Application: OASEE

Section 1. Organization Information

Questions 1-26 ask for basic administrative and fiscal information about your organization.

#	Data Item	Field Options	Instructions
1	Legal organization name
2	Common name (doing business as [DBA])
3	Address line 1
4	Address line 2
5	City
6	State
7	ZIP
8	County
9	Public health region	• Bellwood • West Chicago • Champaign • Marion • Metro East • Peoria • Rockford	Select the public health region where you primarily provide services or that pertains to this application per the Illinois Department of Public Health (IDPH) Health Regions map.
10	Organization phone
11	Organization website address (optional)
12	Type of organization	• Nonprofit • For profit • Tax exempt
13	Year founded/incorporated
14	Illinois Department of Human Services/Division of Substance Use Prevention and Recovery (IDHS/SUPR) licenses, if any
15	Primary contact name
16	Primary contact title
17	Primary contact email address
18	Primary contact phone
19	Alternative contact name
20	Alternative contact title
21	Alternative contact email address
22	Alternative contact phone
23	Indirect cost election	• Federally negotiated rate • 10% de minimis • No indirect costs election	Select your indirect cost election. If you select “Federally negotiated rate,” complete the next question.
24	Negotiated Indirect Cost Rate Agreement (NICRA) letter	Document upload (if applicable)	Upload as Attachment A (if applicable).
25	Current or planned organizational chart	Document upload (required)	Upload as Attachment B.
26	Current fiscal year organizational budget	Document upload (required)	Upload as Attachment C.

Section 2. Pre-Qualification Information

Questions 27-35 ask for organizational information and attestations to verify eligibility to receive an award.

#	Data Item	Field Information	Instructions
27	Federal or State Employer Identification Number (FEIN/EIN)
28	Form W-9, Request for Taxpayer Identification Number and Certification	Document upload (required)	Upload as Attachment D.
29	System for Award Management (SAM.gov) account number
30	Unique Entity Identifier (UEI)
31	Illinois Secretary of State File ID
32	Do you attest that your organization is not on the Federal Excluded Parties List?	Yes No
33	Do you attest that your organization is not on the Illinois Stop Payment list?	Yes No
34	Do you attest that your organization is not on the Department of Healthcare and Family Services Provider Sanctions list?	Yes No
35	Do you attest that your organization is in good standing with the Illinois Secretary of State?	Yes No

Section 3. Internal Controls

Questions 36-81 ask about administrative and management controls within the organization. These questions are used to assess organizational risk.

#	Data Item	Field Options	Instructions
36	Describe the organization’s accounting system. (2.01)	• Manual and/or Spreadsheet Driven • Automated - Off the shelf • Automated - Written in-house or by consulting firm • Not Applicable
37	Does the accounting system require users to have separate sign in/log on credentials for access and approval? (2.02)	• Yes • No
38	Have any new accounting systems been implemented during the last fiscal year? (2.03)	• Yes • No
39	Does the accounting system or do related written policies and procedures separate the receipt and expenditure of grant funds at the grant level? (2.04)	• Tracked outside of the accounting system with spreadsheets • Tracked in the accounting system
40	Does the accounting system or do written policies and procedures include a formal chart of accounts that allows users to record transactions by the categories of the approved budget? (2.05)	• Yes • No
41	How often are the general ledger accounts reconciled? (2.06)	• Monthly • Quarterly • Semi-annually • Annually • Not applicable
42	Does the organization require monthly bank reconciliations? (2.07)	• Yes • No
43	Does the organization have written policies and procedures regarding proper segregation of duties for fiscal activities that include, but are not limited to, a) authorization of transactions, b) recordkeeping for receipts and payments, and c) cash management? (2.08)	• Yes • No
44	Does the organization have written review and approval processes for financial and program-related reporting? (3.01)	• Yes • No
45	Are the annual financial statements prepared in accordance with Generally Accepted Accounting Principles (GAAP) or on a basis acceptable by the regulatory agency? (3.02)	• Yes • No
46	Does the organization have written policies and procedures to ensure program performance measures and deliverables align with the program spending plan? (3.03)	• Yes • No
47	Has the organization taken steps to ensure the individuals who prepare, review, and approve reports have the financial and/or program-related required knowledge, skills, and abilities? (3.04)	• Always • Sometimes • Never • Not applicable
48	Who prepares the organization’s financial statements? (3.05)	• Trained staff who work for the organization • Financial consultants who are not from the organization’s audit firm • Independent auditors who conduct the financial statement audit
49	Who prepares the organization’s program performance reports? (3.06)	• Trained staff who work in the specific program • Grant Managers or Program Directors • Organizational management outside of the program
50	Does the organization have written policies and procedures that support compliance with cost principles? (4.01)	• Yes • No
51	Does the organization have written policies and procedures for allocating costs? (4.02)	• Yes • No
52	Are costs recorded consistently with regulations and written policies and procedures to address uniformity both in grant awards and in the organization’s other activities? (4.03)	• Yes • No
53	Does the organization charge indirect costs? (4.04)	• Yes • No
54	Does the organization keep adequate documentation to support all costs charged to its grant awards? (4.06)	• Yes • No
55	Does the organization have a governing body (for example, Board of Directors, Board of Trustees, City Council, County Board, Leadership, Legislature, Governor’s Office)? (4.07)	• Yes • No
56	Is financial information, including budget to actual revenue and expenditure reports, provided to leadership or the governing body members? (4.08)	• Always • Sometimes • Never
57	Is the governing body engaged in audit function activities such as selection of an audit firm, the audit firm’s presentation of audit results, or follow-up on corrective action of audit findings? (4.09)	• All audit function activities • Some audit function activities • Not involved in audit activities
58	Does the organization make purchases of equipment of $5,000 or more with grant funding? (4.10)	• Yes • No
59	Is a control system in place with adequate safeguards to prevent loss, damage, theft, or unauthorized use of property? (4.13)	• Yes • No
60	Does the organization have written policies and procedures for proper authorization of property disposals? (4.14)	• Yes • No
61	Does the organization have written policies and procedures for purchasing goods and services with grant funds? (4.15)	• Yes • No
62	Does the organization have written policies and procedures that forbid employees, management officers, or agents from participating in the selection, award or administration of a contract supported by a grant award if there is a real or apparent conflict of interest? (4.16)	• Yes • No
63	Does the organization have written policies and procedures that forbid contractors who develop or draft specifications, requirements, statements of work (scope of services) or requests for proposals from competing for such procurements? (4.17)	• Yes • No
64	Does the organization have written policies and procedures that document subrecipient and contractor determinations? (4.18)	• Yes • No
65	In those determinations, has the organization identified any subrecipients? (4.19)	• Yes • No
66	Does the organization have written policies and procedures for assessing subrecipient risk and monitoring program implementation? (4.20)	• Yes • No
67	Does the accounting system or do related written policies and procedures identify expenses in excess of available budget? (4.21)	• Yes • No
68	Are adequate controls in place to ensure that necessary budget revisions receive prior approval from the grantor when applicable? (4.22)	• Yes • No
69	Does the organization have written policies and procedures for allocating personnel time and effort by funding source? (4.23)	• Yes • No
70	Does the organization have written policies and procedures to ensure that all salaries and wages charged to grants accurately reflect work performed (i.e., time and effort or after-the-fact payroll verification)? (4.24)	• Yes • No
71	Does the organization have written policies and procedures to ensure accurate tracking of grant deliverables and performance measures? (4.25)	• Yes • No
72	Does the organization have written policies and procedures to make sure program activities are allowable under the grant agreement and state and federal regulations? (4.26)	• Yes • No
73	Are the terms of the executed agreement and budget shared with the performance or program management staff? (4.28)	• Yes • No
74	Does the organization have written policies and procedures for keeping documentation of participant eligibility determinations? (4.29)	• Yes • No
75	Have there been any changes in key organizational personnel since the last audit, such as changes to Fiscal and Administrative Management, the Executive Director, and/or Program Management? (5.01)	• Yes • No
76	Has the organization had a financial statement audit conducted in the past year? (5.02)	• Yes • No
77	What type of audit was conducted? (5.03)	• Financial audit conducted in accordance with Generally Accepted Auditing Standards • Financial audit conducted in accordance with Generally Accepted Government Auditing Standards • Single Audit/Program Specific Audit in accordance with CFR2 200.501
78	Did the audit find significant deficiencies or material weaknesses? (5.04)	• Yes • No
79	When was the audit conducted?	• [date]
80	Financial Audit Report for the current fiscal year	Document upload (optional, if available)	Upload as Attachment E, if available.
81	Has the organization submitted financial and program-related reporting in a timely manner and as required for prior grant awards?	• Always • Sometimes • Rarely

Section 4. Organization Attestations

Questions 82-87 ask for verification of capacity and truthfulness of information in the application.

#	Data Item	Field Information	Instructions
82	By entering my name, title, and date, I attest that I am authorized to submit the application on my organization’s behalf.	[Name] [Title] [Date]	Enter requested information in fields.
83	I attest that my organization is committed to processing a subaward within six (6) weeks from the Notice of Award.
84	I attest that my organization is responsible for performance and monitoring of external partners, subcontractors, and subrecipients (as allowed by the grant agreement).	• Yes • No
85	I attest that I have reviewed the terms and conditions within this Notice of Funding Opportunity in its entirety and my organization meets the eligibility criteria and has the capacity to fulfill the scope of services described.	• Yes • No
86	I certify that the statements herein are true, complete, and accurate to the best of my knowledge. I agree to comply, on behalf of my organization, with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)	• Yes • No
87	Conflict of Interest Disclosure Upload Conflict of Interest Form as Attachment F.	• Yes • No

Section 5. Executive Summary

Question 88 seeks an overview of your organization and the services you plan to deliver if awarded funding.

#	Data Item	Field Information	Evaluation Criteria
88	Summarize the following: • The activities and outcomes to be achieved by the project • The challenges in measuring the relative impact of a variety of prevention, treatment, and recovery interventions and how those challenges would be met • Your organization’s experience providing similar services, including timeframes • The relevant expertise of the staff bid in the proposal	Up to 1,000 words	(5 points) • The response addresses all elements of the question. • The response provides a specific description of a population of focus and explains the need for the proposed program for that population. • The response demonstrates that the organization has the experience and expertise to successfully implement the proposed program.

Section 6. Need and Opportunity

Question 89 asks how the proposed work will contribute to the purpose of the project.

#	Data Item	Field Information	Evaluation Criteria
89	How does your proposal support the grant program purpose? Describe how the proposed project will evaluate the effectiveness of abatement strategies within different health regions of Illinois, prioritizing communities hardest hit by the opioid crisis, and therefore support the equitable distribution of opioid settlement funds.	Up to 1,500 words	(20 points) • The response addresses all elements of the question. • The response demonstrates a clear understanding of the purpose of the funding need. • The response includes relevant data, including sources.

Section 7. Capacity

Questions 90-94 ask how your organization’s work, approach, and experience are aligned with the intent of the opioid settlement funds and the project requirements.

#	Data Item	Field Information	Evaluation Criteria
90	What is your organization’s experience implementing the tasks described in the scope of work? Describe experience with evidence-based study design, analysis, data collection, and evaluation. Either provide detailed descriptions of relevant prior work or, optionally, upload samples as Attachment G.	Up to 500 words Upload prior work samples as Attachment G (optional).	(10 points) • The response addresses all elements of the question. • The applicant has experience in each of the following: > Multi-variate longitudinal design > Analyzing administrative datasets, particularly state and/or federal behavioral health datasets > Epidemiological data collection and data analyses/studies > Performance/ process evaluations • The applicant demonstrates relevant past experience with examples of prior work.
91	Provide up to five examples of grants or contracts that your organization has successfully managed in the past 5 years, with awarding agencies, dates, and dollar amounts. Include any current fiscal year funding from IDHS/SUPR or IDPH. Select “n/a” if you have not received previous grants or contracts.	Not applicable or list up to 5 grants in the table within the online application tool	(5 points) • The response addresses all elements of the question. • The applicant demonstrates experience with grants management. • The applicant demonstrates experience with services that address the opioid epidemic. • The applicant demonstrates experience providing services like the proposed program. • The applicant demonstrates experience addressing health disparities.
92	Identify staff leadership and describe their experience and qualifications. For new staff, describe your plan to hire people with the necessary qualifications and characteristics (including people with lived and living experience). Upload requested resumes of project leadership.	Up to 2,000 words Upload project lead and project deputy lead resumes as Attachment H.	(10 points) • The response addresses all elements of the question. • The applicant understands the experience and expertise required to implement the proposed program. • The applicant demonstrates an ability to provide qualified staff. • The applicant demonstrates a commitment to hiring people with lived and living experience.
93	Identify the community partnerships that will contribute to the success of the evaluation and describe your organization’s experience with these partners.	Up to 1,000 words	(5 points) • The response addresses all elements of the question. • The response identifies a sufficient range of partners to support the proposed program. • The applicant has existing connections to community partners.
94	Describe how you will make sure evaluation methodologies are culturally and linguistically appropriate based on the diversity of the population to be served by RCCA subrecipients.	Up to 1,000 words	(5 points) • The response addresses all elements of the question. • The applicant follows the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care. • The applicant is prepared to provide interpreters and other accommodations.

Section 8. Quality

Questions 96-98 ask for an explanation of the implementation approach and anticipated outcomes of the proposed activities to be funded.

#	Data Item	Field Information	Instructions
95	Provide a task-by-task description of how your organization will implement the evaluation.	Up to 2,500 words	(20 points) • The response addresses all elements of the question. • The response provides sufficient detail to understand how the evaluation will be conducted. • The applicant has access to an IRB and a mechanism for participatory research. • Relevant participant outcomes are described specifically, including indicators of fatal and non-fatal overdoses. • The response describes how the evaluation team will document the services provided by funded programs. • The response describes relevant process measures related to fulfillment of provider grant requirements. • An explanation of how the comparative effectiveness of funded programs, both within and across funded abatement strategies, is provided. • The applicant describes how other factors, such as increases or decreases in potency of illegal opioids, will be accounted for.
96	Provide a detailed timeline for your proposed approach that includes hiring of staff, anticipated linkage agreements, and other coordination activities necessary to accomplish the goals and objectives.	Upload Project Plan as Attachment I (required)	(10 points) • The response addresses all elements of the question. • The timeline proposed includes all required program elements. • The timeline includes realistic milestones. • The response includes relevant data, including sources.
97	Provide a detailed description of the subrecipient data portal to be developed. Optionally, upload a portal concept plan that includes a description of key elements and a visual representation of the portal Attachment J.	Up to 1,000 words Upload Portal Concept Plan as Attachment J	(5 points) • The response addresses all elements of the question. • The description demonstrates an understanding of the deliverable requirements. • The portal concept plan includes a visual representation of the deliverable.

Section 9. Budget

Questions 99-101 request information about the project budget.

#	Data Item	Field Information	Evaluation Criteria
98	Total funding requested for the period of performance	[currency]	0 points
99	Please select your preferred payment term as described in Section G.2. of this document.	• Advance Payment and Reconcile Method • Reimbursement Method • Working Capital Advance Method	0 points
100	The budget and narrative must tie fiscal activity to program objectives and deliverables and must demonstrate that all proposed costs are • Reasonable and necessary, • Allocable, and • Allowable as defined by program regulatory requirements and Uniform Guidance (2 CFR 200), as applicable.	Upload the Budget Workbook as Attachment K to submit your project budget and advance payment request. (required)	(5 points) • The budget is filled out completely. • Salaries, benefits, and other expenditures appear reasonable for the community in which the proposed program will take place. • Indirect costs meet guidelines (attach NICRA agreement letter if applicable). • All line items correspond to elements of the proposed program.

Online Application

OASEE Application Table of Contents

About the Application