TRIBAL ACCREDITATION SUPPORT INITIATIVE (Tribal ASI)2017-2018

REQUEST FOR APPLICATIONS (RFA)

FUNDING OPPORTUNITY OVERVIEWWith funding from the Office of State, Tribal, Local and Territorial Support, Division of Public Health Performance Improvement (OSTLTS / DPHPI) within the Centers for Disease Control and Prevention, the National Indian Health Board (NIHB) is offering a funding opportunity for Tribal health departments seeking to undertake activities related to public health accreditation, as established by the Public Health Accreditation Board (PHAB).

NIHB will provide funds to 15-20 Tribes in amounts ranging from $5,000 to $10,500 each. Tribes can use these funds to demonstrate a measurable and tangible increase in their own readiness to apply for or achieve public health accreditation – which is the goal of the project.

The completed application (Appendix A) is due by 11:59 PM EDT on Friday, September 1, 2017. The project period will run from approximately October 1, 2017 through June 30, 2018.

NIHB and CDC staff will host a

Pre-Application Webinar Thursday, August 3, 2017, at 2:30 PM EDT

Register for the Pre-Application Webinar or cut and paste this address into your browserhttps://nihb.webex.com/nihb/j.php?MTID=e71272bd092ef7fe428c3ce43aaf8c40f

Additional questions about this RFA may be directed to Karrie Joseph, kjoseph@nihb.org.

NIHB and CDC staff will not answer any questions or provide any information that may provide an unfair advantage to any applicants.

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ELIGIBILITYIn order to be considered eligible for this funding opportunity, all of the following criteria must be met:

Applicants must be an official Tribal entity defined as a federally recognized Tribal Government, Tribal organization, or inter-Tribal consortium as defined in the Indian Self-Determination and Education Assistance Act, as amended.

Applicants should have a strong interest in, and/or demonstrated commitment to, pursuing public health accreditation. Applications related to the pursuit of healthcare accreditations such as AAAHC, JCAHO or CARF are not appropriate for this funding opportunity and will be disqualified.

FUNDING CATEGORIES

Eligible applicants must choose to apply for either the Beginner Cohort or the Advanced Cohort. The Advanced Cohort applicants must also identify an area of need around public health accreditation readiness that falls into one or more of the categories of activities described below. ASI Beginner Cohort: This cohort will consist of Tribes who are new to public health accreditation, meaning they have a sincere interest in public health accreditation but have not begun or completed any public health accreditation activities. These Tribes could be described as being in a “Consideration” phase or “Pre-planning” phase as described below.

Consideration – Health department staff have begun to talk about public health accreditation, and are actively considering how the Tribe could benefit from accreditation and how they could undertake accreditation activities, but have not committed to begin or started activities to pursue the process. Staff have learned about accreditation through webinars, conference presentations, networking, or non-specific venues.

Pre-planning – There is clear recognition that public health accreditation would be beneficial to the Tribe. Either one staff or a group of staff are actively talking about it and seeking buy-in from leadership, administration and front line staff. Staff may have received training specifically on accreditation. An accreditation lead may or may not have been named yet. Efforts are focused on discussion and are not yet detailed.

The ASI Beginner Cohort will complete activities in two phases. In Phase I, the Beginner Cohort will receive training, develop an accreditation team, complete a self-assessment, and develop a short term workplan to work on one public health accreditation domain. At the end of Phase I, the Beginner Cohort will have the choice to advance to Phase II. In Phase II, the awardee will implement public health accreditation activities from their specific work plan that they developed during Phase I.

ASI Advanced Cohort: This cohort will consist of Tribes who are not new to public health accreditation activities and have made a commitment to work toward applying

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and achieving public health accreditation. Tribes will have completed some public health accreditation activities. Tribes in this cohort may or may not be previous Tribal ASI recipients but Tribes who have received Tribal ASI in the past would most likely fit into the ASI Advanced Cohort. Tribes in this cohort will have a clear understanding of the public health accreditation process, have a plan to achieve public health accreditation, have trained staff, and have an active public health accreditation team.

ASI Advanced Cohort will work on 1 or 2 of the following categories (all ASI Advanced Cohort applicants must choose at least 1 category on which to work):

Category 1: Progress on PHAB Domain 1.1Domain 1.1. Participate in or Lead a Collaborative Process Resulting in a Comprehensive Tribal/Community Health Assessment (THA/CHA) The purpose of this category is for Tribes to work on completing a community health assessment in accordance with PHAB Standard 1.1, which is a requirement prior to submitting an application to PHAB for public health accreditation. A Tribal or community health assessment is a collaborative process resulting in a document that describes the health of the population, identifies areas for improvement, identifies contributing factors that impact health outcomes and identifies community assets and resources that can be mobilized to improve population health. The PHAB requirement is that the community health assessment be current within 5 years of the PHAB application.

Category 2: Progress on PHAB Domain 5.2 and/or Domain 5.3Domain 5.2 Conduct a Comprehensive Planning Process Resulting in a Tribal/Community Health Improvement Plan (THIP/CHIP) and/orDomain 5.3 Develop and Implement a Health Department Organizational Strategic PlanThe purpose of this category is for Tribes to work on completing a THIP/CHIP in accordance with PHAB Standard 5.2 or a Tribal or health departmental strategic plan in accordance with PHAB Standard 5.3. Both are requirements for submitting an application to PHAB for public health accreditation. A THIP/CHIP is a long-term, systematic plan to address issues identified in the THA/CHA. Similarly to the community health assessment, these plans should be current within the last 5 years.

Category 3: Progress on PHAB Domain 8.2Domain 8.2 Ensure a Competent Workforce through Assessment of Staff Competencies, the Provision of Individual Training and Professional Development, and the Provision of a Supportive Work EnvironmentWorkforce development activities are essential to ensuring high quality public health services. Workforce development strategies support the health department, individual staff members, staff development, and the overall workplace environment. Significant progress toward a workforce development plan is required prior to application to PHAB for public health accreditation and

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a completed, approved plan in active implementation is required to successfully achieve accreditation.

Category 4: Progress on PHAB Domain 9.1 and/or Domain 9.2Domain 9.1 Using a Performance Management System to Monitor Achievement or Organizational Objectives and/orDomain 9.2 Developing and Implementing Quality Improvement Processes Integrated into Organizational Practice, Programs, Processes, and InterventionsPerformance management (PM) and quality improvement (QI) activities are processes to monitor and improve public health performance and outcomes in a public health department. Significant progress toward a PM system and QI plan is required prior to application for public health accreditation. A completed, approved and active implementation of a QI plan and PM system are required to successfully achieve accreditation.

Category 5: Progress toward completing Other Public Health Accreditation Readiness Activities

(If choosing Category 5, please name at least 1 activity, but no more than 2 activities)Other Deliverable: Applicants may propose one “other” deliverable that falls into any category of work, or is related to other public health accreditation readiness efforts. Tribal health departments have a variety of unique needs and processes related to their ability to apply for and achieve public health accreditation. This category allows applicants to describe their specific needs and their plans to meet those needs by way of this effort. Needs may include but are not limited to: work on any other PHAB domain (applicants must specify which standard(s) and which corresponding measure(s) they will seek to address); work related to increasing staff, leadership, or stakeholder knowledge and buy-in of public health accreditation; development of an accreditation roadmap (i.e., timeline with detailed project plan); a written organizational self-study (against the PHAB Standards, Measures and Required Documentation); PHAB site visit preparation (mock site visits, document review); development of memorandums of understanding (MOUs) with local/state public health related to meeting specific PHAB domains; or formalizing mentor relationships.

Paying for PHAB fees: Under this category, Tribal ASI applicants may propose using up to 50% of their award to pay up to 50% of the PHAB application fee (whichever is less).

Refer to the PHAB’s Standards and Measures Version 1.5 for details and definitions of the specific domains.

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PROJECT REQUIREMENTS

Selected Tribal partners must agree to: Sign and return a Memorandum of Agreement (MOA) with NIHB that stipulates

the amount of funds to be distributed, a schedule of funds distribution, Tribal point of contact, and deliverables. NIHB will furnish the MOA after funding decisions are made and announced.

Designate one main point of contact to serve as the project coordinator. Even if this person will not be leading all project activities, the Tribal partner must designate one individual with whom NIHB will directly communicate on all matters related to this project. This person will be responsible for submitting all deliverables, participating in conference calls, and completing evaluation activities.

For awardees in the Beginner Cohort, at least two health department staff to attend a 2-day public health accreditation planning training coordinated by NIHB.

For non-repeat Tribal ASI awardees in the Advanced Cohort, host and assist in planning a 1day site visit by NIHB staff in the initial months of the project to review project activities, undergo a baseline assessment of accreditation readiness and coordinate the delivery of training(s) and technical assistance activities by NIHB.

Permit NIHB to share project success, lessons learned and deliverables as part of a broader information dissemination strategy.

Participate in monthly peer learning webinars or Cohort conference calls, as well as scheduled individual phone calls with NIHB and possibly CDC staff to discuss progress, barriers, or any technical assistance that may be needed.

Participate in project evaluation and technical assistance activities. Submit Phase I deliverables, if applicable, and a mid-year progress report. A

final progress report and all final deliverables will be submitted to NIHB at the end of the project period.

NIHB and CDC will provide selected sites with: Specified amount of funds that will be paid in installments. For non-repeat Advanced Cohort awardees, an initial site visit to meet project

staff, perform a baseline accreditation readiness assessment, and review the project work plan.

For Beginner Cohort awardees, coordinate a 2-day public health accreditation planning training.

Technical assistance from NIHB and/or CDC staff for identified areas of need. Hosted webinars/conference calls, as appropriate, to support peer learning among

Tribal partners. Connection to learning communities, national networks, existing technical

assistance resources, and activities to support accreditation activities. Structured technical assistance events.

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APPLICATION PROCESS

1) Participate in the optional pre-application conference call on August 3, 2017 (register here)

2) Choose to apply for the Beginner Cohort or Advanced Cohort (see Funding Categories, page 2 for descriptions).

3) Complete the application package (Appendix A). IMPORTANT: Beginner Cohort applicants will fill out all sections in blue as well as sections in white. Advance Cohort applications will fill out all sections in yellow as well as sections in white. The following will comprise a complete application package:

Application, Section A: Tribe and Contact Information Application, Section B: Application Narrative and Scope of Work Application, Section C: Budget Proposal Application, Section D: Accreditation Process Checklist Signed letter of support from Tribal official

4) Submit all sections of the project application (as a single PDF document), the letter of support (as a PDF document), and all other additional materials (as a single PDF document) to Karrie Joseph, kjoseph@nihb.org by 11:59 PM EDT on Friday, September 1, 2017. The subject line of the e-mail should read: ‘Tribal ASI Application.’ No applications will be accepted by fax or postal mail. NIHB shall confirm the receipt of all applications.

SELECTION PROCESS Incomplete application packages will not be reviewed. All complete applications will be reviewed by a team of qualified public health

professionals with experience working in Indian Country and/or public health accreditation readiness.

Applicants that currently or previously have received accreditation-readiness funding (e.g. NIHB, NNPHI, NACCHO ASI funding) are eligible to receive funds but may not necessarily be prioritized.

NIHB shall notify all applicants of the status of their application by September 30, 2017.

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Appendix A:TRIBAL ACCREDITATION SUPPORT INITIATIVE (Tribal ASI)

APPLICATION PACKAGE

Instructions: Fill out this application in its entirety by typing directly onto this document. Submit all sections of the application package (as a single PDF document), the letter of support (as a PDF document), and additional materials, such as letter of support from a consultant or outside contractor (as a PDF document) to Karrie Joseph, kjoseph@nihb.org by 11:59 PM EST on Friday, September 1, 2017. The subject line of the e-mail should read: ‘Tribal ASI Application.’ No applications will be accepted by fax or postal mail.

SECTION A: TRIBE AND CONTACT INFORMATION

CONTACT INFORMATIONContact information for the individual to be contacted for notification of application status:

Name:      

Title:      

E-mail Address:      

Phone Number:      

Fax Number:      

Mailing Street Address:      

City, State, Zip Code:      

Tribe(s):      Total Tribal enrollment:      Resident population:      Size of reservation (sq. mi.):      Tribal health department/organization name:

     

Health department/organization full address:

     

Approximate population size served by health department/organization (number):

      individuals

Name of Tribal health official/director:

     

Electronic signature of health official (typed is permissible):

     

PROJECT COORDINATOR CONTACT INFORMATION

Contact information for the individual to serve as Project Coordinator (if the same as above,

Name:      

Title:      

E-mail Address:      

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then leave all fields blank). This person will be the main point of contact for the project and be responsible for submitting all deliverables, participating in conference calls, and completing evaluation activities.

Phone Number:      

Fax Number:      

Mailing Street Address:      

City, State, Zip Code:      

APPLICATION INFORMATIONApplicants must choose to apply for either the Beginner Cohort or the Advanced Cohort. The Advanced Cohort must also choose at least 1 Category, but no more than 2 Categories for their project. Beginner Cohort please fill out all sections in blue AND white. Advanced Cohort, please fill out all sections in yellow AND white. See page 2 of this document for funding category descriptions.

BEGINNER COHORT

ADVANCED COHORT

Category 1: Progress on PHAB Domain 1.1

Category 2: Progress on PHAB Domain 5.2 and/or Domain 5.3

Category 3: Progress on PHAB Domain 8.2

Category 4: Progress on PHAB Domain 9.1 and/or Domain 9.2

Category 5: Progress toward completing Other Accreditation Readiness Activities

Does the Tribal health department intend to apply to submit an application to PHAB on or before June 30, 2018?

Yes

No

Not sure

If you selected ‘No’ or ‘Not sure’ to the above, does the Tribe intend to submit an application to PHAB after June 30, 2018?

Yes (provide expected month and year of application,      )

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No

Not sure (please provide a general timeframe:      ____________________________________

The year the Tribe began working on public health accreditation     The number of staff working on public health accreditation (including teams and work groups in addition to accreditation coordinator).     Amount being requested (up to $10,500)$     

SECTION B: APPLICATION NARRATIVE AND SCOPE OF WORK

Both Cohorts: CURRENT AND PAST ACCREDITATION EXPERIENCE (250 words maximum) Describe the Tribal health entity’s experiences with public health accreditation, both in the recent past and currently. This could range from internal discussions that have taken place, training that has been received, pre-requisites that have been achieved, statement of intent that has been submitted, etc. An applicant will not be penalized if the Tribe is new to public health accreditation through the Public Health Accreditation Board (PHAB). In this case, this space can be used to talk about why the Tribe wishes to engage in public health accreditation now. (Please note, this initiative is limited to supporting activities related to public health accreditation through the Public Health Accreditation Board (PHAB), but you may wish to describe past experiences with other accreditation efforts here.)      

Beginner Cohort: PROJECT SUMMARY (250 words maximum)

Advanced Cohort: PROJECT SUMMARY (250 words maximum)

Phase I will consist of attending the Beginner Cohort training provided by the

Based on the funding category(ies), provide a general description of the work the Tribe

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National Indian Health Board, and subsequently completing a public health accreditation self-assessment, identifying priorities and formulating a short term work plan. Phase II, if you choose to participate in this phase, will consist of implementing activity(ies) outlined in the work plan generated from Phase I activities.(please add how the funding and the work you will undertake, as described above, will increase the Tribe’s readiness for public health accreditation)     

intends to undertake in the proposed project, the resources the Tribe will tap into to operationalize the plan, and how the work will be sustained beyond the project period, if applicable. Moreover, please describe how this funding and the work you will undertake will result in measurable progress in the public health accreditation readiness of the Tribe. This should be a concise summary; details on activities and deliverables will be reported in the table below.      

SUPPORTING DOCUMENTATION Please select the corresponding box for all supporting materials being submitted with the application package (they can be added as additional pages to this document or as a separate PDF).

Letter of Support from Tribal Health Official/Leader (mandatory, as a separate PDF). The signed letter of support must be from the Tribal health department’s director or CEO, the chair of the Tribal Health committee, Tribal chairperson, or other Tribal official that oversees all or a portion of the public health activities and accreditation activities at the Tribal level). The letter should include the governing body’s awareness of and/or commitment to public health accreditation, awareness of the project activities, and support for completion of all deliverables. If funds are to be used to support a portion of public health accreditation application fees or salary for an accreditation coordinator, then the letter should also state the Tribe’s intent to support the remaining public health accreditation fees or salary expenses, or otherwise indicate where those funds will come from

Letter(s) of Support from Other Entities (optional) If the health department plans to use consultants or outside contractors for the completion of the work plan, a letter of support from that entity is highly encouraged.

Other (please identify:      )The applicant may submit additional material to demonstrate their commitment to public health accreditation, experience with public health accreditation, existence of external collaborators, etc. However, these are not required for a complete application package.

PROPOSED SCOPE OF WORK

Beginner Cohort, all cohort members will follow the same work plan and timeline in Phase I. The work plan (in blue) is below and is pre-filled. The column titled Person Responsible needs to be filled out.

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Advanced Cohort, in the yellow table below, detail your proposed work in terms of these components.

Objectives: Objectives are the specific aims for your work and should be written so that they are “SMART” (specific, measurable, achievable, relevant, and time-based). You might have several different or related objectives, or only one main objective. All objectives should be related to the overall goal of increasing Tribal public health accreditation readiness.

Expected Outcomes: Please develop an expected outcome(s) for each objective written in the work plan. Consider what you anticipate to change as a result of achieving your objective(s) (such as increase in efficiency, increase of leadership buy-in, what additional benefits were gained). Each objective should have at least one expected outcome.

Activities & Deadline: Activities are the specific tasks and work that you will engage in to accomplish your objectives. You will have more than one activity per objective. Each activity should include an expected deadline for completion, such that while the overall objective may not be completed until June 30, 2018, the activities will likely occur throughout the project period.

Deliverables: Deliverables are what you will submit to NIHB to demonstrate achievement of your objectives (e.g., PHAB documentation developed, evidence of processes put in place, completed application to PHAB, etc.). You should have at least one deliverable per objective, and may have smaller deliverables for some activities (not all activities will have a deliverable though). In considering your proposed deliverables, think about how the achievement of your objective will result in progress in terms of the Tribe’s public health accreditation readiness, and how to measure and demonstrate that to NIHB. In addition, if your major deliverable for an objective will not be completed until the end of the project period, consider what interim deliverables for the related activities might be submitted to demonstrate progress.

Additional Guidance / Information Use one table per objective, and number each objective accordingly. Each

outcome and all activities for that objective will be listed within that same table. Add additional tables for additional objectives.

Add additional rows to the tables below as needed to list out more activities. Be sure to represent the full scope of your proposed work.

If intending to apply to PHAB before 6/30/2018 and intend to use Tribal ASI funds for application fees, be sure to include the application as one of the objectives, and list relevant deliverables as appropriate (i.e. evidence of accepted PHAB registration and application).

Please note that selected Tribal awardees will have the following activities added to their memorandum of agreement (MOA) as requirements for this project:

o Provide information and feedback on project activities as requested via questionnaires and/or conversations with NIHB and CDC staff.

o Participate in the NIHB site visit or NIHB training, whichever applies to your

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chosen Cohort.o Complete a mid-year and final report documenting the development of

deliverables, improvements gained, changes in infrastructure and capacity, work with supported agencies and lessons learned throughout the project,

o Submit deliverables for consideration in NIHB’s documentation repository.

Continue to the Work Plan Tables Below

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TABLE 1. PROPOSED SCOPE OF WORK for BEGINNER COHORT (pre-filled, only need to fill out Person(s) Responsible column

Objective 1: By November 1, 2017, one public health accreditation planning team will be established.

Expected Outcome 1: An established public health accreditation planning team will provide structure to the public health accreditation planning process.

Activities Deadlines Deliverables Person(s) Responsible

Activity 1.1: Create team description (purpose, members, schedule of meetings, roles, responsibilities, etc.)

11/1/17 Written team description      

Activity 1.2: Obtain supervisor approval for team members to participate on a regular basis

11/1/17 Written approval from supervisor(s)

     

Activity 1.3: Schedule regular team meetings 11/1/17 Recurring appointment, team description

     

Objective 2: At least two staff will complete the mandatory in-person Tribal ASI Beginner Cohort training by December 1, 2107.Expected Outcome 2: Staff will gain skills, knowledge and tools to complete a Tribal self-assessment, to identify priorities based on the assessment and other factors and to formulate a short-term work plan with SMART objectives.

Activities Deadlines Deliverables Person(s) Responsible

Activity 2.1: Obtain necessary permissions to travel 11/1/17      Activity 2.2: Make staff travel arrangements 11/1/17      Activity 2.3: Attend the entire mandatory training 12/1/17 Completed training      (2 staff)

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Objective 3: A public health accreditation self-assessment using the Self-Assessment Workbook for Tribal Health Departments will be completed by January 12, 2018. Expected Outcome 3: Completed self-assessment and prioritized domain will provide data and a foundation from which to set a course for public health accreditation activities.

Activities Deadlines Deliverables Person(s) Responsible

Activity 3.1: Identify and invite participants to the self-assessment process

12/1/17 Invitation list      

Activity 3.2: Set meeting times and reserve location to complete the assessment

12/31/17 Meeting agenda(s)      

Activity 3.3: Complete the self-assessment 1/12/18 Completed assessment and radar chart

     

Activity 3.4: Identify one accreditation domain priority based on the results of the self-assessment and consideration of other factors such as climate, leadership and resources per the beginner cohort training

1/12/18 One domain selected as a priority

     

Objective 4: A 5-month work plan with SMART objectives to accomplish activity(ies) based on the chosen priority from Objective 3 will be developed by February 1, 2018.

Expected Outcome 4: A well-developed work plan with SMART objectives will provide the Tribe with a road map to accomplish small, measurable gains in accreditation readiness.

Activities Deadlines

Deliverables Person(s) Responsible

Activity 4.1: Complete a 5-month work plan 2/1/18 Work plan      

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TABLE 1. PROPOSED SCOPE OF WORK for ADVANCED COHORTPlease follow the SMART model for writing objectives (See the definition of SMART objectives on page 16)

Objective 1:      Expected Outcome 1:      

Activities Deadlines Deliverables Person(s) Responsible

Activity 1.1:                        Activity 1.2:                        Activity 1.3:                        

Objective 2: Expected Outcome 2:

Activities Deadlines Deliverables Person(s) Responsible

Activity 2.1:                        Activity 2.2:                        Activity 2.3:                        

Objective 3:

Expected Outcome 3:

Activities Deadlines Deliverables Person(s) Responsible

Activity 3.1:                        Activity 3.2:                        

Activity 3.3:                        

Copy and paste additional tables here as needed if you have more than 3 objectives.

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Guidance on Writing SMART Objectives

Specific: Objectives should provide the “who” and “what” of program activities. Measurable: The focus is on “how much” change is expected. Achievable: Objectives should be attainable within a given time frame and with available program resources.Realistic: Objectives should relate to the overall goal of the program or project.Time-phased: What is the time frame for accomplishing the objective?

See Table 1 for the Beginner Cohort on pages 13-14 for examples of SMART objectives.

Continue to Section C: Budget Proposal below

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SECTION C: BUDGET PROPOSAL

The requested award amount should be appropriate to the level of effort required to engage in the proposed scope of work and produce the deliverables outlined in the next table.

These funds will be provided as agreements for goods and services, and will paid as follows:

Beginner Cohort (based on a total award of $10,500)

Advanced Cohort (based on requested amount)

$4000 paid at the beginning of the award cycle to complete Phase I deliverables (approx.. Oct 15, upon receipt of signed funding mechanism (MOU))

50% of the total award paid at the beginning of the award cycle (approx. Oct 15, upon receipt of signed funding mechanism (MOU))

Up to $3250 (50% of the remaining total award and based on Phase II budget) paid upon receipt of Phase I deliverables and agreement to proceed to Phase II, (approx. Feb. 1). If a Phase I awardee chooses not to proceed to Phase II, they will be ineligible for additional funds for this award cycle *up to $3250 (50% of the total remaining award) paid upon receipt of Phase II deliverables (approx. July 15)

50% of the total award paid upon receipt of final report and deliverables (approx. July 15)

*The choice not to advance to Phase II will not affect future Tribal ASI funding decisions in subsequent award cycles.

NIHB is seeking to maximize the reach and effectiveness of these funds, and as such may fund applicants at a slightly lower or slightly higher amount than requested in the application. This payment strategy may be amended in order to minimize financial stress on the Tribes and reduce administrative burden on NIHB staff

Complete the Proposed Budget Table Below

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AWARD AMOUNT REQUEST AND PROPOSED BUDGET Please provide an estimated line item budget that illustrates the funding needed to produce the deliverables outlined in the table in Section B. Awards may not be used to: provide direct support to external individuals (e.g., delivery of patient care); purchase large equipment; pay for food or beverages; support ongoing general operating expenses or existing deficits, endowment or capital costs; or support lobbying of any kind. Due to the size of the award, funds are not eligible to support indirect costs.

For the Beginner Cohort, the award for Phase 1 is set at $4000 to complete the deliverables outlined in the work plan. Budgets should reflect travel/training funds for at least two staff to attend the 2-day NIHB training (estimate airfare, 2-3 nights lodging, per diem, taxi, mileage to airport). As Phase II is dependent on completion of Phase I deliverables and agreement to move forward to Phase II, a more detailed budget, up to $6500, for Phase II will be submitted at the end of Phase I. Requested Funding Amount ($5,000 – $10,500): $     

Requested Funding Amount ($5,000 – $10,500): $     

Beginner Cohort – Phase I budget ($4000)

Advanced Cohort budget(100% of requested amount)

Wages and Salaries:       Wages and Salaries:      Fringe Benefits:       Fringe Benefits:      Contractual Costs (include type or name of potential contractor[s]):      

Contractual Costs (include type or name of potential contractor[s]):      

Supplies:       Supplies:      Meeting Expenses (room rental, A/V, etc):      

Meeting Expenses (room rental, A/V, etc):      

Staff Travel (include cost for at least 2 staff to attend the NIHB public health accreditation planning training):      

Staff Travel:      

Other Direct Costs (e.g., PHAB fee):      

Other Direct Costs (e.g., PHAB fee):      

Phase II Budget (enter up to $6500) a more detailed budget will be submitted at the end of Phase I      

N/A, Leave blank

Please list any additional in-kind contributions that will be made by the Tribe to support the work:      

SECTION D: Accreditation Readiness Process Checklist 18

This checklist is to ascertain if the health entity has put in place some of the recommended processes to pursue public health accreditation. Applications are not scored or chosen according to their level of readiness as indicated by this checklist. Rather, this information is used to gain a deeper understanding of the applicant’s readiness and for technical assistance purposes.

Yes No1. Has the governing entity (the point of accountability for the health

department) been informed about the key elements of the public health accreditation process, e.g., process, timeframes, required resources, fees, etc.?

2. Has the director of the health department appointed or designated an Accreditation Coordinator who will lead the public health accreditation process, department wide?

3. Has the department established a public health accreditation team that has developed a work plan with objectives, realistic timeframes and assigned responsibilities?

4. Does the health department have collaborative working relationships with other Tribal programs or organizations, community groups and other stakeholders in order to address population health issues?

5. Has the department completed a “self-assessment” to review the standards, measures, and required documentation to determine where documentation is present and where documentation needs to be developed/updated?

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