Application: ANCHOR

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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)

In Section 1, enter general information and relevant contact information related to your organization and the program

#	Data Item	Field Options	Instructions
1.1	Legal organization name
1.2	Common name (doing business as [DBA])
1.3	Address line 1
1.4	Address line 2
1.5	City
1.6	State
1.7	ZIP code
1.8	County of primary office location
1.9	Organization phone
1.10	Organization website address (optional)
1.11	Type of organization	Nonprofit For profit Tax exempt	Select your organization type.
1.12	Organization description	Provide a 2-3 sentence description of your organization’s mission, vision, and services.
1.13	Year founded/incorporated
1.14	IDHS /DBHR licenses, if any
1.15	Indirect cost election	Federally negotiated rate De minimis No indirect costs election	Select your indirect cost election.
1.15a	Indirect cost rate		Enter your indirect cost rate.
1.16	Primary Program contact name		The primary contact should be the program manager/director who should receive all program communications and has a responsibility to ensure that other materials are shared with appropriate
1.17	Primary program contact title
1.18	Primary program contact email address
1.19	Primary program contact phone
1.20	Secondary program contact name
1.21	Secondary contact title		The secondary contact may be administrative or fiscal support and will also receive program communications.
1.22	Secondary contact email address
1.23	Secondary contact phone
1.24	Evaluation contact name		The evaluation contact should be the individual who will support data collection and reporting for your program activities.
1.25	Evaluation contact email address
1.26	Evaluation contact phone

Section 2. Prequalification (0 Points)

In Section 2, enter information that demonstrates your organization’s eligibility for receiving grant funds.

#	Data Item	Field Information	Instructions
2.1	Federal or State Employer Identification		Indicate your FEIN/EIN.
2.2	Expiration date of sam.gov account	Enter date
2.3	Unique Entity Identifier		Indicate your UEI.
2.4	Illinois Secretary of State File ID		Indicate your File ID.
2.5	Do you attest that your organization is not on the Federal Excluded Parties List?	Yes No
2.6	Do you attest that your organization is not on the Illinois Stop Payment list?	Yes No
2.7	Do you attest that your organization is not on the Department of Healthcare and Family Services Provider Sanctions list?	Yes No
2.8	Do you attest that your organization is in good standing with the Illinois Secretary of State?	Yes No

Section 3. Internal Controls (0 Points)

In Section 3, enter information about the administrative and management controls within your organization to inform assessment of organizational risk. These questions align with the Illinois Internal Controls Questionnaire.

#	Data Item	Field Information	Instructions
3.1	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.
3.2	Does the accounting system require users to have separate sign in/log on credentials for access and approval? (2.02)	Yes No
3.3	Have any new accounting systems been implemented during the last fiscal year? (2.03)	Yes No
3.3a	If yes, please describe the new accounting system.
3.4	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.
3.5	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
3.6	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.
3.7	Does the organization require monthly bank reconciliations? (2.07)	Yes No
3.8	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
3.9	Does the organization have written review and approval processes for financial and program-related reporting? (3.01)	Yes No
3.10	Are the annual financial statements prepared in accordance with Generally Accepted Accounting Principles or on a basis acceptable by the regulatory agency? (3.02)	Yes No
3.11	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
3.12	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
3.13	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.
3.14	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.
3.15	Does the organization have written policies and procedures that support compliance with cost principles? (4.01)	Yes No
3.16	Does the organization have written policies and procedures for allocating costs? (4.02)	Yes No
3.17	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
3.18	Does the organization charge indirect costs? (4.04)	Yes No
3.19	Does the organization keep adequate documentation to support all costs charged to its grant awards? (4.06)	Yes No
3.20	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
3.21	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
3.22	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.
3.23	Does the organization make purchases of equipment of $5,000 or more with grant funding? (4.10)	Yes No
3.24	Is a control system in place with adequate safeguards to prevent loss, damage, theft, or unauthorized use of property? (4.13)	Yes No
3.25	Does the organization have written policies and procedures for proper authorization of property disposals? (4.14)	Yes No Not applicable
3.26	Does the organization have written policies and procedures for purchasing goods and services with grant funds? (4.15)	Yes No
3.27	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
3.28	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
3.29	Does the organization have written policies and procedures that document subrecipient and contractor determinations? (4.18)	Yes No
3.30	In those determinations, has the organization identified any subrecipients? (4.19)	Yes No
3.31	Does the organization have written policies and procedures for assessing subrecipient risk and monitoring program implementation? (4.20)	Yes No
3.32	Does the accounting system or related written policies and procedures identify expenses in excess of available budget? (4.21)	Yes No
3.33	Are adequate controls in place to ensure that necessary budget revisions receive prior approval from the grantor when applicable? (4.22)	Yes No
3.34	Does the organization have written policies and procedures for allocating personnel time and effort by funding source? (4.23)	Yes No
3.35	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
3.36	Does the organization have written policies and procedures to ensure accurate tracking of grant deliverables and performance measures? (4.25)	Yes No
3.37	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
3.38	Are the terms of the executed agreement and budget shared with the performance or program management staff? (4.28)	Yes No
3.39	Does the organization have written policies and procedures for documenting participant eligibility determinations? (4.29)	Yes No
3.40	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
3.41	Has a financial statement audit of the organization been conducted in the past year? (5.02)	Yes No
3.41a	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.
3.41b	Did the audit find significant deficiencies or material weaknesses? (5.04)	Yes No
3.41c	If yes, please describe the audit findings and describe any corrective actions implemented.	[Text, 300 characters]
3.42	Has the organization submitted financial and program-related reporting in a timely manner and as required for prior grant awards?	Always Sometimes Rarely
3.42a	If “sometimes” or “rarely”, please further describe the situation and describe any corrective actions implemented.

Section 4. Organization Attestations and Attachments (0 Points)

In Section 4, verify organizational capacity and truthfulness of information in the application and upload organization attachments.

#	Data Item	Field Information	Instructions
4.1	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.
4.2	I attest that my organization is committed to processing a subaward within six (6) weeks from the NOIA.	Yes No
4.3	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
4.4	I attest that I have reviewed the terms and conditions within this NOFO in its entirety. My organization meets the eligibility criteria and has the capacity to fulfill the scope of services described.	Yes No
4.5	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
4.6	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
4.7	Conflict of Interest Disclosure	Document upload (required)	Upload as “Attachment A. COI” (.
4.8	Form W-9, Request for Taxpayer Identification Number and Certification	Document upload (required)	Upload as “Attachment B W-9”.
4.9	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 Org Budget”.
4.10	Current or planned organizational chart*	Document upload (required)	Upload as “Attachment D Org Chart”.
4.11	Financial Audit Report (most recent)	Document upload (if applicable)	Upload as “Attachment E Audit”.
4.11a	What period did the audit cover?		Enter the date range of the period covered by audit
4.12	Negotiated Indirect Cost Rate Agreement (NICRA)	Document upload (if applicable)	Upload as “Attachment F NICRA” (if applicable).

Section 5. Executive Summary (5/100 points)

In Section 5, provide a brief overview of your organization, experience, the proposed area and populations of focus, and program results.

5.1

Please select which of the following types of programs will be developed as part of the ANCHOR subaward. You may select more than one. (See Section C.3. fo the NOFO)

Comprehensive interventions including screening and/or crisis response, adolescent treatment services, and outreach and engagement initiatives

Innovative approaches such as online recovery groups, recovery high schools, recovery groups for adolescents, and evidence-based family support interventions

Telehealth services and training and technical assistance to providers to support online activities

• Harm reduction education and programs for adolescents and their families as well as other people who interact with adolescents.

None

5.2

Please select which of the following type of services and activities will be included as part of ANCHOR programming. You may select more than one. See Section C.3 of the NOFO)

Screening and/or Crisis Response

Treatment

Education, outreach, and other support to reduce barriers to care

Youth Recovery Supports

Family/Caregiver Support

Workforce Development

Other (provide brief description)

None

5.3

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

Your organization’s mission and vision

Your organization’s experience with similar programs

The geographic area and populations of focus for the program

The goals and objectives of your program

The results you hope to see

Up to 1,000 words

(5 points)

The mission and vision of the organization are clearly stated in the response and are relevant to the proposed program.
The response summarizes relevant experience and success in similar programs.
The response summarizes the area and populations of focus.
The response summarizes the goals, objectives, and outcomes of the program.
The response addresses all elements of the question.

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

In Section 6, describe the need for the program in the geographic location where services are planned and how the proposed activities will support the program goals.

#	Data Item	Field Information	Evaluation Criteria
6.1	Select the public health region (s) where you plan to provide ANCHOR services per the map shown.	Cook County (Bellwood) West Chicago Champaign Marion Metro East Peoria Rockford Statewide	0 points
6.2a	Please list the county or counties where you will provide ANCHOR services.		(5 points) The municipalities and/or counties in questions 6.2a and 6.2b demonstrate high opioid fatality rates as described in Section C.2. The municipalities and/or counties in questions 6.2a and 6.2b demonstrate high poverty rates as described in Section C.2. The municipalities and/or counties in questions 6.2a and 6.2b demonstrate high rates of firearm violence as described in Section C.2. The municipalities and/or counties in questions 6.2a and 6.2b demonstrate other conditions that hinder overall wellbeing as described in Section C.2.
6.2b	Please briefly describe the municipality(ies) where you plan to provide ANCHOR services.
6.3	How does your proposal support the purpose of the program? Explain the current need and, supported by data, describe how the proposed program will achieve the goal and objectives of the funding. Describe how you will prioritize priority populations based on overdose data in the proposed service area and current availability of services. Describe specific outreach plans for disparately impacted populations (e.g., Native American adolescents). Please cite the source of any data included.	Up to 2,000 words	(25 points) The response demonstrates a clear understanding of the program purpose and priority populations. The response describes how program activities will contribute to positive outcomes. The response addresses all elements of the question. The response includes relevant data, including sources.

Section 7. Experience and Capacity (30/100 points)

In Section 7, describe relevant experience and capacity to effectively perform program requirements.

Data Item

Field Information

Evaluation Criteria

7.1

What is your organization’s experience implementing the tasks described in the scope of services as described in Section C.3 of the NOFO?

Describe experience providing the following services:

Crisis response

Outreach, engagement, and educational resources

Treatment

Youth recovery support

Family/caregiver support

Workforce development

Provide detailed descriptions of relevant prior work.

Up to 1,500 words

(10 points)

The response demonstrates that the applicant has experience providing services related to crisis response, treatment, outreach, engagement, and educational resources, youth recovery support, family/caregiver support, and workforce development.
The applicant demonstrates relevant experience with examples of prior work.
The response addresses all elements of the question.

7.2

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/DBHR or IDPH and awards of similar size and services.

In description, 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

Table below

(5 points)

The applicant demonstrates experience with grants management of comparable size awards.
The applicant demonstrates experience with grants that management for comparable services.

7.3

Identify proposed program leadership and describe their experience and qualifications.

For new staff, describe your plan to hire people with the necessary qualifications and characteristics (including people with lived and living experience and those who live and work in the community).

Additionally, describe the organizational departments and resources who will support the program team.

Upload resumes of program 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 Resumes.”

(5 points)

The applicant understands the experience and expertise required to implement the proposed program.
The applicant demonstrates an ability to provide qualified staff.
The applicant demonstrates a commitment to hiring people with lived and living experience.
The response addresses all elements of the question.

7.4

Identify the community and educational partnerships that will contribute to the success of the program and describe your organization’s experience with these partners.

Up to 1,000 words

(5 points)

The response identifies a sufficient range of partners to support the proposed program.
The applicant has existing connections to community and educational partners.
The response addresses all elements of the question.

7.5

How does your organization ensure services advance equity and racial and social justice?

Describe policies, procedures, and practices related to:

Diversity, equity, inclusion, 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

(5 points)

The response demonstrates organizational commitment, through policy and practice, to advancing equity, racial, and social justice.
The applicant is prepared to provide interpreters and other accommodation in response to cultural and linguistic needs.
The response addresses all elements of the question.

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 (30/100 points)

In Section 8, describe describe your overall approach to implementing program requirements.

#	Data Item	Field Information	Evaluation Criteria
8.1	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	(15 points) The response provides sufficient detail to understand how the applicant will carry out program activities. The response addresses all required tasks.
8.2	Upload a detailed program plan for your proposed approach, including a month-by-month timeline that covers: Coordinating award administration requirements Hiring and training staff Developing required plans Delivering services and activities Collecting required data	Upload Program Plan as “Attachment H. Timeline.”	(10 points) The program plan contains sufficient detail to understand the overall approach and timeline of program activities. The program plan includes all required program elements. The timeline includes realistic milestones.
8.3	Provide three reference letters that describe history and quality of work related to the goals of the funding opportunity.	Upload 3 letters of reference as “Attachment I. References”	(5 points) The organization uploaded at least 3 letters of reference. The letters of reference support the organization’s expertise and experience in work relevant to the funding opportunity.

Section 9. Budget (5/100 Points)

In Section 9, provide information about the program budget.

#	Data Item	Field Information	Evaluation Criteria
9.1	Total funding requested for Funding Period 1 of the period of performance (as shown on the budget summary page of your budget workbook).	[currency]	(0 points)
9.2	Total funding requested for Funding Period 2 of the period of performance (as shown on the budget summary page of your budget workbook).	[currency]	(0 points)
9.3	Please select your preferred payment term as described in Section G.5. of this document. PLEASE NOTE: Advance payment and reconcile is not guaranteed. If you are awarded and your preferred payment method is advanced 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 advanced payment. You must maintain or demonstrate the willingness to maintain both: Written procedures that minimize the time elapsing between the transfer of funds and disbursement by the awardee; and Financial management systems that meet the standards for fund control and accountability as established in 2 CFR § 200.302.)	Reimbursement Method Advance Payment and Reconcile Method Working Capital Advance Method	(0 points)
9.4	Upload the program budget and narrative. This workbook must tie fiscal activity to program objectives and deliverables. The budget 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 Budget Workbook as “Attachment J. ANCHOR Budget” to submit your program budget and advance payment request (required).	(5 points) The budget is filled out completely (including staff/funds allocated for each task). Salaries, benefits, and other expenditures appear reasonable for the community in which the proposed program will take place. Personnel allocated reflect those proposed in application and are sufficient to support administrative requirements of program. All line items correspond to elements of the proposed program.

Application: ANCHOR

NOFO Table of Contents

Section 1. Organization Information (0 points)

Section 2. Prequalification (0 Points)

Section 3. Internal Controls (0 Points)

Section 4. Organization Attestations and Attachments (0 Points)

Section 5. Executive Summary (5/100 points)

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

Section 7. Experience and Capacity (30/100 points)

Section 8. Quality (30/100 points)

Section 9. Budget (5/100 Points)