DELWARE HEALTH FUND ADVISORY COMMITTEE September 13, 2006 Dear Health Fund Applicant: Attached please find the Fiscal Year 2008 Health Fund Application, which includes the statutorily defined criteria that all Health Fund projects must meet in order to receive a Health Fund Award. Please be mindful of the fact that there is limited funding available for new projects in Fiscal Year 2008 because most of the available Health Fund dollars will be committed to sustaining the current, on-going programs. Therefore, the Health Fund Advisory Committee (HFAC) urges you to seriously consider the scope of your project as it relates to the Health Fund criteria, and consider the size of your Health Fund request, before you decide to expend the time and energy that is necessary for you to complete the Health Fund Application Process. The Health Fund Application is due to Lisa Schieffert, HFAC staff, no later than Friday, October 6, 2006. Please answer each question on the application as concisely and as completely as possible. Final application packets should include: 1) one signed and dated application, 2) one extra and unstapled copy of the application, and 3) an annual certified audit. Upon receipt of your application, a date and time for you to present your project proposal before the HFAC will be scheduled. Generally, these presentations are scheduled sometime between mid-October and mid-November. HFAC staff will contact you with more information about preparing for your presentation at a later date. The HFAC thanks you for your interest in promoting the health and well-being of all Delawareans. Should you have any questions, please do not hesitate to contact Lisa Schieffert at (302) 255-9039. Sincerely, The Health Fund Advisory Committee STATE OF DELAWARE HEALTH FUND APPLICATION FORM FISCAL YEAR 2008 FUNDING REQUESTS ARE DUE BY COB ON FRIDAY OCTOBER 6, 2006 TO: Lisa Schieffert Chief Policy Advisor Delaware Health & Social Services 1901 N. DuPont Highway Main Administration Building, Office 157 New Castle, DE 19720 Phone: (302) 255-9039 E-Mail: Lisa.Schieffert@state.de.us _________________________________________________________________________________ Project Criteria In accordance with Section 137 of Title 16 of the Delaware Code, moneys from the Delaware Health Fund shall be expended for Delaware citizens in accordance with any 1 or more of the following: (1) Expanding access to health care and health insurance for citizens of Delaware that lack affordable health care due to being uninsured or under insured; (2) Making long-term investments to enhance health care infrastructure which meets a public purpose; (3) Promoting healthy lifestyles, including the prevention and cessation of the use of tobacco, alcohol and other drugs by the citizens of Delaware; (4) Promoting preventive care for Delawareans in order to detect and avoid adverse health conditions, particularly cancer and other tobacco-related diseases; (5) Working with the medical community by providing funding for innovative and/or cost effective testing regimens to detect and identify lesser-known but devastating and costly illnesses, such as sarcoidosis and hemachromatosis, fibromyalgia, lupus, lyme disease and chronic fatigue immune deficiency syndrome; (6) Promoting a payment assistance program for prescription drugs to Delaware's low income senior and disabled citizens who are ineligible for, or do not have, prescription drug benefits or coverage through federal state or private sources; (7) Promoting a payment assistance program to Delaware's citizens who suffer from debilitating chronic illnesses, such as diabetes and kidney disease which are characterized by onerous recurring costs for equipment, tests and therapy; and/or (8) Such other expenditures as are deemed necessary in the best interests of the citizens of Delaware provided they shall be made for health related purposes. Agency Information 1. Official Name of Organization: 2. Date of Incorporation or Date Established by Law: 3. 9-digit Federal Employer Identification No.: 4. Address of Management Office: 5. Name, Phone Number, and E-mail Address of Primary Contact Representative: 6. Did your agency receive a Health Fund Award in Fiscal Year 2007? 7. Are you a first time applicant? Program Information 1. Why is there a need for the program for which your agency is seeking Health Funds? 2. What are the program goals and objective? 3. Please describe the target population affected by the program. 4. Where will the services be provided? 5. What other agencies or organizations provide services similar to those of your agency, if any? How do you propose to work with these agencies that perform similar services? Funding Request 1. What level of funding is your agency requesting for FY 08? 2. Is the requested funding a one-time request or do you anticipate the need for on-going funding? 3. Does your agency receive funding from any of the following sources? If so, please provide the name of the funding source and the amount of funding received. * State Funds (i.e., General Funds, ASF, Grant-in-Aid):   * Federal Funds (including federal grants): * Other Funds (i.e., corporate grants): Program Evaluation 1. If you are currently receiving Health Funds, how have you evaluated your program’s success at meeting the previously stated goals and objectives? Specifically, identify the performance measures you use and the corresponding results. 2. If you are currently receiving Health Funds, how would you modify your program in any way to better meet the stated goals and objectives? 3. If you are a new Health Fund Applicant, how do you anticipate evaluating the program? Specifically identify the method of evaluation and the performance measures you will use as part of your evaluation process. Agreement ________________________ agrees to the following as a condition of receiving Health Funds: (agency name) 1. To submit funding requests on the forms provided at the times designated and to participate in the allocations review process. 2. To provide an annual certified audit and other financial statements, service figures, and reports or audits as required by the State of Delaware. 3. To cooperate with other organizations, both voluntary and public, in responding to the needs of the community and in promoting high standards of efficiency and effectiveness. 4. To submit accurate information with this application. NOTE: Any misstatement of facts may forfeit any remaining balance of grants due and/or future grants. 5. That this agency meets the criteria established the Health Fund Advisory Committee and uses any funds appropriated by the General Assembly in accordance with those provisions and any additional restrictions that may be set forth in the grant-in-aid legislation. 6. This agency will provide the Office of the Controller General with financial or programmatic information upon request. This agreement has been read and approved on: _____________________ (Date) By: ____________________________________________________ (Cabinet Secretary, President, or Chairman) _____________________________________________________ (Division Director or Executive Director) 5