IHS SAP Application Kit_AcroForm_08-01-2024.pdf

APPLICATION KIT

for FISCAL YEARS 2024

SMALL AMBULATORY PROGRAM

for

AMERICAN INDIANS AND ALASKA NATIVES

Indian Health Service Department of Health and Human Services

FISCAL YEARS 2024 SMALL

AMBULATORY PROGRAM

APPLICATION KIT

GENERAL INFORMATION

Enclosed is the application kit for the Indian Health Service (IHS) fiscal year (FY) 2024 Small Ambulatory Program (SAP). This program is established under the authority of the Indian Health Care Improvement Act, Title III, Section 306, Public Law (P.L.)

94-437, as amended, as codified and implemented by 25 U.S.C. 1636, and as further amended by language in the FY 2009 appropriation House Report 1105, Public Law 111-8.

This application kit contains four sections: (I) Program Announcement; (II) Application Format, Selection Criteria, and Award Processes; (III) Application; and (IV) Application Checklist.

The FY 2024 SAP application will be used: to determine eligibility; for the competitive rating; and to ranking for selection. Applicants should carefully review and ensure they meet the eligibility requirements in the Program Announcement prior to preparing an application. Tribes selected for award will be notified by IHS, then contacted by the Division of Engineering Services (DES) to negotiate contract award.

IHS is 100% responsible for NEPA compliance and costs for all SAP projects. IHS Areas are responsible for reviewing each submitted project and estimating the cost to complete the NEPA process. If the project is awarded that estimate will be retained as a project technical support fee under the Title I 638 contract. Below is an example:

• The Tribe submits a project to the IHS Area Office requesting $1,000,000 in funding.

• The IHS Area reviews the project and estimates $20,000 to complete the NEPA process.

• The IHS Area will include this estimate in its support letter to HQ formally requesting this funding for NEPA compliance.

• The project qualifies for award and receives $1,020,000.

• By Title I 638 contract the Tribe receives $1,000,000 and the Area retains $20,000 labeled as project technical support fee to cover anticipated NEPA compliance costs related to the awarded SAP project.

*Note: The excess funds for NEPA will not go to the Tribe

Fiscal Year 2024 Small Ambulatory Program Application Kit – General Information http://www4.law.cornell.edu/uscode/html/uscode25/usc_sec_25_00001636----000-.html

To be considered, applicants may submit the complete application, with all attachments electronically or as a hard copy. All applications are due no later than 5:00 PM, EST, November 8, 2024. Late applications will not be considered. Applications first must be submitted to the applicable IHS Area for conditional approval and then to the Division of Facilities Planning and Construction (DFPC). Appendix 1 contains SAP contact information for the IHS Areas. Questions may be directed to the SAP Program Manager CDR Omobogie Amadasu, PE, at Omobogie.amadasu@ihs.gov or 301-443-4751.

Submissions by mail require one original copy only. It is recommended that applicants obtain proof of delivery as late applications will not be considered. Submit original application with applicable IHS Area approval letter to Division of Facilities Planning and Construction, Indian Health Service, 5600 Fishers Lane, Mailstop: 10N14C Rockville, MD 20857. Mark envelopes: “FY 2024 SAP APPLICATION.”

Electronic submissions (Preferred method): Will consist of two parts.

Part 1: Navigate to the web address https://grant-review-info.com/2024IHS- Small-Ambulatory-Program and submit Sections A and B by completing the web based form.

Part 2: Complete Section C with signatures, convert/scan to PDF and send to the email address (IHSSapApplications@ihs.gov). Include the following in the subject line: “FY 2024 SAP APPLICATION: (insert Tribe name)”.

This application is now a fillable PDF form. Please use this form as a draft when preparing your application.

Thank you for your interest in the IHS Small Ambulatory Program.

James Ludington P.E. Director, Office of Environmental Health and Engineering

Date Issued (mm/dd/yyyy)

Fiscal Year 2024 Small Ambulatory Program Application Kit http://new.grantreviewinfo.net/content/2022and2023-ihs-small-ambulatory-program-application http://new.grantreviewinfo.net/content/2022and2023-ihs-small-ambulatory-program-application mailto:mailto:IHSSapApplications@ihs.gov?subject=FY 2022 & 2023 SAP APPLICATION: (insert Tribe name) mailto:mailto:omobogie.amadasu@ihs.gov https://grant-review-info.com/2024IHS-Small-Ambulatory-Program https://grant-review-info.com/2024IHS-Small-Ambulatory-Program https://grant-review-info.com/2024IHS-Small-Ambulatory-Program mailto:IHSSapApplications@ihs.gov

TABLE OF CONTENTS

APPLICATION KIT

FISCAL YEARS 2024

SMALL AMBULATORY PROGRAM

Section I Program Announcement I - 1

II Application, Selection and Award Processes II - 1

Application Process II - 2 Selection Process II - 5 Award Process II - 8

III Program Application III – 1 Section A – Applicant’s Administrative Information III – 1 Section B – Applicant’s Eligibility Determination III – 7 Section C – Technical Proposal III – 11

IV Application Checklist IV – 1

Appendix 1 List of IHS Areas SAP Points of Contact APPENDIX 1 - 1

Fiscal Year 2024 Small Ambulatory Program Application Kit – Table of Contents

SECTION I

PROGRAM ANNOUNCEMENT

for

FISCAL YEARS 2024

SMALL AMBULATORY PROGRAM

ANNOUNCEMENT NO.: SAP-2024-01

ANNOUNCEMENT DATE (mm/dd/yyyy): 08/01/2024

PURPOSE OF ANNOUNCEMENT: This announcement provides notice of the availability of funds for the Indian Health Service (IHS) Fiscal Year (FY) 2024 and affords eligible Tribes or Tribal Organizations (T/TO) the opportunity to apply.

NOTE: This announcement does not constitute a notification of funds availability as defined by 25 CFR § 900.120. IHS has conducted Tribal consultation in the development of the SAP Criteria and selection process, fulfilling the requirements of 25 CFR §900.119. Selection for award of a SAP will constitute a notification of funds availability to the selected Tribe or TO and at that time a P.L. 93-638 Subpart J contract will be negotiated and awarded.

PROGRAM TITLE: Fiscal Year 2024 Small Ambulatory Program

PURPOSE OF SMALL AMBULATORY PROGRAM: The SAP awards funding on a competitive basis for qualifying projects to construct, expand, or modernize, T/TO owned, small ambulatory health care facilities that serve American Indian and Alaska Natives (AI/AN) and that are operated pursuant to a health care services contract or compact entered into under the Indian Self-Determination and Education Assistance Act, Public Law (P.L.) 93-638.

AMOUNT OF FY 2023 SAP - FEDERAL FUNDS AVAILABLE: The SAP was funded for $25 million in FY 2024. After the awarding for each application from an IHS Area the remainder of the funding will be split. Applications that are classified as Small (<100,000 square feet for Service Unit Max Supportable Space) will have 75% of the funds set-aside. For projects classified as large (>100,000 square feet for Service Unit Max Supportable Space) the set-aside amount is 25%. Projects will be awarded until funding is exhausted.

SECTION I

PROGRAM ANNOUNCEMENT

APPLICATION KIT

FISCAL YEAR 2024

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section I

NUMBER OF AWARDS ANTICIPATED: The number of granted awards under the FY 2024 SAP is dependent on the number of applicants and the amount of assistance requested. See the Authorization section of this announcement for the various types and the funding range authorized for this program. Awards will be made to applications submitted in response to this notice. Applicants should be aware that in the past the Congress has directed the IHS to use the rank-order list of an application process when funds are appropriated in immediate subsequent fiscal years so prompt awards can be made.

APPLICATION KITS:

Small Ambulatory Program Application Kit has three sections:

Section A - Applicant’s Administrative Information;

Section B – Applicant’s Eligibility Determination; and Section C - Technical Proposal.

Sections A and B of the Program Application will be used in determining the basic eligibility and for competitive rating and ranking for selection.

Applicants may request technical assistance from their respective IHS Area, subject to available resources. Appendix 1 contains a list of all IHS Area SAP Points-of-Contact.

Application Kits in Adobe PDF format can be downloaded on or after August 1, 2024 from: https://www.ihs.gov/dfpc/ (IHS Division of Facilities Planning and Construction). If internet access is not available, a copy of the Application Kit can be requested from the SAP IHS Headquarters Program Manager.

APPLICATION DEADLINE:

It is encouraged applications are submitted to the applicable IHS Area by October 1, 2024. Complete applications must be received by DFPC 5:00 PM EST, November 8, 2024. Then deadline details are shown in the FY 2024 SAP Application Kit.

APPLICATION RECEIPT POINT:

Applications will be received either as “hard copies” by regular mail or online.

To submit online (preferred method):

1. Complete Sections A and B through the Grant Solutions ARM portal http://new.

grantreviewinfo.net/content/2023-IHS-SAP-RequestOnlineAccess

2. Send a signed Section C as PDF to IHSSapApplications@ihs.gov please write in the subject line “FY 2024 SAP APPLICATION: (insert Tribe name).”

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section I https://www.ihs.gov/dfpc/ http://new.grantreviewinfo.net/content/2023-IHS-SAP-RequestOnlineAccess http://new.grantreviewinfo.net/content/2023-IHS-SAP-RequestOnlineAccess mailto:IHSSapApplications@ihs.gov?subject=FY 2022 & 2023 SAP APPLICATION: (insert Tribe name)

3. Email a carbon copy (CC) to the responsible IHS Area Point of Contact.

4. Please note application files bigger than 20 Megabytes (20MB) may need to be sent in parts. Please label each part accordingly.

To submit by mail:

1. Complete the all sections of the application kit.

2. Please label the mail application envelope with “FY 2024 SAP

APPLICATION.”

3. Mail one completed application signed to:

Division of Facilities Planning and Construction Office of Environmental Health and Engineering ATTN: SAP Contact Indian Health Service U.S. Department of Health and Human Services 5600 Fishers Lane Mailstop: 10N14C Rockville, MD 20857

RESPONSIBLE IHS OFFICES AND INFORMATION CONTACTS:

Responsible IHS Headquarters Office:

Division of Facilities Planning and Construction Office of Environmental Health and Engineering Indian Health Service U.S. Department of Health and Human Services 5600 Fishers Lane, Mailstop: 10N14C Rockville, MD 20857

IHS Headquarters SAP Contact:

CDR Omobogie Amadasu, P.E. Program Manager Small Ambulatory Program E-Mail Address: omobogie.amadasu@ihs.gov Telephone: (301) 443-4751 (Do not submit applications to the SAP Contact/ Program Manager)

IHS Area Contacts:

Appendix 1 contains the respective SAP points of contact for each IHS Area.

ENGLISH LANGUAGE REQUIREMENT: Applications must be in the English language.

PROGRAM IMPLEMENTATION: Pursuant to the authorizing legislation, the FY 2024 SAP is being implemented using funds appropriated in FY 2024, as described below.

mailto:omobogie.amadasu@ihs.gov

STATUTORY AUTHORITY: The statutory authority for FY 2024 SAP project awards is in the Indian Health Care Improvement Act (IHCIA), Title III, Section 306, P.L.

94-437, as amended, as codified and implemented by 25 U.S.C. 1636, and as further amended by language in the FY 2009 appropriation House Report 1105, Public Law 111-8.

AUTHORIZATION AND AWARD CONDITIONS:

1. In accordance with the statutory authorities for the SAP, funding may be provided, after competitive selections, to Tribes or Tribal Organizations (T/TO)s meeting the eligibility requirements shown herein.

2. Proposed projects are to be for ambulatory health care facilities, on municipal, private, or Tribal land, and that provide health care services to eligible Indians.

Funds may be provided for the:

• construction of a new satellite facility;

• construction of a replacement facility;

• expansion of an existing facility; or

• modernization of an existing facility.

3. Funding provided under this authorization may cover up to 100 percent of the costs for the project, up to the allowed limit, shown below.

4. A SAP Application will not be considered if the proposed project has previously received an award for SAP funding. This does not preclude applying for a project that was not covered under the scope of a previously completed SAP project.

5. A SAP contract award cannot exceed $3,500,000.

6. A SAP Application will not be considered if on-site construction has already begun. A SAP award will not be made if the T/TO has awarded a construction contract and issued a Notice to Proceed for on-site work before a SAP award is made. However, planning and/or design may be complete.

7. Awards will be made through hybrid SAP construction contracts, as administered pursuant to the conditions of the Indian Self-Determination and Education Assistance Act, P.L. 93-638, Subpart “J” and applicable (as determined by the IHS) sections of 25 CFR Part 900. All contracts will be fixed-price. [Please refer to page III-3 for the required application acknowledgement that a SAP award cannot being a part of any other P.L. 93-638 Construction Management Services contract.]

8. Environmental Review Process. [The SAP projects are subject to the requirements of all Federal environmental laws which include but is not limited to, 1 Apart from a hospital is defined as the proposed project must not be contiguous or immediately adjacent to a hospital.

the National Environmental Policy Act (NEPA), the National Historic Preservation Act (NHPA), the Endangered Species Act and all other applicable statutes.

The application is to acknowledge the applicant’s responsibility for providing all necessary information and documentation to the IHS Area SAP contact person during the project planning stage and prior to construction if planning and/or design has been completed prior to SAP award, so the designated IHS Area NEPA official can perform any necessary compliance requirements. This includes a determination under NEPA, concurrence with the State Historic Preservation Officer (SHPO) or Tribal Historic Preservation Officer (THPO), and the U.S. Fish and Wildlife Service, if required]. Note that the SAP program is a Title I PL 94-638 program and so, even if a Tribe is normally compacted, NEPA and related requirements are an IHS responsibility under SAP.

9. If the Tribal facility receives Operation and Maintenance funding from the M&I program or the 105(l) lease program the facility is still eligible for a SAP award

10. No other IHS funding may be used in conjunction with the SAP project construction, except the applicant may participate in the IHS Replacement Equipment Program and receive equipment funding for the non-IHS funded portion of the SAP project. The awardee is responsible for all costs over and above the IHS SAP award.

11. Funds made available under the SAP may be used as matching shares for other Federal contract or grant programs, from other than IHS, which contribute to the purposes for which a contract under the SAP is made.

12. At no time during or after construction will the IHS have any rights or title to any real or personal property acquired as a part of the construction contract.

13. Awards will occur after the awardee provides documentation that funds are available to complete the entire proposed project. If a contract has not been awarded within a year from notice of selection for an SAP award due to unavailability of funding for the non-SAP portion of the project or other reasons; the IHS may withdraw the SAP award.

2 This is defined that the project has not received any funding already under Section 301 of P.L. 94-437, for the IHS Health Facilities Construction Priority System for inpatient, outpatient, and staff quarters facilities; or with the expired Section 307, which deals with the Indian Health Care Delivery Demonstration Program.

3 Not applicable to a T/TO, whose Tribal government offices are located on an island. For the purposes of carrying out the SAP, the condition of the authorizing legislation containing the phrase “total capacity appropriate for its projected service population” is defined to mean the IHS User Population projected to the opening year of the facility. Likewise, the phrase “no less than 500” is defined to mean that the proposed facility will serve no less that 500 active users as determined by the IHS User Population. The phrase “not less than 2,000” relates to the IHS Service Population. The Service Population is an approximate measure of the potential eligible Indians in a service area determined by the census population.

APPLICANT ELIGIBILITY REQUIREMENTS:

1. Funding, under this authority, may be provided only to a Federally recognized Indian Tribe or Tribal Organization, which, prior to submitting a FY 2024 Application, operates an Indian health care facility pursuant to a health care services contract or compact under The Indian Self-Determination and Education Assistance Act, P.L. 93-638, when the facility:

• Is not owned or constructed by the IHS; or

• Was not originally owned or constructed by the IHS and transferred to the Tribe.

2. If the health care facility entails an Emergency Room (ER), hospital, and/or urgent care in the proposed project, it must be located apart from a hospital.1

3. The proposed project must not have received any funding already under Section 301 or Section 307 of P.L. 94-437.2

4. Upon completion of the proposed project, the health care facility will:3

• Serve no less than 500 eligible Indians annually; and

• Provide ambulatory care in a service area (specified in the services contract entered into under the P.L. 93-638) having not less than 2,000 eligible Indians.

5. Applicants must be able to provide reasonable assurances, that upon completion of the proposed project, the applicant will:

• Have adequate financial support to provide the proposed health care services;

• Make the health care facility available to eligible Indians without regard to ability to pay or source of payment; and

• Provide services to non-eligible persons on a cost basis, per Federal Law without diminishing the quality or quantity of services to eligible Indians.

6. A need must exist for increased ambulatory health care services.

7. The current facility must have insufficient capacity to deliver needed services.

8. The T/TO’s financial management systems must meet the requirements of 25 CFR Parts 900.44 and 900.45. To be in compliance, the Single-Agency Audits provided in compliance with the 2 CFR Part 200 may not have any significant and material weaknesses or unresolved issues of fraud or improper use of previously provided Federal funds.

APPLICATION:

The Application must be submitted in accordance with the guidelines in the Application Kit and will be used to determine basic eligibility, competitive rating and for selection.

The application is to contain only that which is required in the guidelines and only in the detail needed for responding properly to the respective application requirement.

Extra information is not required nor desired (i.e. a full business plan). Applications should not exceed 75 total pages. The application is to demonstrate project need, and the administrative and financial capabilities of the applicant in the appropriate sections.

Applicants are required to use HSP

Access to the Health Systems Planning (HSP) software is needed to calculate required application data. T/TOs are encouraged to create their own login and use the software.

To create an account navigate to https://hsp.ihs.gov and click the button Log in Here, and click the hyper link “Click Here to Request Access to this System”.

The SAP Program manager will provide a training on how to use HSP to complete your SAP application on September 5, 2024 at 1pm EST. This training will be free and open to all who are interested. To attend, please click the Zoom link below.

https://ihs-gov.zoomgov.com/j/1615216368?pwd=RVZjdk9OT1RRSkM4QWJwd1JCb0JzQT09

Meeting ID: 161 521 6368 Passcode: 786201

If you do not have access to a computer to access the training, please contact the SAP program manager.

EVALUATION AND SELECTION PROCESS:

The details about the evaluation and selection processes are included in the Application Kit Section II. As part of the eligibility determination, the applicable IHS Area will review and validate the application, and will provide to the IHS Headquarters an appropriate endorsement for the proposed project.

After the basic eligibility determination, eligible applications will be reviewed, evaluated, rated and ranked for selection through an objective review process, using an Objective Review Team (ORT) that will evaluate applications with the following factors:

• Need for project. (Maximum 40 points)

• Delivery capability. (Maximum 40 points)

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section I https://hsp.ihs.gov https://ihs-gov.zoomgov.com/j/1615216368?pwd=RVZjdk9OT1RRSkM4QWJwd1JCb0JzQT09

• Construction capability. (Maximum 15 points)

• Applicant Financial Contribution. (Maximum 5 points)

The IHS Headquarters DFPC will review the results of the ORT and make selection recommendations for final selection by the Selecting Official, the IHS Headquarters, Director, Office of Environmental Health and Engineering.

AWARD PROCESS:

Hybrid construction contracts adapted for the SAP and administered pursuant to the conditions of The Indian Self-Determination and Education Assistance Act, P.L. 93- 638, Subpart “J” and applicable sections of 25 CFR Part 900 (as determined by the IHS), will be used as the means of providing the Federal assistance pursuant to the SAP. Awards will be made based on the competitive selections of projects using the information contained in both parts of the application. Contracts will include: (1) the contents of the Application (2) the Program Announcement (Application Kit, Section I); (3) the Application, Selection and Award Processes (Application Kit, Section II);

and (4) the Application.

APPLICATION AND AWARD PROCESS SCHEDULE:

The estimated activities schedule for the FY 2022 & 2023 SAP is:

- Application Kit issued

- Application Kit available on web sites:

August 1, 2024 August 1, 2024

- Preferred due date to applicable IHS Area for review/approval October 1, 2024

- Due date for Application, (With IHS Area approval letter)

- Complete eligibility determination, (HQ Review)

- Complete rating and ranking:

- Final selection:

- Notice of selections issued:

- Complete contract awards:

November 8, 2024 November 22, 2024

January 10, 2025 January 17, 2025 January 31, 2025

February 25, 2025

All dates after the due date for the application are tentative and are subject to change.

James Ludington P.E. Director, Office of Environmental Health and Engineering

SECTION II

APPLICATION INFORMATION, SELECTION

CRITERIA, and AWARD PROCESSES for

Fiscal Years 2024

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section II, Page 1

APPLICATION PROCESS

Small Ambulatory Program Application has three sections:

Section A - Applicant’s Administrative Information;

Section B – Applicant’s Eligibility Determination; and

Section C - Technical Proposal.

Sections A and B of the Program Application will be used in determining the basic eligibility and for competitive rating and ranking for selection.

Technical assistance may be requested from the applicant’s respective IHS Area, subject to available resources. Appendix 1 has a list of Area SAP Points-of-Contact.

A. APPLICATION CONTENT

Application Kit Section III contains the items to be included in the application.

Application Kit Section IV is a checklist of items to be in the application.

B. PREPARATION AND ASSEMBLING

(For section C only if submitting by mail)

Avoid the use of jargon and acronyms. Electronic submissions once printed should match the guidelines. To facilitate review, validation, rating, ranking and selection, both parts of the application, with all required attachments, are to be prepared and submitted conforming to the below requirements:

1. Be written in the English language;

2. Be on standard 8-1/2” x 11” size paper;

3. Be printed in 12 point size, black font;

4. Be printed in a regular font style (Arial, Calibri, New Times Roman, etc.);

SECTION II

APPLICATION INFORMATION, SELECTION

CRITERIA, and AWARD PROCESSES for

Fiscal Years 2024

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section II, Page 2

5. Have one-inch margins on all four sides;

6. Be printed on one side only;

7. Be Loose and not bound nor stapled (Hard copy only);

8. Have a header identifying the name of the applicant;

9. Have consecutively numbered pages with the numbers shown in the footer;

10. Be signed by the authorized official of the Tribe or Tribal Organization’s (T/TO).

11. Have a Cover Sheet entitled “FISCAL YEAR 2024 Small Ambulatory

Program,” followed by the applying T/TO’s name and the submission date;

14. Use consistent units (US Customary Standard) and consistent abbreviations.

15. Application is not to exceed 75 total pages.

16. Electronic application submittals larger than 20MB may require to be sent via multiple emails. In the subject line please enter FY 2024 SAP APPLICATION (insert Tribe name) – Part (#).

Application items to be included in order with the application submission:

1. Application Cover Sheet

2. Table of Contents

3. SMALL AMBULATORY PROGRAM APPLICATION

a. Section A – Applicant’s Administrative Information (Preferred online)

b. Section B – Applicant’s Eligibility Determination (Preferred online)

c. Section C – Technical Proposal

d. Signature page

e. Attachments

i. Copy of Auditor’s Summary of Findings of last Single Agency Audit

ii. Tribal Resolution

iii. Location and Site Maps

iv. Space List and Floor Plan

v. Project Administration Organization Chart

4. Application Checklist - For the SAP application is now available in a fillable PDF Form. This form may be used as a tool before submitting online.

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section II, Page 3

C. MAILING OR DELIVERY

Using either the U.S. Postal Service or a commercial delivery service, send one completed signed application, with attachments to:

FY 2024 SAP Application Division of Facilities Planning and Construction (DFPC) Office of Environmental Health and Engineering (OEHE) Indian Health Service 5600 Fishers Lane, Mailstop: 10N14C Rockville, MD 20857

Mail or deliver one copy of a signed original of the complete Application, with all attachments (documentation), to the respective SAP contact person in the applicable IHS Area, using the address shown in Appendix 1.

Mark both Application envelopes: “FY 2024 SAP Application”

For electronic submissions, e-mail a PDF copy (only Section C and attachments if submitting Sections A and B by online portal) and the fillable PDF of the signed original application (digital signatures are allowed) to the IHS Headquarters using the email address IHSSapApplications@ihs.gov and the applicable Area SAP Contact.

Include “FY 2024 SAP Application (insert Tribe Name)” in the subject line.

Electronic application submittals larger than 20MB may require to be sent via multiple emails. In the subject line please enter FY 2024 SAP Application (insert Tribe name) – Part (#). The option to submit the fillable PDF Form by email is allowed but not preferred.

Also note that digital signatures are acceptable.

D. APPLICATION DEADLINE

Complete applications must be received to IHS Headquarters DFPC by November 8, 2024 5:00pm EST, the deadline shown in the FY 2024 SAP Program Announcement.

E. LATE APPLICATION

The application will be considered to be “on time” if it is received, by the IHS Headquarters DFPC on or before the established deadline date and time by e-mail or postmarked regular mail. The applicant, if using the U.S. Postal Service, should request a legibly dated U.S. Postal Service postmark on the envelope, and/or receipt.

Private metered mail postmark will not be accepted as proof of timely mailing. A late application will not be accepted for processing.

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section II, Page 4 mailto:ihssapapplications@ihs.gov

F. NON-CONFORMING APPLICATION

An application will be found as non-conforming if it fails to meet the Application Kit submission, or the SAP eligibility, requirements. Non-conforming applications will not be processed further.

G. PRIVACY ACT

The Privacy Act of 1974 (5 U.S.C. § 552a), with certain exceptions, permits individuals to gain access to information pertaining to themselves in Federal agency records, to have a copy made of all or any part thereof, to correct or amend such records, and to permit individuals to make requests concerning what records pertaining to themselves, are collected, maintained, used or disseminated. The Act also prohibits disclosure of individual’s records without written consent, except under certain circumstances as prescribed.

H. FREEDOM OF INFORMATION ACT

The Freedom of Information Act (5 U.S.C.§ 552) allows requesters to have access to Federal agency records, except those which have been exempted by the Act.

I. IHS AREA ASSISTANCE

Each IHS Area has a SAP Point-of-Contact, as listed in Appendix 1. The IHS Areas are available to assist applicants with the preparation of the Applications, as resources allow.

SELECTION PROCESS

A. IHS AREA ASSISTANCE, REVIEW AND ENDORSEMENT

[Coordinate with Area and insure Area is given adequate time to review and endorse.].

1. Prior to submission of Application. As specified in the application requirements, the applicant, prior to submitting its application, is to coordinate with the applicable IHS Area to seek the required IHS prior concurrence of the statistical data, user population, and existing facilities information used in the Application. As IHS Area resources allow, the respective IHS Area is to provide appropriate assistance to the applicant for this validation process.

2. Review of submitted Application. Using the copy of the Application provided by the applicant directly to the applicable IHS Area, the IHS Area is to review the Application to ensure correctness of the data and information with which the IHS Area is involved, as follows:

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section II, Page 5

a. Validation of Existing Services Contract. The IHS Area is to validate the existing P.L. 93-638 services contract or compact. The IHS Area is to include with its endorsement, as an attachment, copies of the following identified components of the contract [DO NOT provide a copy of the entire contract.]:

(1) Identification of parties who have executed the contract.

(2) Identification of period of contract

(3) Identification of health care services covered by the contract

(4) If the contract is with a T/TO providing health care services for more than 1 Federally recognized Tribe, additional documentation is to be provided to show the legal tie with the Federally recognized Tribes.

(5) Signatures of parties executing the document.

b. Validation of Facilities Information. The IHS Area is to validate the facilities information used in the “Need for Project Calculation” in Item 7 of Section C – Technical Proposal of the Application.

c. Validation of User Population Report. The IHS Area is to validate the Health Systems Planning (HSP) user population report for “Population Certifications” Item 7 and Section B – Applicant’s Eligibility Determination.

d. Validation of Service Unit and Maximum Supportable Space.

The IHS Area is to validate the Service Unit of the proposal and corresponding Maximum Supportable Space (MSS). Then the IHS Area is classify the project as either large (If MSS ≥100,000 ft2) or small (If MSS <100,000 ft2).

3. Certification Endorsement. The IHS Area is to provide an endorsement letter, which includes the Area Point of Contact for NEPA compliance and the estimate to complete the NEPA process. If no project technical support fee is required please state this in the endorsement letter. If the IHS Area determines the cost to comply with NEPA is zero please make this declaration in the memo. The IHS Area is responsible for any and all NEPA cost overruns. This may occur if the IHS Area estimate for NEPA compliance is wrong or the IHS Area mistakenly declared zero cost for NEPA compliance. Also the endorsement letter should certify that the proposed project has been reviewed by the Area, and is consistent with the IHS Area’s master plan for health care facilities. (If a formal master plan does not exist or is not complete for an IHS Area, this certification is to address the project’s relationship with the overall concept of operations under which the IHS Area operates with its Tribes.) This document is to include appropriate comments about the application and a recommendation whether the Area

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section II, Page 6 supports the project as presented in the application. In this endorsement letter the Area must provide a Point of Contact for NEPA compliance.

4. Retention of Application Copy. The copy of the Application used for the above discussed review and certification is to be retained by the IHS Area for future use and reference if the project is selected for an award.

B. IHS HEADQUARTERS REVIEW OF APPLICATION:

1. The applicable IHS Area’s endorsement memorandum will be reviewed.

2. The entire application will be reviewed to determine if it has been prepared in accordance with the Application Kit instructions.

3. Program Application, Sections A and B, will be reviewed to determine conformance with eligibility requirements.

4. Conforming applications will be prepared for the prescribed review, evaluation, rating and ranking described below.

C. REVIEW, EVALUATION, RATING AND RANKING:

Conforming eligible application will be evaluated, rated and ranked for selection by an Objective Review Team (ORT). The rankings will be categorized by size. The ORT will be composed of representatives from the Federal Government and Tribes.

To the extent feasible, ORT members will not be associated with applying T/TOs. The ORT members will be asked to recuse themselves from rating if they have any ties with the applying T/TOs or if there may be any appearance of a conflict of interest. To protect the process confidentially, the names of ORT members and their results will be released only to the selecting officials.

The Application will be reviewed and evaluated to determine the applicant’s ability to accomplish the proposed project and will be scored according to the evaluation criteria contained in the four rating factors below, then ranked for selection.

D. RATING FACTORS:

1 - Need for Project (Maximum 40 points) Evaluation: The ORT will verify the calculated score provided in Application, Section C, Item 7, Need for Project Calculation.

2 - Delivery Capability (Maximum 40 points) Evaluation: Application, Section C, Item 8, Delivery Capability Brief, the applicant’s capability to provide the necessary health care services for the user population after construction is completed will be evaluated by the ORT.

3 - Construction Capability (Maximum 15 points)

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section II, Page 7

Evaluation: Application, Section C, Item 9, Construction Capability Brief, will be evaluated by the ORT to determine to what extent the applicant has the capability to manage the proposed construction project, keeping on schedule, within the budget, with a safe operation and with good quality control.

4 - Applicant’s Financial Contribution (Maximum 5 points)

Evaluation: Application, Section C, Item 10, Applicant Financial Contribution Brief, will be evaluated to determine the applicant’s willingness to commit non- IHS resources to the project. Higher scores will be given to applicants who demonstrate the initiative to have other funds above that being received from the SAP.

E. SELECTION

Using the ranking results received from the ORT, final selections will be recommended by the IHS Headquarters Program Office (Division of Facilities Planning and Construction) for final selection by the Selecting Official, the IHS Headquarters, Director, Office of Environmental Health and Engineering. The scoring by the ORT is used only in the selection process.

AWARD PROCESS

Awards will be made based on the rank order of selected projects. The rank order is used only for determining which projects will receive awards. Once awards are made, the scoring and ranking information has no meaning or bearing on any future actions.

The size categorization will remain until all projects have been funded under that specific size. If funds still remain they will be used to fund the remaining projects under the other categorization. The information submitted will not be maintained or released for future use in selections.

Successful applicants will be notified by an official letter from IHS Headquarters.

Awards will be made through hybrid construction contracts by IHS Division of Engineering Services (DES) adapted for the SAP, as administered pursuant to the conditions of The Indian Self-Determination and Education Assistance Act, P.L.93-638, Subpart “J” and applicable (as determined by the IHS) sections of 25 CFR Part 900.

Discussions/negotiations will be held with selected Tribes or TOs. Partial awards may be offered to allow award amount to match available funding.

Any questions about the award process please contact DES Chief of OEHE Acquisitions Melissa Warmath. Email: Melissa.Warmath@ihs.gov. Office: (214) 767-3517.

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section II, Page 8 mailto:melissa.warmath@ihs.gov

SECTION III

APPLICATION

for Fiscal Years 2024

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section III, Page 1

APPLICATION KIT Fiscal

Years 2024

SMALL AMBULATORY PROGRAM

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section III, Page 1

THE PROGRAM APPLICATION WILL BE USED TO DETERMINE BASIC ELIGIBILITY AND FOR

COMPETITIVE RATING AND RANKING.

PROGRAM APPLICATION

The Program Application is to contain the following information and be assembled in the order shown:

• Application Cover Sheet. [The cover sheet is to identify that the document is an Application for the FY 2024 Small Ambulatory Program, show the name of the applying Tribe or Tribal Organization, and reflect the submission date.]

• Table of Contents. [All pages of the – Program Application, are to be numbered.

The Table of Contents is to list all sections and items in the – Program Application, with the corresponding item numbers and starting page numbers. A maximum of 75 pages ]

SECTION A – APPLICANT’S ADMINISTRATIVE INFORMATION

To complete online (preferred):https://grant-review-info.com/2024IHS-Small- Ambulatory-Program

1. Date of Application Submission (mm/dd/yyyy): ________________________

2. Applicant’s Project Control Number. [Show any control number used by the applicant or “NOT APPLICABLE,” if that is the case with the applicant.]

3. Descriptive Title of Applicant’s Project. [Show the applicant’s short descriptive title for the project.]

4. Amount of Federal Assistance Requested. [Show the dollar amount of Federal assistance being requested in this application. Note: this amount cannot exceed $3,500,000. Also be aware that during the objective review process, the amount being contributed by the Tribe affects the score of the application.]

5. Total Estimated Project Cost. [Show the dollar amount of the estimated total cost for the project.]

6. Percentage of Total Project Cost. [Identify the percentage of the estimated total project cost for which Federal assistance is being requested.] ____________ %

7. Full name, address, telephone number, and “e-mail” address of TRIBE OR TRIBAL ORGANIZATION (APPLICANT). [Show the full legal name of the applicant. Show the actual street location, city, county, state and zip code. If the address for U.S. Postal Service delivery or special delivery services, such as FedEx, is different, please provide also.]

Full Name: _______________________________________________________

Telephone Number: ______________________

Full Address: _____________________________________________________

E-mail address of Tribe or Tribal Organization: ___________________________

a. Tribal/Tribal Organization Leader:

Full Name: _____________________________________________________

Position Title: ___________________________________________________

Full Address: ___________________________________________________

Telephone Number: ___________________ Fax Number: _______________

E-mail address: _________________________________________________

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section III, Page 2

8. Full name, position title, address, telephone number, fax telephone number, and “e-mail” address of the applicant’s DESIGNATED OFFICIALS authorized by applicant’s governing body, as:

a. Contact and responsible official for the application:

Full Name: _______________________________________________________

Position Title: _____________________________________________________

Full Address: _____________________________________________________

Telephone Number: ______________________Fax Number: _______________

E-mail address: ___________________________________________________

Tribal Resolution):

Full Name: _______________________________________________________

Position Title: _____________________________________________________

Full Address: _____________________________________________________

Telephone Number: ______________________Fax Number: _______________

E-mail address: ___________________________________________________

9. General Location of Project. [Such as the city and state, Latitude and Longitude or the name of the reservation and state.] Location: ________________________________________________________

10. Applicant’s Federal Employer Identification Number (EIN). [Show the EIN as assigned by the U.S. Internal Revenue Service.]

EIN: ___________________________

Number is no longer accepted.

UEI: ___________________________

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section III, Page 3

12. System for Award Management (SAM) Certification. [Provide a statement that the applicant is registered in the SAM database. Registration can be done on-line at the Grants.gov website

District: _________________________

District: _________________________

15. The SAP Award Not Part of Any Other Contract Acknowledgement. [The applicant is to acknowledge that the P.L. 93-638 Subpart “J” construction contract that is used for SAP award will not be made part of any P.L. 93-638 Services Contract, Compact, Annual Funding Agreement, or Funding Agreement, and will NOT be subject to “Tribal Shares,” since the SAP is a specifically “earmarked” program that is not discretionary. Section 505 of Title V indicates that “Tribal Shares” are to be provided for discretionary programs, excluding congressionally “earmarked” competitive programs such as the SAP.]

I AGREE I DISAGREE

16. Agreement Statement for Tribal Project Reports Required After Contract

the end of the quarter of contract award:

a. Financial Status Report, Standard Form (SF) 425.

b. Tribal Quarterly Progress Report.

Does the Tribe agree to provide IHS a Financial Status Report Standard Form (SF) 425?

YES NO

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section III, Page 4 https://www.grants.gov/applicants/organization-registration/step-2-register-with-sam.html https://www.grants.gov/applicants/organization-registration/step-2-register-with-sam.html

programs to operate the Tribe’s P.L. 93-638 health services contract or compact with the IHS beyond the current funding level in the contract or compact. Applicant continues to be eligible for future program increases as provided by law.]

Applicant is to acknowledge that the IHS will not provide additional funding for staffing and/or programs to operate the Tribe’s P.L. 93-638 health services contract or compact with the IHS beyond the current funding level in the contract or compact.

I ACKNOWLEDGE I DO NOT ACKNOWLEDGE

18. Statement about Construction Management Contract.4

As required by 25 C.F.R. § 900.125(b)(8), provide “a statement indicating whether or not the Indian Tribe or Tribal Organization has a construction management services (CMS) contract for CMS related to this project”.

Does the Tribe or Tribal Organization have construction management services (CMS) related to this project?

YES NO

19. Assurances for Contract Award. The applicant hereby acknowledges that the following assurances will apply if awarded a contract for SAP funding: [The applicant is to include this exact statement and these assurances in order to be awarded a contract for SAP funding, if the project is selected.]

a. If the Indian Tribe or Tribal Organization elects not to take title (pursuant to Subpart I) [25 CFR Part 900.125] to Federal property used in carrying out the contract, “The Tribe will not dispose of, or change the terms of the real property title, or other interest in the site and facilities without permission and instructions from the awarding agency. The Indian Tribe or Tribal Organization will record the Federal interest in the title of real property acquired in whole or in part with Federal assistance funds to assure nondiscrimination during the useful life of the project;”

WILL RECORD WILL NOT RECORD

4 The requirement for this statement is needed to assure that the IHS is not paying the applicant for construction management services under another contract.

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section III, Page 5

b. “The Tribe will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.)” which prohibits the use of lead based paint in construction or rehabilitation of residential structures;

WILL COMPLY WILL NOT COMPLY

c. “The Tribe will comply, or already complies, with the requirements of Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646),” which provides for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal participation in purchases; and

WILL COMPLY WILL NOT COMPLY

d. “Except for work performed by Tribal or Tribal Organization employees, the Tribe will comply, as applicable, with the provisions of the Wage Rate Requirements (40 U.S.C. §§ 3141 - 3146,” for Federally assisted construction sub agreements;

WILL COMPLY WILL NOT COMPLY

e. “The Tribe will comply with the flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234),”

construction and acquisition is $10,000 or more;

WILL COMPLY WILL NOT COMPLY

f. “The Tribe will comply with all applicable Federal environmental laws, regulations and Executive Orders;”

WILL COMPLY WILL NOT COMPLY

g. “The Tribe will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C.

1271 et seq.) related to protecting the components or potential components of the national wild and scenic rivers system;”

WILL COMPLY WILL NOT COMPLY

h. “The Tribe will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C.

470), Executive Order 11593 (identification and preservation of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. 469a-1 et seq.).”

WILL COMPLY WILL NOT COMPLY

Fiscal Year 2024 Small Ambulatory Program Application Kit – Section III, Page 6

SECTION B – APPLICANT’S ELIGIBILITY DETERMINATION TO COMPLETE

ONLINE (PREFERRED):

https://grant-review-info.com/2024IHS-Small-Ambulatory-Program

[The contents of this Section are to be repeated as written, with the applicant responding where indicated. An application should be prepared and submitted only if the applicant meets all eligibility requirements.]

1. Federally Recognized Tribe. Is applicant included in the Federal Register that provides the Department of Interior, Bureau of Indian Affairs, Notice of Indian Entities Recognized and Eligible to Receive Services for the United States Bureau of Indian Affairs (BIA) (The latest Federal Register edition is Volume 73, Number 66, dated Friday, April 4, 2008.)

YES NO

2. Different Legal Name. Is the legal name of the applicant other than that appearing in the Federal Register listing of eligible Indian Entities for the BIA?

YES NO

[If YES, provide an explanation:

Proceed to next item.]

3. Status of Project. Has on-site construction started for the project?

YES NO

If on-site construction has not started, does the applicant plan to award a construction contract for on-site work…