Positive Alternatives Grant
Program Application
June 20, 2016 –June 30, 2019:
Information and Materials
December 4, 2015
Community and Family Health Division
Maternal and Child Health Section
Positive Alternatives Program
P. O. Box 64882
St. Paul, MN 55164-0882
Phone: 651-201-3581
Fax: 651-201-3590
http://www.health.state.mn.us/divs/cfh/program/paa/
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Table of Contents
Introduction ................................................................................................................. 3
Program Description .................................................................................................... 4
Evaluation and Report Requirements .......................................................................... 5
Eligibility Requirements ............................................................................................... 5
Available Funding ......................................................................................................... 6
Application Requirements ........................................................................................... 7
Grant Application Checklist.......................................................................................... 8
Disposition of Responses ............................................................................................. 9
What happens after application is received? .............................................................. 9
Program Summary ..................................................................................................... 11
Application Instructions and Forms ........................................................................... 13
Form A: Application Face Sheet ................................................................................. 14
Form B: Due Diligence Review Form.......................................................................... 15
Form C: Assurance and Agreements Form ................................................................ 18
Project Narrative ........................................................................................................ 20
Organizational Capacity ............................................................................................. 20
Grant Proposal ........................................................................................................... 21
Logic Model and Evaluation ....................................................................................... 23
Form D: Logic Model and Evaluation ......................................................................... 25
Budget Section ........................................................................................................... 28
Instructions ................................................................................................................ 28
Salary and Fringe ........................................................................................................ 28
Contractual Services .................................................................................................. 29
Travel.......................................................................................................................... 29
Supplies and Expenses ............................................................................................... 30
Other Expenses .......................................................................................................... 31
Evaluation .................................................................................................................. 33
Indirect Costs ............................................................................................................. 31
Form E: Budget Justification Sheet ............................................................................ 33
Form F: Budget Summary Sheet ................................................................................ 35
Budget Summary Instructions ................................................................................... 36
Form G: Indirect Cost Questionnaire ......................................................................... 37
Appendices................................................................................................................. 38
Appendix A: Criteria for Grant Review....................................................................... 39
Appendix B: Sample Logic Model............................................................................... 41
Appendix C: Positive Alternatives Statute ................................................................. 44
Appendix D: Sample of MDH Grant Agreement ........................................................ 47
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Program Overview
Introduction
This document provides the forms and instructions needed to complete the Positive
Alternatives Grant Program application. It is suggested that your organization review this
document, including Appendix A, which includes a copy of the Criteria for Grant Review, before
beginning to write your application. Also included in Appendix C is a copy of the Positive
Alternatives Act, M.S. 145.4235. Other resources to assist in completing this application are
available in the “For Organizations with Positive Alternatives Grants” section of the Positive
Alternative website.
The Minnesota Department of Health (MDH) will be available to answer questions during the
application process. If you have questions contact:
Mary Ottman
Positive Alternatives Program Coordinator
651-201-3581
mary.ottman@state.mn.us
Please note that MDH staff will not be able to help with the actual writing of the application or
critique drafts.
MDH will maintain an “Answers to Grant Application Questions” link on the Positive
Alternatives web site, under the “For Organizations with Positive Alternatives Grants” section.
MDH will host two optional Web-Ex seminars (Webinars) to review the application materials
and answer questions. Attendance at a workshop is not necessary in order to submit an
application. Organizations are encouraged to participate especially if your organization is new
to the Positive Alternatives grant application process or your organization has questions
regarding the application. The seminars will be held on:
1) Tuesday, December 15, 2015, 9:30-11:30 a.m.
2) Thursday, December 17, 2015, 1:00-3:00 p.m.
Applicants are welcome to attend either event. Registration is required. Please send your name,
your organization’s name and contact phone number, the date of the event you will attend, and
your email address to mary.ottman@state.mn.us. Technical instructions will be provided upon
registration.
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Program Description
The Positive Alternatives Program supports, encourages and assists women to carry their
pregnancies to term by providing information on, referral to, and assistance with securing
necessary services that enable women to carry their pregnancies to term and care for their
babies after birth. Positive Alternatives grants provide funds to non-profit organizations
promoting healthy pregnancy outcomes and assisting pregnant and parenting women in
developing and maintaining family stability and self-sufficiency. Caring for her baby after birth
could also include making an adoption plan for her child, if requested.
All grant-funded programs must offer all participants accurate information on, referral to, and
assistance with securing specified necessary services that enable women to carry their
pregnancies to term, support improved pregnancy outcomes, and care for their babies after
birth. Babies are defined as infants up to 12 months old. In addition, the program may elect to
also provide some or all of these services directly.
Necessary Services include, but are not limited to:
 Medical Care
 Nutrition Services
 Housing Assistance
 Adoption Services
 Education and Employment Assistance, including services that support the continuation and
completion of high school
 Childcare Assistance
 Parenting Education and Support Services
Examples of how organizations may expand availability of their current services include:
 Expanding hours of operation
 Hiring staff so more women can be served
 Establishing satellite offices targeting certain neighborhoods
 Expanding outreach activities
 Partnering with other community organizations to coordinate and integrate the delivery of
services to jointly served women
Examples of how organizations may add to their current services include:
 Provide some of the “necessary services” listed above directly
 Add components to existing programs, such as adding a crib or car seat safety component
to a parenting program
 Provide ongoing support to women who are facing significant challenges
 Services could range from periodic phone contact to one-on-one mentoring
 Services could be provided by hired personnel (a client services advocate) or community
agencies under contract
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
Provide women with the resources needed to access necessary services. These could
include providing vouchers for childcare or access to computer work stations for job
searches or educational planning
These are only some examples. Refer to the Positive Alternatives web site for additional
information on what past grantees have done, and for additional resources. Refer to Appendix
B, Sample Logic Model, for a list of suggested activities.
Evaluation and Report Requirements
The following evaluation and report activities will be required of funded programs.
 MDH will require grantees to report on the status of their programs based on their
Work Plans. The Work Plan is derived from the grantee’s application and describes its
contractually-agreed upon goals, duties and responsibilities.
 MDH will require grantees to send a financial report (invoice) monthly or quarterly.
Grantees will be paid for actual expenses on a reimbursement basis. This means your
organization will pay for the grant activity expenditures, and report the expenditures to
MDH on an invoice form. When the invoice is approved your organization will be
reimbursed.
 MDH requires grantees to report only non-identifying demographic information and
responses obtained from program participants to questions asking about the
Organization’s offered Necessary Services.
 Grantees will be required to evaluate at least one of their funded activities. The
evaluation will be based on a measurable intermediate outcome linked to the grantee’s
activity in the Logic Model (refer to page 24 for more information). Grantees will be
required to develop and submit an evaluation plan for approval by December 31, 2016.
A minimum of 5% of grant funds must be budgeted for evaluation purposes. MDH
assistance will be provided to grantees in formalizing program evaluations.
Eligibility Requirements to Apply
To be eligible to apply for a Positive Alternatives Grant, an agency or organization must:
 Be a private, 501(c) 3 nonprofit organization, and maintain this status throughout the
grant period.
 Have had an alternatives-to-abortion program in place for at least one year as of July 1,
2011, or incorporated an alternatives-to-abortion program that has been in existence
for at least one year as of July 1, 2011.
 Ensure that its alternatives-to-abortion program’s purpose is to assist and encourage
women in carrying their pregnancies to term and maximizing their potential thereafter.
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If awarded a Positive Alternatives Grant an agency or organization must:
 Conduct the grant program under appropriate supervision.
 Not charge women for services provided under the program.
 Provide pregnant women who receive counseling with accurate information on the
developmental characteristics of babies and unborn children, including offering the
booklet, If You Are Pregnant: Information on Fetal Development, Abortion and
Alternatives.
 Ensure that health information is medically accurate and that medical services meet
standards defined by the appropriate professional organization, or are broadly
recognized within the medical community.
 Ensure that no funds provided by Positive Alternatives Grant are used to encourage or
affirmatively counsel a woman to have an abortion that is not necessary to prevent her
death, or to provide her an abortion, or to directly refer her to an abortion provider. The
agency may provide a woman who requests it a list of health care providers that provide
abortion services.
 Have written privacy policies and procedures in place to ensure that any information
that might identify any woman seeking services is not made public or shared with any
other agency or organization without the written consent of the woman.
 Adhere to the requirements in Minnesota Statute 144.291 - 298 [Access to Health
Records]. These statutes are available on the Positive Alternatives web site under “Grant
Resources.”
Ensure that only MDH Commissioner of Health approved information on the health risks
associated with abortion be provided to women in grant-funded programs.
Commissioner of Health approved information can be found in the booklet “If You Are
Pregnant: Information on Fetal Development, Abortion and Alternatives”. (You can
find this booklet at: http://www.health.state.mn.us/wrtk/index.html or you can call
651-201-3580 or toll free 888-234-1137 to receive a free copy.)
An organization that provides abortions, promotes abortions, or directly refers to an abortion
provider for an abortion is not eligible to receive a grant under this program. An affiliate of an
organization that provides abortions, promotes abortions, or directly refers to an abortion
provider for an abortion is ineligible to receive a grant under this section unless the
organizations are separately incorporated and independent from each other.
Available Funding
Grant awards will be made for a three year time period (6/20/2016 to 6/30/2019), with the
ability to extend awards to December 31, 2020. Grant renewal is contingent upon the grantee's
satisfactory performance, including execution and fulfillment of work plan, achievement of
objectives, evaluation efforts, and appropriate and expeditious use of the awarded funds.
Funding available for the three year grant cycle is approximately $11,071,000, contingent on
continued state legislative appropriations.
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MDH expects to award:
 Approximately 21 - 26 grants for up to $75,000 per year;
 Approximately 5 – 6 grants between $75,001 and $135,000 per year;
 Approximately 3 – 5 grants between $135,001 and $200,000 per year;
 1 - 2 grants between $200,001 and $300,000 per year to an organization(s) whose
service area includes the entire state.
Application Requirements
 Application should be written in at least 12-point font with one-inch margins.
 All pages should be numbered consecutively.
 One signed unbound original and 6 unbound copies of the complete application should
be submitted. Submissions may be fastened with metal binder clips or large paper clips.
 Applications should meet application deadline requirements. Late applications will not
be reviewed.
 Applications should be complete and signed where noted. Incomplete applications will
not be reviewed.
 Faxed or e-mailed applications will not be accepted.
Late applications, incomplete applications, applications lost in transit, faxed
applications, or e-mailed applications will not be considered for review.
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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 Application Face Sheet (Form A)
Due Diligence and accompanying financial documents (Form B)
Assurances and Agreements Form (Form C)
Logic Model (Form D)
Budget Justification Sheet (Form E)
Budget Summary Sheet (Form F)
Indirect Cost Questionnaire (Form G)
Project Narrative
Copy of your 501 (c)3 form
APPLICATION DEADLINE: Your application must be received by MDH no later than 4:00 p.m. on
Thursday, January 21, 2016, or have a legible postmark from the U.S. Post Office, or a private
courier, date on or before January 21, 2016.
Delivery Address:
Mary Ottman, MPH
Minnesota Department of Health
Division of Community and Family Health
85 East 7th Place, Suite 220
Golden Rule Building, 5th floor
St. Paul, MN 55101
Mailing Address:
Mary Ottman, MPH
Minnesota Department of Health
Division of Community and Family Health
P.O. Box 64882
St. Paul, MN 55164-0882
Late applications, incomplete applications, applications lost in transit, faxed, or emailed
applications will not be considered for review.
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Disposition of Responses
All materials submitted in response to this 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 Minnesota Department of Health (MDH) has completed negotiating the grant
agreement with the selected grantee. If the Responder 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 Responder must:
 Clearly mark all trade secrets 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 judgments
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 Responder
agrees that this indemnification survives as long as the trade secret materials are in
possession of the State.
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.
Sending in a Positive Alternatives Program Grant application does not guarantee funding.
Applications must meet all requirements listed in this packet. Organizations must meet all
eligibility requirements and proposals must meet the criteria and requirements listed in this
application. Awards for Positive Alternatives Grant funding will be based on formal review of
the application and the funding available.
What happens after the application is received?
Only complete applications received on or before January 21, 2016, or postmarked on or before
January 21, 2016, will be reviewed by a grant review committee according to the Criteria for
Grant Review (Appendix A). Reviewers will score applications based on the criteria outlined and
document strengths and weaknesses of each proposal. Applicants with current or past Positive
Alternatives grant awards may have past performance taken into consideration.
Reviewers may include staff from MDH and other state agencies with grants management
expertise; individuals from other organizations that represent a broad range of professionals
with experience in program planning and project management; individuals with experience
working with women with unplanned or challenging pregnancies, or with individuals seeking to
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establish self-sufficiency; and individuals with experience writing and/or reviewing grants.
Reviewers will be required to identify any conflicts of interest and will not review a proposal if
they have a potential conflict of interest relationship with the applicant.
Staff from the Community and Family Health (CFH) Division of MDH will review the applications,
scores from the reviewers, and reviewers’ recommendations for funding. In addition to
reviewer scores and recommendations, staff from the CFH Division will consider:
 diversity in activities funded
 diversity in populations receiving services
 that grants are distributed to organizations to provide access to services throughout the
state
 that grants are distributed to organizations of various sizes
CFH Division staff will recommend to the Commissioner of Health which applications should be
funded. The decisions on grant awards made by the Commissioner will be final; there will be no
appeal process.
It is anticipated that grant award decisions will be made by May 1, 2016. Applicants will be
notified whether or not their grant proposal was funded. MDH reserves the right to negotiate
changes to budgets or work plans submitted.
MDH will enter into grant agreements with those organizations that are awarded grant funds.
The effective date of the grant contract will be June 20, 2016, or date upon which all signatures
to the grant contract are obtained, whichever is later. Grant agreements will be made for a
three year time period, and may be extended for another one and one-half years until
December 31, 2020, subject to satisfactory grantee performance and availability of funding. No
work on grant activities can begin until a fully executed grant agreement is in place.
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Program Summary
Eligibility for
Grant Funds
Total Funds
Available
Grant Cycle
Maximum Grant
Amount
Grant Purpose
Application
Requirements
Complete
Application
Application
Deadline
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
Private non-profit organizations with a 501 (c) 3
Organizations with an alternatives-to-abortion program in place (or
incorporated with an alternatives-to-abortion program) for at least one year
as of July 1, 2011
 Organizations that do not provide abortions, promote abortions, or directly
refer to an abortion provider
Approximately $11,071,000 is available for the three year grant cycle,
contingent on continued state legislative appropriations.
Three years period from 6/20/16 to 6/30/19 with the possibility of a one and
one-half year extension contingent upon satisfactory performance.
 Approximately 21 to 26 grants awarded for up to $75,000 per year.
 Approximately five to six grants awarded for amounts between $75,001 and
$135,000 per year.
 Three to five grants awarded for amounts between $135,001 and $200,000
per year.
 One to two grants to a statewide organization whose service area includes
the entire state between $200,001 and $300,000 per year.
 The number of agencies awarded in each funding category amount may
vary depending upon applications received.
To support, encourage, and assist women in carrying their pregnancies to term
and caring for their babies after birth.
Application should be in at least 12-point font with one-inch margins.
Submit one signed unbound original and six (6) unbound copies.
All pages should be numbered consecutively.
 Application Face Sheet (Form A) - submit by mail with the application and
include a signed original with application
 Copy of 501(c) 3 status
 Due Diligence and accompanying financial documents (Form B)
 Signed Assurance and Agreements (Form C)
 Project Narrative
 Logic Model (Form D)
 Budget Justification Sheets (Form E)
 Budget Summary Form (Form F)
 Indirect Cost Questionnaire (Form G)
Late applications, incomplete applications, applications lost in transit, faxed,
or emailed applications will not be considered for review.
All applications must be received by MDH no later than 4:00 p.m. on Thursday,
January 21, 2016, or have a legible postmark from the U.S. Post Office or a
private courier dated on or before January 21, 2016.
Applications sent:
Late applications, incomplete applications, applications lost in transit, faxed,
or emailed applications will not be considered for review.
Mailing Address:
Mary Ottman, MPH
Minnesota Department of Health
Division of Community and Family Health
P.O. Box 64882
St. Paul, MN 55164-0882
Delivery Address:
Mary Ottman, MPH
Minnesota Department of Health
Division of Community and Family Health
85 East 7th Place, Suite 220
Golden Rule Building, 5th floor
St. Paul, MN 55101
Award Decision
Beginning Grant
Agreement Date
Statutory
Authority
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Approximately May 1, 2016
June 20, 2016 or when all required signatures to execute the grant/contract are
obtained.
M.S. 145.4235 (Appendix C)
Application Instructions and Forms
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Form A: Application Face Sheet
General Applicant Information
Applicant’s Legal Name (do not use a “doing business as” name):
Applicant’s Business Address:
Applicant’s Minnesota Tax Identification Number:
Applicant’s Federal Tax Identification Number:
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: 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
a. If yes, provide details.
9. Have you been a grantee of the Minnesota Department of Health within the last five years?
Yes
No
a. If yes, from which divisions did you receive grants from?
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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
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?
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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
with an annual income of
Under $25,000
Between $25,000 and $750,000
Over $750,000
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Then submit your most recent
Board-reviewed financial statement
IRS Form 990
Certified financial audit
Form C: Assurance and Agreements Form
By signature, the authorized official agrees and assures that the agency is a private nonprofit
501(c) 3 organization and that:
The agency has had an alternatives-to-abortion program in existence for at least one year as of
July 1, 2011; or incorporated an alternatives-to-abortion program that has been in existence for
at least one year as of July 1, 2011.
Their alternatives-to-abortion program’s purpose is to assist and encourage women in carrying
their pregnancies to term and in maximizing their potentials thereafter. Encourage means to
affirmatively counsel a woman on carrying her pregnancy to term unless her life is in danger.
Only accurate information on the developmental characteristics of babies and of unborn
children will be provided to women.
Medical information provided by the agency will be medically accurate, and that medical
services meet standards defined by the appropriate professional organization or are broadly
recognized within the medical community.
The agency does not provide abortions, promote abortions, or directly refer to an abortion
provider.
The agency is not an affiliate of an agency that provides abortions, promotes abortions, or
directly refers to an abortion provider unless the organizations are separately incorporated and
independent from each other.
None of the grant funds will be used to encourage or affirmatively counsel a woman to have an
abortion not necessary to prevent her death, to provide her an abortion, or to directly refer her
to an abortion provider for an abortion. An agency may provide “nondirective counseling” as
defined in Minnesota Statute 145.4235 (Appendix C)
Only Commissioner of Health approved information on the health risks associated with
abortions will be provided to women in grant-funded programs. (Commissioner of Health
approved information can be found in the booklet IF YOU ARE PREGNANT: Information on Fetal
Development, Abortion and Alternatives.)
The agency will not charge women for services provided using grant funds.
The agency has a privacy policy and procedures in place to ensure that the name, address,
telephone number, and any other information that might identify any woman seeking the
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services of the program are not made public or shared with any other agency or organization
without the written consent of the woman.
Medical care provided by the agency, including, but not limited to, pregnancy tests or ultrasonic
scanning, adheres to the requirement in Minnesota Statutes 144.291 – 144.298 that apply to
providers releasing information relating to the medical care provided.
Adoption agencies referred to or adoption services provided are from a Minnesota licensed
adoption agency.
No grant funds will be used to fund religious worship, instruction, or proselytization and that
individuals who receive grant related services will not be required or encouraged to participate
in any religious activities.
If the agency is funded, this agreement will become part of the Grant Agreement the agency
will enter into with the Minnesota Department of Health.
Name of Agency
Address of Agency
Signature of authorized official
Title of authorized official
Date of signature
Telephone number of authorized official
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Project Narrative
The project narrative provides an overall description of your organization, the related issues
your organization would like to address in the community and the proposed activity or activities
for which grant funds will be used. The Project Narrative is broken into four sections:
 Organizational Capacity
 Grant Proposal
 Logic Model and Evaluation
 Budget
Your organization will need to provide specific information in each of these sections. To assist
with completing the application, we have provided detailed instructions on what information
should be included and what grant reviewers will be looking for as they review your
organization’s proposal. Please remember proposals submitted should use at least 12-point
font with one-inch margins. The Project Narrative should be submitted in the same sequence as
listed above. Please review all of the information in the Project Narrative before you begin.
Organizational Capacity
In this section, briefly tell us about your organization.
 Describe your organization, its administrative structure and history
 Describe who your organization serves
 Describe the services your organization provides
 Describe how your organization works with other community organizations and/or
services to support pregnant women
Include information that is important for grant reviewers to understand about your
organization, including your capacity to administer grant funds. If you have a Positive
Alternatives grant now, include information about its successes and/or challenges. Please limit
this section to a maximum of four pages.
The following are examples of items your organization might want to include in this section.
 Provide background information on your organization. How long has your organization
been in existence and what is its mission? How is it funded? Does your organization
have paid staff? How many volunteer hours support your organization’s efforts and in
what ways?
 Describe your facilities and location. How does the space your organization has lend
itself to providing the programming its proposing? Describe your location in relation to
the population you serve.
 Describe the Board of Directors that guides the organization’s work: How do they
represent the community served?
 Describe the services your organization provides. Be sure to include a description of the
alternatives-to-abortion program that has been in existence since 2011. How does this
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

program support, encourage and assist women in carrying their pregnancies to term and
caring for their babies after birth? What services are provided by this program?
Describe your organization’s clientele (ages; Race/Ethnic groups). How many individuals
do you serve per year?
Does your organization work with other community agencies or groups to provide
services to pregnant women and infants? If so, which ones and in what way?
Criteria for Grant Review: The Organizational Capacity section of the application will be reviewed
according to the following criteria (25 Points):
Does the description provide clear and concise information of the history and structure of the
organization?
Is it clear how the organization is funded? How and by whom is it supported?
Does the organization have the capacity (administration, facilities, staff, etc.) to deliver the proposed
activity?
Does the organization adequately describe their alternatives-to-abortion program, that is, a program
that supports, encourages and assists women in carrying their pregnancies to term and caring for their
babies after birth?
Does the organization partner or work with others to serve pregnant women and their infants?
Grant Proposal (How will the Grant Funds be used?)
As stated in the Positive Alternatives statute, to be eligible for a grant, “an organization must…
ensure that its alternatives-to-abortion program’s purpose is to assist and encourage women in
carrying their pregnancies to term and to maximize their potentials thereafter”. It further states
that grants will be awarded “for the reasonable expenses of alternatives-to-abortion programs
to support, encourage and assist women in carrying their pregnancies to term and caring for
their babies after birth”.
In this section, your organization needs to describe each activity for which funds are being
requested, and demonstrate how it will provide assistance and encouragement to pregnant
and/or parenting women, and what it will do to maximize their potentials after the births of
their babies. Give details of each activity for which your organization is requesting funding,
including the following items:
 Describe your organization’s proposed activity, how it will support pregnant women or
women caring for infants, how it will improve pregnancy outcomes or care for babies
after birth, or improve family stability and self- sufficiency.
 Describe the women your organization plans to serve including basic demographic
information.
 Describe how your organization’s proposal will address unmet needs in your
community.
21

Describe how the grant-funded activity will fit into the programs your organization
currently provides. Include information about the needs, strengths, and resources of
your community as they relate to pregnant women or women with infants.
Your narrative should include information your organization thinks is important for grant
reviewers to know in order to understand what it’s planning to do with the grant funds. Please
keep this section to a maximum of ten pages. The following are examples of information your
organization might want to include in this section:










22
Describe the goals and objectives your organization aims to achieve. Describe each
activity your organization plans to implement and why it is important.
Describe how the activity supports, encourages and assists women in carrying their
pregnancies to term and/or caring for their babies after birth.
Describe how your organization’s activity will help women carry their pregnancies to
term, improve pregnancy outcomes, improve and/or support their parenting, and/or
improve family stability and self-sufficiency.
Describe what effect or impact your organization thinks the activity will have on
pregnant or parenting women and why it thinks the effect will be what is described.
Give evidence from research to support the reasoning, your organization’s own
experience, and/or the experience of similar organizations.
Describe the needs of pregnant women and women with infants in your community.
Cite statistics or other data. In what way will your organization’s activity help to meet
their needs?
Describe how your organization’s current activities and resources (staff, facilities) will
support the activities being proposed.
Describe the geographic area your organization will serve; the women it expects to
serve by age, Race/Ethnic group (if targeted) and other characteristics; the number
expected to be served and the frequency of contacts with them for each proposed
activity.
If other agencies or community services will be involved in your organization’s proposal,
describe who they are and what will be their roles and responsibilities.
Describe how your organization will use existing staff, if additional training will be
sought, and if additional staff members will be hired.
Describe how your organization plans to let your target population know about the
services that will be provided.
Criteria for Grant Review: The Grant Proposal section of the application will be
reviewed according to the following criteria (50 points):
Is the proposal clear and understandable? Is it clear what activity or activities the grant would
fund?
Are the goals and objectives of each activity clearly explained?
Does the proposed activity support, encourage and assist women in carrying their pregnancies
to term or in caring for their babies after birth?
Does the proposed activity help women carry their pregnancies to term, improve pregnancy
outcomes, improve or support their parenting, infant care, family stability or self-sufficiency?
Does the proposal include the geographic area to be served, a description of the targeted
population, and information on the number and frequency of women to be served? Are these
numbers realistic?
Does the proposal identify sufficient resources (staff, facilities, etc.) to be successful when
current and proposed resources are combined?
Is the need for the services documented or identified? Does the proposed activity address the
need?
Is the proposed activity feasible? Is it likely to be effective? Is evidence given to support this?
Does the proposal have a reasonable plan to reach (contact, attract) the women to be served?
Does the proposal include partnerships or collaborate with others in the community?
Logic Model and Evaluation: (Please complete Form D for this section)
The purpose of the Logic Model is to visually display the connections between the activities
your organization plans to provide and the outcomes or affects your organization plans to
achieve.
The Logic Model contains short-term and intermediate outcomes that correspond to the
activities that will be funded. Other related short and intermediate outcomes will be considered
for funding. No long-term outcomes will be considered for funding.
The Logic Model will also aid in evaluating your program’s effectiveness. In the logic model an
intermediate outcome associated with an activity will be linked to a measure to help determine
if the activity is achieving the intended outcome.
Your organization’s program evaluation will consist of the measurement of the intermediate
outcome that corresponds to the activity described in your organization’s grant proposal and
23
entered on the Logic Model. (Your organization may have several grant-funded activities, but
will only be required to evaluate one or two, depending on the funding level.) As part of the
Evaluation Plan, your organization will be required to submit an indicator for the intermediate
outcome associated with the activity entered on the Logic Model. An indicator is specific
measurable data collected to document that an outcome has occurred. Indicators are
measurements of the outcomes that report on the activities impact and helps answer the
question, “did the activity achieve the intended outcome.” After funding has been awarded,
Minnesota Department of Health will provide assistance in formalizing evaluation plans.
Do not submit an evaluation plan with your application. Your organization must submit a
Logic Model.
Instructions for completing the Logic Model: There are two Logic Models beginning on page
26, one for the Goal “Support, encourage and assist women in carrying their pregnancies to
term” and one for the Goal “Support, encourage and assist women in caring for their babies
after birth”. Under each Goal is an “Activity Category” column related to that goal. Decide
which “Goal” and “Activity Category” best fits the activity for which your organization is seeking
grant funding. Enter the activity for which your organization is requesting funding under the
“Activity Category” column and row in the Logic Model where it best fits. It will best fit where it
corresponds to the short and intermediate outcomes listed on the same row in the Logic
Model. If your proposal receives funding, your organization will have an opportunity to further
develop your Logic Model. The short-term and intermediate outcomes are suggested outcomes
for the types of activities that will be funded. If your organization’s proposed activity does not
fit into one of the categories, develop and enter your own category and short and intermediate
outcomes. Do not add a long-term outcome. The long-term outcomes will be the same for all
funded proposals. If your organization is asking for more than one activity to be funded, enter
each activity in which funding is sought onto the Logic Model. Refer to Appendix B, for a sample
completed Logic Model.
24
Form D: Logic Model and Evaluation
GOAL 1: Support, encourage and assist women in carrying their pregnancies to term
Activity
Number of
Short-Term Outcomes
Intermediate Outcomes
Category
individuals
served/year
Medical
 Women are aware of their
 Women schedule and attend prenatal
Services
pregnancy status
appointments
 Women are aware of their weight,  Women make healthy changes to
blood pressure and other medical
benefit their own and their babies
indicators related to pregnancy
health during pregnancy
Services to
Women have increased knowledge of  Women schedule and attend prenatal
Support
the benefits of:
appointments
Healthy
 Early prenatal care
 Women take prenatal vitamins
Pregnancy
 Use of folic acid
 Women have healthy meals
Behavior
 Good nutrition
 Women exercise appropriately
 Exercise
 Women quit smoking or reduce
 Smoking cessation
amount or exposure to tobacco
products
 Reducing/eliminating
 Women quit drinking alcohol
Alcohol/drug use
 Women quit drug use or enter
appropriate treatment
Support in
Women have increased knowledge of Women:
Carrying Baby
and access to:
 Make appointments with local
to Term
 Resources and referrals for
agencies to access services to meet
support services
identified needs
 Financial resources
 Contact resources for rental assistance
 Material resources
 Contact resources for maternity and
baby items
 Prenatal development
 Move into or maintain safe, supportive
 Adequate housing
housing
25
Long-Term Outcomes
Women have healthy
pregnancy outcomes
Women have healthy
pregnancy outcomes
Women have healthy
pregnancy outcomes
GOAL 2: Support, encourage and assist women in caring for their babies after birth (caring for a baby after birth could also include
making an adoption plan)
Activity
Number of
Short-Term Outcomes
Intermediate Outcomes
Long-Term Outcomes
Categories
individuals
served/year
Support to
Women have increased knowledge
Women
Women demonstrate
Women to
regarding
appropriate care for
 Use cribs and car seats appropriately
Increase their
their babies
 Sleep safety
 Use safe sleep techniques
Knowledge
 Car seat safety
 Breastfeed their babies
and Skills as
 Infant nutrition
 Demonstrate age-appropriate
Parents
 Age-appropriate developmental
parenting expectations and activities
expectations and activities
 Involve the fathers’ of their babies
 Violence prevention
when the relationship is safe and
supportive
 Engaging fathers of babies
Support to
Women to
Increase their
Ability to
Become Selfsufficient
26
Women have increased access to
and/or knowledge of and/or
resources on
 Adoption
 Accessing child care
 Affordable housing
 Education opportunities
 Supportive employment
 Family stability
Women plan and
 Explore parenting options
 Make informed child care choices
 Make informed housing choices
 Graduate from high school/continue
higher education
 Maintain/gain further employment
Women increase family
stability and selfsufficiency
Criteria for Grant Review: The logic model section of the application will be reviewed according to the following criteria (10
points):
Is there a complete Logic Model included in the application?
Does the Activity Category column of the Logic Model contain each of the major activities described in the Project Narrative?
Will the activity achieve the short and intermediate outcomes?
Does the activity match the organization’s goal, capacity and budget that is submitted?
27
Budget Section
Instructions
Before you begin writing your organization’s budget, consider the specific activity planned and
the resources needed to do it. 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.
The Budget Section of the application is composed of two forms:
 Budget Justification Sheet (Form E)
 Budget Summary Sheet (Form F).
Your organization will need to complete three Budget Justification Sheets, one for each year of
your grant program:
 6/20/16 – 6/30/17
 7/1/17 - 6/30/18
 7/1/18 – 6/30/19
Each Budget Justification Sheet will provide the details of your organization’s expenses and a
brief description of how they support your proposed grant activity for that year. (The full
description of the purpose of each grant-funded position and the necessity of budgeted items
should appear in the Project Narrative.)
The Budget Summary Sheet (Form F) is where your organization will provide the total expenses
for the first three years of your proposal by adding the expenses from the three Budget
Justification Forms together.
The categories below, salary and fringe benefits, contractual services, travel, supplies and
expenses, other costs, evaluation, and indirect costs correspond to the sections in both the
Budget Justification Sheet and the Budget Summary Sheet. The description of costs that may be
included in each category are listed below.
Salary and Fringe Benefits
For each proposed funded position, indicate the title, the full time equivalent (FTE) on this grant
(see box below for a definition), the expected rate of pay, and the total amount you expect to
pay the position for the year. Grant funds can be used for salary and fringe benefits for staff
members directly involved in your organization’s proposed activities. It is strongly suggested
that grantees incorporate into their budget the costs of appropriate financial staff to provide
oversight to the grant. This could be through contracting with an individual or organization or a
direct hire.
28
NOTE: “Full time equivalent” (FTE) is defined as the percentage of time a person will work on
the Positive Alternatives project. To calculate the FTE, divide the hours the person will work by
the standard number of work hours, which is 40 hours per week, 174 hours per month, or 2,088
hours per year. For example, a person who works 20 hours per week is a 0.5 FTE (20/40 = 0.5)
Contractual Services
Grant funds can be used for small contracts with speakers or trainers, and for large contracts if
other organizations will be providing some of the services included in your grant proposal.
Rented or leased equipment for the project should be included in this category. Supplies and
travel expenses for contractors should be included here, if applicable.
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 for;
 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 your staff’s expected 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 during each year. 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.
Any applicant that is awarded a grant agreement 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.
Non-tribal applicants:
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 and motel expenses should be reasonable and consistent with the facilities available.
Grantees are expected to exercise good judgement when incurring lodging expenses.
29
Mileage will be reimbursed at the current IRS rate.
Tribal applicants:
Budget for travel costs using the rates provided by the General Services Administration (GSA).
Current lodging amounts and meal reimbursement rates vary depending on where in
Minnesota the travel occurs. Please reference the per diem rates listed there.
A breakdown of the meals and incidental expenses can be found here.
Mileage will be reimbursed at the current IRS rate.
Supplies and Expenses
Briefly explain the expected costs for items and services your organization will purchase to run
your program. These might include additional telephone equipment; postage; printing and
photocopying; office supplies, training materials, pregnancy tests; baby items; and equipment.
Include the costs expected to be incurred to ensure that community representatives, partners
or clients who are included in your organization’s process or program can participate fully.
Examples of these costs are fees paid to translators, interpreters, or childcare providers, or for
transportation. Include items such as rent for space that is being added for the project. 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.
If you plan on purchasing gift cards to use as incentives or rewards, they must be listed
separately by purpose (food, gas, etc.) and denomination.
We will rely on electronic means to communicate with funded programs (grantees). If your
organization does not have a reliable computer and Internet access, include the cost of these
items in your budget.
Grantees may include reasonable costs to reach women intended to be served by their
programs in their budgets. These outreach expenses may include, but are not limited to, print
ads in newspapers, directories and broadcast ads like internet, radio or theater ads. Outreach
expenses may not exceed $7,000 per year or 7% of the annual budget, whichever is higher.
Print and promotional items like brochures, business cards and logo pens or cups are not
included in outreach expenses.
Food expenses such as meals and/or refreshments can only be considered if residential housing
is being requested as part of the grant program. Funds from Positive Alternatives grant cannot
be used for field trips.
30
Other Expenses
Include in this section any expenses you expect to have for other items 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 grant-funded person. The cost of membership dues for state or
national affiliated organizations cannot be charged to the grant.
Evaluation
Each applicant’s budget must include evaluation costs. Five percent of all of the program
expenses is the minimum required budget line item amount on an applicant’s Budget
Justification Sheet (Form E). Applicants should total all expenses listed on the Budget
Justification Sheet (Form E) except indirect expenses. Multiply that total by 5% and enter the
amount on the line item category “evaluation”. An organization may apply for more than 5% of
the total grant amount requested for evaluation activities. If an organization requests more
than 5% the rationale for the increased amount must be included on the Budget Justification
Sheet (Form E).
Indirect Costs
Indirect Costs are defined as: 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 and/or supervisory salaries and fringe, rent, facilities
maintenance, insurance premiums, etc. It is these costs that could be included in the 10%
maximum but could also be charged directly to the grant. See Form G.
For grantees receiving federal funds: Any salaries from the administrative, accounting, human
resources, or IT support MUST be supported by time studies, or 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 those costs must be included in the Indirect line.
If you have a Federally Negotiated rate, MDH will use that rate. Please submit documentation
of your most current Federally Negotiated Rate to MDH with your application to this RFP.
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. Grant funds may not be
used to purchase any individual piece of equipment that costs more than $5,000.
The scoring of the Budget Section will be done using the Budget Justification Sheets and the
Budget Summary Sheet. If supplementary information is included, it will not be taken into
consideration for scoring purposes.
31
Criteria for Grant Review: The Budget Section of the application will be reviewed and
scored for accuracy according to the following criteria (15 points):
 Are there three complete Budget Justification Sheets (Form E), one for each year
of the grant? Does the sum of the section totals equal the Grand Total on each
Budget Justification Sheets (Form E)?
 Is the Budget Summary Sheet (Form F) complete and do the amounts in each
category add up to the total grant amount being requested?
 Is line 9 (Indirect Costs) less than or equal to 10% of line 8 (Subtotal of Direct
Expenses)?
 Is the information contained in the Budget Justification Sheets consistent with
the proposed activity?
 Is the budget sufficient to accomplish the proposed activity and provides the
appropriate accounting support?
 Are the projected costs reasonable? Is the cost per participant reasonable?
32
Form E: Budget Justification Sheet
(See instructions starting on page 29)
Complete one form for each of the following years:
6/20/16 – 6/30/17
7/1/17 – 6/30/18
7/1/18 – 6/30/19
Applicant Agency:
Contact Person:
Phone Number:
Email Address:
Budget Period: July 1, 20__ to June 30, 20__
Revision # (MDH use only):
1. Salary and Fringe Benefits
For each proposed funded position, list the title, the full time equivalent, the expected REQUESTED
rate of pay, and the total amount you expect to pay the position.
DOLLARS
Budget Justification:
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.
Budget 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.
Budget Justification:
REQUESTED
DOLLARS
Total Travel $
33
4. Supplies and Expenses
Explain the expected costs for items and services your organization will purchase to
REQUESTED
run your program. Include telephone expenses that are part of this proposal; cell
DOLLARS
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 additional rent for program space,
participant transportation, participant training and other direct costs as needed.
Budget Justification:
Total Supplies and Expenses $
5. Other Expenses
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.
Budget Justification:
REQUESTED
DOLLARS
Total Other Expenses $
6. SUBTOTAL (Enter sum of lines 1 through 5):
$
7. Evaluation
5% of grant expenses must be included in the budget for evaluation costs. Multiply
REQUESTED
the amount of line 6, Subtotal, by 5% and enter here. It is not necessary to include any DOLLARS
information on evaluation procedures.
Total Evaluation $
8. SUBTOTAL OF DIRECT EXPENSES (Sum of lines 6 and 7)
$
9. 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 8,
Subtotal of Direct Expenses.
REQUESTED
DOLLARS
Indirect cost rate: _____%
Indirect Total $
10. TOTAL (sum of line 8 + line 9)
34
$
Form F: Budget Summary Sheet
6/20/16 – 6/30/19
Minnesota Department of Health, Positive Alternatives Grant Program
Name of Applicant Agency:
Name of Contact Person for Budget:
Phone:
Fax:
E-mail:
Line Item
1) Salary and Fringe Benefits
2) Contractual Services
3) Travel
4) Supplies and Expenses
5) Other Expenses
6) Subtotal (sum of line 1 through line 5)
7) Evaluation (5% of line 6)
8) Subtotal of Direct Expenses (line 6 + line 7)
9) Indirect Costs (maximum of 10% of Line 8)
10) TOTAL (line 8 + Line 9)
35
Total Proposed Amount
Budget Summary Instructions
This form should be used to show the total requested budget for your organization’s proposed
grant-funded activities from 6/20/16 – 6/30/19. The budget should include funding necessary in
each category for three years of the grant. The total in each category should reflect the total of
that category from the three Budget Justification Sheets: 6/20/16 – 6/30/17, 7/1/17 - 6/30/18
and 7/1/18 – 6/30/19. The Subtotal (line 11) should reflect the total of all the expenses listed
on the three Budget Justification Sheets. Please enter zero (0) in the Total Proposed Amount
column if you do not propose to expend grant funds in a line item.
Please type all items on the Budget Summary Sheet (Form F).
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 Benefits – The total amount of grant funds that will be used during the
three year grant period to cover salary/fringe benefits (add the figures from the “Total
Salary and Fringe” box in all of the Budget Justification Sheets).
2. Contractual Services – The total amount of grant funds that your organization plans to
spend on contractual services (add the figures from the “Total Contractual Services” box
in all of the Budget Justification Sheets).
3. Travel – The total amount of grant funds that your organization plans to spend on travel
(add the figures from the “Total Travel” box in all of the Budget Justification Sheets).
4. Supplies and Expenses – The total amount of grant funds that your organization plans to
spend on supplies and expenses (add the figures from the “Total Supplies and Expenses”
box in all of the Budget Justification Sheets).
5. Other Expenses – The total amount of grant funds that your organization plans to spend
on items that are not listed above (add the figures from the “Other Total” box in all of the
Budget Justification Sheets).
6. Subtotal – The total from adding line 1, line 2, line 3, line 4, and line 5. This figure should
match the sum of the subtotals on your Budget Justification Sheets.
7. Evaluation – Include 5% of the cost of your proposal for evaluation purposes. Multiply the
figure on line 6 by 5% and enter it on line 7. This figure should match the sum of the
evaluation costs on your Budget Justification Sheets.
8. Subtotal of Direct Expenses – Add line 6 and line 7 to calculate the subtotal of direct
expenses and enter in line 8.
9. Indirect Costs - The total amount of grant funds that your organization plans to spend for
indirect costs. The indirect costs cannot exceed 10% of Line 8 .This figure should match
the sum of the indirect costs on your Budget Justification Sheets.
10. Total – The total in adding lines 8 and 9.
36
Form G: Indirect Cost Questionnaire
Applicant’s Legal Name: _________________________________________
Program: Positive Alternatives Grant Program
Please check one of the three options below:
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 fixed 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.
The applicant agency is requesting a rate of
% for the grant program listed above.
Per MDH Policy, the applicant must inform MDH of the types of costs included in the
applicant’s indirect costs. Please list below.
37
Appendices
Appendix A:
Criteria for Grant Review
Appendix B:
Sample Logic Model with Suggested Activities
Appendix C:
Positive Alternatives Act, M.S. 145.4235
Appendix D:
Sample of MDH Grant Agreement
38
Appendix A: Criteria for Grant Review
Section of
Application
Total Points
Available
Organizational
Capacity
25
Review Criteria







Grant Proposal
50















Does the description provide clear and concise information of
the history and structure of the organization?
Is it clear how the organization is funded?
How and by whom is it supported?
Does the organization have the capacity (administration,
facilities, staff, etc.) to deliver the proposed activity?
Does the organization have a history of providing a grant-eligible
alternatives-to-abortion program, that is, a program that
supports, encourages and assists women in carrying their
pregnancies to term and caring for their babies after birth?
How successful has your program been?
Does the organization partner or work with others to serve
pregnant women and their infants?
Is the proposal clear and understandable?
Is it clear what activity or activities the grant would fund?
Are the goals and objectives of each activity clearly explained?
Does the proposed activity support, encourage and assist
women in carrying their pregnancies to term or in caring for
their babies after birth?
Does the proposed activity help women carry their pregnancies
to term, improve pregnancy outcomes, improve or support their
parenting, infant care, family stability or self-sufficiency?
Does the proposal include the geographic area to be served, a
description of the targeted population, and information on the
number and frequency of women to be served?
Are these numbers realistic?
Does the proposal identify sufficient resources (staff, facilities,
etc.) to be successful when current and proposed resources are
combined?
Is the need for the services documented or identified?
Does the proposed activity address the need?
Is the proposed activity feasible?
Is it likely to be effective?
Is evidence given to support this?
Does the proposal have a reasonable plan to reach (contact,
attract) the women to be served?
Does the proposal include partnerships or collaborate with
others in the community?
39
Section of
Application
Total Points
Available
Logic Model
10
Review Criteria




Budget Justification
Sheets
15








Is there a complete Logic Model included in the application?
Does the Activity Category column of the Logic Model contain
each of the major activities described in the Project Narrative?
Will the activity achieve the short and intermediate outcomes?
Does the activity match the organization’s goal, capacity
and budget that is submitted?
Are there three complete Budget Justification Sheets (Form E),
one for each year of the grant?
Does the sum of the section totals equal the Grand Total on each
Budget Justification form E?
Is the Budget Summary Sheet (Form F) complete and do the
amounts in each category add up to the total grant amount
being requested?
Is line 9 (Indirect Costs) less than or equal to 10% of line 8
(Subtotal of Direct Costs)?
Is the information contained in the Budget Justification Sheets
consistent with the proposed activity?
Is the budget sufficient to accomplish the proposed activity?
Are the projected costs reasonable?
Is the cost per participant reasonable?
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Appendix B: Sample Logic Model
Below is a sample of what a completed Logic Model might look like. An applicant would provide the
information written here underlined in bold font. The applicant must insert at least one of the
short-term and one of the intermediate outcomes listed for the goal and category activity. If
more than one short-term and/or intermediate outcome applies the applicant can list all that
apply for the proposed grant activity. Do not change the long-term outcome listed.
GOAL 1: Support, encourage and assist women in carrying their pregnancies to term
Number of
Short-term Outcome
Intermediate Outcome
individuals
served/year
Medical Services
Women are aware of
Women plan for their own and
their pregnancy status.
their babies’ care during
Provide pregnancy 150
pregnancy.
tests
Women make positive changes
to benefit themselves and their
babies during pregnancy.
Women are aware of their
weight, blood pressure and
other medical indicators
related to pregnancy
Women bond with their babies
Services to
Women have increased
Women make appointments
Support Healthy
knowledge of and access with local agencies to access
Pregnancy
to pregnancy support
services to meet identified
Behavior
resources and referrals.
needs.
Activity
Provide necessary
services resources
and referrals
Support in
Carrying Baby to
Term
200
Provide maternity
clothes, baby
clothes and
diapers
300
Women have necessary
material resources (to
assist them in pregnancy
and parenting infants).
Women utilize available
resources to meet their
material needs.
Long-term Outcome
Women have healthy
pregnancy outcomes.
Women have healthy
pregnancy outcomes.
Women have healthy
pregnancy outcomes.
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Activity
GOAL 2: Support, encourage and assist women in caring for their babies after birth
Number of
Short-term Outcome
Intermediate Outcome
individuals
served/year
Support to
Women to
Increase their
Knowledge and
Skills as Parents
Provide parenting
education
program where
cribs are
distributed and
safe sleep
instruction is
provided
Women have increased
knowledge regarding
sleep safety.
Women use cribs safely.
Long-term Outcome
Women demonstrate
appropriate care for
their babies.
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SUGGESTED ACTIVITIES
The chart below lists suggested activities that can be funded under each Activity Category on
the Logic Model. Some programs or services have required components associated with them.
These are identified with an asterisk (*). The required components are listed under the chart.
Activity Category
Provide medical services
Provide education and
services to support health
pregnancy behavior
Provide support in carrying a
baby to term
Possible Funded Programs or
Services
Pregnancy testing*
Prenatal obstetrical or midwife
care*
Ultrasound services*
Pregnancy education program
Case management or client
advocate services
Home visiting assessment and
support services
Provide cribs and safe sleep
education*
Childbirth education classes
Prenatal nutrition classes
Provide Positive Alternatives
Necessary Services intake and
referral
Provide financial assistance directly
or through referrals
Provide material assistance directly
or through referrals
Required Services for the Activity Category
Pregnancy testing*
Prenatal obstetrical or midwife care*
Ultrasound services*
Provide cribs and safe sleep education*
Provide referrals to local resources for
identified needs that applicant cannot meet.
It would be helpful to require a referral to a
clinic/medical provider for prenatal care.
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Activity Category
Provide support to women to
increase their knowledge and
skills as parents
Provide support to women to
increase their ability to
become self-sufficient
These activities may be
funded in any category
without entering them on the
Logic Model
Possible Funded Programs or
Services
Provide housing to pregnant and/or
parenting women
Staff a 24-hour Information hotline
providing referrals and information
Parenting education program
Provide car seats and education*
Provide infant care classes
Mentoring program
Child care
Provide scholarships to ECFE or
other community education classes
Provide licensed adoption services*
Provide or subsidize literacy or ESL
classes
Assist women in employment
and/or education training and/or
searches
Transportation, Interpreters, Food,
Incentives
Required Services for the Activity Category
Provide car seats and education*
Provide licensed adoption services*
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Appendix C: Positive Alternatives Statute
145.4235 POSITIVE ABORTION ALTERNATIVES.
Subdivision 1. Definitions.
For purposes of this section, the following terms have the meanings given:
(1) "abortion" means the use of any means to terminate the pregnancy of a woman known
to be pregnant with knowledge that the termination with those means will, with reasonable
likelihood, cause the death of the unborn child. For purposes of this section, abortion does not
include an abortion necessary to prevent the death of the mother;
(2) "nondirective counseling" means providing clients with:
(i) a list of health care providers and social service providers that provide prenatal care,
childbirth care, infant care, foster care, adoption services, alternatives to abortion, or abortion
services; and
(ii) nondirective, nonmarketing information regarding such providers; and
(3) "unborn child" means a member of the species Homo sapiens from fertilization until
birth.
Subd. 2.Eligibility for grants.
(a) The commissioner shall award grants to eligible applicants under paragraph (c) for the
reasonable expenses of alternatives to abortion programs to support, encourage, and assist
women in carrying their pregnancies to term and caring for their babies after birth by providing
information on, referral to, and assistance with securing necessary services that enable women
to carry their pregnancies to term and care for their babies after birth. Necessary services must
include, but are not limited to:
(1) medical care;
(2) nutritional services;
(3) housing assistance;
(4) adoption services;
(5) education and employment assistance, including services that support the continuation
and completion of high school;
(6) child care assistance; and
(7) parenting education and support services.
An applicant may not provide or assist a woman to obtain adoption services from a provider of
adoption services that is not licensed.
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(b) In addition to providing information and referral under paragraph (a), an eligible
program may provide one or more of the necessary services under paragraph (a) that assists
women in carrying their pregnancies to term. To avoid duplication of efforts, grantees may
refer to other public or private programs, rather than provide the care directly, if a woman
meets eligibility criteria for the other programs.
(c) To be eligible for a grant, an agency or organization must:
(1) be a private, nonprofit organization;
(2) demonstrate that the program is conducted under appropriate supervision;
(3) not charge women for services provided under the program;
(4) provide each pregnant woman counseled with accurate information on the
developmental characteristics of babies and of unborn children, including offering the printed
information described in section 145.4243;
(5) ensure that its alternatives-to-abortion program's purpose is to assist and encourage
women in carrying their pregnancies to term and to maximize their potentials thereafter;
(6) ensure that none of the money provided is used to encourage or affirmatively counsel a
woman to have an abortion not necessary to prevent her death, to provide her an abortion, or
to directly refer her to an abortion provider for an abortion. The agency or organization may
provide nondirective counseling; and
(7) have had the alternatives to abortion program in existence for at least one year as of
July 1, 2011; or incorporated an alternative to abortion program that has been in existence for
at least one year as of July 1, 2011.
(d) The provisions, words, phrases, and clauses of paragraph (c) are inseverable from this
subdivision, and if any provision, word, phrase, or clause of paragraph (c) or its application to
any person or circumstance is held invalid, the invalidity applies to all of this subdivision.
(e) An organization that provides abortions, promotes abortions, or directly refers to an
abortion provider for an abortion is ineligible to receive a grant under this program. An affiliate
of an organization that provides abortions, promotes abortions, or directly refers to an abortion
provider for an abortion is ineligible to receive a grant under this section unless the
organizations are separately incorporated and independent from each other. To be
independent, the organizations may not share any of the following:
(1) the same or a similar name;
(2) medical facilities or nonmedical facilities, including but not limited to, business offices,
treatment rooms, consultation rooms, examination rooms, and waiting rooms;
(3) expenses;
(4) employee wages or salaries; or
(5) equipment or supplies, including but not limited to, computers, telephone systems,
telecommunications equipment, and office supplies.
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(f) An organization that receives a grant under this section and that is affiliated with an
organization that provides abortion services must maintain financial records that demonstrate
strict compliance with this subdivision and that demonstrate that its independent affiliate that
provides abortion services receives no direct or indirect economic or marketing benefit from
the grant under this section.
(g) The commissioner shall approve any information provided by a grantee on the health
risks associated with abortions to ensure that the information is medically accurate.
Subd. 3.Privacy protection.
(a) Any program receiving a grant under this section must have a privacy policy and
procedures in place to ensure that the name, address, telephone number, or any other
information that might identify any woman seeking the services of the program is not made
public or shared with any other agency or organization without the written consent of the
woman. All communications between the program and the woman must remain confidential.
For purposes of any medical care provided by the program, including, but not limited to,
pregnancy tests or ultrasonic scanning, the program must adhere to the requirements in
sections 144.291 to 144.298 that apply to providers before releasing any information relating to
the medical care provided.
(b) Notwithstanding paragraph (a), the commissioner has access to any information
necessary to monitor and review a grantee's program as required under subdivision 4.
Subd. 4.Duties of commissioner.
The commissioner shall make grants under subdivision 2 beginning no later than July 1,
2006. In awarding grants, the commissioner shall consider the program's demonstrated
capacity in providing services to assist a pregnant woman in carrying her pregnancy to term.
The commissioner shall monitor and review the programs of each grantee to ensure that the
grantee carefully adheres to the purposes and requirements of subdivision 2 and shall cease
funding a grantee that fails to do so.
Subd. 5.Severability.
Except as provided in subdivision 2, paragraph (d), if any provision, word, phrase, or clause
of this section or its application to any person or circumstance is held invalid, such invalidity
shall not affect the provisions, words, phrases, clauses, or applications of this section that can
be given effect without the invalid provision, word, phrase, clause, or application and to this
end, the provisions, words, phrases, and clauses of this section are severable.
Subd. 6.Supreme Court jurisdiction.
The Minnesota Supreme Court has original jurisdiction over an action challenging the
constitutionality of this section and shall expedite the resolution of the action.
History:
2005 c 124 s 2; 2007 c 147 art 10 s 15; 2012 c 152 s 1
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Appendix D: MDH Grant Agreement Template
See hyperlink to pdf of MDH Grant Agreement Template on the Positive Alternatives website.
December 2015
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