Appendix B – complete all pages of Title Page
Title Page – Part 1
City of Chicago
Department of Public Health, STI/HIV Division
HIV Prevention Projects (RFP # DA-41-3350-11-2014-003)
Agency Name:Agency Administrative Mailing Address:
Agency Service Site Address:
Agency Tax Identification Number:
Program Category Applying for:
Amount requested for this proposal:
DUNS Number:
Executive Director: / President of the Board of Directors:
Executive Director’s Phone Number: / Executive Director’s Email Address:
Primary Program Contact Person:
Primary Program Contact’s Phone Number: / Primary Program Contact’s Fax Number:
Primary Program Contact’s Email Address:
Fiscal Agent Name (if applicable):
Fiscal Organization Mailing Address:
Fiscal Agent’s Phone Number: / Fiscal Agent’s Fax Number:
Fiscal Agent’s Email Address:
Signature of the Executive Director: Date:
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Appendix B
Title Page – Part 2
City of Chicago
1)Indicate Program Category applied for and, when indicated, geographic region(s) and target population(s)
A1.Targeted HIV Testing and Linkage to Care_____
Region (check all that apply): North____West_____South_____
Within each region proposed, check each population identified through surveillance data and Special Concerns Population to be targeted (check all that apply):
North / West / SouthNon-Hispanic Black MSM 13-19
Non-Hispanic Black MSM 20-29
Non-Hispanic Black MSM 30-49
Non-Hispanic Black MSM 50+
Non-Hispanic Black Female Heterosexual 20-29
Non-Hispanic Black Female Heterosexual 30-49
Latino MSM 20-29
Latino MSM 30-49
Non-Hispanic White MSM 20-29
Non-Hispanic White MSM 30-49
Non-Hispanic White MSM 50+
Special Concerns Populations. If proposing to serve Special Concerns Populations (check all that apply):
North / West / SouthTransgender Individuals
Individuals involved in the Sex Trade
Individuals with Physical & Developmental Disabilities
Non-English/Non-Spanish-Speaking Individuals
Homeless Individuals
Post Incarcerated Individuals
A2. Use of Social Network Strategies (SNS) for Targeted HIV Testing and Linkage to Care ____
Region (check all that apply): North____West_____South_____
North / West / SouthNon-Hispanic Black MSM 13-19
Non-Hispanic Black MSM 20-29
Non-Hispanic Black MSM 30-49
Non-Hispanic Black MSM 50+
Latino MSM 20-29
Latino MSM 30-49
Non-Hispanic White MSM 20-29
Non-Hispanic White MSM 30-49
Non-Hispanic White MSM 50+
Transgender Individuals
A3. HIV Testing and Linkage to Care in High Volume Clinical Settings Serving MSM and High-Risk Minority Male and Female Populations______
Region (check all that apply): North____West_____South_____
B: Citywide HIV Prevention with Intravenous Drug Users (IDU) _____
C1: Prevention with Positives – CDC-Supported High-Impact Prevention (HIP) Behavioral Interventions___
Region (check all that apply): North____West_____South_____
Populations, identified through surveillance data (check all that apply):
North / West / SouthNon-Hispanic Black MSM 13-19
Non-Hispanic Black MSM 20-29
Non-Hispanic Black MSM 30-49
Non-Hispanic Black MSM 50+
Non-Hispanic Black Female Heterosexual 20-29
Non-Hispanic Black Female Heterosexual 30-49
Latino MSM 20-29
Latino MSM 30-49
Non-Hispanic White MSM 20-29
Non-Hispanic White MSM 30-49
Non-Hispanic White MSM 50+
C2: Prevention with Positives - Innovative or Locally Developed Interventions ___
Region (check all that apply): North____West_____South_____
Populations, identified through surveillance data (check all that apply):
North / West / SouthNon-Hispanic Black MSM 13-19
Non-Hispanic Black MSM 20-29
Non-Hispanic Black MSM 30-49
Non-Hispanic Black MSM 50+
Non-Hispanic Black Female Heterosexual 20-29
Non-Hispanic Black Female Heterosexual 30-49
Latino MSM 20-29
Latino MSM 30-49
Non-Hispanic White MSM 20-29
Non-Hispanic White MSM 30-49
Non-Hispanic White MSM 50+
D1. Prevention with Negatives - PrEP Demonstration Projects ____
Region (check all that apply): North____West_____South_____
Populations, identified through surveillance data (check all that apply):
North / West / SouthNon-Hispanic Black MSM 13-19
Non-Hispanic Black MSM 20-29
Non-Hispanic Black MSM 30-49
Non-Hispanic Black MSM 50+
Non-Hispanic Black Female Heterosexual 20-29
Non-Hispanic Black Female Heterosexual 30-49
Latino MSM 20-29
Latino MSM 30-49
Non-Hispanic White MSM 20-29
Non-Hispanic White MSM 30-49
Non-Hispanic White MSM 50+
D2. Prevention with Negatives - Comprehensive Services to High-Risk Negatives Demonstration ___
Region (check all that apply): North____West_____South_____
Populations, identified through surveillance data (check all that apply):
North / West / SouthNon-Hispanic Black MSM 13-19
Non-Hispanic Black MSM 20-29
Non-Hispanic Black MSM 30-49
Non-Hispanic Black MSM 50+
Non-Hispanic Black Female Heterosexual 20-29
Non-Hispanic Black Female Heterosexual 30-49
Latino MSM 20-29
Latino MSM 30-49
Non-Hispanic White MSM 20-29
Non-Hispanic White MSM 30-49
Non-Hispanic White MSM 50+
D3. Prevention with Negatives - Behavioral Interventions for High-Risk HIV Negative Individuals_____
Region (check all that apply): North____West_____South_____
Populations, identified through surveillance data (check all that apply):
North / West / SouthNon-Hispanic Black MSM 13-19
Non-Hispanic Black MSM 20-29
Non-Hispanic Black MSM 30-49
Non-Hispanic Black MSM 50+
Non-Hispanic Black Female Heterosexual 20-29
Non-Hispanic Black Female Heterosexual 30-49
Latino MSM 20-29
Latino MSM 30-49
Non-Hispanic White MSM 20-29
Non-Hispanic White MSM 30-49
Non-Hispanic White MSM 50+
E. Evaluation _____
2) Total amount of funding requested for this one application/program category ______
3) Indicate all other program categories applied for______
4) Indicate total funding requested (for all categories) ______
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Appendix F
Application Checklist
City of Chicago
Department of Public Health, STI/HIV Division
HIV Prevention Projects (RFP # DA-41-3350-11-2014-003)
The application checklist should be used to ensure that the application is complete. Include the checklist with the application. Proposals that do not contain each of the items below will be considered and incomplete and will not be reviewed.
Title Page (Use Appendix B)
Application Checklist (Appendix F, this page)
Table of Contents
Application Narrative and Budget
Project Abstract
Agency Experience & Cultural Capacity
Answer all questions for program category
Program Work Plan
Program Logic Model
Budget (Submit 2 budgets, one for direct program services costs and one for administrative costs. Use Forms from Appendix E).
Program services costs budget
Administrative cost budget (not to exceed 10% of program services budget)
Required Documentation
Internal Revenue Service 501(c)3 tax exempt determination letter
Copy of Articles of Incorporation
Copy of the most recent Financial Statement and OMB Circular A-133 Audit (if applicable)
Board of Directors List (Must include place of employment)
Proof of Insurance
Memoranda of Agreement/Service Agreements (if applicable)
Linkage to Care Protocol (for all programs performing HIV Testing and Linkage to Care)
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