of your organization and the services you plan to deliver if awarded funding.

#	Data Item	Field	Evaluation Criteria
86	Please list the relevant zip codes (required), Chicago Community Area(s), and/or municipalities where you will primarily provide services funded with this award. Select not applicable if this is a statewide initiative.	Enter zip codes OR Not applicable	0 points
87	Summarize the following: The population of focus to be served, including geographic, demographic, and other relevant characteristics. The reason why this population was selected. An overview of the services to be provided. Your organization’s experience providing similar services, including timeframes. The relevant expertise of the staff bid in the proposal.	Up to 2,000 words	(5 points) The response addresses all elements of the question. The response provides a specific description of a population of focus, explains the need for the proposed program, and justifies the need. The response demonstrates that the organization has the experience and expertise to successfully implement the proposed program.

Section 6. Need and Opportunity

#	Data Item	Field	Evaluation Criteria
88	How does your proposal support the grant program purpose? Describe how the proposed project will prevent or delay initial substance use; reduce, prevent, or delay misuse of substances; minimize stigma associated with SUD, treatment, and recovery; and/or reduce harms associated with substance use and misuse, including overdose. Please cite the source of any data included.	Up to 1,500 words	(10 points) The response addresses all elements of the question. The response demonstrates a clear understanding of the purpose of the funding need. The response includes relevant data, including sources.
89	What is the population of focus for the proposed program? Describe the specific geographic area to be served. If proposing services in Cook County, the ZIP code(s) must be included. Include U.S. Census or other relevant data (such as board of education or criminal justice) describing the age, gender, racial, and ethnic demographics, and other relevant population-level data. Explain why the community and population to be served were chosen and how they will benefit from the proposed program. Please cite the source of any data included.	Up to 1,000 words	(10 points) The response addresses all elements of the question. The specific population to be served is clearly defined and in accordance with the priority population. The response includes relevant data, including sources.

Section 7. Experience and Capacity

Questions 90-95 ask how your organization’s work and approach are aligned with the intent of CRTA, your experience in managing previous grants, and about your cultural and linguistic capacity.

#	Data Item	Field	Evaluation Criteria
90	What is your organization’s experience implementing the tasks described in the scope of work? Describe content, size, components, and target audience of the campaign, as well as documented effectiveness of the campaign. Provide up to 3 examples of public awareness campaigns of like size and scope your organization has planned, developed, carried out, and evaluated. Attach sample campaign materials.	Up to 1,500 words and Upload Attachment of Samples as Attachment I	(5 points) The response addresses all elements of the question. The applicant has relevant experience with public awareness campaigns, including but not limited to: Conducting needs assessments Planning public awareness campaigns Developing public awareness campaigns Carrying out public awareness campaigns Evaluating public awareness campaigns. Provided samples are appropriately engaging for the intended audience and meet professional standards of quality.
91	How does your hiring approach ensure your staffing reflects the populations you serve? Discuss how your current staff demographics are reflective of the racial/ethnic community served and describe any changes to hiring processes necessary for ensuring cultural and linguistic appropriateness.	Up to 1,000 words	(5 points) The response addresses all elements of the question. The response includes relevant data regarding staff diversity, which corresponds to the population the applicant serves. The applicant understands how to staff the proposed program to meet the needs of the population of focus.
92	Provide up to five examples of grants or contracts that your organization has successfully managed in the past 5 years, with awarding agencies, dates, and dollar amounts. Include any current fiscal year funding from IDHS/SUPR or IDPH. Select “not applicable” if you have not received previous grants or contracts.	Checkbox for not applicable or Table below	(5 points) The response addresses all elements of the question. The applicant demonstrates experience with grants management. The applicant demonstrates experience: Providing services like the proposed program. Addressing health disparities.
93	Identify the staff who will deliver services and describe their experience and qualifications. If you have selected more than one campaign, please address the staff for each. For new staff, describe your plan to hire people with the necessary qualifications and characteristics.	Up to 2,000 words	(15 points) The response addresses all elements of the question. The applicant understands the experience and expertise required to implement the proposed program.
94	Identify the community partners needed to ensure the success of the program and describe your organization’s experience with these partners. If you have selected more than one campaign, please address the community partners for each.	Up to 2,000 words	(5 points) The response addresses all elements of the question. The response identifies a sufficient range of partners to support the proposed program. The applicant has existing connections to community partners.
95	Describe how you will ensure services are culturally and linguistically appropriate based on the diversity of the population to be served.	Up to 1,000 words	(5 points) The response addresses all elements of the question. The applicant has policies and procedures in place to identify the service needs of the population of focus, including disparities in access. The applicant follows the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care. The applicant is prepared to provide interpreters and other accommodations.

Entry Table

Name and Brief Description of Program	Funder Name	Funder Type	Dollar Amount	Population Served	Start Date (MM/DD)	End Date (MM/DD)
200 characters	200 characters	[Drop Down choices—federal, state, local government, other]	Currency, whole dollar only	200 characters	Date	Date
[same]
[same]
[same]
[same]

Section 8. Quality

Questions 96-98 ask for an explanation of the implementation approach and anticipated outcomes of the proposed activities to be funded.

#	Data Item	Field Information	Evaluation Criteria
96	Describe how your organization will implement the proposed program by task. In your answer, describe how you will: Identify and engage the priority population. Tailor campaigns to the individual needs of the priority population.	Up to 2,500 words	(10 points) The response addresses all elements of the question. The response provides sufficient detail to understand how services will be delivered. The response clearly connects the proposed program to the needs of the population of focus. The service projections are clear and reasonable in relation to the budget request.
97	Describe the intended outcomes of the proposed program and how these are related to the needs described in your proposal. Describe expected outcomes quantitively (e.g., campaign materials produced, number of people to be served), when applicable.	Up to 500 words	(10 points) The response addresses all elements of the question. The response lists specific outcomes that are related to the proposed program.
98	Provide a detailed timeline for your proposed approach that includes hiring of staff, anticipated linkage agreements, and other coordination activities needed to accomplish the goals and objectives.	Upload Project Plan as Attachment G (required)	(10 points) The response addresses all elements of the question. The timeline proposed includes all required program elements. The timeline includes realistic milestones. The response includes relevant data, including sources.

Section 9. Budget

Questions 99-101 request information about the project budget.

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