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HVIP Budget Template 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 $100,000.00 (or more funding if available) to participate in the Hospital Based Violence Intervention Program (HVIP) Expansion- Learning Community between December 2026 - June 2027. 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 | | | | | | 0.00 | |
| 2 | | | | | | 0.00 | |
| 3 | | | | | | 0.00 | |
| 4 | | | | | | | |
| 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 | |
| 2 | | | | = | 0.00 | |
| 3 | | | | = | 0.00 | |
| 4 | | | | | | |
| TOTAL FRINGE | $0.00 | |
| (3) Equipment | List equipment. Include all equipment necessary for program (i.e. computer, printer, telephone, etc.). | | $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 |
| (5) Travel | This covers in-state, out-of-state, and travel to all required trainings. | | | | |
| | In state | Out Of State | Subtotal | |
| Narrative* : | | | | |
| Per Diem: | | | | | $0 | |
| Hotel: | | | | | $0 | |
| Air fare: | | | | | $0 | |
| Reg. fees: | | | | | $0 | |
| Other: | | | | | $0 | |
| Mileage: | Miles: | X | .56 | per mile | $0 | |
| (6) Other (food, gift cards for participants, etc.) | Please list. | | | | | | $0 |
| | $0 | |
| (7) Contracts: | List all sub-contracts and all contractual costs, if applicable. | | $0 |
| (8) Total Direct Costs | (Sum of 1 through 7) | | | $0 |
| (9)Cost Allocation and Indirect Rate | | 0.00% | $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. |