STATE OF DELAWARE HEALTH FUND APPLICATION FISCAL YEAR 2010 FUNDING REQUESTS ARE DUE BY COB ON FRIDAY SEPTEMBER 26, 2008 TO: Lisa Schieffert Chief Policy Advisor Delaware Health and 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 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 Health Funds in Fiscal Year 2009? 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 objectives? 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 the agencies that perform similar services? Funding Request 1. What level of funding is your agency requesting for FY 2010? 2. Is the requested funding a one-time request or do you anticipate the need for on-going funding? Please explain. 3. Please submit a proposed line item budget (i.e., personnel, contractual, travel, supplies, etc.) explaining how you intend to use FY 2010 Health Funds. You will be asked to submit a year-end expenditure report, based on the proposed budget, due 30-days following the end of your Health Fund contract, if one is awarded. 4. If you received Health Funds in FY 2008, please submit a year end expenditure report detailing how those funds have been used. 5. 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 to 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 (Agency name) Health Funds: 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 by 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: ____________________________________________________ (Name) ____________________________________________________ (Title) ____________________________________________________ (Name) ____________________________________________________ (Title) Health Fund 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 healthcare and health insurance for citizens of Delaware that lack affordable healthcare due to being uninsured or underinsured; (2) Making long-term investments to enhance healthcare 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 preventative 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. FY 2010 Health Fund Application - 1