STD/HIV/TB Section
Pre-Exposure Prophylaxis (PrEP)
Project Grant
Request for Proposals
April 4, 2016
Notice of Intent Due: April 20, 2016 at 4:30 p.m.
(Required)
Applications Due on Wednesday, May 4, 2016, at MDH by 4:30 p.m.
Table of Contents
I. Introduction: ............................................................................................................................. 1
At a glance PrEP Request for Proposals (RFP) timeline ...................................................... 1
Background ......................................................................................................................... 2
Purpose ............................................................................................................................... 2
PrEP Minnesota Context ..................................................................................................... 2
Project Overview................................................................................................................. 3
II. Scope of Work ......................................................................................................................... 3
Pre-Exposure Prophylaxis ................................................................................................... 3
Funding Availability ............................................................................................................. 4
Eligible Applicants ............................................................................................................... 4
Project Objectives ............................................................................................................... 5
RFP Tasks ............................................................................................................................. 5
Target Population ............................................................................................................... 7
III. Proposal Submission Requirements ........................................................................................ 8
RFP Timeline........................................................................................................................ 8
Pre-Proposal Conference call .............................................................................................. 8
Notice of Intent ................................................................................................................... 8
Proposal Due Date .............................................................................................................. 9
Questions ............................................................................................................................ 9
IV. Program Information ............................................................................................................. 10
Expectations of Applicants ................................................................................................ 10
What MDH will do for you? .............................................................................................. 10
Award Notification ............................................................................................................ 12
Disclaimer.......................................................................................................................... 12
Conflicts of Interest ........................................................................................................... 12
Proposal Contents ............................................................................................................. 12
Disposition of Responses .................................................................................................. 12
Sample Grant Contract Terms and Conditions ................................................................. 13
V. Proposals Review and Selection Process .............................................................................. 13
Phase I Review .................................................................................................................. 13
Phase II Review ................................................................................................................. 13
Phase III Review ................................................................................................................ 14
Due Diligence Form ........................................................................................................... 14
VI. Proposal Evaluation Criteria and Selection Process .............................................................. 14
Project Narrative Scoring Criteria ..................................................................................... 14
Project Work Plan Narrative Scoring Criteria ................................................................... 15
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Project Evaluation Plan Scoring Criteria ........................................................................... 15
Project Budget Plan/Narrative Scoring Criteria ................................................................ 15
Overall Assessment ........................................................................................................... 15
VII. Response Components of the Proposal ................................................................................ 16
Format and Style Requirements ....................................................................................... 16
Response Content ............................................................................................................. 16
Developing the Proposal ................................................................................................... 17
Project Description Narrative ........................................................................................... 18
Project Work Plan Narrative ............................................................................................. 19
Project Evaluation ............................................................................................................. 19
Budget Plan and Narrative ................................................................................................ 19
FORMS
Form A: Notice of Intent
Form B. Application Checklist for Submission
Form C: Applicant Information and certification Sheet
Form D: Project Narrative
Form E: Work Plan
Form F: Evaluation Plan
Form G: Budget Narrative & Allocations
Form H: Due Diligence Form
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PART I: Introduction
At A Glance PrEP Request for Proposals Timeline
RFP Publication Date on MDH Website
April 4, 2016
RFP Issuance Date/ RFP Announcement date):
April 4, 2016
Applicant Conference Calls
April 19 and 20, 2016
Notice of Intent due
April 20, 2016
Proposal Questions Accepted Though
April 22, 2016
Submission of Full Proposals Due:
May 4, 2016
Applicant Evaluation and Selections
May 24, 2016
Announcement of funding Decisions:
May 31, 2016
Grant Contract Negotiation begin:
June 7, 2016
Grant Agreement Development Ends
June 30, 2016
Grant Agreement Period Begins:
July 1, 2016
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Background
The human immunodeficiency virus (HIV) that causes acquired immunodeficiency syndrome
(AIDS) continues to be a persistent public health problem in Minnesota as is in the rest of the
country. Since the Minnesota Department of Health (MDH) began collecting data on HIV/AIDS,
the number of living cases has steadily increased. As of December 31, 2014 there were 7,988
persons believed to be living with HIV/AIDS in Minnesota. Of which 86% are men who have sex
with men (MSM). The largest disparity within the males living with HIV/AIDS in Minnesota is
African American MSM or MSM/injecting drug users at 74% of all cases. About 1,368 individuals
are MSM of color living with HIV in Minnesota that includes Hispanics, American Indian,
Asian/Pacific Islanders, African American, African born, and persons of multiple races. Also in
the same year, there were 32 transgender persons living with HIV/AIDS in Minnesota. However,
MDH epidemiologists believe that is an underestimate as they only recently added the current
gender identity to the HIV surveillance adult case report form.
Purpose
The MDH is soliciting applications under this Request for Proposals (RFP) for the development,
implementation, and evaluation of pre-exposure prophylaxis (PrEP) services for communities at
the highest risk of HIV infection. The STD/HIV/TB Section within the Infectious Disease
Epidemiology Prevention and Control Division of MDH, received grant funds from the
Minnesota Department of Human Services (DHS) to expand PrEP programming in the state.
PrEP is a highly effective risk reduction strategy for HIV-negative people at high risk for HIV
infection. The population at highest risk include, MSM, transgender persons, and other
populations with ongoing risk behaviors that puts them at substantial risk of acquiring HIV
infection. The overall goal of PrEP is to prevent acquiring HIV infection when a person is
exposed to the virus, by taking a pill that contains two HIV medications daily.
PrEP in Minnesota Context
In Minnesota, PrEP is currently prescribed at private and public clinics as a high impact HIV
prevention for HIV negative persons who have medical insurance or can afford to pay. The fullextent to which PrEP is being utilized in Minnesota is unknown. There are three sites funded by
MDH to implement PrEP services in the state. One program targets MSM, another focuses on
prenatal services, and the other targets a diverse clientele. These programs are currently
overwhelmed with clients seeking PrEP, which demonstrates there is potential to greatly
increase the number of PrEP providers and consumers, as well as expand PrEP education in the
state.
The PrEP services are needed to reach individuals willing to use it, especially MSM, high risk
heterosexuals, and transgender individuals who experience unique health inequities and other
barriers in accessing adequate health care and other services. In addition, transgender
individuals have a high prevalence of HIV and STDs and also experience isolation and lack of
social services. Also, both MSM and transgender persons of color lack adequate culturally
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sensitive health and social service providers within their communities. MSM of color are at
disproportionate risk for HIV and other STDs.
Project Overview
Under this RFP, the MDH wants to expand PrEP services in the state as part of a comprehensive
strategy to reduce new HIV infections. The program is intended for gay, bisexual, and other
MSM including transgender persons and other heterosexual populations with ongoing risk
behaviors that may lead to acquiring HIV infection. PrEP is taking a daily pill, a potent new risk
reduction strategy for HIV negative persons that has been scientifically proven to work when
taken as required. PrEP is recommended by the Center for Disease Control and Prevention
(CDC) as part of the high impact prevention strategy that is aimed at reducing new HIV
infections among these populations.
MDH is seeking providers to design and implement PrEP programs for populations at the
highest risk of HIV infection. These programs will include recruiting individuals at high risk,
screening them for HIV infection and eligibility for PrEP, linking them to PrEP friendly providers
and enrolling and engaging them into comprehensive PrEP Programs. All programmatic
activities shall address the unique barriers within these communities and provide education
about PrEP to potential clients and the community by having established successful
relationships with these communities or partnering with culturally sensitive organizations
and/or clinics. Potential applicants shall assure the provision of culturally sensitive and
competent PrEP services to individuals who may benefit from PrEP therapy, and educate
individuals and communities about PrEP services.
PART II: Scope of Work
Pre-Exposure Prophylaxis
Pre-exposure prophylaxis consists of a pill that contains two antiretroviral medications that is
taken daily by HIV-negative individuals in order reduce the risk of acquiring HIV infection. It has
been scientifically proven to significantly reduce the risk of acquiring HIV. The medication was
first approved by the U.S. Food and Drug Administration (FDA) for use as HIV treatment in 2004
and was later approved for use as PrEP in July 2012. Like any medication, adherence is key to
efficacy. Risk-reduction counseling is also an important component of an effective PrEP
program. When taken as directed, PrEP is greater than 90% effective at preventing HIV. The
overall goal of PrEP is to prevent acquiring HIV infection when a person is exposed to the virus.
Federal PrEP guidelines were released on May 14, 2014 by the US Public Health Service. These
guidelines provides clear criteria for determining a person’s HIV risk and indications for PrEP
utilization. It requires that individuals receive HIV testing to confirm negative status before
starting PrEP. These guidelines also emphasizes the importance of counseling about adherence
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and HIV risk reduction, including encouraging condom use for additional protection. The
recommendations also include, regular monitoring of HIV infection status, medication side
effects, and adherence to treatment and sexual or injection risk behaviors. It also encourages
providers to supplement with additional educational materials and tools for use when
prescribing PrEP. The guidelines recommends daily oral PrEP as one prevention option for
sexually active adult men who have sex with other men at substantial risk for HIV, adult
heterosexually active men and women at substantial risk for HIV, adult injection drug users at
substantial risk for HIV and should be discussed with heterosexually active partners of persons
living with HIV in relation to conception and pregnancy.
Resource links for PrEP:
http://www.cdc.gov/hiv/pdf/guidelines/PrEPguidelines2014.pdf
http://www.cdc.gov/hiv/pdf/guidelines/PrEPProviderSupplement2014.pdf
http://www.cdc.gov/vitalsigns/pdf/2015-11-24-vitalsigns.pdf
http://www.cdc.gov/hiv/pdf/PrEP_fact_sheet_final.pdf
http://www.cdc.gov/hiv/pdf/prep_gl_patient_factsheet_prep_english.pdf
http://www.cdc.gov/hiv/pdf/prep_gl_clinician_factsheet_pregnancy_english.pdf
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6446a4.htm?s_cid=mm6446a4_w
Funding Availability
There is an estimated total award amount of four hundred thousand dollars ($400,000)
annually for three years for a one-time competitive grant for PrEP programming. The MDH
intends to fund between three to five PrEP projects. The average amount to be awarded is
estimated to be $80,000 - $100,000 annually per project but actual awards will be determined
based on availability of funds at the conclusion of the RFP process. The funding cycle for this
program announcement begins on July 1, 2016 and ends on June 30, 2019.
Eligible Applicants
Eligible applicants shall include: clinics, non-profit healthcare facilities, local public health
departments clinics, and any public or private non-profit agency that can meet #1 and #2, of the
following criteria:
1. Is currently providing or has provided at least one of the following in the past five years:
a) HIV testing; b) HIV health education and risk reduction programming; c) services for
people living with HIV/AIDS; or, d) PrEP services to one or more of the high risk
populations outlined in this RFP; and,
2. Is currently serving or expect to serve at least 75 percent of clients from the high risk
populations outlined in this RFP; and,
In addition, clinic sites must meet one of the following:
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3. Currently prescribes PrEP and/or provides other HIV/STD prevention screening and
testing services; or,
4. Is willing to prescribe PrEP and provide continued assessment of PrEP utilization within
their services.
Project Objectives
The overall goal of PrEP is to prevent as many new HIV infections as possible.
Organizations/clinics applying for this RFP should propose to develop an innovative and
comprehensive program that will reach high risk populations and communities impacted by HIV
infection. There are four primary objectives of the PrEP project:
1. To implement PrEP risk reduction strategies to reduce the number of new HIV infections
among MSM, transgender persons, injecting drug users and others at high risk for HIV
infection, particularly persons of color;
2. To increase the number of MSM, transgender persons, injecting drug users, and others
at high risk for HIV infection, particularly persons of color that are prescribed PrEP
therapy;
3. To increase the number of MSM, transgender persons, injecting drug users and others
at high risk for HIV infection that are requesting PrEP for HIV prevention by raising
awareness of the efficacy and benefits of PrEP; and,
4. To integrate PrEP into all HIV prevention activities within the agency.
PrEP Tasks
For clinic-based sites – providing health care to high risk population for HIV infection.
Clinic-based sites are defined as facilities that provide medical services and can prescribe PrEP,
monitor persons on PrEP and are serving members of the proposed target population. Clinical
sites will promote, recruit, counsel, and monitor clients enrolled in PrEP and may have
insurance navigators. The clinic staff will prescribe PrEP medication and conduct the HIV and
STD testing that is an integral part of monitoring a client’s PrEP adherence. Clinic staff will
conduct preliminary (for those that have not tested for HIV) and/or confirmatory HIV tests to
assure an individual is not HIV positive. Further risk assessment information will be generated
to determine if the person is a good candidate for PrEP. Those that are eligible will be enrolled
in the clinic’s PrEP program. Some tasks for clinical sites include but are not limited to:
 Conduct risk assessment to identify persons at risk for HIV infection, particularly those with
ongoing substantial HIV risk.
 Identify potential individuals from clients and educate them about PrEP.
 Conduct Pre-prescription assessment: Screen for HIV, STD, mental health issues, drug use,
domestic violence, trauma, and other risk factors and barriers. Is non-occupational postexposure prophylaxis (nPEP) indicated by the client?
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




Reach interested individuals to be prescribed PrEP, if not insured, assist them in getting
medical insurance and finding other cost payment options available.
Continued engagement and retention in PrEP services and other support services (e.g., case
management, housing, mental health, chemical dependency counseling, peer support
groups, health literacy and education, etc.) as needed.
Support individuals to achieve and maintain medication adherence.
Conduct regular HIV/STI testing as recommended and re-evaluate other risk factors.
Monitor and evaluate the implementation and impact of the PrEP project.
For Community-based-organizations
Community-based-organizations (CBOs) are defined as agencies conducting HIV testing but do
not have the capacity to prescribe PrEP and are serving members of the proposed target
population, who will be referred to PrEP friendly providers. Staff at CBOs will engage and recruit
high risk members of the targeted populations, screen prospective participants, provide rapid
HIV testing, assess eligibility for PrEP and refer individuals that test negative to a PrEP program
at medical clinic when appropriate. The agency must have memorandum of understanding
(MOU) or another documented relationship with the clinics they are referring to so they can
follow up to see if the client completed the referral. The CBO PrEP programming may also
include a health care insurance navigator to work with uninsured or underinsured clients to
obtain adequate health care coverage. Some sample tasks for CBOs will include:
 Conduct outreach activities at sites where targeted populations are likely to congregate.
 Conduct risk assessment to identify persons at risk for HIV infection, particularly those with
ongoing substantial HIV risk.
 Refer individuals testing negative for HIV into PrEP services.
 Provide risk reduction counseling – e.g., harm reduction and condom use.
 Identify/select potential PrEP candidates from individuals who test HIV negative.
 Link/refer those interested in PrEP to health care providers with whom you have a MOU
and are willing to prescribe PrEP and offer other services.
 Monitor and evaluate the implementation and impact of PrEP.
Evaluation tasks
All applicants will be required to use at least 10% of MDH grant funds for evaluating their PrEP
program. Applicants must propose a PrEP evaluation plan that is expected to include, but is not
limited to collecting and analyzing data. Some evaluation tasks may include:
 Number of individuals assessed for PrEP (including HIV rapid testing and/or confirmatory
testing).
 Number of individuals determined eligible for a PrEP referral.
 Number of individuals willing to explore PrEP further.
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Number of individuals actively referred to PrEP clinical program.
Number of individuals enrolled in clinical PrEP program (Insured vs Uninsured).
Number of individuals still engaged in PrEP at three month intervals (3, 6, 9, etc.) indicating
if they were uninsured at first visit, do they now have insurance.
Number of individuals connected to medical insurance resources (if project has an
insurance navigator on site).

Target Population
PrEP is not for everyone. PrEP is for persons who are HIV negative, are “at substantial risk” for
HIV infection through sexual transmission and/or injecting drugs and who want PrEP. As per
CDC, non-HIV infected persons that exhibit the following characteristic of substantial HIV risk
may be appropriate:
Men who have sex with men
(Gay/Bisexual/Transgender)
Heterosexual Women and
Men
Injection Drug Users







HIV positive sexual
partners
Recent bacterial STD
High number of sex
partners
History of inconsistent or
no condom use
Commercial sex work





HIV positive sexual
partners
Recent bacterial STD
High number of sex
partners
History of inconsistent or
no condom use
Commercial sex work
In high-prevalence area
or network


HIV positive sexual
partners
Sharing injection
equipment
Recent drug treatment
(but currently injecting)
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Part III. Proposal Submission Requirements
RFP Timeline
RFP Released
Pre-Proposal conference call
Notice of Intent due by 4: 30 p.m.
Completed Proposals due by 4:30 p.m.
Anticipated Notice of Award
Project Implementation begins:
April 4, 2016
April 19 – 20, 2016
April 20, 2016
May 4, 2016
May 31, 2016
July 1, 2016
Pre-Proposal Conference Calls
The MDH staff will offer two opportunities for potential applicants to participate in a
Conference Call in where they can ask questions related to the RFP, its requirements and
processes, and expectations of applicants. You are encouraged to review the RFP document and
its requirements before the conference call. Applicants are strongly encouraged to call in during
one of these Conference Calls but participation is not mandatory.
Please note that staff will not be able to provide feedback on specific project ideas or the
likelihood of receiving funding during the Conference Call.
The dates for the Conference Calls are scheduled for: Tuesday, April 19, 2016 from 1:00-2:00
p.m. and Wednesday, April 20, 2016 from 10:00 – 11:00 a.m. Registration is required to
participate in the call-in. To register, send an e-mail to Ruth Dauffenbach-Kotrba at
ruth.dauffenbach-kotrba@state.mn.us no later than Monday April 18, 2016. You will receive a
confirmation e-mail with call-in instructions.
Notice of Intent
A notice of intent is required for anyone interested in submitting a proposal and will be due on
Wednesday, April 20, 2016. Submitting a notice of intent does not mean that you have to
submit a proposal. However, proposals will not be accepted from applicants who fail to
submit a notice of intent. Notices of intent are due by 4:30 p.m. on Wednesday, April 20,
2016.
Notice of intent should follow the format presented on the notice of intent form (Form A).
Agencies submitting a notice of intent will receive confirmation from MDH that the notice of
intent was received.
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Notice of intent is accepted electronically only. Complete the notice of intent form (Form A).
Include in the e-mail subject line, “Notice of Intent – PrEP Project Grant” and attach the notice of
Intent form and e-mail to Ruth Dauffenbach-Kotrba at ruth.dauffenbach-kotrba@state.mn.us.
E-mail with the attachment must be received by 4:30.p.m. A notice of Intent received after this
time will be disqualified. A confirmation e-mail will be sent to all applicants when the notice of
Intent is received by MDH.
Proposal Due Date
Completed proposals MUST be submitted electronically to MDH on or before: 4:30 p.m.,
Wednesday, May 4, 2016 in the format described. Late proposals will not be accepted.
(Proposals are not accepted by postal mail or facsimile (fax). Send an e-mail to:
health.hivprevention@state.mn.us with the subject line titled, “PrEP RFP 2016” with four PDF
attachments as follows:
 First, PDF attachment which includes: proposal checklist Form B and the project
narrative Form D. Titled PDF “[agency or clinic name] PrEP Project Narrative.”
 Second, PDF attachment which includes the project work plan narrative Form E and
evaluation plan Form F. Include partnership table and any partners MOUs completed.
Titled PDF “[agency or clinic name] Project Work Plan.”
 Third, PDF attachment which includes the budget plan and narrative (Form G). The
budget must be titled, “[agency or clinic name] PrEP Project Budget.”
 Fourth, PDF attachment which includes: applicant Information certification sheet Form
C and due diligence Form H - (Form H for non-governmental agency only) and
accompanying documents. This must be titled, “[agency or clinic name] Certification.”
PLEASE NOTE: Proposals must be submitted to MDH by 4:30 p.m. on Wednesday May 4, 2016.
All submissions are final. Full and complete proposals not received by 4:30 p.m., Wednesday,
May 4, 2016 will NOT be considered. A confirmation e-mail will be sent to all applicants whose
proposal is received on time. All questions regarding this RFP should be submitted via e-mail to
health.hivprevention@state.mn.us. Individual MDH staff are not authorized to respond.
All submissions deadline are final. Notices of intent and proposals not received by the
deadlines outlined in this RFP will not be considered. All expenses incurred in responding to this
RFP are solely the responsibility of the applicant. MDH will not be responsible for RFP
documents (e.g., Notice of Intent, Proposal) electronically sent to a wrong e-mail address.
Questions
Questions regarding this RFP or the RFP process will be accepted through Wednesday,
April 20, 2016. All questions need to be submitted via e-mail with “PrEP RFP Grant” in the
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subject line to health.hivprevention@state.mn.us. MDH will respond to the person who sent
the question and will post the question and answer on the MDH website. Questions and
answers of a substantive nature will be posted on the MDH website at :
http://www.health.state.mn.us/divs/idepc/diseases/hiv/rfp/prep/index.html where other potential
applicants can access the same information. Please include your name and phone number in
the e-mail.
Part IV. Program Information
Expectations of Applicants
The MDH staff anticipate the contract period to begin on July 1, 2016.
1. Clinical sites will be expected to recruit, screen, prescribe PrEP and counsel and monitor
PrEP enrollees and assist in linking them to health insurance. Clinical site will be
expected to follow the published CDC PrEP guide at:
http://www.cdc.gov/hiv/pdf/guidelines/PrEPguidelines2014.pdf
2. Community-based sites will be expected to recruit and engage high risk members of the
target populations, screen prospective individuals, and provide active referral to a PrEP
program with whom they have a MOU and assist in navigating the health insurance
options.
3. All potential providers are strongly encouraged to “think outside the box” when
developing new ideas for engaging high risk persons into PrEP and addressing their
sexual health needs.
4. All projects will submit a narrative report on the project’s progress quarterly. A form for
this report will be provided by the State. Additional contractual obligations are
contained in the sample contract document that can be accessed at MDH’s website:
http://www.health.state.mn.us/divs/idepc/diseases/hiv/rfp/prep/index.html.
What MDH will do for you?
1. During the RFP process MDH will:
a. Respond to applicant e-mail inquiries about the RFP document, its requirements,
eligibility criteria and this process.
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b. Provide pre-proposal conference calls for applicants to ask questions and receive
clarification about the RFP documents, its requirements, eligibility criteria and this
process.
c. Communicate a summary of the questions and answers for prospective applicants.
2. During the grant agreement period MDH will:
a. Provide or make referrals for technical assistance and training for applicants that will
address topics such as planning, implementation, and evaluation of HIV prevention
activities.
b. Provide technical assistance through administrative and programmatic site visits to
improve the quality of delivered services.
c. As required by the CDC, any product used within the PrEP project needs to be
submitted for review prior to use. MDH provides for the review and approval of all
PrEP project materials submitted in a timely manner. Material review includes, but is
not limited to, technical accuracy, compliance with the federal guidelines and
appropriateness for the target audience.
d. Provide data and information about HIV, STDs, hepatitis, PrEP, and
recommendations for effective prevention activities and promising project
strategies.
e. Coordinate the activities of PrEP with other efforts at the local and state levels to
avoid duplication of efforts and to promote consistency.
f. Assist applicants working with state and local health departments, community
planning groups, funding institutions and other potential partners.
g. Share information regarding educational opportunities and available funding from
foundations and other public and private groups.
h. Work with applicants to effectively implement work plans and provide technical
assistance and training to support them.
i. Work to revise and finalize budgets and work plans and will respond to requests for
prior approval of expenditures and activities.
j. Verify expenditure documentation at least once during the grant period.
i. Assess fiscal responsibility before grants are awarded and before renewals or
extensions.
ii. Provide guidance regarding the required content of the progress and evaluation
reports for all applicants.
iii. Maintain frequent contact and at least one on-site visit to monitor PrEP grant
activities during the grant period.
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Award Notification
The agency will be notified by letter during the week of May 31, 2016 whether or not their
proposal was selected for funding. All decisions are final. We reserve the right to negotiate
changes to the proposed activities and budgets submitted.
Disclaimer
The Minnesota Department of Health reserves the right to withhold the distribution of funds in
cases where proposals submitted do not meet the necessary criteria.
This Request for Proposals does not obligate the state to award a contract or complete the
project, and the state reserves the right to cancel the solicitation if it is considered to be in its
best interest.
Conflicts of Interest
Responder must provide a list of all entities with which it has relationships that create, or
appear to create, a conflict of interest with the work that is contemplated in this request for
proposals. The list should indicate the name of the entity, the relationship and a discussion of
the conflict.
Proposal Contents
By submitting an application, the applicant warrants that the information provided is true,
correct, and reliable for purposes of evaluation for potential grant contract award. The
submission of inaccurate or misleading information may be grounds for disqualification from
the award as well as subject the applicant to suspension or debarment proceedings as well as
other remedies available by law.
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 the Minnesota Statutes, section 13.599 after the
evaluation process is completed. Pursuant to that statute, completion of the evaluation process
occurs when MDH, as the granting agency, has completed negotiating grant agreements with
the selected applicants.
If an applicant submits information in response to this RFP that it believes to be trade secret
materials, as defined by the Minnesota Government Data Practices Act, Minnesota Statute
13.37, the responder must: (a) Clearly mark all trade secret materials in its application at the
time the application is submitted; (b) include a statement with its application justifying the
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trade secret designation for each item; and, (c) defend any action seeking release of the
materials it believes to be trade secrets, and indemnify and hold harmless the State of
Minnesota, its agents and employees, from any judgments or damages awarded against the
state in favor of the party requesting the materials, and any of and all costs connected with that
defense. This indemnification survives the award of any grants pursuant to this RFP. In
submitting an application to this RFP, the applicant agrees that this indemnification survives as
long as the trade secret materials are in possession of MDH. The State will not consider the
prices submitted by the responder to be proprietary or trade secret materials.
Sample Grant Contract Terms and Conditions
Applicants need to be aware of MDH’s standard grant contract terms and conditions in
preparing the application. A sample MDH grant contract agreement can be downloaded from:
http://www.health.state.mn.us/divs/idepc/diseases/hiv/rfp/prep/index.html. Much of the language
reflected in the grant agreement is required by statute. If your organization takes exception to
any of the terms, conditions or language in the contract, you must indicate those exceptions in
your responses to this RFP; certain exceptions may result in your application being disqualified
from further review and evaluation. Only those exceptions indicated in your response to this
RFP will be available for discussion or negotiation.
Part V. Proposal Review and Selection Process
Applications received by the deadline will be reviewed in three phases.
Phase I Review
MDH staff will initially review all applications received for completeness (refer to application
submission checklist Form B) and eligibility. Incomplete applications and non-eligible applicants
will not advance to Phase II review. These applicants will be informed by an e-mail that their
applications did not meet eligibility and/or published submission requirements.
Phase II Review
MDH staff will recruit a diverse group of people as reviewers that consist of the MDH staff, and
other experts in the field who will review the proposals for content. Reviewers will score the
applications individually using a provided score sheet. These reviewers will evaluate complete,
eligible applications in accordance with the detailed descriptions of scoring criteria in the
proposal evaluation and selection section of this RFP.
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Phase III Review
MDH staff will review the recommendations to make final funding decisions. Staff will balance
recommendations by the reviewers with other factors including, but not limited to: reviewers’
numerical score ranking, geographic diversity, representativeness of target population, and
total available funds.
Due Diligence Review
MDH requires non-governmental organizations to complete a Due Diligence review form. If an
organization is using a fiscal agent, the fiscal agent should complete the Due Diligence Review
Form H. Submit this form along with the proposal.
Part VI. Proposal Evaluation and Selection Process
A complete proposal received by the deadline will be reviewed and scored based on the
following:
Project Description Narrative: (30 points)
Project Work Plan Narrative – (35 points)
Project Evaluation plan – (15 points)
Project Budget Plan/Narrative – (15 points)
Overall Proposal Assessment – (5 points)
Each reviewer will independently score and submit individual scores for each proposal. All
reviewers’ scores will be tabulated and ranked. Then the reviewers will participate in a review
meeting where the applications will be discussed. The reviewers will have an opportunity to
modify their scores based on the group discussion. At the end of the process, reviewers will
make preliminary recommendations to MDH for a final funding decision.
Project Narrative Scoring Criteria (30 points)

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
Are the project goals, objectives and activities for this project clearly defined?
Is the population that the project is designed to reach clearly described?
Are the proposed activities consistent with the cultural characteristics of the
population?
Does the applicant adequately describe the need for proposed activities?
Does the agency or organization have a history of implementing successful HIV
prevention programs?
Does the agency or organization adequately describe the capacity and the quality of
experience it has to implement the proposed project?
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

Do activities help integrate PrEP into related STDs and other HIV preventative strategies,
e.g., harm reduction, condom use?
Does the applicant describe ways to maintain a focus on PrEP?
Are skills related to working with persons from diverse backgrounds described?
Are there effective strategies to involve the intended populations?
Will people from diverse backgrounds related to race, ethnicity, sexual
orientation/identification and socioeconomic status be involved in making decisions?
Project Work Plan Narrative Scoring Criteria (35 points)


Does the applicant clearly describe the activities they intend to provide/implement?
Is it clear who will be responsible for implementing activities throughout the project
period?
 Are the timelines for activities reasonable?
 Are the proposed activities for each goal consistent with the cultural and socioeconomic
characteristics of the intended audience(s) and do they demonstrate cultural
appropriateness?
 Overall, is the work plan sufficiently detailed, clear and easy to understand and
demonstrate a clear relationship between the identified needs and the goals and
activities?
Partnership Scoring Criteria (10 points)
 Are the partnerships formed described? Are there any partnership documented
agreements included?
Project Evaluation Plan Scoring Criteria (15 points)

To what extent do the proposed evaluation criteria effectively measure the project’s
process toward meeting their outcomes?
Project Budget Plan/Narrative Scoring Criteria (15 points)
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

Is the Budget Narrative and Allocations (Form G) form complete?
Are the proposed expenses appropriate to the proposed activities?
Does applicant describe how achievements from this project might be sustained into the
future, once funding ends?
Are the proposed ideas feasible?
Overall assessment of grant application (5 points)
Overall, based on reviewing all parts of this proposal and what you consider as the strengths
and weaknesses of this proposal, is this application:
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Excellent: = 5 points
 Outstanding level of quality; significantly exceeds all aspects of the minimum
requirements; high probability of success; no significant weaknesses.
Very Good: = 4 points
 Substantial response; meets in all aspects and in some cases exceeds the minimum
requirements; good probability of success; no significant weaknesses.
Good = 3 points
 Generally, meets minimum requirements; probability of success; significant weaknesses
but correctable.
Marginal = 2 points
 Lacks essential information; low probability of success; significant weaknesses but
correctable.
Unsatisfactory = 1 point
 Fails to meet minimum requirements; little likelihood of success; needs major revision
to make it acceptable.
Part VII. Response Components of the Proposal
Format and Style Requirements
 Proposals must be typed and all pages should be numbered consecutively.
 Use Calibri 12-point font, one-inch margins, and single line spacing.
 Paragraphs should be separated by a blank space.
 The project narrative must not exceed 8 pages, excluding attachments.
 The proposal must be signed where noted.
Response Content
Forms and steps required for all proposals:
Applicants are required to complete Form B “Proposal Checklist Form” as part of the proposal.
All of the required Forms B through H must be completed and included in the proposal. All
these forms can be accessed at:
http://www.health.state.mn.us/divs/idepc/diseases/hiv/rfp/prep/index.html
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Developing the Proposal – Step 1 through 7
A complete proposal consists of Forms B through H.
Step 1:
Complete and submit Notice of Intent form (Form A) by 4:30 p.m., Wednesday April, 20, 2016.
This form is required for someone to be able to submit a proposal. It allows the MDH to plan
the review process.
Step 2:
Complete the proposal checklist form (Form B). This form is self-explanatory. Please check each
item on this form as it is completed.
Step 3:
Complete the applicant information and certification form (Form C). This form provides MDH
contact information and other information required by the State. A signature of the director of
the applicant agency is required on the certification section of Form C.
Step 4:
Complete Project Narrative form (Form D).
The questions that require responses are provided on Form D.
Step 5:
Complete Form E and F: Instructions for completing the forms are included on each form. The
questions that require responses are provided on Form E and F.
Form E: Project Work plan Narrative: Answer all (four) questions on Form E including the
partnership question and complete the partnership chart. Include any MOUs, if applicable with
this form.
Form F: Evaluation Plan form
Step 6:
Complete Form G. Instructions for completing Form G are included.
Form G: Project Budget Plan. Answer all the questions on Form G. Complete the budget
narrative for each line item.
Step 7:
Complete the Due Diligence Form H. (For non-governmental organizations or agencies only)
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Complete Proposal:
The proposal for the PrEP project consists of the following required core components:
 Project Description Narrative: (30 points)
 Project Work Plan Narrative – (35 points)
 Project Evaluation plan – (15 points)
 Project Budget Plan/Narrative – (15 points)
 Overall Proposal Assessment – (5 points)
Project Description Narrative: (30 points) (Maximum 4 pages)
Use Form D: Project description narrative form to answer these questions.
1. Provide a brief overview of the organizational background including mission and major
programming. Also, how the organization meets the eligibility criteria for this RFP? (5
points)
2. Describe in detail, what makes your organization well-suited to provide PrEP programming
and other related services you are proposing? Also describe how PrEP will be integrated
with other HIV/STD prevention messaging. (5 points)
3. Briefly describe the current and/or past experience(s) relevant to working with your
proposed target population, particularly communities of color, individuals with disabilities,
and individuals with limited English proficiency; include activities offered, number of
individuals served, and a summary of evaluations of activities, where applicable. (5 points)
4. Briefly describe the qualities that demonstrate your agency’s capacity to implement the
proposed PrEP project. List people who will be involved – include titles, relevant roles and
qualifications. (5 points)
5. Describe what you propose to do in this project, include the project goals and objectives
you plan to address, the targeted population(s) you intend to reach and why this/these
activities are needed (5 points).
6. Explain how you will engage the population that your program will serve? Describe the
activities and roles the target population you plan to serve will be involved in such as
design, planning, implementation and decision-making processes. (5 points)
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Project Work Plan Narrative – (35 points) (Maximum 3 pages)
(Use Form E: Project work narrative form to answer these questions)
1. Describe how your program activities will be delivered in a culturally and linguistically
appropriate and competent manner? (5 points)
2. Describe how your proposed activities will contribute to reducing HIV transmission among
the target population you will serve? (5 points)
3. List specific PrEP activities that you are proposing (refer to sample tasks in this RFP) to
implement. Using the work plan form (Form E) (completed work plan template is not
included in page limit), describe in detail: how you propose to accomplish the steps
necessary to implement the project proposed. (15 points)
 Dates by when you will do those activities;
 Who is responsible for implementing or accomplishing each activity;
 Estimated number of people to be reached per proposed activity; and,
 How you will demonstrate the outcome of your project.
4.
Partners: Who are the key partners that will help you increase capacity and partner with, if
appropriate. Using the Partner/Collaborator table, include names of your current or
potential partners and collaborators for this project, both formal and informal, and describe
the roles and responsibilities they will have in this PrEP project. Indicate which partners you
have already contacted, those you already have existing relationships with (include MOUs),
and those you plan to contact if you are funded. (10 points)
Project Evaluation – (15 points) (Maximum two pages)
(Use Form F: Project evaluation plan form to answer these questions)
Describe the plan you will use to measure the processes and the impact of those outcomes on
the target population(s) your project is designed to reach? For each activity proposed:
 Identify employees to be involved and their experience leading or implementing an
evaluation; (5 points)
 Briefly describe the type of data to be collected, the frequency of data collection, and
instrument to be used; (5 points)
 Describe how the data will be analyzed, and reports to be generated; and, (3 points)
 How the results will be disseminated and used. (2 points)
Budget Plan and Narrative – (15 points) (Maximum one page)
(Use Form G: Project budget plan/narrative form to answer these questions)
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1. The proposed budget plan must include in-kind funds. Please provide a brief description of
these in-kind funds reflected in the proposed budget plan. (5 points)
2. Please describe how potential outcomes from this project might be sustained once PrEP
funding ends and how your agency will continue to provide support and/or resources for
those outcomes and future activities. (5 points)
3. Using the format of the “Budget Narrative," briefly describe your overall budget plans and
delineate specific line items (i.e., salaries and wages, fringe benefits, travel, supplies,
contractual, other expenses, administrative costs, etc.) It is helpful to consider:
 Is the information in the budget narrative complete, correct, and consistent with the
proposed activities?
 Are the costs projected for the proposed activities and staffing levels reasonable? (5
points)
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Form A: Notice of Intent
Notice of Intent
All applicants who are interested in submitting an application for the PrEP Project Grant are
required to submit a Notice of Intent form by April 20, 2016.
This form must be submitted electronically to Ruth Dauffenbach-Kotrba at ruth.dauffenbachkotrba@state.mn.us by 4:30 p.m. on or before April 20, 2016.
Agency Name
Address
Contact Person’s
Name
Title
Phone
Fax
E-mail
We intend to apply as:
(Select one).
 Clinic-based
agency
 Communitybased agency
FORM B: Proposal Checklist
Proposal Checklist
Please include all of the required information in the proposal including all attachments. Please
do not submit any materials that are not requested.
Use this form to ensure that you have all required materials for submission.
A complete proposal must include the following materials (check below when complete):
Form A: Notice of Intent
Form B: Proposal Checklist
Form C: Applicant Information Certification Sheet
Form D: Project Description Narrative (4 pages)
Form E: Project Work Plan Narrative (3 pages, excludes work plan table pages)
Form F: Project Evaluation Plan (2 pages)
Form G: Project Budget Plan/Narrative (One page, excludes budget plan/narrative)
Form H: Due Diligence Review
Copy of Federally Approved Indirect Rate
One of the following items is required for non-government agency:
 Financial statement - (For organizations with less than $25,000 in revenue)
 IRS Form 990 - (For organizations with $25,000 - $750,000 in revenue)
 Certified Financial Audit - (For organizations with more than$750,000 in revenue)
FORM C: Applicant Information Certification Sheet
Applicant Information and Certification Sheet
Name of Agency
Project Name:
Mailing Address:
Primary Contact Person:
E-Mail Address
Phone:
Fax:
Agency Type:
Non-profit Status? (Yes or No)
Federal Tax Identification number:
Or Minnesota Tax Identification Number:
Total Budget Amount Requested
Proposed Target Population:
Proposed Target Service/Geographic area:
Certification:
I certify that the information contained in this proposal is true and accurate to the best of my knowledge,
does not include any trade secrets, and that I have the authority to submit this application.
X___________________________________
_____________________________
Signature of authorized agency representative
Print name and Title
__________
Date
FORM D: Project Description Narrative
Project Description Narrative – (30 points)
Instructions
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

Answer all six questions
The maximum number of pages cannot exceed four pages
Use Calibri 12-point font
One-inch margins and single line spacing
Paragraphs separated by a blank space
Questions
1. Provide a brief overview of the organizational background including mission and major
programming. Also, how the organization meets the eligibility criteria for this RFP? (5
points)
2. Describe in detail, what makes your organization well-suited to provide PrEP programming
and others related services you are proposing? Also describe how PrEP will be integrated
with other HIV/STD prevention messaging. (5 points)
3. Briefly describe the current and/or past experience(s) relevant to working with your
proposed target population, particularly communities of color, individuals with disabilities,
and individuals with limited English proficiency; include activities offered, number of
individuals served, and a summary of evaluations of activities, where applicable. (5 points)
4. Briefly describe the organizational background and qualities that demonstrate your agency’s
capacity to implement the proposed PrEP project. List people who will be involved – include
titles, relevant roles and qualifications. (5 points)
5. Describe what you propose to do in this project, include the project goals and objectives
you plan to address, the targeted population(s) you intend to reach and why this/these
activities are needed (5 points).
6. Explain how you will engage the population that your program will serve? Describe the
activities and roles the target population you plan to serve will be involved in, such as
design, planning, implementation and decision-making processes. (5 points)
Form E: Project Work Plan Narrative
Project Work Plan Narrative (35 points)
Instructions





Answer all four questions
The maximum number of pages cannot exceed three pages
Use Calibri 12-point font
One-inch margins and single line spacing
Paragraphs must be separated by a blank space
Questions
1. Describe how your program activities will be delivered in a culturally and linguistically
appropriate and competent manner? (5 points)
2. Describe how your proposed activities will contribute to reducing HIV transmission
among the target population you will serve? (5 points)
3. Project work plan: Use the work plan Form F (completed work plan template does not
account to the page limit). List specific PrEP activities that you are proposing (refer to
sample tasks in this RFP) to implement, describe in detail: how you propose to
accomplish the steps necessary to implement the project proposed. (15 points)
a. dates by when you will do those activities;
b. who is responsible for implementing or accomplishing each activity;
c. Number of people to be reached per proposed activity;
d. how you will demonstrate the outcome of your project;
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Applicant Name:
Project Goal:
Targeted Population
Service/Geographic area:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Date(s)
Activities
Person Responsible
Projected
number
Measure or Outcome
of clients
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4. Partnership/Collaboration
Describe the key partners that will help you increase capacity and will partner with, if
appropriate. Using the Partner/Collaborator chart to include names of your current or
potential partners and collaborators for this project, both formal and informal, and describe
the roles and responsibilities they will have in this PrEP project. Indicate which partners you
have already contacted, those you already have existing relationships with (include MOUs),
and those you plan to contact if you are funded.(10 points)
Complete Partner/Collaborator chart
Organization’s Name:
Contact Person:
Telephone Number:
Relationship Status (select one):
o New/Potential
o Current
For how long? _______
o Former
When?
_______
Organization’s Role in Project (within the partnership):
Organization’s Type:
o Profit
o Non-Profit
Any additional Information:
Include any MOU(s).
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FORM F: Project Evaluation Plan
Project Evaluation Plan (15 points)
Instructions

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

Must answer this evaluation question
The maximum number of pages cannot exceed two pages
Use Calibri 12-point font
One-inch margins and single line spacing
Paragraphs must be separated by a blank space
Question
Describe the plan you will use to evaluate the components and impact of your program. For
each PrEP evaluation activity proposed:
 Identify employees to be involved and their experience leading or implementing an
evaluation. (5 points)
 Briefly describe the type of data to be collected, the frequency of data collection, and
instrument to be used (include sample data collection tool). (5 points)
 How the data will be analyzed, and reports to be generated. (3 points)
 How the results will be disseminated and used. (2 points)
FORM G: Project Budget Plan/Narrative
Budget Plan/Narrative – (15 points)
Instructions





Must answer all three budget questions
The maximum number of pages cannot exceed one page
Use Calibri 12-point font
One-inch margins and single line spacing
Paragraphs must be separated by a blank space
Questions
1. The proposed budget plan must include in-kind funds. Please, provide a brief description of
these in-kind funds that will be reflected on the proposed budget. (5 points)
2. Please describe how potential outcomes from this project might be sustained once PrEP
funding ends and how you and/or your agency will continue to provide support and/or
resources for those outcomes and future activities. (5 points)
3. Use the format of the “Budget Narrative” and briefly describe your overall budget plans and
delineate specific line items (i.e., salaries and wages, fringe benefits, travel, supplies,
contractual, other expenses, indirect costs, etc.). (5 points)
 Is the information in the budget narrative complete, correct, and consistent with the
proposed activities?
 Are the costs projected for the proposed activities and staffing levels reasonable?
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PrEP GRANT BUDGET PLAN 2016
Please see
http://www.health.state.mn.us/divs/idepc/diseases/hiv/rfp/prep/BudgetPlan442
016.xlsx
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Name of Individual Applicant or Agency:
Name of Contact Person for Budget:
Budget Narrative: (Provide a brief justification for the budget items requested below, including how costs were
determined.)
Line Item
Proposed Amount
1.
Salaries
$
2.
Fringe Benefits
$
3.
Travel and Subsistence
$
4.
Supplies
$
5.
Contractual (if applicable)
$
6.
Evaluation
$
7.
Other Expenses
$
8.
Subtotal
$
9.
Administrative Costs
$
10.
TOTAL
$
Notes: Please ensure that mathematical calculations are accurate.
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BUDGET PLAN INSTRUCTIONS
Instructions for filling out the Budget Plan 2016 form and the Budget Narrative 2016 form
Applicant
Type agency’s name
Address
Type agency’s address (if the agency has more than one location,
write the address of the fiscal office)
Telephone
Type the phone number of the person responsible for completing the
budget plan
Email
Budget Plan Period
Type the email address of the person responsible for completing the
budget plan
July 1, 2016 through June 30, 2017
1. Salaries:
For each position indicate the name, title, the full time equivalent on this project and the total
amount for the budget period.
 Funds can be used for salary of staff members directly involved in the proposed project
(planning, developing, delivering or supporting).
2. Fringe Benefits:
All other costs, except for compensation, for full- or part-time employees listed in “Salaries”
above. These may, but are not required to, include: employer portion of FICA and Medicare,
medical and dental insurance, long-term disability insurance, life and accidental death and
dismemberment insurance, workers compensation insurance, and unemployment insurance.
 State each staff person’s fringe per year.
 State total fringe amount and percent for the budget period.
3. Travel and Subsistence:
All costs related to the in-state and out-of-state transportation of project employees for
approved project activities. Client travel is reported under Other Expenses.
 Both in-state and out of state travel (mileage & parking) should be calculated here.
Mileage should be calculated at a maximum of the current IRS allowable amount.
 If applicable, in-state travel subsistence (meals, hotel) is listed separately as a sub-line
item.
 Out of state travel should be listed as a sub-line item under travel line item.
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4. Supplies:
All project costs related to the purchase of items with a cost of less than $5,000 must be
itemized.
Examples: condoms & lube, office supplies, copying costs, brochures & educational
material, computer, software, etc.
 If you provide incentives such as gift cards, list the value of each incentive, the number
to be distributed, and the total value. The maximum value of an incentive instrument is
limited to $50.00 with one instrument disbursed per individual per occurrence.
5. Contractual:
If you plan to hire independent contractors for specific services on a fee basis, please
indicate: (1) the name(s) of the contractor(s) or consultant(s); (2) the dollar amount(s);
(3) the specific expense line items; and, (4) the service(s) being provided.
 Contract states, “GRANTEE shall develop documentation of subcontracts and any other
documents that includes, but is not limited to: 1) description of the contracted activities;
2) budget; and, 3) signatures of appropriate staff from both the GRANTEE and the
subcontractor.”
Note: Sub-contracts require prior written approval by the MDH.
6. Evaluation:
Project evaluation is a required activity. Evaluation activities can be conducted by contractual
services or staff time. Enter the allocated amount of dollars. At least 10% of the proposed
budget funds must be used for evaluation.
7. Other Expenses:
All project cost items, not included in the previous definitions must be specified.
Examples: office phone, cell phone, internet access, postage, advertising,
translation/interpretation costs, costs associated with staff training (fees).
8. SUBTOTAL:
Total items 1- 7 above.
9. Administrative Costs:
MDH will accept the applicant’s current federally approved indirect cost rate. Applicant
must submit proof of their federally approved rate. If an applicant does not have a federally
approved indirect cost rate, MDH will allow up to 10% of the total grant award for indirect
cost on both federal and state funded program.
 Administrative Costs percentage must match the cost allocations of the PrEP project in
relationship with other programs in the agency.
 Administrative Costs are defined as costs that represent the expenses of doing business
that are not easily identified with a particular grant, contract, project, function, or
activity but are necessary for the general operation of the organization and the conduct
of activities it performs.
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Note: Administrative expenses will not be provided to other government agencies or
universities.
10. TOTAL:
Total of 8 + 9 above.
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FORM H: Due Diligence Review
Due Diligence
MDH must conduct due diligence reviews for non-governmental organizations (NGOs) applying
for grants. Due diligence refers to the process through which MDH researches an organization’s
financial and organizational health and capacity. 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 an NGO and other sources to make an informed funding decision.
Instructions
As an applicant for MDH funds you must answer the following questions about your
organization, and any required additional documentation required.
Organization Information Questionnaire
Question
Response
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 organization's total revenue in the most recent 12month accounting period?
4. How many different funding sources does the total revenue come
from?
5. Does your organization have a current 501(c) 3 status from the IRS?
Circle Yes or No
6. Has your organization done business under any other name(s) within
the last five years? Circle Yes or No
If yes, list name(s) used.
7. Is your organization affiliated with or managed by any other
organizations, such as a regional or national office? Circle Yes or No
If yes, provide details.
8. Does your organization receive management or financial assistance
from any other organizations? Circle Yes or No
If yes, provide details.
9. Have you been a grantee of the Minnesota Department of Health
within the last five years? Circle Yes or No
If yes, from which division(s)?
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Question
Response
10. Does your organization have written policies and procedures for
accounting processes? Circle Yes or No
If yes, please attach a copy of the table of contents.
11. Does your organization have written policies and procedures for
purchasing processes? Circle Yes or No
If yes, please attach a copy of the table of contents.
12. Does your organization have written policies and procedures for payroll
processes? Circle Yes or No
If yes, please attach a copy of the table of contents.
13. Which of the following best describes your organization's
accounting system? Check one response.
Manual
Automated
Both
14. Does the accounting system identify the deposits and
expenditures of program funds for each and every grant
separately? Check one response.
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? Check one response.
16. Are time studies conducted for employees who receive
funding from multiple sources? Check one response.
17. Does the accounting system have a way to identify overspending of grant funds? Check one response.
18. If grant funds are mixed with other funds, can the grant
expenses be easily identified? Check one response.
19. Are the officials of the organization bonded? Check one
response.
20. Did an independent certified public accountant (CPA)
ever examine the organization's financial statements?
Check one response.
21. Has any debt been incurred in the last six months? Circle Yes or No.
If yes, what was the reason for the new debt?
What is the funding source for paying back the new debt?
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Question
Response
22. What is the current amount of unrestricted funds compared to total
revenues?
23. Are there any current or pending lawsuits against the organization?
Circle Yes or No
24. If yes, could there be an impact on the organization's financial position?
Circle one response.
25. Has the organization lost any funding due to accountability issues,
misuse, or fraud? Circle Yes or No
If yes, please describe the situation, including when it occurred and
whether issues have been corrected.
Additional Documentation Required
The following documentation is required in addition to the due diligence form.
IF you’re an NGO with annual income of…
THEN submit your most recent:
under $25,000
Board-reviewed financial statement
between $25,000 and $750,000
IRS Form 990
over $750,000
Certified financial audit
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