Community Grant Program Application

Community Grant Program

South Dakota Opioid Settlement Fund
Important Notice for Naloxone Distribution and Overdose Training Applicants
Thank you for your interest in the Opioid Settlement Community Grant Program. Before proceeding, we want to inform you that the Division of Behavioral Health has launched a comprehensive Naloxone saturation effort. As part of this initiative, direct support is being offered with the followinginitiatives:
1. Naloxone purchase and distribution
2. Increasing public access points for Naloxone
Please do not proceed with the application process if your proposal is solely for any three of the initiatives identified above. Instead, we invite you to complete a brief contact form to receive support for these initiatives through the Division of Behavioral Health.

If your grant proposal includes additional strategies other than described above, please proceed with the application process.

For questions please refer to FAQ’s or contact letsbeclear@state.sd.us.
Complete Contact Form

1 | Applicant Information

If you need to work on this form at different times, there are options to save or print at the bottom of the form next to the "Submit Final Application" button. Contact Grants@sageprojectconsultants.com for questions about the Grant Program.
Organization Legal Name*
Primary Contact Person*

First NameLast Name
Organization Address*

Street Address

Street Address Line 2

CityState

Zip Code
Error: Must be a South Dakota Organization
Phone Number*
Please enter the best phone number to reach the primary contact person about matters pertaining to this application, as needed.
Email*
example@example.com
Application Organization Type*
Applicant Organization Status*
Optional Fiscal Agent Information

No grants/contracts can be made to individuals. Complete the following fields if applying through a fiscal agent.
Fiscal Agent Legal Name
Primary Contact Person

First NameLast Name
Fiscal Agent Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number
Please enter the best phone number to reach the primary contact person about matters pertaining to this application, as needed.
Email
example@example.com
File Upload - Substitute W-9 Form*

The form should reflect information for the applicant organization (if not using a fiscal agent) or for the fiscal agent identified above.
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File Upload for Letters of Commitment or Support from Participating Local Governments*

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3 | Project Description
Project Start and End Date

All approved projects will be extended a contract dated June 1, 2025 through May 31, 2026 and be allowed the full year to complete approved scope of work. Projects may start or end in between those dates.
Project Start Date

MonthDayYear
Date must be on or after June 1, 2025.
Project End Date

MonthDayYear
The project timeline is at the discretion of the applicant based on what is needed to accomplish the proposed activities. The timeline cannot exceed 12 months and must be complete by May 31, 2026.
Describe the target population(s) for this project.*
Describe the target geographic area(s) for this project.*
List specific towns, counties, or note statewide if applicable.
Describe your organization's experience in opioid-related prevention, recovery, and/or treatment efforts.*
Describe your goal(s) for this grant request and provide a brief summary of what you aim to accomplish. *
Ensure that your objectives can be measured and are actionable.
Identify any partners and their role(s) in the implementation of your project including the role of participating local governments. *
Describe how the project expands, supports, and/or improves upon existing efforts or services currently available.*
Describe the supporting evidence or basis for your project. How do you know the project will work as you intend it to?*
Include reference to any evidence-based programs or protocols, or other basis or research, that support the implementation of your project.
Describe your plan for sustaining this project beyond the grant award period. How will you ensure its continuation and effectiveness after the initial funding ends?*

4 | Measures of Success
Describe two to three measures you will use to assess your specific needs and issues.*
Examples of things to measure may include increasing referrals to treatment for opioid use disorder from an emergency department, increasing knowledge in prescribing practices among providers, or decreasing stigma.
Approximately how many individuals will your project serve?*

5 | Cost Proposal

A budget is required with your application.
Total Amount Requested ($)*
A. Personnel

Include direct staff costs requested by noting name or role to be filled. Personnel rates should be inclusive of any applicable, requested fringe benefits. Time and effort associated with reimbursement of fee-for-service delivery should not be included in this section.
Personnel Expenses Narrative
Narrative discussion should include a brief description of roles and responsibilities to be filled in alignment with the proposed project.

Personnel Description

	Name/Role	Activities/Comments	Budget Request Amount
1
2
3
4
5
6
Total Amount

Personnel Total ($)
B. Travel

Include the unit rate cost requested for travel. In-state reimbursable travel rates may be used if an applicant organization does not have established reimbursement rates. State Travel Reimbursement Rates
Travel Expense Narrative
Narrative discussion should include rationale for travel to support the proposed project activities.
Lodging

Description Total Amount

1

Per Diem

	Breakfast	Lunch	Dinner
Count
Rate
Total Amount

Mileage

	Miles	Rate	Total Amount
1

Other Travel Expenses

	Description	Total Amount
1
2
3
4
Total Amount

Travel Total ($)
C. Equipment

Include units and unit cost for applicable equipment. Items in this category should exceed $5,000 in value.
Equipment Expense Narrative
Narrative discussion should include the equipment name and what the equipment will be used for. If a quote has been obtained, you may attach that to the application form under "Other Attachments".

Equipment

	Description	Total Amount
1
2
3
4
5
Total Amount

Equipment Total ($)
D. Supplies

Include units and unit cost for requested supplies.
Supplies Expense Narrative
Narrative discussion is not necessary if the line item is self-explanatory (e.g., DisposeRx packets, 1000 units, $$$ unit price).

Supplies

	Description	Units/Costs	Total Amount
1
2
3
4
5
Total Amount

Supplies Total ($)
E. Contractual/Consultants

Include hourly rates, staff types, and level of effort (units/hours) to be charged to the project. Include Consultant Name / Agency Name as applicable.
Contractual/Consultant Expense Narrative
Narrative discussion should expand upon what service, training, development, or related activity will be provided by the contractor. Any relevant quotes may be attached to the application form using the "Other Attachments" field.

Contractual/Consultants

	Description	Units/Hours	Total Amount
1
2
3
4
5
Total Amount

Contractual/Consultants Total ($)
F. Other Charges

Include units/hours and costs for any other direct charges not captured above.

Costs such as scholarships, supports for behavioral health practitioners, or any patient-support costs, for example, would align with this category.
Other Charges Expense Narrative
Narrative discussion should explain how these costs would be leveraged to support the Approved Uses of settlement funds.

Other Charges

	Description	Units/Hours	Total Amount
1
2
3
4
5
Total Amount

Other Charges Total
G.1 Fee for Service/Professional Services

Should treatment, recovery support, case management, or other like services with established reimbursement fee structures through CMS, SD Medicaid, or other payers be proposed, include a service code/descriptor, the rate at which reimbursement is proposed, and units anticipated for service delivery for each service type.
Fee for Service/Professional Services Expense Narrative
Narrative discussion should explain any deviation in reimbursement rates from CMS and SD Medicaid current rate structures.

Fee for Service/Professional Services

	Description	Total Amount
1
2
3
4
5
Total Amount

Fee for Service/Professional Services Total
G.2 Administrative/Indirect Costs

Should administrative or indirect costs be requested, include discussion on the eligible cost base for the request and the rate applied.

No more than 10% of applicable direct costs may be requested for an applicant's indirect cost recovery. Fee for service, professional services, and equipment should be excluded from the eligible cost base in all situations.
Administrative/Indirect Costs Expense Narrative
Narrative discussion should explain how these costs would be leveraged to support the Approved Uses of settlement funds

Administrative/Indirect Costs

	Description	Total Amount
1
2
3
4
5
Total Amount

Administrative/Indirect Costs Total
Percent of Total Budget Request
Error: Administrative Costs/Indirect Costs greater than 10% of total budget. No more than 10% of applicable direct costs may be requested for an applicant's indirect cost recovery.
If additional funds are being used to support the project above and beyond this grant request, briefly describe those here.*
Budget Summary

Please carefully review your budget summary for accuracy. If you identify any discrepancies or need to make changes, update the relevant sections above.

Budget Summary

	Total Amount
A. Personnel
B. Travel
C. Equipment
D. Supplies
E. Contractual/Consultants
F. Other Charges
G.1 Fee for Service/Professional Services
G.2 Administrative/Indirect Costs
Total Budget Amount

Budget logic test
Warning: Total Budget Amount does not match Requested Budget Amount
Other Attachments

Upload any additional documents that support the proposed project.
Cancelof

Application Submission
On behalf of South Dakota's Opioid Abuse Advisory Committee, thank you for applying to the Opioid Settlement Fund Community Grant Program.

{primaryContact} as Primary Contact for {organizationLegal} will be provided an electronic copy of the form upon submission. To send a copy to another individual, provide their name and email address below.
Secondary Contact Information

First NameLast Name
Email
example@example.com
As an authorized representative of the Applicant organization:
Authorized Representative Signature*

Clear
Printed Name*

First NameLast Name
Should be Empty:

Community Grant Program

Important Notice for Naloxone Distribution and Overdose Training Applicants

1 | Applicant Information

Optional Fiscal Agent Information

2 | Alignment with the National Settlement Agreement

3 | Project Description

4 | Measures of Success

5 | Cost Proposal

Application Submission

As an authorized representative of the Applicant organization: