mn DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION. GRANT APPLICATION REGIONAL MEDICAL PROGRAM LEAVE BLANK — FOR HSMHA USE ONLY Project Identification Number , 4 | Program Data TO BE COMPLETED BY APPLICANT 1. TITLE OF PROJECT (OR PROGRAM) (Limit to 53 spaces) 2. NAME AND ADDRESS OF APPLICANT (Street Number, Street Name, City, County, State or Country, ZIP Code) 6. PROJECT PERIOD (TRIENNIUM) FROM (Mo., Day, Yr.) THROUGH /{Mo., Day, Yr.) 6. BUDGET PERIOD FROM (Mo., Day, Yr.) THROUGH (Mo. Day, Yr.) CONG. DISTRICT 7, AMOUNT REQUESTED FOR a. BUDGETPERIOD §$ 3. EMPLOYER'S |OENTIFICATION NUM8SER (Incl 4. DIRECTOR OF PROJECT (Program or Center Director, Coordinator or Principal Investigator} NAME (Last, First, Middle Initial) 8. FINANCIAL MANAGEMENT OFFICIAL NAME (Last, First, Middle Initial} O mr. O mr. O Miss O Miss a Mrs, C Mrs. (Specify) a (Specify) TITLE TITLE DEGREE SOCIAL SECURITY NUMBER ADDRESS (Street Number (or Box Number), Street Name, City, State for Country), ZIP Code) ADDRESS {Street Number for Box Number), Street Name, City, State (or Country), ZIP Code) OFFICE TELEPHONE (Area Code, Tel. No., Extension) OFFICE TELEPHONE (Area Code, Tel. No., Extension} Rae 34 (Formerly RMP-34-1) (page 1) FORM APPROVED: O.M.B. NO, 68-R1197 PROJECT IDENTIFICATION NO, ASSURANCES AND CERTIFICATIONS BY APPLICANT The following assurances and certifications are part of the project grant application and must be signed by an official duly authorized to commit and assure that the applicant will comply with the provisions of the applicable laws, regulations, and policies relating to the project. The applicant hereby assures and certifies that he has read and will comply with the following: Title VI—Civil Rights Act of 1964 (PL 88-352) and Part 80 of Title 45, Code of Federal Regulations, so that no person will be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination on the grounds of race, color, or national origin. Patents and inventions (Current PHS Policy Statement) under which all inventions made in the course of or under any grant shall be promptly and fully reported to HEW. Specific assurances, policies, guidelines, regulations and requirements in effect at the time the grant award is made and applicable to this project (including the making of reports as required and the maintenance of necessary records and accounts, which will be made available to the Department of HEW for audit purposes) which are contained and listed in the grant application package and made a part hereof. SIGNATURES - Use tnk, person(s} authorized to sign in their behalf, APPLICANT NO. 1 (Name only) Autographic signature of Official authorized to sign for applicant and Project Director or other (Signature only) DIRECTOR DATE (Mo., Dey, Yr.) OF PROJECT SIGNATURE DATE (Mo., Day, Yr.) OFFICIAL AUTHORIZED NAME (First, middle Initial, (ast} AND TITLE DEGREE TO SIGN FOR O mr. APPLICANT O mas. O miss 7 (Specify) a COMPLETE FOR RMPS ONLY SIGNATURE OF CHAIRMAN OF ADVISORY GROUP DATE (Mo, Day, Yr.) ORGANIZATION AND PERFORMANCE PROJECT IDENTIFICATION NUMBER SITE DATA 1, APPLICANT (Name only) REGION RMP Mo. YR PAGE ORGANIZATIONAL LEVEL - 1 Ne Me | cee | v8) O) core | | | | | 193 “ORGANIZATIONAL LEVEL - 2 1] DEVELOPMENT COMPONENT C] OPERATIONAL ACTIVITY NO. — 2 (9-9-2) ORGANIZATIONAL LEVEL - 3 7. car FEDERAL FACILITIES TO 1 BE USED FOR THIS PROJECT? (14-16) 10 no 2(O ves % of time ORGANIZATIONAL LEVEL - 4 8. ORGANIZATION DESCRIPTORS A, TYPE . (2) PUBLIC SPONSORED ORGANIZATIONAL LEVEL - 5 (1) PUBLIC ; (17)0] Federal (22) C1 county (ze) O Community ga State (23) O city (27) C) sponsored Organization (19)C] interstate (i200 Metropolitan (24) (] School District (28) 1 Special Unit (28) C) other (specify) (21 10 Other (specify) (3) PRIVATE NONPROFIT Indicate the type of proof of NON-PROFIT STATUS furnished: (a) IRS Cumulative List Reference Submitted * (b) IRS Tax Exemption Certificate (29) O (c) State Certificate Statement (30) C] (d) Certificate of incorporation (31) O (e) Statement of Affiliation with Parent (32) O Organization % (33-35) * Indicate the Place and Date filed: 5. INVENTIONS (Complete for continuation applications only) (36) B. FUNCTION (39) CO Planning (41) | Hospital 4. O No : : (37) CO) Educational (40) () Service s. CO YES -NOT PREVIOUSLY REPORTED (38) CJ: Other (specify) c. O YES - PREVIOUSLY REPORTED 6. HUMAN SUBJECTS AT RISK (42) 0 Yes CI] No (see instructions) 9. GEOGRAPHIC SCOPE 1 2 D Yes - Approved (Date) 43) C) National (48) () Statewide (47) C1 Local CERTIFICATION O yvYes- Pending Review (Date) (43) . . (44} oO Regional (46) C) Areawide (48) (1 other (specify) SPECIAL ASSURANCE (certification attached?) 0 10. PERFORMANCE SITE(S): The places where the project will be concluded; (49) a. (] AT APPLICANT Bs. C1 AT APPLICANT ADDRESS c. 0 aT OTHER IF “B’ OR "C”, IDENTIFY ADDRESS ONLY AND OTHER SITES SITES ONLY OTHER SITES BELOW. SITE NO. (Name) SITE NO. (Name) ADDRESS (Street Number, Street Name, City, County, State or Country) CONG. DISTRICT ADDRESS (Street Number, Street Name, City, County, State or Country} CONG. DISTRICT SITE NO. (Name) ADDRESS (Street Number, Street Name, City, County, State or Country) CONG. DISTRICT] SITE NO. ______s (Name) ADDRESS (Street Number, Street Name, City, County, State or Country) (CONG, DISTRICT ORGANIZATION AND PERFORMANCE SITE DATA-Continued PROJECT IDENTIFICATION NO. PERFORMANCE SITE(S)—The places where work will be performed SITE NO, (name) SITE NO. (name) ADDRESS (Street Number, Street Name, City, County, State or Country} CONG. DISTRICT ADDRESS /Street Number, Street Name, City, County, State or Country) CONG. DISTRICT SITE NO. (name) SITE NO. (name) ADDRESS (Street Number, Street Name, City, County, State or Country) CONG. DISTRICT ADDRESS (Street Number, Street Name, City, County, State or Country) CONG. DISTRICT SITE NO, ___. (name) SITE NO, (name) ADDRESS (Street Number, Street Name, City, County, State or Country} CONG. DISTRICT ADDRESS (Street Number, Street Name, City, County, State or Country) CONG. DISTRICT SITE NO. (name) SITE NO. (name) ADDRESS (Street Number, Street Name, City, County, State or Country) CONG. DISTRICT ADDRESS (Street Number, Street Name, City, County, State or Country) CONG. DISTRICT SITE NO. (name) SITE NO. (name) ADDRESS (Street Number, Street Name, City, County, State or Country) CONG. DISTRICT ADDRESS (Street Number, Street Name, City, County, State or Country) CONG. DISTRICT SITE NO. {name} SITE NO. (name) ADDRESS (Street Number, Street Name, City, County, State or Country) CONG. DISTRICT ADDRESS (Street Number, Street Name, City, County, State or Country) CONG. DISTRICT HRA-T4 (Formerly RMP-34-1) (Page 3B) DATE RMP OL. uc. yr. | PAGE LIST OF MEMBERS OF THE REGIONAL ADVISORY GROUP (hea) |(3-4) , (5-8)} (7-8) © AND STEERING OR EXECUTIVE COMMITTEE | | {04 (1) (2) INSTITUTION AND/OR (3) CATEGORIES OF (Acneck ir OCCUPATION REPRESENTATION EXC. COMM. 9 fio ul lis NAME AND ADDRESS CO © 5 HRA-T4 (Formerly RMP~34~-1) (Page 4) " “aah -. a © | | RMP DATE PAGE RMP NO. | MO. , YR. (1-2) | (3-4) | (4-5) | (7-8) RAG BOARDS/COMMITTEES AND RMP LOCAL ADVISORY GROUPS tii yp 345 TYPE NAME OF (Check one} NO. MEMBERS NO COMMITTEE MTGS. FUNCTIONS AND RESPONSIBILITIES Stand-| AD- LAST OR GROUP ing | HOC. TOTAL |MINORITY] Vear (9-11) | | (12) (13-15) (16-18) (19-21) O dQ 1 2 (9-31) | {12} (13-15) (16-18) (19-21) {a a 1 2 {9-11) \ i | (12) (13-15) (16-18) (19-21) 0 Oo 1 2 {9-14] | (12) (13-13) (16-18) {19-21} Oo oO 1 2 {o-45) { | | (12) (13-15) (16-18) (19-21) O oO 1 2 {9-11} | | | (12) (12-15) | (16-18) (19-21) oO a FT 2 (9-11) | | (12) 4 (03-15) (16-18) (19-21) Oo Qa 1 2 HRA TS ‘(Formerly RMP 34-1) (page 5) -— 6 5 + » RMP RMP NO. DATE PAGE (1-2) |} MO YR (7-8) CORE PERSONNEL ___|ta-4}, (5-6) — RMP JOB UI “l IDENT. DISCIPLINE % TIME RMP RP * INSTITUTIONAL OR HHH NO. OR POSITION TITLE NAME AND DEGREE PROFESSIONAL OR AFFILIATION ®* EFFortT}| SALARY t9-17} (42-38) OTHER SPECIALTY (32-34) (35-39) HRA-T4 (Formerly RMP~34-1) (page 6) *1¢ position not filled write vacancy. *¥spow particular school where appropriate. #* Hyp fringe benefits ere not thcluded, show 2-74 total fringe benefits on separate line. — EQUAL EMPLOYMENT OPPORTUNITY x PLANNING AND ADVISORY CORE STAFF PROJECT STAFF / OURS AND COMMITTEES Professional '?! Secretarial "9? Professional!) Secretarial '? Regional {9} Other {9) and Technical [4 Clerical [2] _and Technical [3° Clerical [4 | Advisory Group [5 [6] __ No. FTE ** | No. FTE ** | No. FTE ** | No. FTE ** | No. FTE" |No. FTE** TAL STAFF OR VISORY GROUP -MBERS ft (10-14) (15-19) {10-14} (15-19} (10-14) (15-19) (10-14) (15-19) (rosa) | (re-19)) | (10-14) (15-19) MALE —--- ee oO TTT ~ Gower [ izszey [ tao2s) | (25-297 | “o-zay J T2829) 7] “t20-24) [ (25-29) “\2o-2ay | (28-20) | (20-24) [ (25-29) -EMALE ITAL MINORITY 20UP STAFF OR YVISORY GROUP MEMBERS (30-34) (35-39) (30-34) (35-39) (30-34) (35-39) (30-34) (35-39) (30-34) (35-39) (30-34) (35-39) BLACKS *** ote — (aos) | (asa) | (40-44) | ~ (as-a9) | (40-eay” —(a5-48) ~| “ao-aay T [as-aay) | (40-44) | “as-a9) | (40-44) 45-49) AMERICAN INDIANS *** oes — (50-54) [| (55-59) | (50-54) ~(ss's0) | (so-sa) | (55-89) r (S084) | (ss-59) | (30-54) iss-59) | (s0-sa) | (55-59) SPANISH SURNAMES wee nan 1 {co-6a) | (65-69) | (60-64) | “j6s-69) | \e0-6s) | (65-69) | 60-64) | (ese) | (60-64) | jes-69) | (60-64) t es-69) ORIENTAL *** OTHER MINORITY TTT Ty j7orza) | (78-79) | (70-74) T Tscvey | (70-74) | (75-79) S Aravay T izscv9) T (0-74) || (75-79) | (70-74) | (75-79) GROUPS (Specify) *The total of “Professional and Technica!” and ‘Secretarial and Clerical’ personnel should equal the number of positions shown on Page 6 “RMP Job or Position Title” column less any vacancies. **Give best estimate of full time equivalent (FTE). ***Give best estimate where records are not maintaieed. RA Th (Formerly RMP-34-1) (Page 7) RMP RMP DATE PAGE y NO. | MO. | YR. DISCRETE ACTIVITY SUMMARY ee es | feel | 69-83 | | {_{1|5 1. TITLE 2. IDENT. | 3, DATE OF INITIAL NUMBER RMPS SUPPORT {9-12) MONTH YEAR L414 iat (rst6) 3. GEOGRAPHIC AREA SERVED TERMINATION . SPONSOR (Institution/Organization) (17-18) . DIRECTOR 6. EST. ___DAT Mo. (19-20) | E OF RMPS SUPPORT YEAR (21-22) 9. TARGET GROUP(S) (25-28) - PRIMARY ACTIVITY AND DISEASE EMPHASIS (23-24) A. CONSUMERS AND/OR PATIENTS B. PROVIDERS (29-30) 10. SIGNIFICANT RELATIONSHIPS WITH OTHER FEDERAL PROGRAMS (Check all applicable) $ 131) 4 0 o€0 (34) D C] CHP-A (38) H O MOD. CITIES ’ (42) L O NIH-INSTITUTES (32) 8 DO EXP. HEALTH (38) € 0 CHP-8 (39) | CO HMO (43) M C.. HEALTH MANPOWER PLAN. & DELIV. (36) F O CHP-C (ao) J 0 FDA (44) NC] OTHER (Specify) (33) C (1) HEALTH RESEARCH ¢37) G (1) CHP-E t414) K () APPALACHIA +1, PROPOSAL PERIOD 12. PROGRESS PERIOD FROM (48-48} THROUGH (49-52) FROM (53-56) THROUGH (57-60) mo. YR. mo. YR. mo. | YR. | MO. YR. | | i | | ! | | || A. WHAT ARE THE GENERAL OBJECTIVES? B, WHAT SPECIFIC ACTIVITIES WILL BE UNDERTAKEN DURING THE ABOVE PERIOD? WHAT RESOURCES WILL BE EMPLOYED? WHAT SPECIFIC OUTPUTS ARE PLANNED c. D. FOR THE ABOVE PERIOD? D. E. OF SUPPORT, A. WHAT SPECIFIC ACTIVITIES WERE UNDERTAKEN? WHAT WERE THE RESULTANT OUTPUTS? C,. WHAT SIGNIFICANT BENEFITS OR FINDINGS HAVE OCCURRED TO DATE? WHAT PROBLEMS, IF ANY WERE ENCOUNTERED? IF RMP SUPPORT HAS BEEN OR WILL BE TER- MINATED, EXPLAIN (1) WHY? (2) WHETHER THE ACTIVITIES WILL BE CONTINUED WITH OTHER SUPPORT AND, IF SO, (3) THE LEVEL HRA-T4 (Formerly RMP-34-1) (Page 15) 2-74 — (Formerly RMP-34-1) [Amp] COMPON-T ©) | ACTION (13) ACTION CODES nay Surruny Cubes weaen - Y. our T (Page 16) Mo | ENT. wale 1 t. 1O request. FOR ORMP USE ONLY 1D New, not previously approved 4 DApproved, not previously initiated vA ut Hie 13} 2 DexPenviTURE 4C) AMENDED 20 Continuation beyond approved 5 Li continuation within approved pariod (1516) FINANCIAL DATA RECORD . . 3CIRESUDGET AWARO period of support of support ! 1 tt l ! 1 l sClAwano Qa & SPONSOR (INSTITUTION/ORGANIZATION) . 4 es?) REGION NAME: 1 RMP. F NT ‘anit comp z COMPONENT TITLE (Use only significant words} SUPP | 4 {18-671 6aso 2 BUDGET PERIOD TERMINATION DATE FOR ORMP USE ONLY o COORDINATOR/PROJECT DIRECTOR FROM & (Last Name, First Name, Initial) mo.| yr CASE CODE st. | enty | city 0 iz {18-47} [48-49)| (50-54 ke (73-75) | (76-79, 3 bo \ 1 V4 a PERSONAL SERVICES PATIENT CARE EQUIPMENT CONSTRUCTION c €| SALARY/wacEs EES INPATIENT OUTPATIENT BUILT-IN MOVABLE NEW MOU ATIONS 17 (18-24) (25-39) (32-33) (39-45) (46-52) _ (53-59) (69-66) ___{67:73) 4 / a CONSULTANT upp TRAVEL RENT MINOR ALT. & PUBLICATION CONTRACTUAL - $ Ss SUPPLIES DOMESTIC FOREIGN SPACE OTHER RENOVATIONS cOsTS SERVICES 12 (18-24) (28-31) (32-38) (39-45) (46-32) (33-59) (60:66) (67-73) (74-80) 5 - 8) COMMUNICA- COMPUTER & TRAINEE COSTS DIRECT ASSISTANCE <{ TION COSTS DATA OTHER é PROCESSING STIPENDS OTHER PERSONAL SERV. EQUIPMENT SUPPLIES OTHER i {18-24} TSES ) (32-38) (39°45) {46-52) {53-59} __{60-66) ___ (67-73) (74-80) 6 , : Q)DIR. COSTS AUTH. | DAMP DIRECT INDIRECT COSTS THIS BUDGET PERIOD DAMP SUPPORT (DIRECT COSTS ONLY} _ INDIRECT COST CODES (EXPENDITURE COSTS THIS wl w ADDITIONAL w ADDITIONAL w FOR CARD 7( (NiO 64)” S| REPORTS ONLY! | BUDGET PERIOD TOTAL % RATE BASE g| %RATE BASE | guocer PERIOD |] BUDGETPERIOD |4 ‘ARD 7 (51 AND 64} 17 {#8-24} (25-31) (32-38) (39-43) (44-50) 8 {52-56) (57-63) 8 68-71 Go {73-79} 3 1. Salary and wages only. 153) [S4) 72 Lf 7 Lpey ao r 2. Total Allowable Direct Costs. a GRANT RELATED! ME OTHER ~— IRE TOTAL FUNDS & fr Ret ATEoinee STATE LOCAL FEDERAL NON FEDERAL TOTS TANCE. THIS PERIOD < FUNDS FUNDS DERA' INTEREST OTHER FUNDS FUND: Not Direct Cost) (All Sources} ‘ ‘ j 1 (is-24) | 125-391. (32-28) (29-45) (46-82) (33-59 (60-66 (67-73)