RFGAAttA - Application Form~2.docx
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- Attached to
- RFGA S-44300-00010881 for Culturally and Linguistically Specific Behavioral Health Services
- Solicitation number
- S-44300-00010881
- Issued by
- Multnomah County, Oregon
About this file
This is an Application Form (Attachment A) for Request for Grant Applications (RFGA) #S-44300-00010881 issued by the Oregon Health Authority for Culturally and Linguistically Specific Behavioral Health Services. The RFGA seeks providers who can deliver culturally and linguistically specific behavioral health services through various allowable program activities including telehealth initiatives, crisis intervention teams, peer support programs, integrated care models, cultural training, crisis stabilization centers, mobile response teams, data analytics, community outreach, and respite care services. Applicants must demonstrate their qualifications as either a Culturally and Linguistically Specific Behavioral Health Organization (CLSBHO), an outpatient entity providing such services, an independently licensed Medicaid-eligible clinician in private practice, or a private/governmental entity applying on behalf of their cultural behavioral health program.
The application requires detailed information about the applicant's geographic service area within Oregon's counties, commitment to health equity, experience with minoritized communities, implementation strategies, and sustainability plans. Applicants must provide insurance certificates and complete a Federal Funding Accountability and Transparency Act (FFATA) form including their SAM.gov Unique Entity Identifier. The form includes sections for budget proposals, applicant certification, and disclosure exemptions. Notably absent from the document are specific funding amounts, pricing terms, or contract duration details.
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RFGA # S-44300-00010881 for Culturally and AttA Linguistically Specific Behavioral Health Services
ATTACHMENT A - APPLICATION FORM
Request for Grant Applications (RFGA) # S-44300-00010881 for Culturally and Linguistically Specific Behavioral Health Services
APPLICANT INFORMATION:
Legal Name of Applicant:
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Assumed business name (DBA), if applicable:
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☐ Not Applicable
| FEIN, if applicable: |
| Click or tap here to enter text. |
☐ Not Applicable
Street Address:
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City, State Zip Code:
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Contact Name:
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Contact phone:
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Contact Email address:
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Webpage (if applicable):
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Total Grant amount requested:
Oregon Business Registry Number (if applicable):
Note: Current registration for all private business entities is required before OHA can issue a Grant Agreement to such entities.
Number: Click or tap here to enter text.
☐ Not Applicable
Oregon Department of Justice Charitable Organization Registration Number (if applicable):[footnoteRef:1] [1: Registration with the Oregon Department of Justice Charitable Activities Division is required if Applicant is one of the following:
• A corporation organized in Oregon as a public benefit nonprofit;
• A corporation organized in another state as a nonprofit which solicits, holds assets or does business in Oregon;
• A trust which holds assets in Oregon for charitable beneficiaries; or
• An association organized for charitable purposes.
For more information on when registration with DOJ is required, see this website: https://www.doj.state.or.us/charitable-activities/starting-or-closing-a-charity/registering-a-new-charity/
Number: Click or tap here to enter text.
☐ Not Applicable
| List any collaborating organizations, subcontractors or subrecipients, if applicable: |
| Collaborating organizations: |
Subcontractors:
Subrecipients:
Not Applicable ☐
INSTRUCTIONS TO APPLICANTS:
Provide your responses to all items below. This document and Attachment C – Applicant’s Information and Certification must be signed by an authorized representative of Applicant.
Note: all references herein to the RFGA or RFGA Sections refer to RFGA # S-44300-00010881 for Culturally and Linguistically Specific Behavioral Health Services or sections of that RFGA.
| Application Attachments: |
| Check applicable boxes to indicate items are attached hereto: |
· A completed Budget Proposal (Attachment B) as required by RFGA Section 3.4 Budget Proposal Requirements;
☐ Attached
· A completed Application Information and Certification Sheet (Attachment C) – as required by RFGA Section 3.5; and
☐ Attached
· A completed Disclosure Exemption Affidavit (Attachment E) if applicable as required by RFGA Section 3.6
☐ Attached
| · A completed Sample Federal Funding Accountability and Transparency Act (FFATA) Form (Attachment F) as required by RFGA Section 3.3.2(2) |
| ☐ Attached |
Check all applicable boxes to indicate which Counties in Oregon where Applicant will perform allowable Program activities if awarded a Grant Agreement under this RFGA:
| ☐ Baker |
| ☐ Benton |
| ☐ Clackamas |
| ☐ Clatsop |
| ☐ Columbia |
| ☐ Coos |
| ☐ Crook |
| ☐ Curry |
| ☐ Deschutes |
| ☐ Douglas |
| ☐ Gilliam |
| ☐ Grant |
| ☐ Harney |
| ☐ Hood River |
| ☐ Jackson |
| ☐ Jefferson |
| ☐ Josephine |
| ☐ Klamath |
| ☐ Lake |
| ☐ Lane |
| ☐ Lincoln |
| ☐ Linn |
| ☐ Malheur |
| ☐ Marion |
| ☐ Morrow |
| ☐ Multnomah |
| ☐ Polk |
| ☐ Sherman |
| ☐ Tillamook |
| ☐ Umatilla |
| ☐ Union |
| ☐ Wallowa |
| ☐ Wasco |
| ☐ Washington |
| ☐ Wheeler |
| ☐ Yamhill |
RFGA Section 3.1 Minimum Qualifications
In order for an Applicant’s Application to be considered for evaluation under this RFGA Applicant must confirm and demonstrate how the Applicant meets the following minimum qualifications in the Applicant’s Applicant Form (Attachment A) that the Applicant is one of the following:
Minimum Qualification
Check the applicable box and provide supporting information to demonstrate that Applicant meets the Minimum Qualifications of Section 3.1:
| a. Applicant is a “Culturally and Linguistically Specific Behavioral Health Organization” (CLSBHO) –that is, Applicant is an outpatient entity or institution whose mission is to provide Culturally and Linguistically Specific Behavioral Health Services. |
| Does Applicant qualify as this entity type? |
Applicant’s Response: Yes ☐
Information supporting above response:
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| b. Applicant is an outpatient entity or institution that provides Culturally and Linguistically Specific Behavioral Health Services but does not qualify as a CLSBHO under 3.1.2 (a) and the Applicant’s mission does not focus on a Minoritized community as defined in Section 2.2.3. |
| Does Applicant qualify as this entity type? |
Applicant’s Response: Yes ☐
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| c. | Applicant is an independently licensed and Medicaid eligible clinician who provides Culturally and Linguistically Specific Behavioral Health Services and is in private practice, and not employed by a governmental entity. |
| Does Applicant qualify as this entity type? |
Applicant’s Response: Yes ☐
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| d) | Applicant is a private or governmental entity which is applying on behalf of the Applicant’s Culturally and Linguistically Specific Behavioral Health Program as defined in Section 2.2.3. |
| Does Applicant qualify as this entity type? |
Applicant’s Response: Yes ☐
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RFGA Section 3.3.1 Executive Summary
1) In the space below, summarize the program objectives and the anticipated impacts that Applicant’s proposed Culturally and Linguistically Specific Behavioral Health Services will have on the communities and populations being served.
Applicant’s Response:
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2) In the space below, identify the geographic areas of Oregon where the target population(s) reside(s), including any rural areas which are ten or more miles from the centroid of a population center of 40,000 people or more.
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RFGA Section 3.3.2 Insurance Requirements
If Applicant is selected for a Grant award under this RFGA, check the “Yes” box below to confirm that:
1) Applicant will provide OHA certificates of insurance in compliance with Requirements of Exhibit C – Insurance Requirements of Attachment D- Sample Grant Agreement; and
2) Applicant will provide OHA with a completed FFATA form (RFP Attachment F), including Applicant’s SAM.gov Unique Entity Identifier (UEI) number, in compliance with the Federal Funding Accountability and Transparency Act (FFATA).
Applicant’s Response: Yes ☐
RFGA Section 3.3.3 Description of Key Strategies:
Applicants may or may select one or more of the Allowable Program Activity options listed below from Section 2.4 or may propose one or more other innovative Culturally and Linguistically Specific Behavioral Health Services in order to bridge service gaps, particularly in distinct Minoritized Communities and Culturally Specific Communities.
| Proposed Program Activities | |
| Check all Allowable Program Activities selected by Applicant: |
| 2.4.1. Telehealth and Telemedicine Initiatives |
| ☐ |
| 2.4.2. Crisis Intervention Teams (CIT) |
| ☐ |
| 2.4.3. Peer Support Programs |
| ☐ |
| 2.4.4. Integrated Care Models |
| ☐ |
| 2.4.5. Culturally Specific Training |
| ☐ |
| 2.4.6. Community Crisis Stabilization Centers |
| ☐ |
| 2.4.7. Mobile Crisis Response Teams |
| ☐ |
| 2.4.8. Data Analytics and Outcome Monitoring |
| ☐ |
| 2.4.9. Community Outreach and Education |
| ☐ |
| 2.4.10. Respite Care Services |
| ☐ |
Applicant’s Proposed Activity re: Innovative Culturally and Linguistically Specific Behavioral Health Service
☐ Applicant’s Proposed Activity (describe in the space below):
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For each Allowable Program Activity selected or proposed by Applicant, Applicant shall describe in the space below:
· The specific Proposed Program Activity;
· Goals sought to be achieved through the Proposed Program Activity;
· Specific Outcomes Applicant expects to result from completing the Proposed Program Activity;
· Timeline for completing Proposed Activity; and
· Populations to be served through the proposed Program Activity.
In addition, Applicant shall:
· Describe Applicant’s ability to complete activity and provide specific examples that demonstrate that ability; and
· Describe and include specific examples of Applicant’s capacity for designing and implementing innovative projects to address behavioral health needs of the Minoritized Cultural Community that Applicant serves.
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RFGA Section 3.3.4 Additional Required Information re: Applicant and Applicant’s Proposed Program Activities
a) Commitment to Promoting Health Equity and Inclusivity: Describe Applicant’s commitment to mitigating health disparities and inequities within the Minoritized Cultural Community that Applicant serves.
· Describe the “Minoritized Cultural Community” that Applicant currently serves.
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· Describe Applicant’s knowledge of specific health inequities experienced by the Minoritized Cultural Community that Applicant currently serves.
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· Describe how Applicant’s services are fundamentally designed to address the specific linguistic needs and cultural values, beliefs and needs of the Minoritized Cultural Community that Applicant currently serves.
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b) Location of Services: Describe the location of services Applicant will provide if awarded a Grant from this RFGA, including telehealth service; and if applicable, describe how Applicant will prioritize providing services to Rural Oregon residents using telehealth, and describe how Applicant will conduct outreach to Rural Oregon.
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c) State if Applicant is a Rural Provider.
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d) State how many employees Applicant currently employs.
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e) Describe any challenges that Applicant expects to face in performing the proposed Program activities and how Applicant plans to overcome those challenges.
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f) Describe any technical assistance, tools, resources needed for successful completion of the proposed Program activities and why such assistance, tools and resources are needed.
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g) Describe Applicant’s knowledge and experience necessary for developing and implementing Culturally and Linguistically Specific Behavioral Health Services.
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h) Describe Applicant’s potential partnerships with other culturally specific organizations, programs, and/or providers to address the unique needs of clients with intersectional identities. Such potential partnerships may include but are not limited to referrals, collaboration between providers, or other means of addressing the unique need of individuals with intersection identities.
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RFGA Section 3.3.5 Overall Strategy
a) For the Allowable Program Activities selected by Applicant, Applicant shall: explain Applicant’s overall strategy, Applicant’s experience in performing similar work, and Applicant’s ability to expand, enhance or create Culturally and Linguistically Specific Behavioral Health Services and Co-Occurring Disorder Services for Oregonians.
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b) Also, Applicant shall clearly describe Applicant’s plans for implementation, scalability, and long-term sustainability of the Culturally and Linguistically Specific Behavioral Health Services proposed by Applicant.
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Applicant certifies that the services Applicant intends to provide are evidence-informed, trauma-informed, culturally specific, linguistically responsive, person-centered and nonjudgmental.
Applicant’s authorized representative’s name / signature:
Signature: _______________________________________________
Name: ___________________________________________________
Title: ___________________________________________________
Date: ___________________________________________________
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