5814 Attachment#2 Budget Template Form~1.xlsx
XLSX spreadsheet 25 KB Posted
- Attached to
- Hospital Based Violence Intervention HB4045
- Solicitation number
- S-44300-00011096
- Issued by
- Multnomah County, Oregon
About this file
This document is a budget template and narrative worksheet for the Hospital Based Violence Intervention Program (HVIP) Expansion Learning Community, which is being procured by the Oregon Health Authority (OHA). The purpose of this opportunity is to support planning, training, and capacity building for hospitals and community-based organizations (CBOs) to develop HVIP services in communities outside of Multnomah County. Eligible activities include staffing, partner development, provider training and certification, technical assistance, and organizational capacity building. Applicants may apply individually for up to $125,000, with OHA anticipating making 3-8 grant awards. The grant period is from July 1, 2024 to June 30, 2025. Applicants must submit a proposed budget and narrative justification, as well as participate in quarterly progress reporting and program evaluation activities.
The total funding available for this Request for Grant Applications (RFGA) is up to $1,000,000. This opportunity is open to 501(c)(3) organizations and health systems with emergency departments/urgent care facilities located outside of Multnomah County. Partnerships between CBOs and health systems with overlapping geographic catchment areas are strongly encouraged. Successful awardees will be eligible to apply for future funding to support HVIP implementation. The awarded funds may not be used for lobbying activities.
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Other files
| File | Type | Posted |
|---|---|---|
| 5814 Attachment#3 Grant Agreement Form.pdf | ||
| 5814 Attachment#2 Budget Template Form.xlsx | XLSX spreadsheet | |
| 5814 final.pdf | ||
| 5814 final~1.pdf | ||
| 5889 - Attchment H - Sample Grant Agreement.pdf | ||
| 5814 final~2.pdf |
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Text version
09.2024-06.2025 Line Item Budget and Narrative Worksheet
INSTRUCTIONS: Please fill out the following proposed budget for your organization using the spreadsheet below. Please also provide a brief justification of this budget in the space below the spreadsheet. Applicants may apply for up to $125,000 or more of funding to participate in the Hospital Based Violence Intervention Program (HVIP) Expansion- Learning Community between September 2024 - June 2025. Because this round of funding is intended as seed money, successful applicants will submit an invoice using a template provided by OHA to receive funding as a lump sum.
| Hospital Based Violence Intervention Program Learning Community | Formula (do not enter) | |||||||
| Organization Name: | ||||||||
| Fiscal Contact: | ||||||||
| E-mail address: | ||||||||
| Phone Number: | Fax Number: | |||||||
| Budget Categories | Description | Total | ||||||
| (1) Salary - | Position # | Title of Position | Salary (Full, annual base salary amount without fringe benefits) | % of time (FTE) | # of months requested | Total Salary | $0 | |
| 1 | 12 | 0.00 | ||||||
| 2 | 12 | 0.00 | ||||||
| 3 | 12 | 0.00 | ||||||
| 4 | 12 | 0.00 |
| TOTAL SALARY | $0.00 |
| Narrative* : |
| (2) Fringe Benefits (including health insurance, retirement costs, etc. Use either 'base' or '%' depending on how your organization calculates.) | Position # | Total Salary (autopopulated from lines I10-I13 above) | Base If Applicable | % | = | Total Fringe | $0 |
| 1 | 0.00 | = | 0.00 | ||||
| 2 | 0.00 | = | 0.00 | ||||
| 3 | 0.00 | = | 0.00 | ||||
| 4 | 0.00 | = | 0.00 |
| TOTAL FRINGE | $0.00 | ||
| (3) Equipment | List equipment. Include all equipment necessary for program (i.e. computer, printer, telephone, etc.). | $0 | $0 |
| Narrative description of equipment |
| (4) Office Supplies | Do not list. These items include supplies for meetings, general office supplies ie. paper, pens, software, highlighters, binders, folders, etc. | $0 | $0 | ||
| (5) Travel | This covers in-state, out-of-state, and travel to all required trainings. | $0 | |||
| In state | Out Of State | Subtotal | |||
| Narrative* : |
| Per Diem: | $0 | |||||||
| Hotel: | $0 | |||||||
| Air fare: | $0 | |||||||
| Reg. fees: | $0 | |||||||
| Other: | $0 | |||||||
| Mileage: | Miles: | 0 | X | .56 | per mile | $0 | ||
| (6) Other (food, gift cards for participants, etc.) | Please list. | $0 | ||||||
| $0 | ||||||||
| $0 | ||||||||
| $0 | ||||||||
| $0 | ||||||||
| $0 | ||||||||
| (7) Contracts: | List all sub-contracts and all contractual costs, if applicable. | $0 | ||||||
| $0 | ||||||||
| $0 | ||||||||
| (8) Total Direct Costs | (Sum of 1 through 7) | $0 | ||||||
| (9)Cost Allocation and Indirect Rate | Indirect @ | 0.00% | $0 | $0 |
(10) TOTALS (Sum of 8 & 9). $0
| Narrative Justification |
| Instructions: Please use the space below to describe how the funds requested will support participation in the Learning Community and development of partnerships to establish hospital-based violence intervention services in your community. While clear and concise answers are welcome, there is no maximum or minimum word count; use the amount of space you need. |
| Please write your narrative justification here. |
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