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About the Application

This page lists all the questions you will be asked to respond to in the SurveyMonkey Apply platform. The application is organized into 9 sections. The information in Sections 1–4 is about the organization overall. The information in sections 5-9 is specific to this funding notice and scored as part of the merit-based review. In sections 5-9, please carefully note the associated criteria for each question. These criteria are used to score each question.

Section 1. Organization Information (0 points)

Questions 1–26 request general information, contact details, and documentation related to your organization.

#	Data Item	Field Information	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 Multiple [logic, answer 9a]	Select the public health region(s) where you primarily provide services or that pertains to this application per the 2023 IDPH Health Region Map.
9a	If you chose multiple, please briefly describe which regions will be served by the strategies funded 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 15% de minimis No indirect costs election	Select your indirect cost election. If you select “Federally negotiated rate,” continue to item 24. If you select “15% de minimis” or “No indirect costs election,” skip item 24 and continue with item 25.
24	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. Prequalification (0 Points)

Questions 27–34 requests information and documentation to demonstrate 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 (0 Points)

Questions 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).

#	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	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 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 76–78, continuing with item 79.
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 2 CFR § 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 (0 Points)

Questions 80–86 ask for verification of capacity and truthfulness of information in the application, and for disclosure of conflicts of interest.

#	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 Intent to 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, including at least two years of experience providing harm reduction services as a CHRP, 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	I attest that my organization will adhere to applicable standards within 77 Ill Admin Code Part 2060 Administrative Rule, pertaining to treatment off-site.	Yes No
86	Conflict of Interest Disclosure	Document upload (required)	Upload as “Attachment F.”

Section 5. Executive Summary (5/100 points)

Question 87 asks for a brief overview of your organization, experience, the proposed area and populations of focus, and project results.

#	Data Item	Field Information	Evaluation Criteria
87	Provide a summary of your organization and project, including the following: · Your organization’s mission and vision · Your organization’s experience in similar projects · The geographic area and populations of focus for the project · The goals and objectives of your project · The results you hope to see	Up to 1,000 words	(5 points) 1) The mission and vision of the organization are clearly stated in the response and are relevant to the proposed project. 2) The response summarizes relevant experience and success in similar projects. 3) The response summarizes the area and populations of focus 4) The response summarizes the goals, objectives, and outcomes of the project. 5) The response addresses all elements of the question.

Data Item

Field Information

Evaluation Criteria

Provide a summary of your organization and project, including the following:

· Your organization’s mission and vision

· Your organization’s experience in similar projects

· The geographic area and populations of focus for the project

· The goals and objectives of your project

· The results you hope to see

Up to 1,000 words

(5 points)

1) The mission and vision of the organization are clearly stated in the response and are relevant to the proposed project.

2) The response summarizes relevant experience and success in similar projects.

3) The response summarizes the area and populations of focus

4) The response summarizes the goals, objectives, and outcomes of the project.

5) The response addresses all elements of the question.

Section 6. Need and Opportunity (30/100 points)

Questions 88–90 asks you to describe the need for the program and how the proposed activities will support the project goals.

#	Data Item	Field Information	Evaluation Criteria
88	What is the need for harm reduction services in your community? Include: · The geographic area of focus · The priority population(s) you plan to serve · Gaps and disparities among different populations · The negative health, social, and economic consequences of the opioid crisis and substance use in your community · Relevant, up-to-date data to support the need Cite the sources of any data you include.	Up to 2,000 words	(15 points) 1) The geographic area focuses on densely populated areas with high rates of opioid use, overdose, or overdose fatality, and/or addresses the unique challenges of rural communities. 2) The priority population(s) are clearly described, and includes people who are historically and currently disproportionately impacted by criminalization and marginalization due to substance use, among other priority populations 3) The response uses relevant, up-to-date data to support the need for harm reduction services for the priority population. 4) The response identifies gaps in current services and explains how the proposed project will address them. 5) The response addresses all elements of the question, including citations of any included data.
89	How will you expand and enhance your harm reduction services to address the identified needs in the community? · Describe the proposed harm reduction services and strategies, per the SAMHSA Harm Reduction Framework, that are needed to meet the gaps in services and population disparities in the community. Cite the sources of any data you include.	Up to 1,500 words	(10 points) 1) The response clearly describes specific harm reduction services in accordance with the SAMHSA Harm Reduction Framework. 2) The response connects program activities with the community and priority population needs identified in question #88. 3) The response addresses all elements of the question, including citations of any included data.
90	How will the program create lasting positive change for the community? · Explain how the proposed services will help reduce negative impacts on health, social, and economic outcomes for individuals in active use of substances in your community, including populations that have been disproportionately impacted. Cite the sources of any data you include.	Up to 1,000 words	(5 points) 1) The response clearly describes the desired outcomes for populations that have been disproportionately impacted. 2) The response demonstrates how proposed project activities will contribute to positive outcomes. 3) The response addresses all elements of the question, including citations of any included data.

Section 7. Experience and Capacity (40/100 points)

Questions 91–96 asks you to describe relevant experience and capacity to effectively perform program requirements.

#	Data Item	Field Information	Evaluation Criteria
91	What is your organization’s experience carrying out core harm reduction practices described in the SAMHSA Harm Reduction Framework for at least two years? Describe, with detailed descriptions of prior work (including time frames), your experience in: · Engaging and including people who are historically and currently disproportionately impacted by criminalization and marginalization due to substance use, and other priority populations · Providing education and support on safer practices · Facilitating access for the above populations to one or more of the following: o Safer settings o Safer access to healthcare o Safer transitions to care	Up to 2,000 words	(15 points) 1) The response demonstrates that the applicant has at least two years of experience in engaging members of priority populations. 2) The response demonstrates that the applicant has at least two years of experience in providing education and support to individuals in active use of substances. 3) The response demonstrates that the applicant has at least two years of experience in facilitating safer settings, safer access to healthcare, and safer transitions to care (per proposed activities; all three are not required). 4) The applicant demonstrates at least two years of relevant experience with detailed descriptions of prior work. 5) The response addresses all elements of the question, including citing data, if relevant.
92	What is your organization’s experience and past performance in managing grants and contracts? · 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 and past funding from IDHS/SUPR or IDPH, as well as awards of similar size and services, similar priority population, or focus on health disparities. In the description within the table, note whether services relate to the services proposed for this award. Select “not applicable” if you have not received previous grants or contracts.	Checkbox for not applicable or Table below	(2 points) 1. The response demonstrates experience with grants management of comparable size awards. 2. The applicant’s prior grants experience demonstrates experience with the following: Providing services like the proposed program. Working with the priority populations. Addressing health disparities.
93	How does your organization’s staffing approach reflect the community served? · Describe how the current organization staff demographics reflect the community served. · Describe how PWLE from the community are engaged in leading the planning and oversight, program development and evaluation, and resource/funding allocation for harm reduction initiatives, programs, and services. · For new staff, describe the plan to hire people with the necessary qualifications and characteristics (including PWLE and those who live and work in the community).	Up to 1,500 points	(8 points) 1. Organization staff demographics are clearly described and reflect the community served. 2. The applicant ensures PWLE lead harm reduction initiatives. 3. The applicant demonstrates a commitment to hiring PWLE and members of the community. 4. The response addresses all elements of the question, including citations, if relevant.
94	How does your organization’s expertise and experience demonstrate your ability to successfully implement the project? · Identify program leadership and describe their experience and qualifications. · Identify program staff who will be allocated or hired to complete delivery of services. · Describe the organizational resources who will provide administrative and operations support to support program leadership and staff. · Upload resumes of project leadership or, if to be hired, the organizational leadership who will serve in the interim.	Up to 1,000 words Upload resumes as “Attachment G.”	(8 points) 1. The applicant understands the experience and expertise required to implement the proposed program. 2. The response demonstrates the ability to provide qualified staff to support program operations and delivery of services. 3. The response addresses all elements of the question, including citations, if relevant.
95	What is your organization’s experience in working with other interest holders in the community to deliver harm reduction services? · Identify the community and educational partnerships that will contribute to the success of the project. · Describe your organization’s experience with these partners, including informal and formal arrangements (such as MOUs)	Up to 1,000 words	(5 points) 1. The response identifies a sufficient range of partners to support the proposed program. 2. The applicant has existing connections, including MOUs, with community and educational partners. 3. The response addresses all elements of the question, including citations, if relevant.
96	How does your organization ensure services advance equity and racial and social justice? Describe your policies, procedures, and practices in the following areas: · Diversity, equity, inclusion · Social and racial justice · Equitable access to support and services · Implicit bias · Culturally responsive, culturally humble, and trauma-sensitive services, including providing interpreters and other accommodations	Up to 1,000 words	(2 points) 1. The response demonstrates organizational commitment, through policy and practice, to advancing equity, racial, and social justice. 2. The applicant is prepared to provide interpreters and other accommodation in response to cultural and linguistic needs. 3. The response addresses all elements of the question, including citations, if relevant.

Question 91. 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 (20/100 points)

Questions 97–99 ask you to describe your overall approach to implement program requirements.

#	Data Item	Field Information	Evaluation Criteria
97	Describe how your organization will complete each task listed in Section C of the funding notice. For each task, include: · The steps and activities to be completed · Who will be responsible for each task	Up to 2,000 words	(10 points) 1. The response provides sufficient detail to understand how the applicant will carry out program activities. 2. The response addresses all required tasks.
98	Upload a detailed project plan for your proposed approach, including a month-by-month timeline that covers: · Coordinating award administration requirements · Hiring and training staff · Developing required plans · Establishing anticipated linkage agreements · Delivering services and activities	Upload Project Plan as “Attachment H.”	(7 points) 1. The project plan contains sufficient detail to understand the overall approach and timeline of project activities. 2. The project plan includes all required program elements. 3. The timeline includes realistic milestones.
99	Provide three references that describe history and quality of work related to the goals of the funding opportunity.	Upload letters of reference as “Attachment I.”	(3 points) 1. The organization uploaded at least 3 letters of reference. 2. The letters of reference support the organization’s expertise and experience in work relevant to the funding opportunity.

Section 9. Budget (5/100 Points)

Questions 100–102 request information about the project budget.

#	Data Item	Field Information	Evaluation Criteria
100	Total funding requested for the period of performance	[currency]	(0 points)
101	Please select your preferred payment term as described in Section G.5. of this document. Please note, if you are awarded and your preferred payment method is advance payment and reconciliation, you will be asked to send documents that demonstrate your eligibility per 2 CFR § 200.302 and 2 CFR § 200.305. Illinois requires that the following conditions must be met to receive advance payment. You must maintain or demonstrate the willingness to maintain both: i. written procedures that minimize the time elapsing between the transfer of funds and disbursement by the awardee; and ii. financial management systems that meet the standards for fund control and accountability as established in 2 CFR § 200.302.)	· Advance Payment and Reconcile Method · Reimbursement Method · Working Capital Advance Method	(0 points)
102	Upload the project budget and narrative. This workbook must tie fiscal activity to program objectives and deliverables. The budget must demonstrate that all proposed costs include: · Reasonable and necessary · Allocable · Allowable as defined by program regulatory requirements and Uniform Guidance (2 CFR 200), as applicable	Upload the Budget Workbook as “Attachment J” to submit your project budget (required) and advance payment request, if applicable.	(5 points) 1. The budget is filled out completely. 2. Salaries, benefits, and other expenditures appear reasonable for the community in which the proposed program will take place. 3. Personnel allocated reflect those proposed in application and are sufficient to support administrative requirements of program. 4. All line items correspond to elements of the proposed program.