State Opioid Settlement Funds Grant Application

State Opioid Settlement Funds Grant Application

Please contact Destinie Triplett at destinie.triplett@odp.idaho.gov with any questions.
Organization Information
Organization Name*
Organization Address*

Street Address

Mailing Address, if different

CityState

Zip Code
Region
Click here to view a map of the Idaho public health districts.
Primary Contact Information
Primary Contact Name*

First NameLast Name
Primary Contact Title*
Primary Contact Email*
example@example.com
Primary Contact Phone Number*

Area CodePhone Number
Do you have a fiscal agent?*

YesNo

Fiscal Agent Information
Fiscal Agent Organization
Fiscal Agent Contact Name

First NameLast Name
Fiscal Agent Email
example@example.com
Fiscal Agent Phone Number

Area CodePhone Number
Address

Street Address

Mailing Address, if different

CityState

Zip Code

Problem Identification

Use the fields below to (1) Identify the specific substance misuse problem(s) in your community that will be addressed by the program/activity, (2) identify the root cause(s) that you believe contribute to the problem(s), and (3) provide supporting data that demonstrates the problem(s). Applicants are encouraged to use local, county, or regional data.
What is the problem?
Why is this a problem?
How do you know this is a problem?

Activity #1

In the following section, please provide the requested planning, implementation, and budget information for the proposed program/activity.
Proposed Evidence-Based Program or Prevention Activity*
Strategy & IOM Category
- Click here to view CSAP prevention strategies & definitions.
- Click here to view IOM categories & definitions.
Strategy*
IOM Category*
Activity Description*

0/1000
Timeline for Implementation*
Lead Person*
Activity Location*
Partners (persons or organizations)*
Activity 1 - Budget

State Opioid Settlement Fund Grant awards provide funding in three budget categories: (1) Staff – which includes all staff costs related to program implementation, (2) Mileage – which includes mileage reimbursement costs related to program implementation, and (3) Other – which includes costs for all supplies and materials that are necessary for program implementation. In the following table, please provide a breakdown and justification for the proposed Staff, Mileage, and Other Budgets for the proposed activity.
Requested Staff Budget Amount
Requested Staff Budget Justification
Requested Mileage Budget Amount
Please calculate mileage using $0.655 per mile
Requested Mileage Budget Justification
Requested Other/Supplies Budget Amount
Requested Other/Supplies Budget Justification
Activity #1 - Total Requested Budget*
Are you requesting funding for another activity?*

YesNo

Activity #2

In the following section, please provide the requested planning, implementation, and budget information for the proposed program/activity.
Proposed Evidence Based Program or Prevention Activity
Strategy & IOM Category
- Click here to view CSAP prevention strategies & definitions.
- Click here to view IOM categories & definitions.
Strategy
IOM Category
Activity Description

0/1000
Timeline for Implementation
Lead Person
Activity Location
Partners (persons or organizations)
Requested Staff Budget Amount #2
Requested Staff Budget Justification #2
Requested Mileage Budget Amount #2
Please calculate mileage using $0.655 per mile
Requested Mileage Budget Justification #2
Requested Other/Supplies Budget Amount #2
Requested Other/Supplies Budget Justification #2
Activity #2 - Total Requested Budget
Are you requesting funding for another activity?

YesNo

Activity #3

In the following section, please provide the requested planning, implementation, and budget information for the proposed program/activity.
Proposed Evidence Based Program or Prevention Activity
Strategy & IOM Category Selection
- Click here to view CSAP prevention strategies & definitions.
- Click here to view IOM categories & definitions.
Strategy
IOM Category
Activity Description

0/1000
Timeline for Implementation
Lead Person
Activity Location
Partners (persons or organizations)
Requested Staff Budget Amount #3
Requested Staff Budget Justification #3
Requested Mileage Budget Amount #3
Please calculate mileage using $0.655 per mile
Requested Mileage Budget Justification #3
Requested Other/Supplies Budget Amount #3
Requested Other/Supplies Budget Justification #3
Activity #3 - Total Requested Budget

Total State Opioid Settlement Funds Requested
Activity #1 Budget
Activity #2 Budget
Activity #3 Budget
Total Requested Grant Funds
Statement of Assurances

Please review and initial the following Statement of Assurances. Compliance with all assurances is mandatory in order to receive consideration for funding
1) Assurance of Compliance with ODP Substance Abuse Program Standards

I hereby assure the following:

I will maintain detailed records on all grant funded projects, which indicate the date, time and nature of services delivered under the grant award. Grantees will be required to collect evaluation data for all projects and submit that data to ODP as required. Grantees providing direct services will be required to collect and submit survey data for all program participants. These records shall be subject to inspection by ODP. ODP has the right to audit billings both before and after payment and to contest any billing or portion thereof.
2) Assurance of Compliance with State Laws

I hereby assure the following:

I will abide by all State laws, rules, regulations, and executive orders of the Governor of the State of Idaho, pertaining to equal opportunity. Pursuant to all such laws, rules, regulations, and executive orders, the Applicant assures ODP that no person in the State of Idaho shall, on the grounds of race, color, religion, sex, national origin, age, or disability, be excluded from employment with or participation in, be denied the benefit of, or be otherwise subjected to discrimination under any program or activity performed under a grant award(s) entered into pursuant to this Grant Application.
3) Assurance of Compliance with Parental Consent Policy

I hereby assure the following:

All program(s) conducted with Grant Funds to provide services to minors will comply with the Parental Consent Policy. All applicable staff will be fully informed of and will abide by the policies and requirements set forth therein.
4) Assurance of Faith-Based Status and Policy Compliance.

I hereby assure the following:

I have read the Substance Abuse Prevention Charitable Choice Policy along with the related State Regulation.
5) Assurance of Compliance with ODP Lobbying Policy

I hereby assure the following:

I understand that lobbying activities will not be conducted using grant funds.
6) Assurance of Compliance with ODP Policy regarding Supplanting of Funds

I hereby assure the following:

I have read the definition below and understand ODP grant funds, if awarded, will not be used to supplant expenditures from other Federal, State, or local sources.

Grant funds cannot be used to supplant current funding of existing activities. Under Definition: Supplant is to replace funding of a recipient’s existing program with funds from a Federal, State, or local grant.

The above assurances will be effective at the time a Grant Award Agreement is signed between the Grantee and Office of Drug Policy, and will remain in effect for the grant term for which funding is being sought.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

State Opioid Settlement Funds Grant Application

Primary Contact Information

Fiscal Agent Information

Problem Identification

Activity #1

Activity #2

Activity #3

Statement of Assurances

5) Assurance of Compliance with ODP Lobbying Policy