PBSP Application 2011
Extra Tables for Multi-Agency or Clinic Applicants
These tables are meant additional information beyond the application tables’ capacity.
Please use this form as needed and attach with your application.
Applicant:
Item 1B – Tables for breastfeeding rates.
BF rates by subgroups, ALL
State of Minnesota
Agency:
Clinic:
Clinic:
Clinic:
Clinic:
BF rates by subgroups, ALL
State of Minnesota
Agency:
Clinic:
Clinic:
Clinic:
Clinic:
BF rates by subgroups, ALL
State of Minnesota
Agency:
Clinic:
Clinic:
Clinic:
Clinic:
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
BF Ever
#
%
11404
74.29
< 2 Weeks
#
%
1575 13.90
> 6 mo
#
%
5198 45.88
> 12 mo
#
%
3225
28.46
BF Ever
#
%
11404
74.29
< 2 Weeks
#
%
1575 13.90
> 6 mo
#
%
5198 45.88
> 12 mo
#
%
3225
28.46
BF Ever
#
%
11404
74.29
< 2 Weeks
#
%
1575 13.90
> 6 mo
#
%
5198 45.88
> 12 mo
#
%
3225
28.46
Additional comments:
PBSP 2011 Application Extra Tables Form for (Agency Name)
1
Item 1D: Tables for numbers of participants in proposed services areas.
Location for peer services
Pregnant
(Note Agency name/all or name of
specific clinic site.)
PP BF
PP NBF (not
(breastfeeding)
breastfeeding)
Total
Women
Total Infants
State
12169
9128
8254
29551
29373
Location for peer services
Pregnant
PP BF
PP NBF (not
breastfeeding)
Total
Women
Total Infants
(breastfeeding)
(Note Agency name/all or name of
specific clinic site.)
State
12169
9128
8254
29551
29373
Location for peer services
Pregnant
PP BF
PP NBF (not
breastfeeding)
Total
Women
Total Infants
(breastfeeding)
9128
8254
29551
29373
(Note Agency name/all or name of
specific clinic site.)
State
12169
Additional comments:
Item 3B: Tables for Schedule of peer service availability
Clinic name:
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)
PBSP 2011 Application Extra Tables Form for (Agency Name)
2
Clinic Name:
Mon
Tues
Wed
Thu
Fri
Sat
Sun
Comments
Sun
Comments
Sun
Comments
Sun
Comments
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)
Clinic Name:
Mon
Tues
Wed
Thu
Fri
Sat
Days and
hours peers
available
Plan for backup of Peer Support Staff; IBCLC, manager, back-up WIC staff
WIC staff
available for
backup
(hours)
Clinic Name:
Mon
Tues
Wed
Thu
Fri
Sat
Days and
hours peers
available
Plan for backup of Peer Support Staff; IBCLC, manager, back-up WIC staff
WIC staff
available for
backup
(hours)
Clinic Name:
Mon
Tues
Wed
Thu
Fri
Sat
Days and
hours peers
available
Plan for backup of Peer Support Staff; IBCLC, manager, back-up WIC staff
WIC staff
available for
backup
(hours)
Clinic Name:
Mon
Tues
Wed
Thu
Fri
Sat
Days and
hours peers
available
Plan for backup of Peer Support Staff; IBCLC, manager, back-up WIC staff
WIC staff
available for
backup
(hours)
PBSP 2011 Application Extra Tables Form for (Agency Name)
3
Item 6: WIC and Other Staff Involvement as Peer Program Lead Staff
Name, position and
credentials
Breastfeeding Training
or plans for training
Hours/
week or
FTE
Name, position and
credentials
Breastfeeding Training
or plans for training
Hours/
week or
FTE
Additional comments:
PBSP 2011 Application Extra Tables Form for (Agency Name)
4
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
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 curriculum 3
Attend the 2 required meetings/year for MN PBSP peer lead staff 4
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:
PBSP 2011 Application Extra Tables Form for (Agency Name)
5
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
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 curriculum 3
Attend the 2 required meetings/year for MN PBSP peer lead staff 4
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:
PBSP 2011 Application Extra Tables Form for (Agency Name)
6
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
PBSP 2011 Application Extra Tables Form for (Agency Name)
7
Any additional comments about your peer program plans:
PBSP 2011 Application Extra Tables Form for (Agency Name)
8