REQUEST FOR PROPOSALS
Minnesota WIC Peer Breastfeeding Support Program
Intent to Apply and Application
Intent to apply Due
March 18, 2011
Submitting this form does not obligate you to complete the application
Application Due
Thursday, April 20, 2011
Minnesota Department of Health
Community and Family Health
Minnesota WIC Program
P.O. Box 64882
St. Paul, MN 55164-0882
651-201-4444
http://www.health.state.mn.us/divs/fh/wic/
March 2011
PBSP Application 2011 for (Agency Name)
Intent to Apply
2011 Request for Proposals for
Minnesota WIC Peer Breastfeeding Support Program
Due March 18, 2011
Completing this form does not obligate you to submit a grant application. It is meant to help us
in planning.
We plan to submit an application for Minnesota WIC peer breastfeeding support funding.
We don’t plan to submit an application at this time, but may be interested in the future if funds
are available.
Optional: Comments on why you are not applying at this time and what would help you to
develop a program:
Intent to apply completed by (name):
Position:
Director
WIC Coordinator,
WIC Breastfeeding Coordinator,
Other
Agency name:
Street address:
City:
Zipcode:
Phone:
Fax:
E-mail:
The application and guidance will be available on the MN WIC website the week of February 28,
2011.
Conference calls are available for those with questions about the peer program and the RFP. Please
indicate the session you plan to attend. Call information will be sent prior to the call date.
I plan to attend the conference call for questions about the PBSP RFP on:
March 23, 12:30 – 1:30pm
OR
March 24, 8:30 – 9:30am
By March 18, 2011 please submit this form
 By fax at 651-215-8951 or
 E-mail Linda.dech@state.mn.us with “PBSP Intent to apply” in the subject line.
If you fax the intent to apply please contact us to verify receipt by phone.
If you have questions please contact:
Linda Dech at linda.dech@state.mn.us or 651-201-3649.
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Request for Proposal
(RFP)
Application
for
Minnesota WIC
Peer Breastfeeding Support Program
(PBSP)
Community and Family Health
Minnesota WIC Program
P.O. Box 64882
St. Paul, MN 55164-0882
651-201-4444
http://www.health.state.mn.us/divs/fh/wic/
Application due
April 14, 2011
WIC Agency Name:
Are you a current Minnesota WIC Program Grantee?
Yes
No (If no, not eligible to apply)
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Blank page
iv
Minnesota Department of Health
Grant Application Face Sheet
Minnesota WIC Peer Breastfeeding Support Program
2011
See Guidance for Face Sheet Instructions
1. Applicant Agency with which Grant Agreement would be executed:
Legal Name and Address:
Minnesota Tax I.D. Number:
Federal Tax I.D. Number:
2. Non-profit Status – 501.C3
Requested Funding:
Yes (proof of tax-exempt status form attached)
Not Applicable
$
3. Director of Applicant Agency
Name, Title and Address:
E-Mail Address:
Telephone Number:
FAX Number:
4. Fiscal Management Officer of Applicant Agency
Name, Title and Address:
E-Mail Address:
Telephone Number:
FAX Number:
5. Operating Agency (if different from number 1. above)
Name, Title and Address:
E-Mail Address:
Telephone Number:
FAX Number:
6. Contact Person for Operating Agency (if different from number 2. above)
Name, Title and Address:
E-Mail Address:
Telephone Number:
FAX Number:
7. Contact Person for Further Information on Application (if different from number 5. above)
Name, Title and Address:
E-Mail Address:
Telephone Number:
FAX Number:
8. Certification
I certify that the information contained herein is true and accurate to the best of my knowledge
and that I submit this application on behalf of the applicant agency.
,
,
(Please print)
Signature of Director of Applicant Agency, Title, Date
HE-01274-05 (4/01) - PART A
IC# 140-428
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For your reference all questions are included here and instructions are in the Guidance document.
Please see the Guidance for more details and assistance with application questions.
1. A. Need for peer support services. Please briefly describe the needs in your WIC population
that you believe could effectively be addressed through peer breastfeeding support (PBS).
B. Please include breastfeeding rates in your proposed service area(s). (Due to HuBERT roll-out,
use WIC Summary Statistics Supplemental Report – Breastfeeding for September 2010, all clinics
quarterly reports.) List by WIC agency name and any individual clinics where peer program is
planned.
BF rates by subgroups, ALL
State of Minnesota
Agency:
Clinic:
Clinic:
Clinic:
Clinic:
BF Ever
#
%
11404 74.29
< 2 Weeks
#
%
1575
13.90
> 6 mo
#
%
5198
45.88
> 12 mo
#
%
3225
28.46
Note that for smaller agencies the % will vary from month to month. This will give you a snapshot of rates in your agency.
C. For those with current peer programs, what impact have peer services had on your
breastfeeding rates and WIC clinic breastfeeding services? Include supporting documents as
Attachment B.
D. Please include numbers of participants in your proposed service area(s). (Use WIC Summary
Statistics Participation report September 2010, all clinics report. If serving your entire program
use the “all clinics” report. If the service area will be specific clinics complete one row for each
clinic and note the name of the clinic or agency. You can insert additional grids if several
agencies will share a peer program. (Contact Linda Dech at 651-201-3649 if you have questions about
formatting.)
Location for peer services
Pregnant
(Note Agency name/all or name of
specific clinic site.)
State
12169
PP BF
PP NBF (not
(breastfeeding)
breastfeeding)
9128
8254
Total
Women
Total Infants
29551
29373
2. Plan for addressing needs. Describe how peer counselors will address the needs as identified
above. Include priorities of needs.
New Peer Program Application Part 1 for (Agency Name)
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3. Direct Peer Services – Location and Availability
A. Indicate where peer counseling services will be available.
Peer service areas:
Specific WIC clinics:
The entire local WIC program.
Other:
Peer work locations: (Check all that apply)
Peer’s home
Home visits
WIC Clinic
Breastfeeding classes / Support groups at WIC
Hospital Visits
Other:
B. Schedule of peer service availability. Many breastfeeding problems occur after regular
clinic hours. FNS requires that peers be available outside regular clinic hours and clinic settings.
Having peer support with WIC backup available 24/7 may not be feasible for all programs. Also,
back-up WIC staff are needed for breastfeeding issues beyond the role and scope of the peer.
Please identify the hours you plan to have peers and backup staff available. (See Guidance, 3B
for more information.)
Mon
Tues
Wed
Thu
Fri
Sat
Sun
Comments
Days and
hours peers
available
Plan for backup of Peer Support Staff; IBCLC, manager, back-up WIC staff
WIC staff
available for
backup
(hours)
Insert additional grids if needed for different clinic or county locations .
Add comments to help us understand your plans.
What resources are available to participants for referrals beyond the scope of practice of the peer
and back-up staff?
Peer Program Staffing (See Guidance under Staffing for assistance)
4. A. Peer Counselors
1. For new applicants, how many peer counselors do you plan to hire?
2. For current programs, how many peer counselors do you currently have?
How many peers do you plan to have?
Add comments to explain the number of peers
2
B. How do you plan to hire or how do you hire peer counselors?
We (WIC) plan to hire peers by contract.
We (WIC) plan to hire peer support staff through our county or WIC agency.
We (WIC) plan to hire peers through an employment agency.
We plan to use current WIC staff who meet the FNS definition of a breastfeeding peer
counselor. Describe their current role and how they meet the FNS peer support definition:
We plan to use staff from another (non-WIC) program for peer breastfeeding support. Please
describe their current role and how they meet the FNS peer support definition:
Additional comments about hiring peers:
C. On average, how many hours a week do you anticipate each peer will work? (A range of hours
is fine.)
5. International Board Certified Lactation Consultant (IBCLC) involvement.
A. An IBCLC must be available on staff or by contract. (See Guidance: Staffing, Item 5.)
We have an IBCLC(s) on staff who will be involved with the peer program.
The IBCLC is:
We don’t have an IBCLC on staff and we plan to
hire or
contract an IBCLC.
Describe your plan for the IBCLC’s role in the peer program:

B. How many hours per week do you plan to have the IBCLC work on the peer program?
hours or
FTE.
C. For large service areas, such as a very large county or a multiple county program, please
comment on how the IBCLC will be available for issues beyond the scope of the on-site WIC clinic
staff:
Any other comments on IBCLC involvement:
6. WIC and Other Staff Involvement as Peer Program Lead Staff
Identify staff you plan to have involved in supervision, management, training, and/or back-up of
peer support staff. Include their lactation training completed (name and date of training program)
or plans for training on breastfeeding management. Include the estimated staff hours per week for
the peer program. (See Guidance, Section 6, for assistance.)
Hours/ week
Name, position and credentials Breastfeeding Training
or FTE
or plans for training
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7. Essential Peer Breastfeeding Support Functions Plan
7A. Please complete the grid on the next page. It is meant to help with planning the peer
program. It contains the essential duties of the FNS/MN WIC Peer Breastfeeding Support
Program. See Guidance, section 7 on Essential PBSP Functions for more details.
Abbreviations:
PBSP – Peer Breastfeeding Support Program
PBS – Peer Breastfeeding Support
7B. WIC agencies partnering with another organization to provide any essential peer program
function must include a letter or a memo of understanding (MOU) from that organization
agreeing to fulfill the designated required functions if the grant is awarded. The letter should
outline roles and define who has decision-making authority for the peer functions in the
organization. See Item 10 in application and Guidance. Include MOU(s) as Attachment A.
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7A.
Essential Peer Program Functions. This grid is intended to help with planning. It contains the essential duties of the FNS/MN WIC Peer
Breastfeeding Support Program.
Identify the person and their role in the peer program (check the appropriate columns).
Comments:
Enter the Names and Roles of peer lead staff in the column
headers. 1
IBCLC
Manage/ coordinate the PBSP²
Develop local agency PBSP consistent with FNS model and MNWIC
Program policies
Develop PBS staff position description (see Guidance Appendix)
Recruit PBS staff
Hire PBS staff
Supervise peers, including periodic review of peer documentation.
Submit progress reports, annual work plan and budget
Manage number of peer(s) participant caseload, re-assigning when
needed due to leave or turnover
Be trained on FNS peer management curriculum3
Be trained on FNS peer counselor training curriculum3
Attend the 2 required meetings/year for MN PBSP peer lead staff4
Provide initial training for peers
Provide ongoing training for peers
Ensure that peers have the opportunity to meet regularly with other
peer counselor staff
Ensure that all peer staff have the opportunity to meet with WIC
CPAs at least 2x/year 5
Maintain regular contact with peers
Provide random spot checks of peer’s participants to assess their
perspective on peer support and verify that services are being
provided
Provide back-up for issues outside peer’s scope of practice and if
unavailable
Identify referral resources and plan for issues beyond peer’s and
back-up lead staff scope of practice
Provide outreach about the WIC PBSP
1. Example for a column heading: Mary Smith, Supervisor. Other role examples are: Manager, Back-up, IBCLC, admin (administrative or clerical)
2. Functions can be shared by more than one person. Indicate the persons responsible for duties that will be shared.
3. Indicate who has already attended the FNS Loving Support peer program trainings in the Comments column.
4. Not all staff identified need to attend the two yearly lead staff meetings. Those involved with direct and daily management are expected to attend.
5. Options include having peers attend WIC staff meetings, having CPA staff attend peer meeting or working from clinic with opportunity to talk w CPA staff.
Any other comments to add about peer lead staff and roles:
5
Training and Integrating Peer Program with other WIC services
8 A. Training on USDA FNS Loving Support© through Peer Counseling Curriculums
We understand that our peer managers / coordinators must be trained on the FNS Loving
Support© to Manage Peer Counseling and FNS Loving Support© through Peer Counseling
curriculums. We have indicated on the 7A Essential Peer Program Functions grid who
has attended training. Staff who have yet to be trained are:
B. Peer Lead Staff Meetings
We anticipate having
staff participate in the two yearly required Minnesota WIC
Program peer lead staff management meetings.
The staff is/are:
Comments:
C. Ongoing Training Plan for Peer Counselors. Check all that apply.
Regular peer meetings to provide training opportunities and to discuss questions,
successes and challenges. Frequency of meetings is anticipated to be
.
Opportunity to shadow IBCLC or other WIC staff trained in lactation management.
Opportunity for new peers to shadow experienced peers.
Other:
D. Ongoing Training Plan for Peer Lead Staff
Training on breastfeeding topics by IBCLC, other peer lead staff or guest presenter
WIC breastfeeding conference sessions as available and appropriate
Breastfeeding workshops/seminars
Online breastfeeding course offerings
Self study
Other:
Add any comments about training:
9. Plans for Integrating the Peer Program into the WIC program. Check all that apply.
Orient WIC staff to peer program by providing an overview of peer services
Peers have an opportunity to observe WIC clinics as a part of their orientation.
Peers are introduced to WIC staff as a part of their orientation
Peers are present in WIC clinics
Peers attend some WIC staff meetings and/or WIC CPA staff attend some peer meetings.
Additional plans for peer staff integration into WIC:
Collaboration
10. Plan for Collaboration with Others to Deliver Peer Services. Check all that apply.
We plan to provide peer services within our WIC program and do not plan to contract
or collaborate with other agencies or counties to provide essential peer services.
(Continue to budget page.)
6
We plan to collaborate with neighboring WIC program(s) to provide peer support
services.
We
plan to collaborate with a MN WIC Program with an existing peer program.
We
plan to collaborate with a MN WIC Program that does not have an existing peer
program.
Describe your plan. Include the agencies you will be collaborating with and the activities
you will be sharing:
The letter of support or memo of understanding (MOU) is attached from all WIC
agencies we will collaborate with to deliver peer services. The MOU lists the agencies
agreement to fulfill the designated required functions if the grant is awarded, specifying
roles and who has decision-making authority for the peer functions. (Attach as
Attachment A.)
We plan to collaborate with a non-WIC agency, and to provide peer support services
through their staff who meet the FNS peer definition. If you plan to pursue this
option contact the State WIC Peer Coordinator to discuss your plans before you
submit this application or enter into an agreement with the non-WIC agency.
Please briefly describe your plan:
How will you assure the FNS requirements are met?
How will you integrate peer breastfeeding support staff and coordinate peer services with
your WIC program?
The required support letter or memo of understanding (MOU) is attached from all
agencies or organizations with whom we will collaborate. The MOU is the agencies
agreement to fulfill the designated required functions if the grant is awarded, specifying
roles and who has decision-making authority for the peer functions. (Attach as
Attachment A.)
11. Outreach Plan for the Peer Program (See Guidance.)
Describe your plans for informing others in your community about your peer program.
12. Evaluation and Agency Capacity
Evaluation / Progress Reports. You will be asked to provide a written evaluation and
progress report periodically. See Guidance under Evaluation/Agency Capacity for more
information.
We will provide the required progress reports, the annual work plan and budget, and share
tips and quotes from the peer program that may benefit other agencies.
7
13. Agency Capacity
We have discussed with our program and nutrition consultants our readiness to add or
continue a peer breastfeeding support program without compromising requirements of other
WIC services.
Add any other comments about the peer program and reasons on how your program can
successfully implement peer services
Budget
14. Other Funding Sources. (Other funding sources encouraged, but not required. See Guidance
under Budget, Section 14).
In addition to the designated peer funds we will use the following funding sources to
supplement the peer program funding:
We receive the following in-kind services:
We use WIC grant funds for the following peer program expenses:
We plan to seek or receive outside funding from:
8
15A Budget: Minnesota WIC Peer Breastfeeding Support Program Grant Application
Please fill out this form completely. Use the budget narrative form on the following page for your
category calculations and to explain your budget totals. (See the Guidance, 15 B Budget section for
instructions and additional information to help in planning and calculating your budget.)
For any item that is not applicable, indicate N/A
Name of Applicant Lead Agency:
Name of Contact Person for Budget:
Phone:
Fax:
Item
E-mail:
Amount October 1, 2011 - September 30, 2012
Salary and Fringe Benefits for
employees
$
Contracted staff (e.g. IBCLC, peers)
$
Training
$
Travel
$
Supplies/Reference materials/Training
materials
$
Communication / Cell phones
$
Other
$
Indirect
$
Total
$
9
15B. Budget Narrative
Include a narrative description explaining the details of your budget from October 1, 2011
through September 30, 2012 in two pages or less. See Guidance Budget section, 15B for
more information and examples.
1. Salary and Fringe Benefits
a. Employees (list names if known and all titles)
b. Contracted staff (list names if known and titles)
2. Training
3. Travel
4. Communication costs
5. Supplies, Reference and Training materials
6. Other costs
7. Indirect
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ACCOUNTING SYSTEM AND FINANCIAL CAPABILITY QUESTIONNAIRE
This is the standard form to be used in order to determine the financial capacity of grant applicants. The creation and
implementation of this form is in response to the best practices stated in the Office of Legislative Auditor’s report “State Grants to
Nonprofit Organizations,” January 2007.
This form should be used for applicant agencies that: are requesting, or will receive, more than $50,000; are new to state granting;
are recently incorporated (five years or less); had previous unfavorable financial performance with federal and/or state funds; had
significant audit findings; or for any applicant whose financial capacity is unknown or questionable.
No applicants will be excluded from receiving funding based solely on the answers to these questions.
SECTION A: APPLICANT INFORMATION
1. Organization Name and Address
2.Employer
Identification Number
3.Number of Employees
Full Time:
Part Time:
4. When did the applicant receive its 501(c)3 status?
(MM/DD/YYYY)?
5. Is the applicant affiliated with or managed by any other organizations (Ex.
6a. Total revenue in most recent accounting
regional or national offices)?
YES
NO If “Yes,” provide details:
period (12 months).
5b. Does the applicant receive management or financial assistance from any
other organizations?
YES
NO If “Yes,” provide details:
6b. How many different funding sources does
the total revenue come from?
7. Does the applicant have written policies and procedures for the following business processes?
a. Accounting
Yes
No
Not Sure If yes please attach a copy of the table of contents
b. Purchasing
Yes
No
Not Sure If yes please attach a copy of the table of contents
c. Payroll
Yes
No
Not Sure If yes please attach a copy of the table of contents
SECTION B: ACCOUNTING SYSTEM
1.Has a Federal or State Agency issued an official opinion regarding the adequacy of the applicants accounting system for the
collection, identification and allocation of costs for grants
Yes
No
Note: If a financial review occurred within the past three years, omit Questions 2 – 6 of this Section and 1-3 of Section C.
a. If yes, provide the name and address of the reviewing agency:
b. Attach a copy of the latest review and any
subsequent documents.
2. Which of the following best describes the accounting system?
Manual
Automated
3. Does the accounting system identify the deposits and expenditures of program funds for
each and every grant separately?
4. If the applicant has multiple programs within a grant, does the accounting system record
the expenditures for each and every program separately by budget line items?
5. Are time studies conducted for an employee(s) who receives funding from multiple
sources?
6. Does the accounting system have a way to identify over spending of grant funds?
Combination
Yes
No
Not Sure
Yes
No
Not Sure
Not Applicable
Yes
No
Not Sure
No Multiple Sources
Yes
No
Not Sure
1. Is a separate bank account maintained for grant funds?
Yes
No
Not Sure
2. If grant funds are mixed with other funds, can the grants expenses be easily identified?
Yes
No
Not Sure
3. Are the officials of the organization bonded?
Yes
No
Not Sure
Yes
No
Not Sure
SECTION C: FUND CONTROL
SECTION D: FINANCIAL STATEMENTS
1. Did an independent certified public accountant (CPA) ever examine the organization’s
financial statements?
SECTION E: CERTIFICATION
I certify that the above information is complete and correct to the best of my knowledge.
1. Signature
2. Date
/
/
3. Title
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Attachment A
Letters from collaborating organizations for providing essential peer functions
WIC agencies collaborating to provide any peer program essential functions through
arrangements with another organization must include a letter of support from that organization
agreeing to fulfill the designated required functions if the grant is awarded, outlining roles, and
defining who has decision-making authority for the peer functions in the organization.
Letters are attached from the following organizations:
Attachment B
Include any supporting documents or statistics for agencies with peer programs. If attaching files
with the application list the file name here.
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Submitting your application.
 To be considered for funding, your proposal must be mailed or delivered to:
Mailing Address
Stacia Pomrenke
Minnesota WIC Program
Minnesota Department of Health
Post Office Box 64882
St. Paul, Minnesota 55164-0882
Delivery Address
Stacia Pomrenke
Minnesota WIC Program
Minnesota Department of Health
85 East Seventh Place, Room 220
St. Paul, Minnesota 55101
If no one is available in room 220 to accept the
application do not leave the application - call and
make sure a WIC staff person accepts the delivery.
There is a phone in room 220 you can use.
To meet the deadline, your proposal must:
 Have a legible postmark from the U.S. Post Office or a private carrier dated on or
before April 20, 2011. We will not accept a postmark from a private, in-office metering
machine as proof that you mailed your proposal on time, or

Be hand delivered to the address listed above and date-stamped upon delivery before
4:30 p.m. on April 20, 2011.
o If no one is in the room to accept the proposal call 651-201-4411 or 651-201-3649 to
have a WIC staff person accept and date-stamp the proposal.

We will accept emailed proposals if received before 4:30 pm on April 20, 2011.
Proposals must be attached as a Microsoft Word document or PDF. It is the
responsibility of the applicant agency to verify that the emailed proposal was
received. This verification must be made before the deadline. Occasionally email
delivery systems are slow. Email with viruses or files that are too large are not delivered.
The State email system does not inform you if a document was not delivered.
o If you submit a proposal by email you must also mail in pages that require
signatures, with an original signature.
o E-mail the proposal to stacia.pomrenke@state.mn.us with “WIC PBSP” in the
subject line. Copy linda.dech@state.mn.us on the email.

We will not accept FAXED proposals.
If an organization plans to provide some essential peer services through collaboration with
another WIC program or organization a signed letter from that organization must be
included for the peer proposal to be considered.
Proposals will not be considered if they are not from a current MN WIC Program Grantee
WIC is an equal opportunity provider
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