Support Services to Families:
Deaf and Hard of Hearing Mentor
Request for Proposal Materials
Grant Period: July 1, 2016 – June 30, 2021
Proposal Deadline: Monday, May 2, 2016
Nicole Brown, MSN, PHN, CPNP
Early Hearing Detection and Intervention Coordinator
Community and Family Health Division
Children with Special Health Needs Section
85 East 7th Place, P.O. Box 64882
St. Paul, MN 55164-0882
(651) 201-3737 phone
E-mail: nicole.brown@state.mn.us
Table of Contents
Program Overview...................................................................................................... 3
Program Description ................................................................................................... 4
Program Requirements ............................................................................................... 6
Program Summary...................................................................................................... 9
Project Narrative and Work Plan............................................................................... 10
Budget Section ......................................................................................................... 12
Form Instructions and Required Forms ..................................................................... 14
Form A Grant Application Face Sheet ..................................................................................... 15
Form B Grant Application Checklist......................................................................................... 16
Form C Deaf and Hard of Hearing Mentor Work Plan Form ................................................... 17
Form D Budget Justification Instructions & Form .................................................................. 18
Form E Budget Summary Instructions & Form ........................................................................ 23
Form F Due Diligence Form ..................................................................................................... 25
Form G Indirect Cost Questionnaire Form .............................................................................. 28
Appendices .............................................................................................................. 30
Appendix A
Criteria for Scoring Grant Applications ........................................................... 31
Appendix B
Work Plan – 2016 Grant RFP Example ............................................................ 33
Appendix C
2015 MN Statute 144.966, subd. 3a. .............................................................. 34
Appendix D
MDH Grant Agreement Sample ...................................................................... 35
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Program Overview
Introduction
The purpose of these instructions is to provide assistance in preparing an application for the
Early Hearing Detection and Intervention Support Services To Families: Deaf and Hard of
Hearing Mentor grant. It is suggested that these instructions and a copy of the Criteria for Grant
Review Score Sheet (Appendix A), be examined PRIOR to writing the application. This will
provide guidance relative to the content and format necessary to prepare a complete
application.
This Request for Proposal (RFP) document provides the forms and information needed to
complete the Support Services To Families: Deaf and Hard of Hearing Mentor grant application.
These documents are available on the Minnesota Department of Health (MDH) Children Youth
with Special Health Needs (CYSHN) website.
The MDH will be available to provide consultation and guidance during the application process.
For assistance, please contact nicole.brown@state.mn.us. Please note that MDH staff will not
be able to help with writing the application.
MDH will maintain an “Answers to Grant Application Questions” link on the Children and Youth
with Special Health Needs web site. Questions and Answers will be updated regularly before
the application deadline.
The application can be downloaded at the Children and Youth with Special Health Needs web
site.
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Program Description
Background
The 2012 Minnesota Legislature authorized grant funding to provide trained deaf and hard of
hearing mentors to provide individualized support and assistance (including instruction in ASL
as well as other supports) to families of children who are deaf or hard of hearing.
Funding is provided to one non-profit organization.
Funding for the Deaf and Hard of Hearing Role Model/Mentor program will be up to $156,000
each year beginning July 1, 2016 through June 30, 2021.
Purpose of the Funding
The purpose of this funding is to support the use of adult role models/mentors who are deaf
and hard of hearing in order to enhance the language acquisition and social development for
families of infants and young children who are deaf and hard of hearing. Deaf or hard of hearing
adult role models/mentors do this by sharing personal experiences or information about being
deaf and hard of hearing, educational and communication opportunities, using hearing
technology, and about the Deaf community and Deaf culture. For families who have chosen to
use American Sign Language (ASL), the use of adult mentors and role models trained in ASLbased mentoring curriculums specifically supports the family’s learning of ASL.
Program Goal and Components
Approximately 200 infants and children are identified with permanent hearing loss each year in
Minnesota. The goal of Minnesota’s Early Hearing Detection and Intervention Program is to
identify all infants and children who are deaf and hard of hearing as early as possible and
connect those children/families to timely and appropriate intervention services in order to
maximize their linguistic and communicative competence, literacy and social/emotional
development. The goal of this funding is to enhance linguistic and communicative competence,
literacy and social/emotional development through the use of of adult role models/mentors.
The Early Hearing Detection and Intervention program also strives to develop and support a
state system that meets the recommendations provided by the Joint Committee on Infant
Hearing (JCIH). In 2013, comprehensive guidelines on establishing strong early intervention
systems with appropriate expertise to meet the needs of children who are deaf and hard of
hearing were published by the Joint Committee on Infant Hearing 1. One important intervention
identified by the Joint Committee on Infant Hearing for infants and children who are deaf and
hard of hearing and their families included deaf or hard of hearing mentors. Deaf or hard of
hearing mentors or role models are uniquely qualified to provide a child, parent and
professional with a positive and hopeful perspective from their day-to-day, real life experiences
as a deaf and hard of hearing person living in a hearing world.
This funding aims to promote children’s development of strong language and social skills,
regardless of the route or routes taken by the family (e.g., spoken language, ASL, visually
supported spoken language). Deaf or hard of hearing role models/mentors who represent the
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diversity of the Early Hearing Detection and Intervention population (e.g. deaf culture, hard of
hearing, cochlear implant and hearing aid users, unilateral hearing loss, auditory neural hearing
loss, cultural diversity) are valuable in supporting language and social development for the
family by sharing “personal experiences or information about being deaf and hard of hearing,
educational and communication opportunities, using hearing technology, or about the deaf
community and deaf culture” (JCIH, 2013).
JCIH (2013) also highlighted that “an area that has been particularly deficient for families who
choose ASL is access to an EI provider who is a fluent/native ASL signer. Families with children
who are D/HH in the process of learning ASL require access to competent and fluent language
models”. For families who have chosen to use ASL, the use of deaf mentors trained in evidence
based Deaf Mentor models can support a family’s learning of ASL. “The families can be given
resources and support in acquiring ASL through collaboration with professionals who are deaf
and hard of hearing and who communicate in ASL.” (JCIH, 2013).
In 2015, the Amherst H. Wilder Foundation conducted a needs assessment to better
understand the needs and preferences of families with respect to family mentor services, and
provided key findings and recommendations for best practices to implement in providing family
mentor services2. These results should be considered in any grant applications.
1) American Academy of Pediatrics, Joint Committee on Infant Hearing. Supplement to the
JCIH 2007 Position Statement: Principles and Guidelines for Early Intervention After
Confirmation That a Child Is Deaf or Hard of Hearing. Pediatrics, 2013; 131 (4)
http://pediatrics.aappublications.org/content/early/2013/03/18/peds.2013-0008.citation
2) Wilder Research. (2015). Families with Young Children who are Deaf and Hard of Hearing in
Minnesota. Minneapolis, MN: Author www.wilderresearch.org
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Program Requirements
The grant program will utilize trained deaf and hard-of-hearing role model/mentors to deliver
individualized support to families of children who are deaf and hard of hearing.
The grantee must be able to support families of children who are deaf and hard of hearing by:
1) Structuring the program to meet the diversity of needs and preferences among families
with young children who are deaf and hard of hearing in Minnesota, honoring the
family’s preferred mode(s) of communication, and offering a variety of support options
including instruction in ASL.
2) Providing mentor/role model services by people who are deaf or hard of hearing,
including personal experiences about being deaf or hard of hearing, and providing
factual information about educational and communication opportunities, using hearing
technology, or about the deaf community and deaf culture. Information must be
presented in a nonjudgmental manner.*
3) The grantee will be able to provide instruction in ASL as an option to families of children
who are deaf and hard of hearing and choose ASL.
i) All curricula used in instruction in ASL as an available option must be evidence-based
and approved by MDH.
ii) Deaf mentors providing instruction in ASL must accept, without judgment, a family’s
use of their sign language skills with or without spoken language.
4) Policies and procedures must be utilized to establish consistency, define a systematic
approach to implementing expectations, plans, and work routines, etc.
5) The emphasis will be to support families of children who are newly identified as deaf
and hard of hearing.
6) The grantee will provide ongoing education and development for staff which will include
but not be limited to 1) parent leadership; 2) data privacy and confidentiality; 3) child
development including language development
7) The grantee will need to be guided by an advisory group composed of professional
stakeholders of the Early Hearing Dectection and Intervention and deaf and hard of
hearing community, parents of children who are deaf and hard of hearing, and
individuals who are deaf and hard of hearing. Members of the committee must
represent the diversity of the Early Hearing Detection and Intervention population (e.g.
deaf culture, hard of hearing, cochlear implant and hearing aid users, unilateral hearing
loss, auditory neural hearing loss, cultural diversity).
8) The grantee will provide deaf and hard of hearing role model/mentor support services
to families in all regions of Minnesota. The grantee should consider utilization of all
technology, including computer and videophones, to support families.
9) The grantee will collaborate with existing deaf and hard of hearing and Early Hearing
Detection and Intervention programs, professionals and the community. Deaf and hard
of hearing role model/mentor staff will provide input into the Early Hearing Detection
and Intervention System through collaboration and participation in national, state and
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local workgroups and committees including the MN Newborn Hearing Screening/ Early
Hearing Detection and Intervention Advisory Committee.
10) The grantee will have a plan for providing culturally appropriate parent support services
regardless of cultural or ethnic background. The plan will address supporting families
whose native language is not English. Services are comparable to services provided to
native English-speaking families.
11) The organization will participate in program oversight, program coordination,
consultation, program improvement** and evaluation, with MDH staff and partners.
Programs are required to work with the MDH staff to develop and implement an
evaluation of programs and report on measurable outcomes that demonstrate how
children who are deaf and hard of hearing and their families are better off as a result of
the services provided. **This will include standardized procedures to monitor and
assess accomplishments relative to their objectives/work plan. They are also
encouraged to engage in evaluation activities specific to their local activities. Grantees
will contribute to the measurement of overall outcomes of children who are deaf and
hard of hearing. **Please go here for more information on the Result Based
Accountability process for developing measurable outcomes
12) The grantee will submit standardized written quarterly progress report and invoices for
project expenses. The grantee will be required to work closely with MDH staff and at a
minimum, communicate one to one in person, by phone or in writing on a monthly
basis. Grantees must have the capacity to receive notifications, complete reports, and
communicate on-line (internet).
Application Submission Requirements
 Narrative portions of the application should be written in 12-point font, single spaced
with one-inch margins. The Work Plan can be in 11 point font.
 All pages should be numbered consecutively.
 Narrative pages should be double-spaced with one inch margins. The application must
be limited to ten (10) pages. Applications greater than ten (10) pages will not be
reviewed.
 Submit the entire application as one PDF document in the order listed on Form B Grant
Application Checklist Form and submit by email to health.cyshn@state.mn.us. Merge
the narrative (Applicant Information and Organizational Capacity, Linkages and
Collaboration, Statement of Need and Year 1 Work Plan) and all required forms into one
PDF document.
 The deadline for submission of applications is 4:00 PM on Monday, May 2nd, 2016. No
application will be accepted for consideration after this time.
Application Review and Award Process
This is a competitive grant application. Applications will be reviewed and scored according to
the Criteria for Scoring Support Services To Families: Deaf and Hard of Hearing Mentor Grant
Applications (Appendix A).
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Reviewers may include staff from the MDH, staff from state agencies with experience related to
family support services for children who are deaf and hard of hearing, or individuals who are
familiar with or who have provided services to children who are deaf and hard of hearing.
Reviewers will be required to identify any conflicts of interest and will not review an application
if they have a direct relationship with the applicant.
Final funding recommendations will be based on the scores and comments from reviewers.
When making awards, consideration will be given to distributing funding throughout the state
and/or regions and meeting the funding priorities identified in the legislation (Appendix C). It is
anticipated that grant award decisions will be made in May 2016. Applicants will be notified
whether or not their grant application was funded.
Thereafter, the grant contract will be executed with the applicant agency awarded the funds.
The effective date of the contract will be July 1, 2016, or the date upon which all signatures to
the agreement are obtained, whichever is later. The grant award will be in effect for the period
of July 1, 2016, through June 30, 2021.
The grantee will be legally responsible for assuring the implementation of the work plan,
compliance with all state and federal requirements, including worker’s compensation,
nondiscrimination, data privacy, budget compliance, and reporting requirements.
Applications are nonpublic until opened. Once opened, the name of the applicant, the address
of the applicant, and the amount the applicant requested is public. All other data in an
application is nonpublic data until completion of the evaluation process. After the evaluation
process has been completed, all data submitted by the applicant is public.
All materials submitted in response to this Request for Proposal (RFP) will become property of
the State and will become public record in accordance with Minnesota Statutes, section
§13.599 after the evaluation process is completed. Pursuant to the statute, completion of the
evaluation process occurs when the government entity has completed negotiating the grant
agreement with the selected grantee. If the applicant submits information in response to this
RFP that it believes to be trade secret materials, as defined by the Minnesota Government Data
Practices Act, Minnesota Statute §13.37, the applicant must:



Clearly mark all trade secret materials in its response at the time the response is submitted;
Include a statement with its response justifying the trade secret designation for each item;
and,
Defend any action seeking release of the materials it believes to be trade secret, and
indemnify and hold harmless the State, its agents and employees, from any judgements or
damages awarded against the State in favor of the party requesting the materials, and any
and all costs connected with that defense. This indemnification survives the State’s award
of a grant contract. In submitting a response to this RFP, the applicant agrees that this
indemnification survives as long as the trade secret materials are in possession of the State.
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Program Summary
The Minnesota Early Hearing Detection and Intervention Deaf and Hard of Hearing
Mentor/Role Support funds will be made available to support communities through the grant
as follows:
Eligibility for Grant
Funds
Total Funds Available
Per Year
Grant Cycle
Grant Purpose
Application
Requirements
Application Deadline
Support Services To Families: Deaf and Hard of Hearing Mentor funding is
directed to one non-profit organization with the ability to provide deaf and
hard of hearing role model/mentor family support services throughout the
state.
Up to $780,000 ($156,000 per year) will be awarded to one applicant
organization.
July 1, 2016 – June 30, 2021 (60 months)
To identify all infants and children who are deaf and hard of hearing as early
as possible and connect those infants and children/families to timely and
appropriate intervention services in order to maximize their linguistic and
communicative competence, literacy and social/emotional development.
These funds will provide support and assistance to families with infants and
children who are deaf or have a hearing loss. The family support provided
must include access to individualized deaf and hard of hearing mentors who
provide education, including instruction in ASL as an available option.
 Narrative portions of the application should be in 12-point font with
one-inch margins and be double spaced
 All pages should be numbered consecutively
 Submitted proposals must use forms provided in this application
packet
 Proposal must not exceed 10 page limit, excluding forms
 All forms included in this application
 One PDF document submitted electronically to
Health.CYSHN@state.mn.us
All applications must be received electronically by MDH no later than 4:00
p.m. (CST) on Monday, May 2, 2016.
Late applications will not be considered for review.
Beginning Grant
Agreement Date
July 1, 2016, or date upon which all signatures to the agreement are obtained,
whichever is later.
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Project Narrative and Work Plan
The project narrative and work plan describes the applicant’s organization and what is intended
to be accomplished. To assist applicants, MDH has provided detailed instructions on what
information should be included and what grant reviewers will be reviewing in each application.
The Project Narrative is divided into distinct sections and should be submitted in the sequence
as below:
A. Applicant Information and Organizational Capacity
B. Linkages and Collaboration
C. Assessing Project Need & Target Population
D. Work Plan: Goals, Objectives, and Strategies (Form C)
A. Applicant Information and Organizational Capacity
Keep this section to two or fewer pages. Applicants should use 12-point font with one-inch
margins for this portion.
Background Information: Briefly summarize the background information about your
organization. Summarize your agency’s mission and goals.
Applicant Capacity
1. Briefly describe the administrative structure of the applicant agency and its current
experience in providing deaf and hard of hearing role model/mentor services, and its
grant related experience.
2. Briefly describe the applicant’s capacity to provide deaf and hard of hearing role
model/mentor services.
3. Include a statement about the agency’s ability to provide developmental, process, and
outcome evaluation to ensure that the program meets the needs of families and to
assess the impact of the program.
4. Provide a summary of relevant training and/or experience of the key persons who will
provide deaf and hard of hearing role model/mentor services in your project.
B. Linkages and Collaboration
Keep this section to two or fewer pages.
Each grantee must collaborate with community partners. Collaboration is essential to
providing support to families of children who are deaf or hard of hearing.
1. Describe your links or collaborative efforts to coordinate services to families of children
who are deaf and hard of hearing with other organizations, such as school districts,
public health agencies, clinicians such as audiologists, or other organizations.
2. Describe plans for or descriptions of collaborative activities with other providers serving
children who are deaf and hard of hearing throughout each region in Minnesota. The
description should be detailed and include information you think is important for grant
reviewers to understand your collaborative efforts.
3. Describe plans for program outreach and awareness.
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C. Statement of Need
Keep this section to two or fewer pages.
Please complete a narrative description of the community the project proposes to serve.
Include information about target population (if known) and any needs assessment that was
completed by the applicant separately or in collaboration with, other community partners.
Describe how your program will have a local, regional, and statewide impact.
D. Work Plan: Goals, Objectives, and Strategies
Complete all of the following on Work Plan Form C. Please limit the entire Work Plan to
four or fewer pages.
Please use the format in Form C for writing your Year One Work Plan. Add as many goals,
objectives, program activities/timelines and performance indicators as needed to explain
what you are proposing. The content in Appendix B is provided as an example only. You are
not required to use this content.
Note: If the application is approved and funded at the level requested, the Work Plan will be
incorporated into the grant agreement between MDH and the applicant as Grantee’s duties.
Work Plans for subsequent years of the grant will be required annually. Work Plans must be
completed according to directions so they can be separated easily from the rest of the
application. (See Appendix B for Work Plan examples.)
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Budget Section
Before you begin writing your organization’s budget, consider the specific activity planned and
the resources needed. Which resources does your organization already have and what needs to
be purchased? Which items will need to be replaced during the program (grant time period)?
When considering the skills needed to carry out the activity, remember to include any training
that will be needed for paid staff or volunteer members.
Generally the cost of food is not an allowable item. However, if there will be grant meetings or
grant activities where there is justification for a grantee to provide food, please include those
food costs in the Supply line of your budget and follow the guidelines below.
 Food can only be provided if the majority of the attendees are non-grantee staff.
 Grant funds may not be used to provide food for award dinners, grant project
celebrations or parties, etc.
 Grant funds may be used to provide food for grant activities provided the food costs are
included in the budget justification under “Other.”
 For meals to be allowable as a reimbursable cost, the activity/meeting must be four
hours or more in length and occur over what is typically considered a meal time. If meals
are provided, the following limits as stated in the Commissioner’s Plan, apply:
o Lunch – MDH will reimburse for actual costs up to $11.00/person, whichever is
lower. This $11.00 includes beverages.
o Dinner – MDH will reimburse for actual costs up to $16.00/person, whichever is
lower. This $16.00 includes beverages. Dinner can only be provided if event starts, or
lasts until after, 7:00 p.m.
o Snacks – Snacks may be covered if the activity/meeting is over two hours long. MDH
will reimburse for actual costs up to $4.00/person, whichever is lower. MDH
encourages the purchase of healthy snacks.
o Alcoholic beverages are never allowed.
Costs of entertainment, including amusement, diversion, and social activities and any costs
directly associated with such costs (tickets to shows or sporting events, meals, lodging, rentals,
transportation, and gratuities) are unallowable.
The Budget Section of the application is composed of three items:
 Budget Justification Form (Form D)
 Budget Summary Form (Form E)
 Indirect Cost Questionnaire (Form F)
The applicant will need to complete one Budget Justification Form AND one Budget Summary
Form for the first budget year (7/1/16 to 6/30/17). Budgets will be requested each year for the
remaining years of the grant agreement.
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Budget Justification Instructions and Form (Form D)
Please read the instructions for the Budget Justification Form carefully before completing the
Budget Justification Form. For each line item on the budget, provide a rationale and details
relative to how the budgeted cost items were calculated.
Each Budget Justification Form should provide the details of the applicant’s expenses and a
brief description of how they support the proposed grant activity for that time period. (The full
description of the purpose of each grant-funded position and the necessity of budgeted items
should appear in the Project Narrative.)
Budget Summary Instructions and Form (Form E)
Please read the instructions for the Budget Summary Form carefully before completing the
Budget Summary Form. Expenses in the line items should match the amounts listed in the line
items on the corresponding Budget Justification Form.
Each Budget Summary should be where the applicant provides the total expenses for the time
periods of the proposal by adding the expenses from the Budget Justification Form.
REMINDERS:
 Provide one Budget Justification Form AND one Budget Summary Form for the first year
of the grant agreement.
 Total all lines and columns and check for mathematical accuracy.
 Make sure that the budget summary totals match the amount listed in number 1 on the
Grant Application Face Sheet (Form A).
Indirect Cost Questionnaire (Form G)
If the applicant will be using a Federally Negotiated Indirect Cost Rate, please include a copy of
that federally approved rate with the completed Indirect Cost Questionnaire Form.
Budget Scoring
The scoring of the Budget Section will be done using the Budget Justification Form and the
Budget Summary Form. If supplementary information is included, it will not be taken into
consideration for scoring purposes.
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Form Instructions and Required Forms
Form A : Grant Application Face Sheet
Form B: Grant Application Checklist
Form C: Deaf and Hard of Hearing Mentor Work Plan
Form D: Budget Justification Instructions & Form (one form for the first year of the
grant)
Form E: Budget Summary Instructions & Form (one form for the first year of the grant)
Form F: Due Diligence
Form G: Indirect Cost Questionnaire
All required forms can be accessed individually at the Children and Youth with Special Health
Needs web site.
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Form A: Grant Applicant Face Sheet
General Applicant Information
Applicant’s Legal Name (do not use a “doing business as” name):
This should be the same name used when a federal tax identification number was obtained.
Applicant’s Business Address:
Applicant’s Minnesota Tax Identification Number:
Applicant’s Federal Tax Identification Number:
SWIFT Vendor ID Number (if you have one):
Director of Applicant Agency
Name:
Business Address:
Phone Number:
Email:
Financial Contact, or Fiscal Agent, for this grant
Name of Financial Contact for this grant:
Name of Fiscal Agent for this grant, if applicable:
Phone Number:
Email:
Contact Person for this grant
Name:
Business Address:
Phone Number:
Email:
Requested Funding
Total Amount on Proposed Budget: $
I certify that the information contained above is true and accurate to the best of my knowledge; that I
have informed this agency’s governing board of the agency’s intent to apply for this grant; and, that I
have received approval from the governing board to submit this application on behalf of the agency.
Signature of Authorized Agent for Applicant
Date of signature
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Form B: Grant Application Checklist
Use this checklist to ensure that you have included all the required items for your grant
application. Any application that does not contain all required items will be considered
incomplete and will not be reviewed.
Have you included the following required items?
Grant Applicant Face Sheet (Form A)
Grant Application Checklist (Form B)
Copy of letter granting 501c3 status
If applicant has tax exempt status from the Minnesota Department of Revenue, include
a copy of exemption letter
Table of Contents
Project Narrative
Deaf and Hard of Hearing Mentor Work Plan (Form C)
Budget Justification (Form D) for first year of grant
Budget Summary (Form E) for first year of grant
MDH Due Diligence (Form F)
MDH Indirect Cost Questionnaire (Form G)
Current Grantees: go to SWIFT and login and confirm that your information is correct.
APPLICATION DEADLINE:
Not later than 4:00 PM (CST) on Monday, May 2, 2016
Delivery Address:
Health.CYSHN@state.mn.us
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Form C: Work Plan-2016 Grant RFP
Non-Profit Organization:
Contact Person for Work Plan including name, email, and phone number:
Goal 1:
Objective 1:
Program Activities/Timelines
Performance Indicators
Program Activities/Timelines
Performance Indicators
Objective 2:
Objective 3:
Goal 2:
Objective 1:
Objective 2:
Objective 3:
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Form D: Budget Justification Instructions and Form
Before the applicant begins writing the organization’s budget, consider the specific activity
planned and the resources needed to do it. What resources does the applicant need to be able
to plan for implementation of a new EDHI program or expand an existing Early Hearing
Detection and Intervention program? Which items will need to be replaced during the grant
time period? When considering the skills needed to carry out the activity, remember to include
any training that will be needed for staff.
It is strongly suggested that applicants incorporate into their budgets the costs of appropriate
financial staff to provide financial oversight to the grant. This could be through contracting with
an individual or organization or a direct hire.
Applicant will need to complete a Budget Justification Forms (Form D), for the first year of the
grant period.
 7/1/16-6/30/17
The categories listed below (salary/fringe, contractual services, travel, supplies/expenses,
other, and indirect) describe the costs that may be included in each category and correspond to
the sections in both the Budget Justification Form and the Budget Summary Form.
Salary and Fringe
For each proposed funded position, indicate the title, the full time equivalent (FTE) on this grant
(see example below), the expected rate of pay, and the total amount applicant expects to pay
the position for the year. Grant funds can be used for salary and fringe benefits for staff
members directly involved in applicant’s proposed activities.
Any salaries from the administrative, accounting, human resources, or IT support, MUST be
supported by some type of time tracking, in order to be included as a direct line expense. If
these salary expenses are not supported by time reporting documentation, then the expenses
must be included in the indirect line.
Full time equivalent (FTE): The percentage of time a person will work on the 2016-2020 NurseFamily Partnership Grant project. Each position that will work on this grant should show the
following information:
EXAMPLE:
Public Health Nurse:
$30.40/hourly rate
x 2080/annual hours (or whatever your agency annual standard is)
$63,232 annual salary
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Multiply annual salary by your agency’s fringe rate:
$63,232 annual salary
x 23% fringe rate (or whatever your agency fringe rate is)
$14,543 fringe amount
Now add the annual salary and the fringe amount together:
$63,232 annual salary
+$14,543 fringe
$77,775/annual salary and fringe total
Multiply the annual salary and fringe total by the FTE being charged to this grant:
$77,775 annual salary and fringe total
X .50 FTE assigned to grant
$38,888 total to be charged to grant for this position
Contractual Services
Applicants must identify any subcontracts that will occur as part of carrying out the duties of
this grant program as part of the Contractual Services budget line item in your proposed
budget. The use of contractual services is subject to State review and may change based on
final work plan and budget negotiations with selected grantees.
Applicant responses must include:
 Description of services to be contracted;
 Anticipated contractor/consultant’s name (if known) or selection process to be used;
 Length of time the services will be provided; and,
 Total amount to be paid to contractor.
Travel
List the expected travel costs for staff working on the grant, including mileage, hotel, and
meals. At a minimum, your organization must include the cost for at least one staff member to
attend the Annual National Early Hearing Detection and Intervention Meeting. If project staff
will travel during the course of their jobs or for attendance at educational events, itemize the
costs, frequency, and the nature of the travel. Grant funds cannot be used for out-of-state
travel without prior written approval from MDH. Minnesota will be considered the home state
for determining whether travel is out of state.
 Budget for travel costs using the rates listed in the State of Minnesota’s Commissioner’s
Plan. Please reference the meal allowances rates listed there.
 Hotel/motel expenses should be reasonable and consistent with the facilities available.
Grantees are expected to exercise good judgement when incurring lodging expenses.
 Mileage will be reimbursed at the current IRS rate.
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Supplies and Expenses
Briefly explain the expected costs for items and services the applicant will purchase to run the
program. These might include additional telephone equipment; postage; printing;
photocopying; office supplies; training materials; and equipment. Include the costs expected to
be incurred to ensure that community representatives, partners, or clients who are included in
the applicant’s process or program can participate fully. Examples of these costs are fees paid
to translators or interpreters. Grant funds may not be used to purchase any individual piece of
equipment that costs more than $5,000, or for major capital improvements to property.
Other
Include in this section any expenses the applicant expects to have for other items that do not fit
in any other category, such as staff training, and food expenses for grant related group events.
Grant funds cannot be used for capital purchases, permanent improvements; cash assistance
paid directly to individuals; or any cost not directly related to the grant. Please refer back to the
Budget Section for details on amount limits for food.
Indirect Costs
Indirect costs are expenses of doing business that cannot be directly attributed to a specific
grant program or budget line item. They can include: executive and/or supervisory salaries and
fringe, rent, facilities maintenance, insurance premiums, etc. These costs are often allocated
across an entire agency. If you are able to do time tracking for any of these salary costs they
should be included under Salary and Fringe. The total allowed for indirect costs can be either
charges up to your federally approved indirect rate, or up to a maximum of 10%. To calculate
indirect costs, multiply the direct expenses in the budget (Line 6. Subtotal of this form) by what
you are using as your indirect cost rate.
If the applicant will be using a Federally Negotiated Indirect Cost Rate, you will need to submit
with your application your most current federally approved indirect rate.
20
Form D: Budget Justification Instructions and Form
Complete one form for the first year of the grant.
MDH Grant Program Name:
Applicant Agency:
Contact Person:
Phone Number:
Email Address:
Budget Period: July 1, 2016 to June 30, 2017
Revision # (MDH use only):
1. Salary and Fringe: For each proposed funded position, list the title, the full time equivalent, the
expected rate of pay, and the total amount you expect to pay the position.
Justification:
REQUESTED DOLLARS: Total Salary and Fringe
$
2. Contractual Services: List the services your organization expects to contract out, the contractor’s
or consultant’s name, whether the contractor is non-profit or for-profit, the length of time the
services will be provided and the total amount expected to be paid. Supplies and travel of
contractor should be included, if applicable. Itemize equipment rented or leased for the project
Justification:
REQUESTED DOLLARS: Total Contractual Services
$
3. Travel: Explain your expected instate travel costs, including mileage, hotel and meals. At a
minimum, your organization must include the cost for at least one staff member to attend two
MDH-sponsored statewide or regional meetings. If program staff will travel, itemize the costs,
frequency and the nature of the travel.
Justification:
REQUESTED DOLLARS: Total Travel
$
21
4. Supplies and Expenses: Explain the expected costs for items and services your organization will
purchase to run your program. Include telephone expenses that are part of this proposal; cell
phones and new telephone equipment to be purchased, if applicable. Estimate postage if part of
the project. List printing and copying costs necessary for the project (other than occasional copying
on an office copy machine). List office and program supplies and expendable equipment such as
training materials, curriculum and software. Generally supplies include items that are consumed
during the course of the project, equipment under $5,000 and items such as rent for program
space, participant transportation, participant training and other direct costs as needed.
Justification:
REQUESTED DOLLARS: Total Supplies and Expenses
$
5. Other: Briefly describe any expenses that do not fit in any other category. An example is staff
training, which can be charged to the grant at a rate not to exceed $250 per year per person.
Justification:
REQUESTED DOLLARS: Total Other
$
6. SUBTOTAL (sum of lines 1 through 5):
$
7. Indirect Costs: If applicable, enter the indirect cost rate below. In the box to the right, enter the
amount of indirect costs being requested. Maximum indirect rate is 10% of line 6, Subtotal of
Direct Expenses.
Indirect cost rate:
%
REQUESTED DOLLARS: Total Indirect
$
8. TOTAL (sum of line 6 + line 7)
$
22
Form E: Budget Summary Instructions and Form
This form should be used to show the total requested budget for the applicant’s proposed
grant-funded activities for each time period of the program. The budget should include funding
necessary in each category for each year of the grant. The total in each category should reflect
the total of that category from the corresponding Budget Justification Form.
Please enter zero (0) in the Total Proposed Amount column if you do not propose to expend
grant funds in a line item.
Enter the following items on the top portion of the Budget Summary Form
 Name of MDH Grant Program – enter name of the grant program for which you are
applying
 Name of Applicant Agency – Legal name of the agency applying for grant funds.
 Name of Contact Person for Budget – Person who may be contacted for questions related
to the budget proposal.
 Phone – Telephone number of the person listed.
 Fax – Fax number of the person listed.
 E-Mail – E-mail address of the person listed.
1. Salary and Fringe: The total amount of grant funds that will be used during each time period
to cover salary/fringe benefits. Add the “Salary and Fringe” amounts from each of the
Budget Justification forms together and enter that sum here.
2. Contractual Services: The total amount of grant funds the applicant plans to spend on
contractual services. Add the “Contractual Services” amounts from each of the Budget
Justification forms together and enter that sum here.
3. Travel: The total amount of grant funds that the applicant plans to spend on travel. Add the
“Travel” amounts from each of the Budget Justification forms together and enter that sum
here.
4. Supplies and Expenses: The total amount of grant funds that the applicant plans to spend
on supplies and expenses. Add the “Supplies and Expenses” amounts from each of the
Budget Justification forms together and enter that sum here.
5. Other: The total amount of grant funds that the applicant plans to spend on items that are
not listed above. Add the “Other” amounts from each of the Budget Justification forms
together and enter that sum here.
6. Subtotal: The sum of lines 1 through 5.
7. Indirect Costs: The total amount of grant funds that the applicant plans to spend for indirect
costs. Indirect costs can be up to an applicant’s federally approved indirect rate, or up to a
maximum of 10%, multiplied by the direct expenses in the budget (line 6 of this form). This
amount should match the sum of all the indirect costs on the Budget Justification Forms.
8. Total: The sum of lines 6 and 7.
23
Form E: Budget Summary Instructions and Form
Complete one form for the first year of the grant.
Name of MDH Grant Program:
Name of Applicant Agency:
Name of Contact Person for Budget:
Budget Period: July 1, 2016 to June 30, 2017
Phone:
Fax:
E-mail:
Line Item
Total Proposed Amount
1) Salary and Fringe
2) Contractual Services
3) Travel
4) Supplies and Expenses
5) Other
6) Subtotal (sum of lines 1 through 5)
7) Indirect Costs (your federally approved rate,
or maximum of 10%, multiplied by line 6)
8) TOTAL (sum of line 6 + line 7)
24
Form F: Due Diligence Review Form
The Minnesota Department of Health (MDH) must conduct due diligence reviews for nongovernmental organizations (NGOs) applying for grants, according to MDH Policy 240.
Due diligence refers to the process through which MDH researches an organization’s financial
and organizational health and capacity (MDH Policy 240). The due diligence process is not an
audit or a guarantee of an organization’s financial health or capacity. It is a review of
information provided by a NGO and other sources to make an informed funding decision.
As an applicant for MDH funds you must answer the following questions about your
organization, and return the form (along with any required additional documentation) to the
grant manager.
1. How long has your organization been doing business?
2. How many employees does your organization have, both part time and full time?
3. What was your organizations total revenue in the most recent 12 month accounting period?
4. How many different funding sources does the total revenue listed in question #3 come
from?
5. Does your organization have a current 501(c) 3 status from the Internal Revenue Service?
Yes
No
6. Has your organization done business under any other name or names within the last five
years?
Yes
No
a. If you answered yes to questions #6, list the names previously used.
7. Is your organization affiliated with or managed by any other organizations, such as a
regional or national office?
Yes
No
8. Does your organization receive management or financial assistance from other
organizations?
Yes
No
If yes, provide details.
9. Have you been a grantee of the Minnesota Department of Health within the last five years?
Yes
No
If yes, from which divisions did you receive grants from?
25
10. Does your organization have written policies and procedures for accounting processes?
Yes
No
If yes, please attach a copy of the table of contents of the written policies and procedures.
11. Does your organization have written policies and procedures for purchasing processes?
Yes
No
If yes, please attach a copy of the table of contents of the written policies and procedures.
12. Does your organization have written policies and procedures for payroll process?
Yes
No
If yes, please attach a copy of the table of contents of the written policies and procedures.
13. Which of the following best describes your organization’s accounting system?
Manual
Automated
Both
14. Does the accounting system identify the deposits and expenditures of program funds for
each and every grant separately?
Yes
No
Not Sure
15. If your organization has multiple programs within a grant, does the accounting system
record the expenditures for each and every program separately by budget line items?
Yes
No
Not sure
Not Applicable
16. Are time studies conducted for employees who receive funding from multiple sources? Yes
No
Not sure
Not Applicable
17. Does the accounting system have a way to identify over-spending of grant funds?
Yes
No
Not sure
18. If grant funds are mixed with other funds, can the grant expenses be easily identified?
Yes
No
Not sure
19. Are the officials of the organization bonded?
Yes
No
Not sure
20. Did an independent certified public accountant ever examine the organization’s financial
statements?
Yes
No
Not sure
26
21. Has any debt been incurred in the last six months?
Yes
No
a. If yes, what was the reason for the new debt?
b. What is the funding source for paying back the new debt?
22. What is the current amount of unrestricted funds compared to total revenues?
23. Are there any current or pending lawsuits against the organization?
Yes
No
24. If yes, could there be an impact on the organization’s financial position?
Yes
No or Not Applicable
25. Has the organization lost any funding due to accountability issues, misuse, or fraud?
Yes
No
If yes, please describe the situation, including when it occurred and whether issues have
been corrected.
The following documentation is required in addition to the due diligence form.
If you’re an Non-Governmental Organization Then submit your most recent
with an annual income of
Under $25,000
Board-reviewed financial statement
Between $25,000 and $750,000
IRS Form 990
Over $750,000
Certified financial audit
27
Form G: Indirect Cost Questionnaire
Background
Applicants applying for a grant from the Minnesota Department of Health (MDH) may request
an indirect rate to cover costs that cannot be directly attributed to a specific grant program or
budget line item. This allowance for indirect costs are a portion of any grant awarded, not in
addition to the grant award.
It is important to know the difference between administrative type costs and indirect costs
before completing the Indirect Cost Questionnaire Form. Please read the information on this
page carefully and then complete the Indirect Cost Questionnaire Form on the next page.

Administrative costs are expenses not directly related to delivering grant objectives, but
necessary to support a particular grant program. Examples may include a portion of
administrative, accounting, human resource or IT support and other general office
expenses.
These administrative type costs should be included in the grantee budget as direct budget
line items whenever possible. Note that any administrative staff salary/fringe included in
the salary/fringe line MUST be supported by time studies or other time documentation;
and, must be attributable and appropriately tracked to specific awards.

Indirect costs are expenses of doing business that cannot be directly attributed to a specific
grant program or budget line item. These costs are often allocated across an entire agency
and may include: executive/supervisory and support salaries/fringe not backed by time
documentation, rent, facilities maintenance, utilities, insurance premiums, etc.
Instructions
A. Fill in the applicant’s legal name.
B. Check the appropriate checkbox.
1. If the applicant is not going to request any indirect costs, the applicant should check the
first box and return the form as part of their application.
2. If the applicant has a federally approved indirect rate, the applicant should check the
second box, follow the instructions listed, and return the form as part of their
application.
3. If the applicant does not have a federal approved indirect rate, AND is planning to claim
indirect costs, the applicant should check the third box, fill in the rate being requested,
list the expenses being included in the indirect cost pool, and return the form as part of
their application. The maximum indirect rate an applicant can request from MDH is
10%.
28
Form G: Indirect Cost Questionnaire Form
Applicant’s Legal Name: _________________________________________
Program: Support Services to Families: Deaf and Hard of Hearing Mentor
Please check one of the three boxes below, follow any instructions relevant to that option, and
return this form as part of your application.
1. Not applicable: No charges to the grant program listed above are for indirect costs.
2. Federally Approved Indirect Cost Rate Agreement
A federally negotiated rate is to be charged against all grant programs. A copy of the
federally approved Indirect Cost Rate Agreement covering the current federal fiscal year
is attached.
3. No federally approved indirect cost rate – requesting up to 10% maximum
Up to 10% of the direct expenses in the budget for the grant program listed above can
be used for indirect costs per CFR Part 200 - Uniform Administrative Requirements,
Costs Principles, and Audit Requirements for Federal Awards, and per MDH policy for
State funds.
The applicant agency is requesting a rate of
% for the grant program listed above.
Per MDH Policy, list the types of costs included in the applicant’s indirect costs below.
29
Appendices
Appendix A
Criteria for Scoring Applications
Appendix B
Deaf and Hard of Hearing Mentor/Role Model Work Plan Example
Appendix C
2015 Minnesota Statute 144.966, Subd. 3a.
Appendix D
Minnesota Department of Health Grant Agreements Sample
30
Appendix A: Criteria for Scoring Grant Applications
I. Applicant Information and Organizational Capacity (28 points)
A. Does the applicant organization have the capacity (administration, facilities,
computer/internet access, cultural competency, etc.) to implement the project?
B. Does the applicant describe support they have received related to the application
including any governing board, advisory group or agency support?
C. Does the organization have a successful history and experience in providing deaf and
hard of hearing model/mentor services?
D. Does the applicant agency show that they have well-trained and experienced staff to
deliver deaf and hard of hearing role model/mentor services?
E. Is there a statement regarding the organization’s ability to provide developmental,
process, and outcomes evaluation as a strategy to ensure the deaf and hard of hearing
Mentor/Role Model program meets the needs of families, and to assess the impact of
the program on outcomes?
II. Linkages and Collaboration (8 points)
A. Does the applicant indicate that there are parents of children who are deaf and hard of
hearing in the planning process? Do the parents represent the diversity of the Early
Hearing Detection and Intervention population (e.g. deaf culture, hard of hearing,
cochlear implant and hearing aid users, unilateral hearing loss, and auditory neural
hearing loss)?
B. Does the applicant indicate that individuals who are deaf and hard of hearing are
involved in the planning process? Do the individuals who are Deaf and Hard of Hearing
represent the diversity of the Early Hearing Detection and Intervention population (e.g.
deaf culture, hard of hearing, cochlear implant and hearing aid users, unilateral hearing
loss, and auditory neural hearing loss)?
C. Does the applicant provide a clear description of linkages with a) other deaf and hard of
hearing professionals and b) other agencies in all geographic areas of MN to assure
outreach and access to services for families of children who are deaf and hard of
hearing?
D. Does the applicant describe how they plan to provide outreach and program marketing?
E. Does the applicant provide a clear description of linkages with diverse cultural groups to
assure outreach and access to services for families of children who are deaf and hard of
hearing from various racial, ethnic, and cultural backgrounds?
F. Are these collaborative relationships effective, well-established, and likely to assure
coordination?
III. Statement of Need (24 points)
A. Has the applicant identified the community need that the applicant hopes to address
with the application and why they are suited to provide services to that target
population?
B. Does the applicant include in their description of need:
31
C. A target population with an emphasis on infants and young children recently identified
as deaf and hard of hearing and their family?
D. A strong Statement of Need for providing support services and propose solutions to
overcome the identified barriers to these services.
E. A clear description of how they will provide culturally appropriate outreach and services
to families from various racial and ethnic backgrounds? In all regions of Minnesota?
F. A clear description of the how their program approach will address the diversity of
needs and preferences among families with young children and how they will honor and
align programming in the family’s chosen/preferred mode(s) of communication
(including ASL as one option).
G. A clear description of services provided by staff familiar with both local and statewide
resources.
IV. Work Plan: Goals, Objectives, Strategies (26 points)
A. Do the proposed activities demonstrate the capacity to achieve goals/objectives in the
work plan?
B. Does the applicant clearly describe the family support components that they propose to
provide?
C. Are the objectives and strategies in the work plan clearly described, appropriate and
realistic?
D. Does the work plan clearly define deliverables and outcomes? Do they include specific
milestones and outcomes that will be used to demonstrate the program’s effectiveness?
E. To what extent do the proposed evaluation criteria effectively measure the project’s
progress toward meeting their objectives?
F. Does the applicant clearly describe how they will reach out to hard to reach families,
such as those with no telephone, who don’t speak English, etc.?
G. Does the applicant give evidence that each Early Hearing Detection and Intervention
program is guided by an advisory group composed of professional stakeholders of the
EHDI and deaf and hard of hearing community, parents of children who are deaf and
hard of hearing, and individuals who deaf and hard of hearing and that members of the
committee represent the diversity of Early Hearing Detection and Intervention
population?
H. Does the applicant discuss how they are connected to the Early Hearing Detection and
Intervention System through collaboration and participation in national, state and local
workgroups and committees?
I. Does the applicant give evidence that the deaf and hard of hearing mentor/role model
program will provide families support that will address the diversity of needs and
preferences among families with young children and how they will honor and align
programming in the family’s chosen/preferred mode(s) of communication (including ASL
as one option)?
J. Does the applicant give evidence that they have an internal quality improvement
process woven into the program?
32
V. Budget (14 points)
A. Are the budget forms complete?
B. Do the amounts in the Budget Summary and the Budget Justification match?
C. Is the information contained in the budget and work plan consistent?
D. Are the projected costs, reasonable, cost-effective and sufficient to accomplish the
proposed activities?
33
Appendix B: Work Plan-2016 Grant RFP Example
Non-Profit Organization: ABC Agency
Contact Person for Work Plan including name, email, and phone number: Example, example@gmail.com, xxx-xxx-xxxx
Goal 1: Provide deaf and hard of hearing mentor services for families with newly identified infants and children who are Deaf and
Hard of Hearing.
Objective 1:
Provide deaf and hard of
hearing role
model/mentors support to
XX# of families of children
identified as deaf and hard
of hearing
Program Activities/Timelines
Performance Indicators
a)
95% of families report they are very satisfied (at
least ‘4’ on a 1-5 scale) with information/ services
received
By xx/xx/2016, develop and maintain a process for selecting families to receive
mentor services so that families in rural areas have the same level of opportunity
to receive services as families in more urban area.
b)
c)
d)
95% of families report they improved their
knowledge about the use of hearing technology (at
least ‘4’ on a 1-5 scale).
Establish an Advisory
Committee for
Mentor/Role Model
program.
a) By XX/XX/2016, recruit advisory committee members who reflect the diversity of
the D/HH Community.
b)
c)
d)
Objective 3:
a)
Objective 2:
Provide ASL instruction to
XX# families of children
who are deaf and hard of
hearing who have chosen
to use ASL.
By xx/xx/2016, identify curriculum to be used for families of children who have
chosen to use ASL.
b) By xx/xx/2016, train Deaf Mentors in the identified Deaf Mentor Curriculum
c)
d)
34
At least 40% of the clients served will be from
Greater Minnesota.
Four quarterly meetings of the Advisory Committee
annually
At least 50% of committee members are adults who
are deaf and hard of hearing and represents the
diversity of the deaf and hard of hearing
community.
90% of families served report a significant increase
in their ability to communicate with their child as
measured through pre-test, mid-curriculum test and
post-test.
Appendix C: 2015 Minnesota Statute 144.966, Subd. 3a.
144.966 EARLY HEARING DETECTION AND INTERVENTION PROGRAM.
Subd. 3a.Support services to families.
(a) The commissioner shall contract with a nonprofit organization to provide support and assistance to families
with children who are deaf or have a hearing loss. The family support provided must include:
(1) direct hearing loss specific parent-to-parent assistance and unbiased information on communication,
educational, and medical options; and
(2) individualized deaf or hard-of-hearing mentors who provide education, including instruction in American
Sign Language as an available option.
The commissioner shall give preference to a nonprofit organization that has the ability to provide these
services throughout the state.
(b) Family participation in the support and assistance services is voluntary.
35
Appendix D: Minnesota Department of Health Grant Agreement Sample
Minnesota Department of Health
Grant Agreement
This grant agreement is between the State of Minnesota, acting through its Commissioner
of the Department of Health ("State") and Insert name of Grant ("Grantee"). Grantee's address is
Insert complete address.
Recitals
1.
Under Minnesota Statutes 144.0742 and Insert the program’s specific statutory
authority to enter into the grant, the State is empowered to enter into this grant agreement.
2.
The State is in need of Add 1-2 sentences describing the overall purpose of the grant.
3.
The Grantee represents that it is duly qualified and will perform all the duties described in
this agreement to the satisfaction of the State. Pursuant to Minnesota Statutes section
16B.98, subdivision 1, the Grantee agrees to minimize administrative costs as a condition of
this grant.
Grant Agreement
1. Term of Agreement
1.1 Effective date Spell out the full date, e.g., January 1, 2012, or the date the State obtains
all required signatures under Minnesota Statutes section 16C.05, subdivision 2, whichever is
later. The Grantee must not begin work until this contract is fully executed and the
State's Authorized Representative has notified the Grantee that work may commence.
1.2 Expiration date Spell out the full date, e.g., December 31, 2012, or until all obligations
have been fulfilled to the satisfaction of the State, whichever occurs first.
1.3 Survival of Terms The following clauses survive the expiration or cancellation of this
grant contract: 8. Liability; 9. State Audits; 10.1 Government Data Practices; 10.2 Data
Disclosure; 12. Intellectual Property; 14.1 Publicity; 14.2 Endorsement; and 16. Governing
Law, Jurisdiction, and Venue.
2. Grantee's Duties The Grantee, who is not a state employee, shall: Attach additional pages if
needed, using the following language, "complete to the satisfaction of the State all of the
duties set forth in Exhibit A, which is attached and incorporated into this agreement."
3. Time The Grantee must comply with all the time requirements described in this grant
agreement. In the performance of this grant agreement, time is of the essence, and failure to
meet a deadline may be a basis for a determination by the State's Authorized Representative that
the Grantee has not complied with the terms of the grant.
The Grantee is required to perform all of the duties recited above within the grant period. The
State is not obligated to extend the grant period.
36
4. Consideration and Payment
4.1 Consideration The State will pay for all services performed by the Grantee under
this grant agreement as follows:
(a) Compensation. The Grantee will be paid Explain how the Grantee will be paid—
examples: "an hourly rate of $0.00 up to a maximum of X hours, not to exceed $0.00 and
travel costs not to exceed $0.00," Or, if you are using a breakdown of costs as an
attachment, use the following language, "according to the breakdown of costs contained
in Exhibit B, which is attached and incorporated into this agreement."
(b) Total Obligation The total obligation of the State for all compensation and
reimbursements to the Grantee under this agreement will not exceed TOTAL AMOUNT
OF GRANT AGREEMENT AWARD IN WORDS] dollars [($ INSERT AMOUNT IN
NUMERALS).
(c) Travel Expenses [Select the first paragraph for grants with any of Minnesota’s 11
Tribal Nations. Select the second paragraph for all other grants. Delete the paragraph that
isn’t used.
The Grantee will be reimbursed for travel and subsistence expenses in the same
manner and in no greater amount than provided in the current "GSA Plan”
promulgated by the United States General Services Administration. The current GSA
Plan rates are available on the official U.S. General Services Administration website.
The Grantee will not be reimbursed for travel and subsistence expenses incurred
outside Minnesota unless it has received the State’s prior written approval for out of
state travel. Minnesota will be considered the home state for determining whether
travel is out of state.
OR
The Grantee will be reimbursed for travel and subsistence expenses in the same
manner and in no greater amount than provided in the current "Commissioner's Plan"
promulgated by the Commissioner of Minnesota Management and Budget ("MMB").
The Grantee will not be reimbursed for travel and subsistence expenses incurred
outside Minnesota unless it has received the State's prior written approval for out of
state travel. Minnesota will be considered the home state for determining whether
travel is out of state.
(d) Budget Modifications. Modifications greater than 10 percent of any budget
line item in the most recently approved budget (listed in 4.1(a) and 4.1(b) or
incorporated in Exhibit B) requires prior written approval from the State and must
be indicated on submitted reports. Failure to obtain prior written approval for
modifications greater than 10 percent of any budget line item may result in denial
of modification request and/or loss of funds. Modifications equal to or less than
10 percent of any budget line item are permitted without prior approval from the
37
State provided that such modification is indicated on submitted reports and that
the total obligation of the State for all compensation and reimbursements to the
Grantee shall not exceed the total obligation listed in 4.1(b).
4.2 Terms of Payment
(a) Invoices The State will promptly pay the Grantee after the Grantee presents an
itemized invoice for the services actually performed and the State's Authorized
Representative accepts the invoiced services. Invoices must be submitted in a timely
fashion and according to the following schedule: Example: "Upon completion of the
services," or if there are specific deliverables, list how much will be paid for each
deliverable, and when. The State does not pay merely for the passage of time.
(b) Matching Requirements If applicable, insert the conditions of the matching
requirement. If not applicable, please delete this entire matching paragraph.
Grantee certifies that the following matching requirement, for the grant will be
met by Grantee:
(c) Federal Funds Include this section for all federally funded grants; delete it if
this section does not apply. Payments under this agreement will be made from
federal funds obtained by the State through Title insert number, CFDA number
insert number of the insert name of law Act of insert year, including public law
and all amendments. The Notice of Grant Award (NGA) number is ________.
The Grantee is responsible for compliance with all federal requirements imposed
on these funds and accepts full financial responsibility for any requirements
imposed by the Grantee's failure to comply with federal requirements. If at any
time federal funds become unavailable, this agreement shall be terminated
immediately upon written notice of by the State to the Grantee. In the event of
such a termination, Grantee is entitled to payment, determined on a pro rata basis,
for services satisfactorily performed.
5. Conditions of Payment All services provided by Grantee pursuant to this agreement
must be performed to the satisfaction of the State, as determined in the sole discretion of its
Authorized Representative. Further, all services provided by the Grantee must be in accord
with all applicable federal, state, and local laws, ordinances, rules and regulations.
Requirements of receiving grant funds may include, but are not limited to: financial
reconciliations of payments to Grantees, site visits of the Grantee, programmatic monitoring
of work performed by the Grantee and program evaluation. The Grantee will not be paid for
work that the State deems unsatisfactory, or performed in violation of federal, state or local
law, ordinance, rule or regulation.
6. Authorized Representatives
6.1 State's Authorized Representative The State's Authorized Representative for
purposes of administering this agreement is insert name, title, address, telephone
number, and e-mail, or select one: "his" or "her" successor, and has the responsibility
to monitor the Grantee's performance and the final authority to accept the services
provided under this agreement. If the services are satisfactory, the State's Authorized
Representative will certify acceptance on each invoice submitted for payment.
38
6.2 Grantee's Authorized Representative The Grantee's Authorized Representative
is insert name, title, address, telephone number, and e-mail, or select one: “his” or
“her” successor. The Grantee's Authorized Representative has full authority to
represent the Grantee in fulfillment of the terms, conditions, and requirements of this
agreement. If the Grantee selects a new Authorized Representative at any time during
this agreement, the Grantee must immediately notify the State in writing, via e-mail
or letter.
7. Assignment, Amendments, Waiver, and Merger
7.1 Assignment The Grantee shall neither assign nor transfer any rights or obligations under
this agreement without the prior written consent of the State.
7.2 Amendments If there are any amendments to this agreement, they must be in writing.
Amendments will not be effective until they have been executed and approved by the State
and Grantee.
7.3 Waiver If the State fails to enforce any provision of this agreement, that failure does not
waive the provision or the State's right to enforce it.
7.4 Merger This agreement contains all the negotiations and agreements between the State
and the Grantee. No other understanding regarding this agreement, whether written or oral,
may be used to bind either party.
8. Liability The Grantee must indemnify and hold harmless the State, its agents, and employees
from all claims or causes of action, including attorneys' fees incurred by the State, arising from
the performance of this agreement by the Grantee or the Grantee's agents or employees. This
clause will not be construed to bar any legal remedies the Grantee may have for the State's
failure to fulfill its obligations under this agreement. Nothing in this clause may be construed as
a waiver by the Grantee of any immunities or limitations of liability to which Grantee may be
entitled pursuant to Minnesota Statutes Chapter 466, or any other statute or law.
9. State Audits Under Minnesota Statutes section 16B.98, subdivision 8, the Grantee's books,
records, documents, and accounting procedures and practices of the Grantee, or any other
relevant party or transaction, are subject to examination by the State, the State Auditor, and the
Legislative Auditor, as appropriate, for a minimum of six (6) years from the end of this grant
agreement, receipt and approval of all final reports, or the required period of time to satisfy all
state and program retention requirements, whichever is later.
10. Government Data Practices and Data Disclosure
10.1 Government Data Practices Pursuant to Minnesota Statutes Chapter 13.05, Subd.
11(a), the Grantee and the State must comply with the Minnesota Government Data Practices
Act as it applies to all data provided by the State under this agreement, and as it applies to all
data created, collected, received, stored, used, maintained, or disseminated by the Grantee
under this agreement. The civil remedies of Minnesota Statutes section 13.08 apply to the
release of the data referred to in this clause by either the Grantee or the State.
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If the Grantee receives a request to release the data referred to in this clause, the Grantee
must immediately notify the State. The State will give the Grantee instructions concerning
the release of the data to the requesting party before any data is released. The Grantee's
response to the request must comply with the applicable law.
10.2 Data Disclosure Pursuant to Minnesota Statutes section 270C.65, subdivision 3, and
all other applicable laws, the Grantee consents to disclosure of its social security number,
federal employee tax identification number, and Minnesota tax identification number, all of
which have already been provided to the State, to federal and state tax agencies and state
personnel involved in the payment of state obligations. These identification numbers may be
used in the enforcement of federal and state tax laws which could result in action requiring
the Grantee to file state tax returns and pay delinquent state tax liabilities, if any.
11. Ownership of Equipment If this grant agreement disburses any federal funds, select option
#1 and delete option #2. If this grant agreement disburses only state funds, select option #2 and
delete option #1.
Option #1
Disposition of all equipment purchased under this grant shall be in accordance with 2 CFR
200. For all equipment having a current per unit fair market value of $5,000 or more, the
State shall have the right to require transfer of the equipment, including title, to the Federal
Government or to an eligible non-Federal party named by the STATE. This right will
normally be exercised by the State only if the project or program for which the equipment
was acquired is transferred from one grantee to another.
Option #2
The State shall have the right to require transfer of all equipment purchased with grant funds
(including title) to the State or to an eligible non-State party named by the State. This right
will normally be exercised by the State only if the project or program for which the
equipment was acquired is transferred from one grantee to another.
12. Ownership of Materials and Intellectual Property Rights
12.1 Ownership of Materials The State shall own all rights, title and interest in all of the
materials conceived or created by the Grantee, or its employees or subgrantees, either
individually or jointly with others and which arise out of the performance of this grant
agreement, including any inventions, reports, studies, designs, drawings, specifications,
notes, documents, software and documentation, computer based training modules,
electronically, magnetically or digitally recorded material, and other work in whatever form
("materials").
The Grantee hereby assigns to the State all rights, title and interest to the materials. The
Grantee shall, upon request of the State, execute all papers and perform all other acts
necessary to assist the State to obtain and register copyrights, patents or other forms of
protection provided by law for the materials. The materials created under this grant
agreement by the Grantee, its employees or subgrantees, individually or jointly with others,
shall be considered "works made for hire" as defined by the United States Copyright Act.
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All of the materials, whether in paper, electronic, or other form, shall be remitted to the State
by the Grantee. Its employees and any subgrantees shall not copy, reproduce, allow or cause
to have the materials copied, reproduced or used for any purpose other than performance of
the Grantee's obligations under this grant agreement without the prior written consent of the
State's Authorized Representative.
12.2 Intellectual Property Rights Grantee represents and warrants that materials produced
or used under this grant agreement do not and will not infringe upon any intellectual property
rights of another including but not limited to patents, copyrights, trade secrets, trade names,
and service marks and names. Grantee shall indemnify and defend the State, at Grantee's
expense, from any action or claim brought against the State to the extent that it is based on a
claim that all or parts of the materials infringe upon the intellectual property rights of
another. Grantee shall be responsible for payment of any and all such claims, demands,
obligations, liabilities, costs, and damages including, but not limited to, reasonable attorney
fees arising out of this grant agreement, amendments and supplements thereto, which are
attributable to such claims or actions. If such a claim or action arises or in Grantee's or the
State's opinion is likely to arise, Grantee shall at the State's discretion either procure for the
State the right or license to continue using the materials at issue or replace or modify the
allegedly infringing materials. This remedy shall be in addition to and shall not be exclusive
of other remedies provided by law.
13. Workers' Compensation The Grantee certifies that it is in compliance with Minnesota
Statutes section 176.181, subdivision 2, which pertains to workers' compensation insurance
coverage. The Grantee's employees and agents, and any contractor hired by the Grantee to
perform the work required by this Grant Agreement and its employees, will not be considered
State employees. Any claims that may arise under the Minnesota Workers' Compensation Act on
behalf of these employees, and any claims made by any third party as a consequence of any act
or omission on the part of these employees, are in no way the State's obligation or responsibility.
14. Publicity and Endorsement
14.1 Publicity Any publicity given to the program, publications, or services provided
resulting from this grant agreement, including, but not limited to, notices, informational
pamphlets, press releases, research, reports, signs, and similar public notices prepared by or
for the Grantee or its employees individually or jointly with others, or any subgrantees shall
identify the State as the sponsoring agency and shall not be released without prior written
approval by the State's Authorized Representative, unless such release is a specific part of an
approved work plan included in this grant agreement.
14.2 Endorsement The Grantee must not claim that the State endorses its products or
services.
15. Termination
15.1 Termination by the State or Grantee The State or Grantee may cancel this grant
agreement at any time, with or without cause, upon thirty (30) days written notice to the other
party.
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15.2 Termination for Cause If the Grantee fails to comply with the provisions of this grant
agreement, the State may terminate this grant agreement without prejudice to the right of the
State to recover any money previously paid. The termination shall be effective five business
days after the State mails, by certified mail, return receipt requested, written notice of
termination to the Grantee at its last known address.
15.3 Termination for Insufficient Funding The State may immediately terminate this
agreement if it does not obtain funding from the Minnesota legislature or other funding
source; or if funding cannot be continued at a level sufficient to allow for the payment of the
work scope covered in this agreement. Termination must be by written or facsimile notice to
the Grantee. The State is not obligated to pay for any work performed after notice and
effective date of the termination. However, the Grantee will be entitled to payment,
determined on a pro rata basis, for services satisfactorily performed to the extent that funds
are available. The State will not be assessed any penalty if this agreement is terminated
because of the decision of the Minnesota legislature, or other funding source, not to
appropriate funds. The State must provide the Grantee notice of the lack of funding within a
reasonable time of the State receiving notice of the same.
16. Governing Law, Jurisdiction, and Venue This grant agreement, and amendments and
supplements to it, shall be governed by the laws of the State of Minnesota. Venue for all legal
proceedings arising out of this grant agreement, or for breach thereof, shall be in the state or
federal court with competent jurisdiction in Ramsey County, Minnesota.
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IN WITNESS WHEREOF, the parties have caused this grant agreement to be duly executed intending to be
bound thereby.
APPROVED:
1.
Grantee
2.
State Agency
The Grantee certifies that the appropriate
persons(s) have executed the grant agreement on
behalf of the Grantee as required by applicable
articles, bylaws, resolutions, or ordinances.
Grant Agreement approval and certification that
State funds have been encumbered as required by
Minn. Stat. §§16A.15 and 16C.05.
By:___________________________________
By:____________________________________
(with delegated authority)
Title:__________________________________
Title:____________________________________
Date:__________________________________
Date:____________________________________
By:__________________________________
Title:_________________________________
Date:___________________________________
Distribution:
Agency – Original (fully executed) Grant Agreement
Grantee
State Authorized Representative
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