HomeMy WebLinkAboutS Grant - Community and Schools Phase III Tobacco Use Prevention and Cessation Initiative Grant Acceptance~i~1 ^~v I3 aaQ ~
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A. This Agreement, all Attachments, and the Request for Grant Proposal represent the entire Agreement
between the Parties and supersede all prior oral or written statements or agreements.
B. All promises, indemnities, requirements, terms, conditions, provisions, representations, guarantees,
and warranties contained herein shall survive the contract expiration or termination date unless
specifically provided otherwise herein, or unless superseded by applicable federal or state statutes of
limitation.
C. The Agreement may be amended only in writing duly signed by authorized representatives of both
Parties.
D. If any term of the Request for Grant Proposal and applicable addenda or the Grantee Application
(Attachment A-1) conflict with any term of this Grant Agreement, the terms of this Grant Agreement
shall control.
NORTH CAROLINA HEALTH AND
WELLNESS TRUST FUND COMMISSION
Lieutenant Governor Beverly E. Pardue
Chair
~! U ~ 2 2 2(15
Date:
Orange County
Health Department
;'
osemary L. , Dr.PH
Health Direct
Date:
20
ATTACHMENT A -PERFORMANCE OBLIGATIONS
A-1-GRANT APPLICATION
A-2 -COMMISSION APPROVED AMENDMENTS
A-3 -MINIMUM REQUIREMENTS
A-4 ACTION PLAN
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TABLE OF CONTENTS
Section I Definitions
A. Application
B. Approved Project Budget
C. Area of Service
D. Attachments
E. Capital Expenses
F. Carry-forward
G. Client(s)
H. Commission Amendments
I. Contract Performance Period Extension
J. Effective Date
K. Financial Report Formats
L. Governmental Entities
M. Grant
N. Grant Cycle(s)
O. Grantee Evaluation and Development Provider
P. Grant Program or Program
Q. NC Health and Wellness Trust Fund Commission
R. Non-Governmental Entities
S. Outcome Evaluator(s)
T. Performance Obligations
U. Project
V. Reports
W. Request for Grant Proposal
X. Technical Assistance Provider(s)
Y. Termination Date
Section II Term
Section III Grantee's Representations and Warranties
A. Compliance
B. Organizational Form
C. N. C. Entity
D. Use of Funds
1. Prohibition on supplanting existing funds
2. Cost Principles
3. Travel and Subsistence Rates
E. For-Profit Prohibited
F. Inability to Perform
G. Binding Obligation
H. Authority and Approvals
I. No Adversarial Proceedings
J. Insurance and Indemnity
Section IV Grantee's Obligations
A. Performance Obligations
1 Scope of Project
2 Action Plan
Please Return. This Copy to the
Clerk's Office for the Permanent
Agenda Tile
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3. Satisfactory Performance
4. Cooperation
a. To Work and Cooperate
b. To Notify
c. To Provide
B. Reporting Requirements
1. General
2. Suspension of Grant Payments
3. Required Reports
a. Action Plan
b. Monthly Expense and Project Evaluation Reports
c. Six (6) Month Progress Reports
d. Consolidated Annual Report
e. Annual Certification of Account Balances
f. Final Project Report
g. Reports for Outcome Evaluator(s)
h. Program Specific Reports
i. Additional Reports
j. Legally Required Reports
1 Non-Governmental Entities
2 Governmental Entities
C. Project Records and Visits
1. Record Retention
a. Five (5) Years Following Termination Date
b. Records If Grantee Dissolves
2. State Auditor
3. Commission Staff
a Grantee Shall Make Available
b. Grantee Shall Allow
D. Subcontracting
1. Notice
2. Bound by Terms
3. Grantee Responsibility
4. Payment of Subcontractors and Partners
a. Implement
b. Pre-audit
i. Validity
ii. Payment due date
iii Adequacy of documentation
iv. Legality
c. Assure adequate control of signature stamps, plates;
d. Assure adequate control of negotiable instruments;
e. Implement procedures
f. Assure adherence
E. Media, Publicity and Publications
I. Obtain Prior Written Approval
2. To Provide in Writing Details of Paid Media
3. Disclaimer
4. Not to Market Information
5. Furnish a Minimum of Two Copies
6. Placing Signage at Project Site(s) and Placing Commission Logo on Any Printed
Materials
7. Follow Trademark and Intellectual Property Guidelines.
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F. Ownership of Intellectual Property
1. Ownership of Deliverables
2. Intellectual Property Right
G. Computer Support
1. Use Computer Technology to Support Its Project
2. Have Fu11y Operational All Hazdwaze and Soflwaze Necessary to Support the Project
Services
H. Grant Funding
1. Grant Cycles
2. Capital Expenditures
3. Method of Payment
a. Straight Reimbursement
b. Initial Payment
4. Carry-forward
5. Additional Grant Cycle(s)
6. Segregated Accounts
7. Repayment Obligation
8. Political Activity Prohibited
Section V Commission's Obligations
A. Grant Funding
1. Grant Cycles
2. Capital Expenditures
3. Method of Payment
a. Straight Reimbursement
b. Initial Payment
4. Carry-Forward
5. Additional Grant Cycle(s)
B. Reports
C. Grants Administration
Section VI Independent Status of the Parties
A. Independent Entities
B. No Agency
C. No Liability for Grantee Expenses
D. No Third Party Beneficiary
Section VII Termination and Availability of Funds
A. General Termination
B. With Cause
C. Lack of Funding
D. Termination Process
1. Commission Has No Responsibility for Additional Payments and Grantee Shall
Repay Within Thirty (30) Days All Unspent Grant Funds Plus Interest
2. Grantee Agrees That Termination Will Be Conducted in a Professional, Orderly
Process
3. All Records Will Be Maintained and All Reports Will Be Made
Section VIII Liabilities and Losses
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A. No Liability
B. Insurance
C. Indemnity
1. Non-governmental Entities
a. Arise From Grantee's Violation of Any Proprietary Right or Right of Privacy
b. Arise From a Claim By Any Other Person, Firm or Corporation
c. Arise From Any and All Claims and Losses
2. Governmental Entities
3. All Grantees
D. Survival
Section IX Notice
Section X Construction
Section XI Special Provisions and Conditions
A. Non-discrimination
B. Conflict of Interest
C. Compliance with Laws
D. Non-Assignability
E. Personnel
F. Restriction on the Use of the Funds
G. Non-Waiver
H. Approvals
I. Attachments
Section XII Entire Agreement
A. This Agreement, All Attachments, and the Request for Grant Proposal
B. All Promises, Indemnities, Requirements, Terms, Conditions, Provision,
Representation, Guarantees, and Warranties Contained Herein Shall Survive
C. May Be Amended Only in Writing Duly Signed
D. If Any Conflict, Term of Grant Agreement Shall Control
List of Attachments
Attachment A -Performance Obligations
A-1 -~ Grant Application
A-2 -Commission Approved Amendments to Grant Application
A-3 -Minimum Requirements
A-4 -Action Plan
Attachment B -Approvals
B-1 -Approved Project Budget
B-2 -Grant Cycle Approval Letter
Attachment C -Area of Service
Attachment D -Agreement and Certification
Attachment E -Financial Report Formats
E-1 -Monthly Expense Report
E-2 -Annual Certification of Account Balance
Attachment F -Guidelines for Using HWTFC Logo & Name
Attachment G -Program Specific Reports
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Name of Grantee: OranEe' county Health Department Grant ID:
Type of Grant: TEEN PHIII ` Grant Amount $289,000
Grant Cycle: Initial
Effective Date: July 1.2006
Terminatign Date: June 30, 2007
NC HEALTH AND WELLNESS TRUST FUND COMMISSION
GRANT AGREEMENT
Grant Agreement (also the "Agreement") is entered into this 1st day of July, 2006 (the "Effective
Date") by and between the North Carolina Health and Wellness Trust Fund Commission (the "Commission"),
an agency of the State of North Carolina organized pursuant to Article 6C of Chapter 147 of the N.C. General
Statutes, funded by a portion of North Carolina's receipts from the Master Settlement Agreement with
participating tobacco manufacturers, whose principal place of business is 501 North Blount Street, Raleigh,
North Carolina 27604 and the entity identified in detail in Attachment D (also, the "Grantee"), (also, together
"the Parties" and each in the singular "the Party").
In consideration of mutual promise and such other valuable consideration as is set out in the
Agreement, the Parties do mutually agree to the following:
Section I Definitions
The following definitions shall apply to this Agreement:
A. Application -The Grantee's written response to the Commission's Request for Grant Proposal. The
Application is set forth in Attachment A-1.
B. Approved Project Budget -Amount of the Grant allocated to specific expenditure categories as
approved by the Commission and set forth in Attachment B-1. The line items within an Approved
Project Budget may be modified with the prior written approval of Commission staff, but the total
amount of the Grant must remain the same unless the Commission gives written approval to change
the amount of the Grant.
C. Area of Service -The county(ies) which will receive Grantee's Project Services as set forth in
Attachment C.
D. Attachments -Those documents labeled as Attachments A through G which are attached to this
Agreement and incorporated herein by reference as a substantive part of this Agreement. If there is a
conflict between the language contained in an Attachment and this Agreement, the language of the
Agreement shall control.
E. Capital Expenses -Funds used to purchase furniture, fixtures and equipment, with a unit price of at
least $500, dedicated to the Project and designated as "Capital" in the Approved Project Budget.
F. Carry-forward - Any funds allocated to the Grantee by the Commission for any term of the Project but
not spent by the Grantee in that term.
G. Client(s) -The North Carolina residents or entities who will benefit from Grantee's Project.
H. Commission Amendments -Any amendments to the Application made by the Commission shall be
set forth in Attachment A-2.
I. Contract Performance Period Extension -For grant monies that remain after the final Termination
Date for the project period established by the Request for Grant Proposals, the Commission may
approve an additional Grant Cycle to use any remaining balance for further progress of the Grantee's
Project.
J. Effective Date -The date the initial Grant Cycle begins, as designated by the Commission.
K. Financial Report Formats- Grantee's Monthly Expense Report(s) and Annual Certification of Account
Balance, in the form set forth in Attachment E-I and E-2, respectively.
L. Governmental Entities - A state agency and a local government or other political subdivision of the
State or a combination of such entities. A list of local (non-stateagencies) Governmental Entities may
be found at www.ncauditor.net.
M. Grant -Total amount approved by the Commission for Grantee's Project and set forth in Attachment
B-1.
N. Grant Cycle -Each period of up to twelve (12) months for which the Commission approves funding.
O. Grantee Evaluation and Development Provider (GEDP~ The entity(ies) or person(s) designated by the
Commission to provide annual needs assessment and action planning, Regular performance and
budget monitoring and evaluation, and coordinate delivery of Technical Assistance and training.
P. Grant Program or Program -The specific initiative which Grantee's Project is designed to support..
The Program addressed by this Project Grant is described in the Grantee's Grant Application in
Attachment A-l, Commission Approved Amendments to the Grantee's Grant Application in
Attachment A-2, Minimum Requirements in Attachment A-3, and Action Plan in Attachment A-4.
Q. NC Health and Wellness Trust Fund Commission (Commission) -The governmental entity that
provides funding for the Project(s) in support of Commission Program(s) as established by N.C.
General Statute § 147-86.30 et seq. and is governed by Chapter 10 of the North Carolina
Administrative Code.
R. Non-Governmental Entities - Anon-profit corporation which has a significant purpose promoting the
public's health. A list of local Governmental Entities may be found at www.ncauditor.net.
S. Outcome Evaluator(s) (OE) - Agency(ies) and/or entity(ies) used by the Commission to collect,
analyze and report on the effectiveness ofthe overall Program including the individual Projects funded
under the Program.
T. Performance Obligations -The specific items the Grantee agrees to perform as set forth in this
Agreement and Attachment A. Attachment A includes the Grantee's Application in Response to the
Commission's Request for Grant Proposal,- any Commission Approved Amendments to the Grant
Application, any other minimum requirements or deliverables that Grantee must perform in order to
receive and maintain the Grant, and an Action Plan.
U. Project -The Program services set forth in Attachment A which the Grantee agrees to implement.
V. Reports -All required documents as defined in this Agreement and as may be requested from time to
time by the Commission with respect to the Project and the Grant.
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W. Request for Grant Proposal -The Commission document dated March 29, 2005 and entitled Teen
Tobacco Use Prevention and Cessation: Community/School Prevention Program or Special Project
RFP seeking applications from entities that wish to establish or expand existing Projects to implement
the Commission Program. This Request for Grant Proposal is incorporated by reference as a
substantive part of this Agreement as if set forth verbatim, but is not attached to this document.
X. Technical Assistance Provider(s) -The entity(ies) or person(s) designated by the Commission to
provide specific expertise, corrective action and training to assist in the successful completion of the
Grant Program and Grantee's Project.
Y. Termination Date -Date on which the Grant Cycle ends, or the date funding for the Project terminates
pursuant to other terms within this Agreement.
Section II Term
The term shall begin with the initial Grant Cycle. The initial Grant Cycle begins July 1, 2006, the effective
date, and ends on June 30,2007, the termination date. The Commission may renew this Agreement for
additional Grant Cycle(s). If an additional Grant Cycle(s) is approved, (i) the terms will follow in consecutive
increments of up to twelve (12) montTis, (ii) the Parties will agree upon a new Action Plan for each additional
Grant Cycle and attach the Commission approved Action Plan to this Agreement as Attachment A-4, and (iii)
all other provisions of this Agreement will remain in full force and effect for the term of the additional Grant
Cycle(s). The Commission may renew only iffunding is available and the Commission, in its sole discretion,
determines the Grantee's performance is satisfactory. The Effective Date and Termination Date for each
additional Grant Cycle shall be established by the Commission. At the beginning of the additional Grant
Cycle(s), the Commission will notify the Grantee by letter in the form set forth in Attachment B-2.
Section III Grantee's Representations and Warranties
Grantee represents, warrants and agrees that:
A. Compliance -The Grantee.agrees to comply with all Laws, ordinances, codes, rules, regulations and
licensing requirements applicable to the conduct of its business, including but not limited to those
federal, state and local laws and agencies having jurisdiction and/or authority over the Grantee, G.S.
143 6.2, and the performance of this Agreement.
B. Organizational Form -The information set forth in Attachment D, entitled Agreement and
Certification, is a true and accurate representation of Grantee's organizational form as defined by the
State Auditor's website located at www.ncauditor.net.
C. N.C. Entity -The entity is duly organized and validly existing under the laws of the State of North
Carolina.
D. Use of Funds -Grantee shall use all fiznds awarded under this Grant exclusively to support the Project
and shall spend the funds in accordance to Attachment B-l, the Approved ProjectBudget. Each year,
the Grantee shall certify the proper use of the funds in the form set forth in Attachment E-2, the
Annual Certification of Account Balance.
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1. Grantee shall not use funds awarded under this Agreement to substitute or supplant
funds from other sources that are currently supporting any existing services.
2. Cost Principles- Grantee shall follow all applicable cost principles, including but not
limited to Federally established guidelines: OMB Circular A-87, OMB Circular A-22, or
'OMB Circular A-122 as recommended by the NC State Auditor.
3. Travel and Subsistence Rates- All travel and subsistence expenses must be reimbursed
under the prevailing State rates and policies for State employees. State travel rates may
be found in the Budget Manual at www.osbm.state.nc.us. All conference registration and
related travel expenses over $75.00 must be pre-approved in writing by Commission
staff. International travel shall not be reimbursed. under this Contract.
E. For-Profit Prohibited -Grantee will not direct Clients of this Project to purchase goads or services
from any for-profit entities with whom Grantee has a formal or informal relationship.
F. Inability to Perform -Grantee will immediately notify the Commission in writing of any event that
may significantly affect its ability to perform the Project, including but not limited to the loss of
funding from any other sources or changes in the organization's status, staff make-up or structure.
G. Binding Obligation -This Agreement constitutes a binding obligation of Grantee, enforceable against
it in accordance with its terms.
H. Authority and Approvals -Execution and delivery of this Agreement have been duly authorized by all
necessary action on the part of Grantee. The Agreement does not violate any applicable organizational
document of the Grantee or any agreement or undertaking to which it is a Party or by which it is
otherwise bound. All consents or approvals, if any are required, from any governmental authority(ies)
as a condition to the execution and delivery of this Agreement by the Grantee or the performance of
any of its obligation under the Agreement have been obtained.
I. No Adversarial Proceedings -There is no action, suit, proceeding, or investigation in law or equity or
before any court, public board or body pending or to the Grantee's knowledge, threatened against or
affecting it, that could or might adversely affect the Project or any of the transactions contemplated by
the Agreement, the validity or enforceability of the Agreement or the Grantee's ability to discharge its
obligations under this Agreement.
J. Insurance and Indemnity -Grantee has sufficient insurance and/or adequate resources to protect itself,
the Commission, the Commission staff and others against any liability or loss as set forth in Section
VIII below.
Section IV Grantee's Obligations
The Grantee agrees to perform the following:
A. Performance Obligations:
1. Scope of Project -Grantee shall in a timely and professional manner develop, perform and
complete all the work set out in Attachments A, A-l, A-2, A-3 and A-4. The work shall be
performed in the Area of Service designated in Attachment C.
2. Action Plan -During each Grant Cycle, the Grantee must develop an Action Plan in consultation
with Commission staff, the Grantee Evaluation and Development Provider (GEDP) and/or the
Commission's Technical Assistance. Provider(s). The Action Plan shall be based upon the
Grantee's Performance Obligations and shall be tied to the Approved Project Budget line items
(see Attachment B-1). The Action Plan must receive the prior written approval of the
Commission before implementation. The Grantee shall satisfactorily perform all items set forth in
the Commission approved Action Plan (see Attachment A-4).
Satisfactory Performance - In determining whether Grantee will receive funding for an additional
Grant Cycle, Grantee understands and agrees that the Commission staff will evaluate the
Grantee's completion of the Action Plan items, its Performance Obligations, its Reporting
Requirements, and its compliance with the terms of this Agreement. If the Commission
determines Grantee's performance is not satisfactory, Grantee understands and agrees that it will
not be eligible for. an additional Grant Cycle and may have payments within the current Grant
Cycle withheld or reduced upon non-compliance with the terms of this agreement.
4. Cooperation
The Grantee agrees to the following:
a. To work and cooperate with the Commission staff, GEDP, Technical Assistance Provider(s),
and/or Outcome Evaluator(s).
b. To notify the Commission Policy Director in writing of any concerns related to this
Agreement which involve the Commission staff, Technical Assistance Provider(s), and/or
Outcome Evaluator(s).
c. To provide Reports as may be requested by the Commission staff concerning services
provided by the Commission staff, Technical Assistance Provider(s), and/or Outcome
Evaluator(s).
B. Reporting Requirements:
General -Grantee shall provide Reports via a-mail to HWTFC~a,ncmail.net by dates specified and
in the formats required by the Commission staff. Grantee understands that reporting formats may
change from time to time and agrees to contact Commission staff for updates. Grantee
understands that a criterion for continuation of funding is compliance -with Reporting
Requirements. Grantee shall also participate in a state-Ievel outcomes study by complying with all
reasonable requests made by the Commission staff and the Commission's selected Outcomes
Evaluator(s).
2. Suspension of Grant Payments -Grantee agrees that if it fails to report in the appropriate format
by the submission date designated by Commission staff, the Commission may withhold any
subsequent Grant payment until the Reports are received in an acceptable format and approved by
Commission staff. Grantee acknowledges that the Commission must withhold payments if it fails
to provide the Legally Required Reports set forth in Section N (B) (3) (j) below.
3. Required Reports -Reports include, but are not limited to:
a. Action Plan -Action Plan is due on or before the date specified by the Commission staff. If
additional Grant Cycle(s) is approved, the Action Ptan for each Grant Cycle is due on or
before the date specified by the Commission staff.
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b. Monthly Expense and Project Evaluation Reports -After the Effective Date of the
Agreement, these Reports aze due on or before the twentieth (20r'') day of each month for the
prior month.
c. Six (6) Month Progress Reports -After the Effective Date of the Agreement, these reports are
due as specified by Commission staff at six (6) month intervals.
d. Consolidated Annual Report - Due as specified by Commission staff.
e. Annual Certification of Account Balance -Due annually on or before December 31 during
the Agreement Term. See Attachment E-2 for format.
f. Final Project Report -Due within sixty (60) days after end of last Grant Cycle including any
Contract Performance Period Extension. At a minimum this Report shall demonstrate how
successfully the Project met its goals and performance obligations.
g. Reports for Outcome Evaluator(s) -Due on dates specified and in the format specified by
OE's and approved by the Commission. Grantee agrees to cooperate with OE's who will
conduct periodic site visits and telephone interviews.
h. Program Specific Reports -Those Reports set forth on Attachment G that aze unique to the
Program this Project supports.
i. Additional Reports -Additional information, which will assist the Commission with
evaluation of the short and-long range impact of its Programs and this Project. The Grantee
recognizes that such requests may occur during or after termination of this Agreement.
Grantee agrees to use its best efforts to provide any and all Reports requested by the
Commission in a timely and professional manner and in the format requested by the
Commission.
j. Legally Required Reports - As required by North Carolina General Statutes: Complete details
are available at www.ncauditor.net.
(1) Non-Governmental Entities -Non-Governmental Entities aze required to comply with
N.C. General Statute § 143-6.2 in the format required by the State Auditor. Grantee
agrees to submit all reports required in compliance with N.C. General Statute § 143-6.2
via electronic mail, except for any Certifications requiring asignature/notary which will
be sent via postal mail.
(2) Governmental Entities -Governmental entities must comply with the state's requirement
for annual independent audits pursuant to N.C. General Statute § 159-34.
C. Project Records and Visits
The Grantee agrees to the following:
1. Record Retention
a. Five (5) Yeazs Following Termination Date - For a period of five (5) yeazs following the
Termination Date, Grantee shall maintain full, accurate and verifiable financial records,
supporting documentation, and all other pertinent data for this Grant and this Project. These
records must be maintained so as to identify and document cleazly the expenditure of
Commission funds provided under this Agreement separate from accounts for other awards,
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monetary contributions or other revenues sources for this Project. In the event such records
are audited, all Project records shall be retained beyond such five (5) year period until all
audit findings have been resolved.
b. Records If Grantee Dissolves - In the event the Grantee dissolves or otherwise goes out of
existence before the end of the Grant, or within five (5) years following the Termination Date,
Grantee shall notify the Commission in writing and agrees that it will make arrangements for
the retention of its records.
2. State Auditor -Grantee shall allow the State Auditor or the State Auditor's designee to enter its
premises and to audit, examine and copy its records in accordance with N.C. General Statute §
147-64.7.
3. Commission Staff
a. Grantee shall make available to the Commission or its designated representative all of its
records which relate to the Grant and the Project for audit, examination and copying. Access
to these records shall be allowed upon request at any time during normal business hours and
as often as the Commission or its representative may deem necessary.
b. Grantee shall allow periodic visits by Commission staff or its designated representative at the
Commission staff s discretion. The purpose of these visits is to verify contract compliance,
assist Grantees, facilitate the dissemination of information and ideas among all Grantees, and
to increase the statewide effectiveness of the Program.
D. Subcontracting
The Grantee agrees to the following:
Notice -Grantee shall notify the Commission in writing at least five (5) business days in advance
of Grantee disbursing Commission funds to any subcontractors, partners and subgrantees during
the term of this Grant. Such notification must include the detailed purpose of the disbursement,
total amount that will be disbursed over the term of the grant to that subcontractor, partner orsub-
grantee and reporting requirements for subcontracts made between the Grantee and this other
entity.
2. Bound by Terms -All subcontractors, partners and subgrantees shall be subject to all terms and
conditions of this Agreement through a subcontract with the grantee.
Grantee Responsibility -Grantee is responsible for the performance of any subcontractor, partner,
or subgrantee and continues to be responsible for all services provided under this Agreement
regardless of who may be providing them. Grantee is responsible for the notification and the
monitoring of all subcontractors, partners, or subgrantees in regards to all applicable reporting
requirements as specified by this contract, including but not limited to N.C. General Statute § 143-
6.2.
4. Payment of Subcontractors, Partners and Subgrantees -Grantee is responsible for paying all
subcontractors, partners and subgrantees for services and ensuring that all funds are spent in
accordance with the purposes for which they were granted. As a condition of this Contract,
Grantee acknowledges and agrees to make disbursements in accordance with the following
requirements:
a. Implement adequate internal controls and oversight of all disbursements;
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b. Pre-audit all vouchers presented for payment to determine:
i. Validity and accuracy of payment
ii. Payment due date
iii Adequacy of documentation supporting payment
iv. Legality of disbursement
c. Assure adequate control of signature stamps, plates;
d. Assure adequate control of negotiable instruments;
e. Implement procedures to insure that account balance is solvent and reconcile the account
monthly; and
f. Assure adherence to all applicable laws and terms and conditions of this agreement.
E. Media, Publicity and Publications
The Grantee agrees to the following:
1. To obtain the prior written approval of the Commission for all paid media and publications; and to
include appropriate acknowledgement of the support of the Commission (including the
Commission logo) in a format agreed upon by the Commission.
2. To provide in writing to h c~ncmail.net, details of all paid media expenditures for each month
which Grantee reports expenses in the Media budget category; this is to be submitted along with
the monthly expense report for the month in which the Media expense is reported.
3. To include on/in any publication a disclaimer statement to the following effect:
Any opinion, finding, conclusion or recommendations expressed in this publication
are those of the author(s) and do not necessarily reflect the view and policies of the
North Carolina Health and Wellness Trust Fund Commission.
4. Not to market the information related to the Project for profit, unless a waiver is granted by
Commission staff.
5. To furnish a minimum of two (2) copies to the Commission of any published materials resulting
from the work ofthe Project at least five (5) working days before the published materials are made
available to the public.
6. To place signage at the Project site or sites identifying the Project as receiving Commission funds
and to place the Commission logo on any printed materials.
7. To follow the trademark and intellectual property guidelines set forth on Attachment F and to
abide by any updated guidelines that may be issued by Commission staff during the term of this
Agreement.
F. Ownership of Intellectual Properly
The Grantee agrees to the following:
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1. Any deliverable items resulting from this Agreement, funded in its entirety by HWTFC as
specified in the Grantee's Application which is incorporated into this Agreement (Attachment A-
1)shall become the sole property of the Commission. Any deliverable items resulting from this
Agreement, for which HWTFC is one of two or more funding organizations as specified in the
Grantee's Application which is incorporated into this Agreement (Attachment A-1) shall become
the property ofthe Commission proportionate to the percentage ofHWTFC funding used towazds
creation of the deliverable(s). The Grantee may use information and data gathered to prepare
deliverable items for making reports, publications and presentations in the manner described in
Section N (E) (7).
2. If work done pursuant to this Agreement results in any intellectual property right accruing to the
Grantee, the Grantee hereby grants to the Commission an assignable royalty-free, non-exclusive
irrevocable license to publish, translate, reproduce, deliver, perform or use the material covered by
the intellectual property right.
G. Computer Support
The Grantee agrees to the following:
1. To use computer technology to support its Project. Grantee may use software designated by the
Commission or any other software for provision of Project Services and/or reporting provided
Grantee ensures all required Reports are submitted in the consistent, uniform format required by
the Commission staff.
2. To have all fully operational hazdwaze and software necessary to provide Project Services no later
than the end of the first three (3) months of the Grant Cycle unless Commission staff grants an
extension in writing.
H. Grant Funding
The Grantee agrees to the following:
Grant Cycles -The Approved Project Budget divides the total Grant into Grant Cycles of up to
twelve (12) months with separate budgets. The Grant funds for the initial Grant Cycle will be
released by the Commission in the manner specified in Section N (H) (3) below. Additional
Grant Cycle(s) may be approved by the Commission provided funds are available, and the
Commission, in its sole discretion, determines at the end of each Grant .Cycle that Grantee
satisfactorily completed its Performance Obligations as set forth in Section 1V (A).
2. Capital Expenditures -Unless prior written approval is given by Commission staff, the Grant
funds designated in the Approved Project Budget (Attachment B-1) for Capital Outlay must be
expended within the first three (3) months of the Grant Cycle and the Capital Expenses cannot
exceed the amount budgeted in the Capital Outlay section of the Approved Project Budget
(Attachment B-1). Any Capital Expenditures not used within the first three (3) months must be
reallocated to other budget line .items as approved by Commission staff.
3. Method of Payment - As soon after the Effective Date as the Grantee makes a written and/or
electronic selection from among the payment setup options offered by the Commission, the
Commission agrees to commence payment as selected by the Grantee and in the format specified
by the Commission. Payments shall cease at such time as the grand total of payments made to the
Grantee equals the total amount of the grant award.
13
a. Straight Reimbursement -Grantees who elect not to receive initial payment as described in
N (IT) (3) (b) and/or elect not to establish segregated accounts as described in N (I~ (6) shall
be reimbursed by the amount submitted on approved monthly expense reports (Attachment E-
1)without any initial payment.
b. Initial Payment - As soon after the Effective Date as the Grantee provides an invoice for start-
up activities, as specified by the Commission, the Commission agrees to make an initial
payment of (25%) of the total amount of the initial Grant Cycle Budget, to assist in the initial
start-up of the Project. Grantee shall be reimbursed by the amount submitted on approved
monthly expense reports (Attachment E-1) at such time as the total amount paid to the
Grantee is less than initial payment and approved reported expenditures.
4. Carry Forward -Any funds allocated to the Grantee by the Commission for any term of the
Project but not spent by the Grantee in that term shall be known ascarry-forward. Carry-forward
amounts shall be determined by calculating the difference between the cumulative amount of
approved expenditures reported on the final monthly expense report for the term and the approved
budget for that term or the balance of the grant awazd, whichever is less. Carry-forward may be
spent during any subsequent. term of the Project subject to prior approval by Commission staff.
Any carry-forward request shall be submitted to Commission staff by the Grantee as a Budget
Adjustment Request within 45 days after the end of the term in which the carry-forward was
generated. Carry-forward not approved for use during the project period established by the
Request for Grant Proposal shall automatically be carried forward to any Commission Approved
Contract Performance Period Extension.
5. Additional Grant Cycle(s) - If approved by the Commission, the payment cycle and monthly
amounts will be specified in the Grant Cycle Approval Letter (Attachment B-2).
Segregated Accounts -Should the Grantee be designated as anon-governmental entity in
Attachment D, the Grantee shalt place all sums not immediately spent in a separate, segregated,
interest bearing account that is fully insured for the maximum amount of money that will be
placed in the account. The Grantee agrees thaf any interest accrued on these sums along with any
unspent funds remaining in the account shall belong to the Commission at the conclusion of the
Project. Should the Grantee be designated as a governmental entity in Attachment D, the Grantee
shall place-all sums not immediately spent in a restricted grant lure item that can not be used for
any purpose other than the Project.
7. Repayment Obligation - In the event the Grantee breaches any ofthe material terms or conditions
of this Agreement, the Project may be terminated and the Grantee agrees to repay within thirty
(30) days of the Termination Date to the Commission the full amount of sums awarded under this
Agreement and any interest that has accrued on that sum.
8. Political Activity Prohibited -The Grantee agrees it shall not use these funds to support or engage
in any effort to participate in political activities or lobbying, including but not limited to support of
or opposition to candidates, ballot initiatives, specific legislation, referenda and other similar
activities.
Section V Commission's Obligations
The Commission agrees to the following:
14
A. Grant Funding
Grant Cycles -The Approved Project Budget divides the total Grant into Grant Cycles of up to
twelve (12) months with separate budgets. Grant funds will be released by the Commission in the
manner specified in Section V (A} (3}below. Additional Grant Cycles may be approved by the
Commission provided funds are available and the Commission, in its sole discretion, determines at
the end of each Grant Cycle that Grantee satisfactorily completed its Performance Obligations as
set forth in Section N (A).
2. Capital Expenditures -Unless prior written approval is given by Commission staff, Grant funds
designated in the Approved Project Budget (Attachment B-1) for Capital Outlay must be
expended within the first three (3) months of the Grant Cycle and Capital Expenses cannot exceed
the amount budgeted in the Capital Outlay section of the Approved Project Budget (Attachment
B-1). Any Capital Expenditures not used within the first three (3) months must be reallocated to
other budget line items if Commission staff gives written approval or must be returned to the
Commission.
3. Method of Payment - As soon after the Effective Date as the Grantee makes a written and/or
electronic selection from among the payment setup options offered by the Commission, the
Commission agrees to commence payment as selected by the Grantee and in the format specified
by the Commission. Payments shall cease at such time as the grand total of payments made to the
Grantee equals the total amount of the grant award.
a. Straight Reimbursement -Grantees who elect not to receive initial payment as described in
N (I~ (3) (b) and/or elect not to establish segregated accounts as described in N (IT) (6) shall
be reimbursed by the amount submitted on approved monthly expense reports (Attachment E-
1)without any initial payment.
b. Initial Payment - As soon after the Effective Date as the Grantee provides an invoice for start-
. up activities, as specified by the Commission, the Commission agrees to make an initial
payment of (25%) of the total amount of the initial Grant Cycle Budget, to assist in the initial
start-up of the Project. Grantee shall be reimbursed by the amount submitted on approved
monthly expense reports (Attachment E-1) at such time as the total amount paid to the
Grantee is less than initial payment and approved reported expenditures.
4. Carry-Forwazd -Any funds allocated to the Grantee by the Commission for any term of the
Project but not spent by the Grantee in that term shall be known as carry-forward. Carry-forward
amounts shall be determined by calculating the difference between the cumulative amount of
approved expenditures reported on the final monthly expense report for the term and the approved
budget for that term or the balance of the grant awazd, whichever is less. Carry-forward may be
spent during any subsequent term of the Project subject to prior approval by Commission staff.
Any carry-forward- request shall be submitted to Commission staff by the Grantee as a Budget
Adjustment Request within 45 days after the end of the term in which the carry-forwazd was
generated. Carty-forward not approved for use during the project period established by the
Request for Grant Proposal shall automatically be carried forward to any Commission Approved
Contract Performance Period Extension.
5. Additional Grant Cycle(s) - If approved by the Commission, the payment method will be
specified in the Grant Cycle Approval Letter (Attachment B-2).
15
B. Reports -Commission staff will provide formats and instructions for Reports required by the
Commission and the State Auditor. As Report formats and instructions may change from time to time,
Commission staff will provide written updates of any changes to the Grantee and will notify Grantee
of due dates for Reports.
C. Grants Administration -Commission staff or its designated representative may visit Grantee
periodically to evaluate and review the Project and its effectiveness within Area of Service.
Commission staffwill act as a conduit for sharing information and receiving feedback from Grantee to
assist in the overall goals of the Commission and other Grantees. Commission staff may also
periodically provide information and updates on the correct usage of Commission logos and
trademarks.
Section VI. Independent Status of the Parties
A. Independent Entities -Parties are independent entities. Neither this Agreement nor any provision of it
shall be deemed to create a partnership or joint venture between the Commission and the Grantee.
B. No Agency -Grantee shall not represent itself as an agent of the Commission nor is this Agreement
intended to be construed so as to make the Grantee an agent of the Commission. The Grantee shall
not have the ability to bind the Commission to any agreement for payment of goods or services, nor
shall it represent to any person or entity that it has such ability.
C. No Liability for Grantee Expenses -Expenses incurred by the Grantee are its sole responsibility and
the Commission shall not be liable for the payment of any obligations incurred in the performance of
the Project.
D. No Third Party Beneficiary -Parties agree that this Agreement has not been made for the benefit of
any third party, and no third party to this Agreement has authority to attempt to enforce it in any way.
Section VII Termination and Availability of Funds
A. General Termination - Either Party shall have the ability to terminate this Agreement with or without
cause on thirty (30) days' prior written notice.
B: With Cause -The Commission may terminate the Grant for breach if, after notice and reasonable
opportunity to cure the breach, the Grantee fails for any reason to fulfill in proper manner its
obligations under this Agreement or violates any of the material terms or conditions of this Agreement.
The Commission shall have the right to terminate this Agreement by giving sixty (60) days' prior
written notice to the Grantee of such termination.
C. Lack of Funding -Any and all payments to the Grantee are dependent upon and subject to the
availability of funds to the Commission to fund the Project. In the event that funds for this Project
become unavailable, the Commission may terminate this Agreement immediately upon notice to the
Grantee. Upon notice of the unavailability of funds, all obligations of the Commission to make
payments under this Agreement shall cease except for work performed prior to such notice.
D. Termination Process
I6
In the event of termination as set forth in Section VII (A), (B), or (C), the Commission shall have
no responsibility to make additional payments under this Agreement after the Termination Date.
No further expenditures shall be made under this Agreement except for such work as shall have
already been performed prior to the Termination Date and the Grantee shall repay within thirty
(30) days alI unspent Grant funds plus interest as well as any funds that may be determined to be
due the Commission as a result of an audit upon the demand of the Commission together with any
additional interest accrued.
2. Grantee agrees that termination of the Project will be conducted in a professional, orderly process
that reflects positively on the Grantee and the Commission.
3. All records will be maintained and all Reports will be made in accordance with the terms of this
Agreement and any applicable laws.
Secfion VIII Liabilities and Losses
A. No Liability -The Commission assumes no liability with respect to accidents, bodily injury, illness,
breach of contract or any other damages, and/or claims or losses arising out of any activities
undertaken by the Grantee under this Agreement, with respect to persons or property of the Grantee or
third parties.
B. Insurance -Grantee agrees to obtain insurance to protect it and others as it may deem desirable, or, if
it elects not to obtain such insurance, it represents and warrants that it has adequate resources available
to it to protect it and others.
C. Indemnity
1. Non-governmental Entities who are Grantees agree to indemnify, defend and save harmless the
Commission and its officers, agents and employees against any liability, including but not limited
to, any and all costs, expenses and attorneys' fees that may:
a. Arise from the Grantee's violation of any proprietary right or right of privacy arising out of
the publication, translation, reproduction, delivery, performance, use or disposition of any
information published resulting from the work of the Proj ect or based on any libelous or other
unlawful matter contained in such information;
b. Arise from a claim by any other person, firm or corporation famishing or supplying work,
services, material or supplies in connection with the Project and the performance of this
Agreement; or
c. Arise from any and all claims and losses accruing or resulting to any person, firm, or
corporation who may be injured or damaged by the Grantee or its agents in the performance
of the Project.
2. Governmental entities and state agencies who are Grantees agree to indemnify, defend and save
harmless the Commission, its officers, agents and employees to the extent allowed by law.
17
3. All Grantees represent and warrant they shall make no claim of any kind or nature against the
Commission, its staff, agents, officers, or directors who may be involved in the processing and
administration of this Grant.
D. Survival -The terms of Section VIII shall survive the termination of this Agreement.
Section IX Notice
All notices required by Section VII of this Agreement shall be in writing and shall be deemed given when
personally delivered, faxed with a confirmation receipt, deposited in the United States mails certified, return
receipt requested, first class, postage prepaid, or when sent via overnight delivery service with a tracking
number (such as Federal Express or UPS) and addressed as follows:
If to the Commission: Mr. Jim Davis
Executive Director
NC Health and Wellness Trust Fund Commission
Physical Address for Personal Hand Delivery or Overnight Delivery Service
(e.g. Federal Express or UPS):
501 North Blount Street, Raleigh, NC 27604-11 I9
Mailing Address for Delivery via US Postal Service:
7090 Mail Service Center, Raleigh, NC 27699-7090
Tel: (919) 733-4011
Fax: (919) 733-1240
Email: hwtfc@ncmail.net
If to the Grantee: Name
Title
Agency
Address 1
Address2
Address3
Tel:
Fax:
Email:
Ros~v Steers
Health Director _
Orange c~nty~ Health ` epartr~~enf
3D0 t~, Ton Str~eeT
~-Iiilsboreu~h N~' 2727&
gl9 Z~15-2412
913-644-3~t1Z
~stim~rsr>co.orat~ e.nc.u
Each Party may designate another notice recipient by written communication to the other Party. All other
notices may be delivered via email. As this information changes, grantee agrees to notify the Commission in
writing, providing to the Commission complete contact information for this Grant.
Section X' Construction
This Agreement is made under and shall be construed and governed in accordance with the laws of the State of
North Carolina. The place of this Agreement, its situs and forum, shall be Wake County, North Carolina,
where all matters, whether sounding in contract or tort, relating to its validity, construction, and interpretation
shall be detennined.
18
Section XI Special Provisions and Conditions
A. Non-discrimination -Grantee agrees not to discriminate by reason of age, race, religion, color, sex,
national origin or disability in the administration of this Agreement and to abide by the Grant Program
and Project policies with respect to the delivery of its Performance Obligations.
B. Conflict ofInterest -Grantee certifies that to the best of its knowledge neither Grantee nor any agent,
subcontractor, employee, board member or officer of the Grantee has any pecuniary interest in the
business of the Commission or of the Project and that neither the Grantee nor any person associated
with the Grantee in any way has any interest that would conflict in any manner with the performance
of the Agreement. Grantee certifies that to the best of its knowledge neither Grantee nor any agent,
subcontractor, employee, board member or officer of the Grantee has any pecuniary interest in the
business of the Commission or of the Project and that neither the Grantee nor any person associated
with the Grantee in any way has any interest that would conflict in any manner with the performance
of the Agreement. Grantee certifies that the Commission has been supplied and has on file a copy of
Grantee's Conflict of Interest Policy prior to receiving any disbursements from the Commission as a
result of this contract, required by N.C. General Statute § 143-6.2.
C. Compliance with Laws -Grantee shall at all times observe and comply with all applicable laws,
ordinances, rules and regulation of the state, federal and local governments.
D. Non-Assignability -Parties shall not assign any interest in the Agreement; provided, however, that
claims for money due to the Grantee from the Commission under this Agreement may be assigned
after written notice to and approval from the Commission.
E. Personnel -Grantee represents that it has or will secure at its own expense all personnel required to
carry out and perform the scope of services required under this Agreement. Such personnel shall be
fully qualified and. shall be authorized under state and local law to work on the Project. Such
employees shall not be employees of the Commission.
F. Restriction on Use of the Funds -Grantee will expend funds consistent with the terms and conditions
of this Agreement.
G. Non-Waiver - No failure or waiver or successive failures or waivers on the part of either Party, its
successors or permitted assigns, in the enforcement of any condition, covenants, or provisions of this
Agreement shall be deemed to be a waiver of enforcement for the breach of any other provision in this
Agreement or of any subsequent breach of the same or other provision.
H. Approvals -All approvals required under this Agreement must be in writing.
Attachments -Attachments A, A- l, A-2, A-3, A-4, B, B-1, B-2, C, D, E, E-1, E-2, F and G are
attached to this Agreement and incorporated herein as a substantive part ofthis Agreement. Attached
is a form letter which will be used to notify Grantee of the Effective Dates of its additional Grant
Cycle(s). The Parties agree when letters are sent to the Grantee, establishing the Effective and
Termination Dates of the additional Grant Cycle(s), copies of the letters to the Grantee will be
substituted for the form letters and attached to this Agreement as Attachment B-2.
Section XII Entire Agreement
19
Orange County Signature Page
NC Health and Wellness Trust Fund Commission
Community and Schools Phase III Tobacco Use Prevention and Cessation Initiative
July 1, 2006 to June 30, 2007
i d~
Date
,~ ~ .
D to
D
Health Director Dat
Finance Director
A. This Agreement, all Attachments, and the Request for Grant Proposal represent the entire Agreement
between the Parties and supersede all prior oral or written statements or agreements.
B. All promises, indemnities, requirements, terms, conditions, provisions, representations, guarantees,
and warranties contained herein shall survive the contract expiration or termination date unless
specifically provided otherwise herein, or unless superseded by applicable federal or state statutes of
limitation.
C. The Agreement may be amended only in writing duly signed by authorized representatives of both
Parties.
D. If any term of the Request for Grant Proposal and applicable addenda or the Grantee Application
(Attachment A-1) conflict with any term of this Grant Agreement, the terms of this Grant Agreement
shall control
NORTH CAROLINA HEALTH AND
WELLNESS TRUST FUND COMMISSION
Lieutenant Governor Beverly E. Perdue
Chair
Orange County
Health Department
osemary L. S m r.PH
Health Directo
Date: Date: ~ ~~ ~~ I
20
ATTACHMENT A -PERFORMANCE OBLIGATIONS
A-1-GRANT APPLICATION
A-2 -COMMISSION APPROVED AMENDMENTS
A-3 -MINIMUM REQUIREMENTS
A-4 -ACTION PLAN
21
ATTACIiMENT A-1
GRANT APPLICATION
22
Health and Wellness Trust Fund Commission
Application for Teen Tobacco Use Prevention and Cessation Initiative:
Community/School Prevention Program or Special Proiect Grant
Instructions to Applicants
Only one proposal from each applicant organization will be accepted. All applicants
must submit a complete written application by the deadline identified in the Timeline section
of the 1tFP in order to be considered for a grant award. Applicants are strongly encouraged to
use the Microsoft Word-based online application found at www.hwtfc.or~, comprised of
Parts I, II and III of the Application. Applicants also need to complete and submit the
Microsoft Excel-based budget format (referenced in Part III of the Application and available
on the HWTFC website, www.hwtfc.or~). In addition, for applications to be considered
complete, the Additional Materials listed in Part IV are mandatory and must be sent by mail
or delivery service in one package, postmarked by March 29, 2005.
This application consists of Part I (Standard HWTFC Grant Application), Part II (Proposed
Project), Part III (Proposed Budget and Fiscal Information) and Part IV (Additional
Materials).
The Application is available either as an MS/Word document (.doc file) or an Adobe
document (.pdf file). Applications must be submitted via email to hwtfc e,ncmail.net by 5:00
PM, March 29, 2005. The title of the email and all attached documents must start with the
lead applicant organization's Federal ID number and name (e.g. 123454321 Wright
Hospital.doc).
It is recommended that you save the online document on your local network or computer
hard drive and continue to save it until it has been completed and submitted. This saved
copy is for your internal records.
Enter your responses to application. questions in the highlighted spaces provided in each
section by double-clicking on a field and tabbing between the questions. Please be concise in
your response (fixed character limits are used). There is a free text section at the end of Part I
where you can provide additional information for clarification.
When complete, submit to HWTFC via email attachment at hwtfc(a~ncmail.net by 5:00 PM,
Mazch 29, 2005. The Additional Materials listed in Part IV aze mandatory and must be sent
by mail or delivery service in one package, postmarked by March 29, 2005.
Part I -Standard HWTFC Grant Application
Applicant Organization(s)
Lead Applicant OrganizaNon/Fiscal Agent
Organization Name Orange County Health Department (OCHD)
Address 1 300 West Tryon Street
Address 2
City
County (office location)
ZIP Code
Organization Director(s)
Title(s)
Website Address
Federal Employer ID #
Hillsborough
Orange
27278
Rosemary Summers
MPH, DrPH
www.co.orange.nc.us/health
56-6000327
Grant Applicant and Grant Administrator
Application prepared by
Title Youth Tobacco-Use Program Manager
Phone
Fax
Email address
Grant Administrator*
Title
Phone
Fax
Email address
919-245-2424
919-644-3007
Letitia Burns
Business Officer - OCHD
919-245-2410
919-644-3007
lburns@co.orange.nc.us
*Grant Administrator will be the principal contact point following award
Grantee Status (check only one)
^ New HWTFC grant applicant
® Current HWTFC grantee
Project Type (check only one) Note: Proposals that provide services in more than one
programmatic category should select the one project type category below that is most
representative of their overall project.
® Community/School Project
^ Special Project
^ Priority Population Project
Total Budget Request: $ $289,130.00
2
How did you learn of this RFP? Tobacco Reality Unfiltered Listserv
Grant Summary
In the space below, describe in 100 words or less how the proposed HWTFC Grant will be
used. What services will be provided, what populations} will be served, and what objectives
will be achieved. This Grant Summary will be used to present your Application to the HWTF
Commissioners for consideration
The OCHD, iri partnership with Orange County school districts, will strengthen current
programming on youth tobacco-use prevention, cessation, and secondhand smoke
eliminiation. The program will recruit and train diverse high school peer educators to lead
prevention education in middle and high schools, and at community events. Anew media-
based social norms campaign will work to further denormalize tobacco use in schools. The
program will enhance its advocacy with family-oriented restaurants and partner with the
Orange County Asthma Coalition (OCAC) on a smoke-free dining campaign. These
activities will lead to an increase in recent declines in youth tobacco-use.
Co-Apulicant /Partnership Summary
In the space below, describe in 100 words or less your partners (if any). List the individual
organizations, their roles in delivering services under the Grant, and the means by which you
propose to share funding.
The Chapel Hill Carrboro City Schools (CHCCS) and Orange County Schools (OCS) are
active and commited partners. The School Health Coordinators from each school system will
continue to act as liaisons for the tobacco prevention coordinator from the health department.
They will help facilitate entry into the schools and connect the coordinator with the
appropriate teachers, classes and students to implement the project. The schools will receive
mini-grant monies for middle and high school-based groups to conduct special prevention
projects. The project will also partner with the OCAC to implement asmoke-free dining
campaign. Funds for this campaign will be managed by the OCHD.
3
Specific Areas of Service
If you ARE proposing Statewide coverage check here: ^ (Will provide services in all 100
counties)
If you are NOT proposing Statewide coverage indicate the counties in which you will be
providing services: (check all counties that apply)
^ALAMANCE ^FRANKLIN
^ALEXANDER ^GASTON
^ALLEGHANY ^GATES
DANSON ^GRAHAM
DASHE ^GRANVILLE
^AVERY ^GREENE
^BEAUFORT ^GUILFORD
^BERTIE ^HALIFAX
^BLADEN ^HARNETT
^BRUNSWICK ^HAYWOOD
OBUNCOMBE ^HENDERSON
^BURKE ^HERTFORD
~CABARRUS ^HOKE
^CALDWELL OHYDE
^CAMDEN DIREDELL
^CARTERET ^JACKSON
^CASWELL ^JOHNSTON
^CATAWBA ^JONES
^CHATHAM ^LEE
^CHEROKEE ^LENOIR
^CHOWAN ^LINCOLN
^CLAY ^MCDOWELL
]CLEVELAND ^MACON
COLUMBUS ^MADISON
^CRAVEN ^MARTIN
^CUMBERLAND ^MECKLENBURG
^CURRITUCK ^MITCHELL
ODARE ^MONTGOMERY
^DAVIDSON ^MOORE
^DAVIE GNASH
^DUPLIN ONEW HANOVER
QDURHAM NORTHAMPTON
^EDGECOMBE ^ONSLOW
[]FORSYTH ®ORANGE
^PAMLICO
^PASQUOTANK
OROBESON
^ROCKINGHAM
ROWAN
^RUTHERFORD
^SAMPSON
^SCOTLAND
^STANLY
^STOKES
^SURRY
^SWAIN
^TRANSYLVANIA
^TYRRELL
BUNION
^VANCE
^WAKE
^WARREN
^WASHINGTON
^WATAUGA
^ WAYNE
^ WILKES
^WILSON
DYADKIN
^YANCEY
Free Test Section
In the space below, provide any information, comments, or clarifying points supporting this
Application. These may include points of organizational change, specific contact
information, alternative funding, limitations, or proposed contingencies. Information entered
here will be reviewed but may not be factored into the award decision.
End of Part I
5
Part II-Proposed Proiect
Description of Need
(3,800 characters) 10% of Total Score
Include in your response:
• Community Need: Describe the community's need for the services described in the. plan
of work in the proposed service area..
• Teen Demographics: Provide current demographic information about teen tobacco use in
the proposed service area.
• Youth Activities and Infrastructure: Provide information on current youth tobacco use
prevention activities and infrastructure in the proposed service area.
• Geographic Area and Populations: Describe the proposed service area and how the
population will benefit from the program.
The OCHD program is the only program working to prevent youth tobacco-use in the county.
The current program has detected needs to enforce 100% TFS policies within both districts
and plans to enhance policy communication, supplement the current middle school-based
health curricula with youth-driven educational presentations, develop youth-led social
norms/counter marketing activities to reduce the influence of tobacco advertising, and
develop a sustainable smoke-free dining campaign.
Ina 2001YRBS of the two school systems, between 3-12% of middle school students had
smoked in the last 30 days. 2005 YRBS results from one district show that the percent of
middle school students smoking rose from 3% in 2001 to 6% in 2005. This reveals a need to
further strengthen prevention and cessation efforts in the middle schools. In high schools, the
2001 YRBS results showed that 20-25% of high schools students had smoked in the last 30
days. 2003 and 2005 YRBS results show a 5% and 12% drop in high school smokers in both
districts. YRBS data also show that 9-17% more high school students had never smoked a
whole cigarette in 2004/2005 compared to 2001. These results reveal that county-wide
prevention efforts, along with a statewide media campaign, have been effective in reducing
the number of high school smokers.
The 2003 YRBS also shows that the percentage of high school smokers attempting to quit in
the past year dropped from 17% to 10%. This reveals a need for continued 100% TFS policy
enforcement through implementation of cessation programs (NOT) and increased awareness
of cessation resources.
Currently, 41 high school peer educators are actively involved in the program. Peer
educators give Tobacco 101 presentations in the middle schools, conduct prevention
activities in the high schools and community, advocate for smoke-free family restaurants, and
educate decision makers on scientifically supported pro-health policies. Local school-based
media is developed by peer educators for delivery through media sources targeting youth in
their schools and communities. Peer educators and program supporters also write letters to
the editor and PSAs on issues related to the program's goals. In order to sustain youth
involvement, peer educators recruit and train new peer educators during. the school year.
6
Peer educators receive a nominal stipend upon completing 20hrs. of training and are provided
other non-monetary incentives throughout their involvement in the program.
Current infrastructure includes 41 peer educators, close partnerships with 2 school health
coordinators, 24 trained NOT/ATS facilitators in middle and high schools, extensive 100%
TFS signage in middle and high schools in one district, two district substance abuse policies
that promote the NOT and ATS programs, one self-sufficient high school T.R.U. Club,
numerous educational and instructional materials and aids, and one full time program
coordinator with office space and equipment.
Orange County is the service area reached. According to the 2000 Census, OC had 118,183
residents of which 20% are under 18 years old. The youth population is the primary focus of
this program. Youth. are predominantly engaged through the schools but also through extra-
curricular, community, and faith-based groups. The business and restaurant communities are
also engaged in the program in order to protect youth from tobacco advertising and exposure
to secondhand smoke. Adult populations are engaged to help youth advocate for pro-health
policies and practices that protect young people from tobacco use. Racial and ethnic
minorities are reached through the program and the peer educators currently involved in the
program represent various racial, ethnic, and religious backgrounds.
Proaosed Program Plan
(24,000 characters) 45% of Total Score
Describe your proposed program plan for the entire grant period, including specific goals,
objectives, best practice activities and indicators to measure progress. Your local objectives
must be S.M.A.R.T. -Specific, Measurable, Achievable, Realistic and Relevant, and Time
Limited. For more information, refer to the Goals, Objectives, Best Practice Activities and
Program Indicators and General Guidelines sections of the HWTFC RFP.
Include in your response:
• Innovative Approaches: Describe how your program demonstrates innovation at the
community, county, regional or state level.
• Target Audience and Their Involvement: Identify the proposed service recipients and
your commitment to involve target audiences in program development.
• Timeline for Program Implementation for the entire grant period
• Sustainability Plan for Program Continuation Past June 2009
• Plan to Increase Healthcare Capacity
• Results of Previous Efforts: Describe results and outcomes for previous teen tobacco use
intervention programs serving the target population.
The OCHD program is innovative in its ability to develop a comprehensive, best practice-
guidedprogram around a diverse group of actively involved youth peer educators. The
program's peer educators are integral participants in all four focus areas: preventing youth
tobacco initiation, providing youth tobacco cessation support, eliminating youth exposure to
secondhand smoke, and involving and engaging diverse youth populations. The program
7
develops extensive culturally diverse youth groups that become change agents in developing
a tobacco-free norm in the schools and community. This is done by directing efforts toward
changing youth attitudes and behaviors through direct involvement and educational outreach.
Activities aim to reduce the number of risk factors influencing young people to smoke and
replace those risk factors with protective factors that discourage tobacco use.
Expected Program Outcomes:
1) By June 2009, 2009 YRBS results will show a 7% and 5% decline in the number of OCS
and CHCCS middle and high school students respectively who have smoked cigarettes in the
last 30 days using 2003/2005 YR.BS data as the baseline.
2) By June 2009, 2009 YRBS results will show a 6% and 4% increase in the number of OCS
and CHCCS middle and high school students respectively who have never smoked a whole
cigarette using 2003/2005 YRBS data as the baseline.
3) By June 2009, 2009 YRBS results will show a 2% increase in the number of OCS and
CHCCS high school students who have attempted to quit smoking in the last 12 months
using 2003/2005 YRBS data as the baseline.
Focus Area 1: Preventing Youth Initiation
Goal 1: The program will recruit and train youth peer educators from CHCCS and OCS high
schools, involving them as active participants in the four focus areas.
Local Objective: By June 2009, 90 students will be recruited from OCS and CHCCS high
schools and trained as TRU peer educators. This will be measured by required
parentaUguaxdian permission forms provided by parents/guardians of peer educators.
Strategies: New peer educators will be identified and recruited through recruitment
campaigns conducted by current peer educators and teacher and student assistance counselor
referrals. Large group peer educator trainings will be held twice a year during the school
year and summer.
Timeline: Peer educators will be recruited throughout the school year and trained twice a
year during the grant period.
Goal 2: The program will mobilize peer educators to implement educational Tobacco 101
and Media Literacy programs and strategies to reduce tobacco initiation by middle school
youth.
Local Objective: By June 2009, a total of 1,500 middle school students in OCS and CHCCS
will have participated in a Tob. 1 O1 or Media Literacy presentation led by TRU peer
educators. This will be measured by participant and teacher evaluations completed at the end
of each presentation.
Strategies: Trained TRU peer educators will continue to provide Tobacco 101 presentations
in middle school classrooms and will add a Media Literacy presentation. The Media Literacy
presentation will be amulti-media, interactive presentation focusing on tobacco industry
marketing and youth participation in creating counter marketing messages.. Working
relationships already exist with teachers in OCS and CHCCS middle schools and these
relationships will be maintained to schedule presentations.
Timeline: An average of 3-4 presentations will be given each month during the school year
during the grant period.
Goa13: The program will conduct, in consultation with youth peer educators, a social norms
campaign in OCS and CHCCS middle and high schools.
8
Local Objective 1: By June 2009, 45% of middle school students and 60% of high school
students surveyed will report being exposed to at least one of the social norms campaign
components. This will be measured by a youth-led media exposure survey conducted in the
middle and high schools.
Strategies: Using the Alamance Co. program as a model, youth peer educators will develop a
social norms campaign that heightens the social undesirability of tobacco use and develops a
healthy stigma that tobacco use is an unattractive behavior. Emphasis will be placed on
smokers being in the minority and challenge pro tobacco youth norms currently accepted by
students. Key messages will be diffused via school-based media and distribution of
promotional materials.
Timeline: Starting during the 2005-2006 school yeaz peer educators will begin developing
the campaign (key messages, concepts, diffusion sources, etc.) in consultation with program
staff. The campaign will be rolled out during the second semester of the school yeaz and
continue each semester during the grant period.
Local Objective 2: By June 2009, 15 mini-grants will have been awarded to OCS and
CHCCS middle and high school groups to develop educational projects and projects that
supplement the social norms campaign. This will be measured by final project summazies
reporting the activities conducted using mini-grant funds.
Strategies: The program will conduct yearly mini-grant cycles in the fall and spring of each
school year. Five established student organizations or clubs (limit of one per school per
semester) will be eligible for a grant of up to $500 to carry out a special project. A review
board of TRU peer educators will review applications and select mini-grant recipients.
Student organizations or clubs will be required to complete a final project summary reporting
on the project's activities. Monies for these mini-grants will be managed by OCS and
CHCCS as part of the health coordinator's program budget (see attached letters of
agreement).
Timeline: Mini-grant prepazation will occur during the first semester of the 2005-2006
school year. Mini-grants will be available to school groups during the second semester of
that yeaz and Smini-grants will be awarded among 10 schools each year during the grant
period.
Focus Area 2: Promoting youth cessation
Goal 1: Work with CHCCS and OCS districts to enhance the enforcement of their 100%
TFS policies by implementing the ATS and NOT programs.
Local Objective 1: By June 2009, each CHCCS and OCS middle and high school will have
maintained at least two school-based adult ATS/NOT program facilitators. This will be
measured by maintaining contact with school health coordinators and training records from
ATS/NOT trainings.
Strategies: The program coordinator will work with OCS and CHCCS health coordinators to
maintain two trained facilitators in each middle and high school. A record of trained
ATS/NOT facilitators is maintained by the coordinator and if additional school personnel
require training the coordinator will arrange for their participation in an ALA run ATS/NOT
training. At the end of each school yeaz ATS/NOT trained facilitators, CHCCS and OCS
health coordinators, and the program coordinator will meet to evaluate progress of the two
programs.
Timeline: Ongoing throughout grant period.
9
Local Objective 2: By June 2009, 75% of middle and high school students caught in violation
of the school tobacco policy will have attended 4 sessions of the ATS program. This will be
measured through school health coordinators accessing district disciplinary recording
systems (NOWISE, etc.)
Strategies: The program coordinator, TRU peer educators, and OCS and CHCCS health
coordinators will promote ATS awareness among teachers, student assistance counselors, and
administrators through in-person meetings and periodic written correspondence. All parties
will convene at the end of each semester to monitor tobacco policy violations and the self-
referral of violators to the ATS programs.
Timeline: Ongoing throughout grant period. Review of violations at end of each semester.
Local Objective 3: By June 2009, each OCS and CHCCS high. school will have conducted at
minimum three NOT programs (1 per year) led by a trained school-based NOT facilitator.
This will be measured by yearly NOT facilitator attendance records.
Strategies: ATS/NOT facilitators will be encouraged to apply for ALA NOT mini-grants to
fund NOT programs. Intensive efforts will be made by TRU peer educators, ATS/NOT
facilitators, and the program coordinator to increase teacher and administrator awareness of
the NOT program's supportive, non-punitive approach. Additional, peer educator-led,
recruiting will be done using school-based media and offering incentives to youth smokers
who successfully complete the NOT program.
Timeline: Recruitment efforts will take place during the beginning of each semester. NOT
programs must start with at least 10 weeks left in the semester unless NOT is modified by the
facilitator to take less time. These efforts will be continuous during the grant period.
Goal 2: Work with CHCCS and OCS districts to enhance the enforcement of their 100%
TFS policies by communicating the 100%TFS policy to all students, staff, and visitors.
Local Objective 1: By June 2009, all CHCCS middle and high schools will have on display
1 TFS banner, 2 TFS sandwich boards, and 2 TFS outdoor wall signs. This will be measured
by an environmental inspection conducted by the program coordinator and confirmed by the
school principal. (Note: OCS middle and high schools currently have above signage in
place.)
Strategies: Signs will be purchased through the TPCB vendor and distributed with a
principal letter describing their proper display. Health coordinators will follow up with
principals if barriers to their proper display are detected.
Timeline: Signage will be distributed to each school by the end of the semester of the 2005-
2006 school year. Signs should be posted by the first week of the second semester of the
same year and left on display indefinitely.
Local Objective 2: By June 2009, all CHCCS and OCS high schools will have
institutionalized the practice of reminding sporting event attendees of the school's 100% TFS
policy via an announcement during each game. This will be measured by a letter from each
high school's athletic director confirming inclusion of the 100% TFS announcement.
Strategies: Results from the UNC-SPH Tackle Smoking Project will be consolidated and
shared with school principals and athletic directors. A sample announcement will be given to
school athletic directors with instructions to require game announcers to read the
announcement.
Timeline: Communication with athletic directors will occur prior to the start of the 2005-
2006 school year in order to have the announcement in use for fall sporting events.
Announcements will be read indefinitely.
10
Goa13: All adult school-based personnel will be aware of local cessation services and
resources such as quitlines and web-based services. Smoke-free adult personnel will
strengthen the OCS and CHCCS district's 100% TFS policies by acting as smoke-free role
models for students.
Local Objective: By June 2009, all OCS and CHCSS school-based personnel will have
received materials promoting local, phone, and web-based cessation services. This will be
measured by a mailing records kept by school health coordinators.
Strategies: Cessation resources will be posted and available in teacher/staff break rooms as
well as distributed through district mailings.
Timeline: Resources will be provided to school health coordinators prior to the start of the
2005-2006 school year for posting prior to the start of classes. Resources and personnel
mailings will be refreshed each semester.
Focus Area 3: Eliminate youth exposure to secondhand smoke
Goal: The program will increase parent awareness of the harmful effects of secondhand
smoke on children.
Local Objective 1: By June 2009, all OCS and CHCCS elementary schools will have at
minimum two "Love Our Lungs" signs posted at every parent/guardian drop-off/pick-up
point on school property. This will be measured by an environmental inspection conducted
by the program coordinator and confirmed by the school principal.
Strategies: Signs will be purchased from the vendor used by Healthy Alamance and
distributed to OCS and CHCCS elementary schools with a principal letter describing their
proper display. Health coordinators will follow up with principals if barriers to their proper
display are detected.
Timeline: Signs will be distributed to schools by the end of the first semester of the 2005-
2006 school year and should be displayed by the first week of the second semester of that
year. Signs will be on display indefinitely.
Local Objective 2: By June 2009, TRU peer educators will have conducted a total of 24
secondhand smoke awareness outreach activities at parentlguardian drop-off/pick-up points
at all CHCCS and OCS elementary schools. This will be measured by the program
coordinator's entries into the iPTS system.
Strategies: 2-3 peer educators will conduct outreach during hours of drop-off or pick-up.
Peer educators will hand static cling "Love Our Lungs" window stickers and other awareness
materials to parents/guardians dropping off/picking up their children.
Timeline: Peer educators will start outreach during the second semester of the 2005-2006
school year. 4 elementary schools will be reached each semester during the grant period.
Goal: The program will increase the number of smoke-free family restaurants in Orange
County.
Local Objective 1: By June 2009, 100% of restaurants applying for a permit in Orange
County will receive an informational packet from the Environmental Health Services
Division (EHSD) of the OCHD communicating the advantages of opening smoke free. This
will be measured by EHSD records.
Strategies: This strategy has recently been implemented as part of the current program and
requires organizational institutionalization. The program coordinator will provide
informational packets to the EHSD on a monthly basis. EHSD records will monitor the
distribution of the packets to new restaurants.
11
Timeline: Ongoing throughout grant period and indefinite beyond grant period.
Local Objective 2: By June 2009, 25% of restaurants opened during the grant period will
open smoke free.. This will be measured by EHSD records and the restaurant database
maintained by the program coordinator.
Strategies: See previous "strategies".
Timeline: Ongoing throughout grant period and indefinite beyond grant period.
Local Objective 3: By June 2009, 120 Orange County restaurants will be listed on the
OCHD online smoke-free dining guide. This will be measured by viewing the OCHD guide
at www.co.orange.nc.us/health smoke-free.htm.
Strategies: The OCHD, in partnership with the OC Asthma Coal. and TRU peer educators,
will recruit smoke-free restaurants for its online smoke-free dining guide. Recruitment will
be via direct mailings and in-person contact by peer educators. To publicize the online
guide, a paid and earned media campaign will be utilized to feature smoke-free restaurants
and diffuse the guide throughout the community. Restaurant owners and managers will be
consulted in the development of this media campaign. This campaign is modeled after the
successful Wake Co. stoplight campaign.
Timeline: Recruitment of restaurants and media will be ongoing throughout grant period.
Focus Area 4: Eliminate Health Disparities
Goal: Involve diverse youth as peer educators in order to provide culturally competent
educational outreach to minority populations in Orange County.
Local Objective 1: By June 2009, at least 25% of peer educators will be minority students
from OCS and CHCCS. This will be measured by completed applications of accepted peer
educators.
Strategies: Current peer educators will actively recruit minority students into the TRU peer
educator group. Emphasis has been ,and will continue to be, placed on the importance of
representing minority groups in order to effectively work with minority students to reduce
disparities. Existing linkages with minority student groups/clubs will be strengthened and
additional linkages will be pursued.
Timeline: Ongoing throughout grant period.
Local Objective 2: By June 2009, peer educators will have conducted educational outreach
at 12 minority-focused community and/or school events. This will be measured by the
coordinator's iPTS reporting.
Strategies: Peer educators will maintain their participation in existing minority-serving
school and community fairs and events and pursue new opportunities. Peer educators will
improve the cultural appropriateness of educational materials and outreach strategies,
translating materials into Spanish when necessary.
Timeline: School and community events have been identified and occur primarily in the fall,
spring, and summer of each year. Attendance at these events will be ongoing throughout the
grant period.
Sustainability:
Much emphasis has been placed on building school and community-based capacity to carry
out core activities in the focus areas above without substantial funding. Training materials
have been developed for peer educator training and adult NOT/ATS facilitators have been
trained within each middle and high school. Peer educators, with the assistance of trained
12
school-based personnel, could carry on with Tob. 101 and Media Literacy presentations in
the middle schools at minimal cost. Additionally, the smoke-free dining guide, once initiated
and achieving community awareness, could be passed onto the local Chamber of Commerce.
Upkeep of this .dining guide is minimal and low-cost. Beyond June, 2009 the program plans
to sustain it's full programmatic activities by requesting that the OC County Commissioners
provide funding for the continuation of the program. Additional community funding and
grants will be pursued.
Improve Healthcare Capacity:
In addition to relieving strain on the local healthcare system by preventing future tobacco
related disease, the OCHD is well positioned to influence county health clinic and private
provider practices regarding tobacco-use prevention and cessation counseling. The OCHD
enjoys an excellent reputation with the OC healthcare community and will continue to share
best practices materials with providers (Ex. Recent TPCB 5 A's card). OCHD clinic staff
already do tobacco counseling during prenatal visits and will begin to promote the use of
Medicaid for certain nicotine replacement therapy treatments.
Results of Past Programming:
Major Policy Accomplishments and Key Achievements -
1 Z Schools adopt ATS and NOT policies
24 school-based personnel trained to implement new ATS/NOT policies
4 new schools promote 100% TFS through signage
1 restaurant adopts 100% smoke-free policy
1 bowling alley adopted improved smoke-free policy
Over 200 restaurant patron surveys conducted and 4 smoke-free business presentations given
to restaurant bowling alley managers or owners
1 permanent high school club established
2 permanent district TRU peer educator groups established (40 trained peer educators)
Over 700 middle school youth reached. through Tobacco 101 presentations
Over 1,000 youth reached through community outreach events
Media Involvement -
6 TRU advertisments placed in school papers regarding cost of tobacco use
6 articles written by TRU peer educators
3 articles written by program staff _
2 articles written by program supporters
8 articles written by newspaper staff on program
Program featured on two radio programs
Program featured on two state-wide TV programs
100s of NOT recruitment posters placed in schools
1,OOOs of TRU promotional items distributed
Intern Professional Development:
1 intern from UNC-CH School of Public Health for summer 2004
1 intern from NCCU Dept. of Health Educ. for Winter-Spring 2005
The program has effectively collaborated with a number of current HWTF grantees on
various training and educational outreach events. Those collaborative partners include:
Question Why Central Region, Old North State Medical Society, Durham County Health
13
Department, North Carolina Amateur Sports Association, LTNC-CH School of Public Health,
Office of Minority Health/State Baptist Convention, Ruiz Agency, and the Community
Backyard of Orange and Chatham Counties
The program enjoys strong relationships with elected OC representatives in the NC General
Assembly, at the county level, and an active relationship with the OCHD Board of Health.
Organizational Capacity
(8,000 characters) 25% of Total Score
Include in your response:
• Overview of the Lead Applicant Organization: Describe how the lead agency will
administer the grant and ensure that the program action plan is implemented.
• Staffing for the Grant: Describe the position(s) including responsibilities, qualifications
and classification. Where does the position fit into the organizational structure? To whom
does the position report? If this application covers more than one county, how will the
position relate to personnel in other counties?
• Evidence of Organizational Experience: Please describe the lead applicant organization's
experience in planning, implementing and promoting teen tobacco use prevention
programs. Briefly describe relevant training received by staff and volunteers and any
training/workshops conducted by the lead applicant organization.
• Partnerships and Collaborations: Provide a brief overview of all partners (co-applicants)
including expertise in teen tobacco use prevention and cessation and proposed
responsibilities in implementing the program action plan. Include information on the
integration of the program with existing services, partnering organizations, and
community support in planning and implementation.
• Media Collaboration and Support: Describe examples of previous or current media
campaigns including programs that received earned media. Discuss relations with media
and any local media involvement in state media campaigns.
• Youth Involvement and Collaboration: Provide information on how you would provide
opportunities for youth involvement in program development and implementation.
The lead applicant for this project is the Orange County Health Department (OCHD). The
OCHD has been serving the Orange County community by providing clinical services, health
promotion and education, dental health, environmental health and animal control for more
than 25 years. Through our broad array of services we provide public health to residents in
three separate clinics and in the field. The health promotion and education division in
particular is involved in bringing prevention programs to the community through schools,
community groups, health fairs and other settings. Orange County has been involved in
tobacco policy initiatives since 1988 when the commissioners approved a policy limiting.
smoking in county buildings. The OCHD advocated for and the Board of Health passed
14
Smoking Control Rules in 1993 restricting ETS in public places, work sites and restaurants.
In 1997 the Boazd of Health created asmoke-free committee, made up of OCHD and
community representatives who worked to develop a county anti-smoking plan. This plan
included encouraging restaurants to go 100% smoke-free and the group developed,
published, and distributed asmoke-free dining guide that included more than 75 restaurants.
In November 2000 the Healthy Carolinians Preventive Services committee organized
activities for the Great American Smoke Out. The OCHD has also offered smoking cessation
groups by request for many years and has a public health educator who is a trained American
Lung Association cessation group facilitator. OCHD is a government organization with the
capacity to oversee a project such as this one with ease.
The OCHD has three health educators with experience in tobacco use prevention and
cessation. The current program coordinator for youth tobacco use prevention is a full-time
Senior Health Educator with a Masters degree in Public Health. This position is in the
Division of Health Promotion and Educational Services. The coordinator has extensive
training and experience in program planning, implementation, and evaluation. The
coordinator also has nearly two years of experience managing the youth tobacco-use
prevention grant. The program coordinator has received training and technical assistance
from the North Carolina Tobacco Prevention and Control Branch (TPCB), has attended a
national conference on tobacco control, and is a graduate of the North Carolina Governor's
Academy of Prevention Professionals (GAPP) training in substance abuse prevention. The
Director of the Health Promotion and Education Division, also holding a MPH, provides
oversight for the program. The Lead applicant employs undergraduate and graduate level
interns to assist with program implementation and trains interns as TATU and NOT/ATS
facilitators. Additionally, the lead applicant has trained more than 40 youth peer educators
and organized American Lung Association trainings for 24 adult NOT/ATS facilitators. Peer
educators from the program have been invited to present to other county youth and have
assisted the Central Region Question Why Youth Empowerment Center with an out-of-
county training.
OCS has 6,628 students in grades pre-K through 12, including seven elementary, two middle
and two high schools. The Chapel Hill Carrboro City Schools (CHCCS) has 10,350 students
in grades pre-k through 12. There are 8 elementary, 4 middle and 2 high schools. Both
districts are committed to working with the OCHD to prevent tobacco use in teens and
eliminate youth exposure to ETS. Both districts will continue to survey students on an
annual basis and provide survey results to the OCHD for evaluation purposes. CHCCS have
been 100% tobacco -free since 1990 and can continue to provide guidance to the OCS as
they strengthen the enforcement of their 100% TFS policy.
The School Health Coordinators from each school system will act as liaisons for the tobacco
prevention coordinator from the health department. They will help to facilitate entry into the
schools and connect the coordinator with the appropriate teachers, classes and students to
implement the project. In particular, the School Health Coordinators and other school-based
personnel will continue to provide in-kind contributions totaling 20 hours a month. Both
school districts have health and physical education teachers that currently provide basic
health education on the dangers of tobacco use on human health. These teachers work
closely with TRU peer educators to schedule Tobacco 101 and other presentations. As a
result of the current program, 24 school-based personnel (2 in each middle and high school)
are trained as adult facilitators for the NOT/ATS programs.
15
The current program has received extensive coverage through print, radio, and TV media.
The T.R.U. program was awarded a monthly column in the News of Orange County which
featured articles written by youth peer educators on a variety of youth tobacco-use prevention
issues. In addition to contributions to the Chapel Hill News and the Chapel Hill Herald,
youth peer educators have been interviewed on Iocal news channels during training events,
and featured on NCCU's 90.7 Spanish language radio program called "Cita Dominical". One
Orange County youth was featured on the MTV Music Awards T.R.U. commercial
developed by CapStrat. Additionally, the program coordinator has been asked to appear as a
guest on two statewide TV programs: Univision's Enfoque Latino (Spanish) and UNC-TV's
High School Assembly. Local school-based media has included articles in high school
newspapers, announcements at high school sporting events, and announcements over school
intercoms and television stations. A11 of the above mentioned media, except school
newspaper advertisements, have been earned at no cost to the program. The program
recently initiatied a Smoke-Free Dining Campaign that is featured on the OCHD's webpage
and has distributed smoke-free decals and certificates to 20 OC restaurants. Additional paid
media is proposed for the promotion and strengthening of this campaign and the school-
based social norms campaign.
Youth will continue to be the driving force behind the program. The program staff have
taken a "youth-led, adult-assisted" approach throughout current programmatic activities and
plan on expanding the scope of youth influence in the proposed plan. More than 40 peer
educators meet on a bi-weekly basis with the program coordinator to plan prevention
activities, develop and schedule educational presentations, and coordinate smoke-free
advocacy efforts with local establishments. Peer educators are also responsible for training
newly recruited peer educators in a train-the-trainers model.
Outcomes and Local Evaluation Plan
(4,000 characters) 10% of Total Score
As a condition of receiving a grant awazd, HWTFC requires that each grantee participate in a
state-level outcomes study using acomputer-based activity tracking system, "indicator
Progress Tracking System" (iPTS), provided by the UNC-CH, Department of Family
Medicine, in collaboration with the NC Tobacco Prevention and Control Branch, and funded
by HWTFC. The iPTS system tracks specific program indicators to measure project progress
toward meeting goals and objectives. All local evaluation efforts should be consistent with
the overall evaluation outcome program. For purposes of local evaluation, you will need to
determine how you measure the quality and quantity of your proposed teen tobacco use
prevention and cessation activities.
A. Outcomes:
Include in your response:
• Description of expected outcomes of the proposed project
• Definition of the long term impact of the proposed project
16
The program will increase the knowledge/skills of middle and high school students of/on
the dangers of tobacco use and how to avoid use, the harmful effects of secondhand smoke
and how to prevent exposure, and pro tobacco marketing influences and how to protect
oneself from those influences. The "Love Our Lungs" campaign will help parents/guardians
increase their knowledge of the dangers of youth exposure to SHS and skills to protect youth
from exposure. It is expected that this knowledge and skill set will lead to youth and adults
viewing tobacco use negatively (attitudes) and modify behavior to avoid tobacco use or
exposure to secondhand smoke. This, in addition to changes in the physical environment,
will lead to fewer youth tobacco users and reduced exposure to SHS.
B. Local Evaluation Plan:
Include in your response:
• Description of school and community policies, media and program services you will
monitor during the length of the program.
• Description of the procedures to measure progress toward goals and objectives
• Description of how the evaluation results will be communicated to the proposed service
area.
The program will monitor the following school policies through the assistance of school
health coordinators within OCS and CHCCS: 100% TFS, ATS, NOT. In particular, the
program will conduct environmental inspections for 100% TFS signage, NOT recruitment
materials, and "Love Our Lungs". Sporting event announcements will be monitored through
athletic director confirmation and random attendance of sporting events. The program will
also monitor the smoking policies of family restaurants and youth-oriented hangouts.
The program staff, school health coordinators, and peer educators regularly monitor media
for relevant developments and coverage of the program's achievements. All program-
specific media messages are kept in a scrap book on file in the health department.
Additionally, important corzespondence with key school, community, and county leaders are
kept on file in the health department.
The program will monitor its services according to the local objective-specific measurements
and strategies described in the Program Plan above. The OCHD is pursuing a department
wide effort to measure customer/client satisfaction and once these measurement tools are
developed they will be applied to the youth tobacco-use prevention program.
Progress will be measured by employing process objectives for each outcome-oriented local
objective described in the Program Plan. Process objectives will ensure that activities are
being carried out in a timely fashion and in order to meet key milestones.
Communication of evaluation results will be done both formally and informally with the
general public and key partners. Results of evaluation will be shared through media for the
general public. Results of evaluation will be shared with key partners through summary
reports and correspondence through meetings, emails, and telephone conversations. At the
end of the grant period a final summary of the status of proposed goals and objectives will be
compiled and communicated to both the general public, partners, and other stakeholders.
17
C. indicator Progress Tracking System (iPTS):
Indicate your organization's willingness, capacity/readiness and ability to participate in iPTS
by responding to the items below:
• Windows 98 or higher
® Yes ^ No If No, ^Agree to by this date (MM/DD/YY):
• Computer capable of supporting Microsoft Office 97 or higher
® Yes ^ No If No, ^Agree to by this date (MM/DD/YY):
• Dedicated computer access
® Yes ^ No If No, ^Agree to by this date (MM/DD/YY):
• Dedicated Internet access
® Yes ^ No If No, ^Agree to by this date (MM/DD/YY):
• E-mail address
® Yes ^ No If No, ^Agree to by this date (MM/DD/YY):
• Software-Microsoft Office OR Microsoft Word and Microsoft Access
® Yes ^ No If No, ^Agree to by this date (MM/DD/YY):
End of Part II
18
10% of Total Score
Part III- Prouosed Budget and Fiscal Information
A. In the Microsoft Excel-based budget format spreadsheet (available on the HWTFC
website, www.hwtfc.or~), provide the projected project budget for the proposed project.
A description of the HWTFC approved budget categories is also available on the
HWTFC website (www.hwtfc.org) and must be used to budget expenses to the correct
line items. The budget must be submitted along with the application in order to be
considered for funding. The document title must start with the lead applicant
organization's Federal ID number and name (e.g. 123454321 Wright Hospital.xls).
Organizations that are NOT currently receiving HWTFC funding must complete the
Excel spreadsheet titled "Budget Format for NEW Grantee".
Organizations that ARE currently receiving HWTFC funding must complete the Excel
spreadsheet titled "Budget Format for EXISTING Grantee"
B. In the space below, provide a narrative budget justification by budget line item. Identify
the source and amount of any in-kind resources that will contribute to the project. (5,000
characters)
Direct Expenses: $49,257 in Salary reflects the year one salary and fringe benef is of one
full-time Senior Public Health Educator who will serve as the coordinator of the project with
an annual S% increase for merit and COLA included for years two and three.
$8,800 in In-kind Salary is based on an average of 20 hours per month at $20/hr. for 10
months for school system personnel who will be involved in the implementation of the
project; also for 20 hrs. per month for OCHD staff who will provide supervision and fiscal
management for 12 months each year.
Contracted Staff: $2,645 For a stipend for interns working no more that 1 S project hrs. a
week for 10 weeks during June, July, and August for a total of $1,500. $1,000 for peer
educators taking on leadership roles and managing special projects. The sum equals 10 peer
educators receiving $10/hr. for working a least 10 hrs. $140 for $3S registration fee for 4
additional NOT/ATS facilitators to be trained. $500 will be provided in-kind from OCHD
staff volunteering to support the program.
$8,100 in Other Direct Expenses. $3,600 will pay 30 peer educators per year $120 each to
undergo training in tobacco prevention education. $2,500 will provide mini-grant funds for
five school-based groups/clubs to conduct special projects on tobacco-use prevention. $2,000
will provide $SO incentives for 40 youth smokers to complete the 10-session NOT program.
$12,000 in year(s) one, two and three for Salary In-Kind for the peer educators who will
provide voluntary service in this project. The sum is based on a calculation of $10/hr for 4
hrs per month for 10 months in the first, second, and third years.
Other Than Personnel Support OTPS: $3,000 for 100% Tobacco Free School signage for
middle and high schools within CHCCS, "Protect Our Lungs" signage and car stickers for
T9
elementary schools and parents/guardians within OCS and CHCCS This signage will help
communicate the 100% TFS policy and help schools achieve a gold standard policy. The
sum is based on 6 TFS banners at $39.95 each, 12 TFS schools stands at $56.95 each, 50
"Love our Lungs" signs at $15.47 each, 1,500 "Protect our Lungs" car window stickers at .69
cents each, plus shipping costs.
$3,000 for supplies and materials each year includes paper for. printing (NOT recruitment
posters), educational materials; brochures and other office supplies as needed. The OCHD,
OCS and CHCCS will provide approx. $1,500 per year in in-kind supply costs, including
photocopying and miscellaneous office supplies.
$1,215 for Communication Costs will include $555 for postage, 1,500 mailings at .37 each.
Office telephone and cell phone costs will be $55/month or $660 annually. A cell phone will
be required for the coordinator who will be traveling around the county a great deal. The
OCHD will cover FAX and computer networking costs in-kind.
$9,600 in Occupancy Costs will be covered in-kind by the contribution of an office space
provided by the OCHD valued at $12.50 per sq. foot. At 64 sq. foot office would run $800
per month.
$2,000 for Capital Outlay for an LCD projector, speakers, and camcorder for media-based,
interactive media literacy presentations in middle schools. The sum includes $1,500 for LCD
projector, $100 for speakers, $400 for camcorder. The camcorder will be used to record peer
educator activities and develop educational media.
$4,000 Other OTPS: Purchase of promotional items such as TRU gear and social norms
campaign promotional items such as t-shirts, stickers, temp. tattoos, etc. It is estimated that
the bulk of these items will be purchased in year one, with a decreasing number purchased in
subsequent years.
Central Media Fund $10,000:
Social Norms Campaign ($5,504): 1) newspaper ads in 4 middle and 4 high school papers
(12 issues x $35 per issue x eight schools) for $3,360; 2) 200 posters (20 posters per middle
and high school) at $1.98 per poster for $396; 3) movie slides at local theatres for $1,748.
Smoke-Free Dining Campaign ($4,496): 1) radio spots on two OC radio stations for $1,500;
2) Newspaper insert for $2,000; 3) promo items for restaurants including coasters and table
tents for $946. $3,000 will be provided by earned media and dollar matches by newspaper
and radio.
$7,800 in Travel Expenses includes $4,000 for 4 peer educators and 2 adult chaperones to
attend a national conference, and $2,000 for program coordinator, program supporters, and
peer educators to attend TPCB, HWTF, and ?Y regional and state-wide summits. An
additional $1,800 will be for local travel reimbursement at .375 cents per mile for an average
of 400 miles per month as it is an approximate 25 mile round trip between the two school
systems and health department.
20
$6,000 in Meeting Expenses will include the cost of two peer educator trainings and team
building weekends. Refreshments and other costs for planning meetings for two peer
educator groups meeting bi-weekly during the year (approx. 45 meetings).
C. Provide a description of the bank accounts, internal accounting ledgers, books and
procedures that will be-used to account for HWTFC grant funds. (Note: Successful
applicants will enter into a grant agreement with HWTFC that requires nonprofit
organizations to open an interest bearing account exclusively far HWTFC funds.
Governmental organizations will be required to deposit HWTFC funds in a restricted
grant account.) (1,000 characters)
The grant money is accounted for on the general ledger under an account number specific to
this grant. All money coming into the County is deposited into the county's main cash
account. Any checks received or money expended is documented on the ledger either by PO,
check requisition or internal posting (motor pool). The Health Department has a Business
Officer who approves purchases, and keeps copies of all purchases and checks received from
HWTF. The requests for payment go to the County Finance department where they are
checked again for appropriateness. The program coordinator and Health Promotion and
Educational Services Division Director will maintain an excel spreadsheet that will track
monthly grant expenditures and provide an accurate record of line item amounts.
D. Provide a complete list ofsub-recipients of HWTFC funding under the grant (including
partners, collaborators and other contractors), the amount of HWTFC funding each will
receive and a specific description of how the lead applicant organization will account for
funds disbursed to sub-recipients. (3,000 characters)
Sub-recipients of funds are the Chapel Hill-Carrboro City Schools and Orange County
Schools. Sub-recipients will receive funds as part of the mini-grant program. The amount of
funds that each sub-recipient will receive is dependent on the mini-grant projects awarded
within each school district. The mini-grant funds are not to exceed $500 per project and a
maximum of five projects will be awarded each year. During each mini-grant cycle, the
combined amount of mini-grant awards for each district will we calculated and the OCHD
will write a check to each district for the specified amount. The Health Coordinator for each
district will manage expeditures of the funds in collaboration with adult leaders (teachers) of
mini-grant recipient groups. A written summary detailing activities will be required of each
mini-grant recipient upon completion of the mini-grant.
End of Part III
21
Part IV-Additional Materials
For applications to be considered complete, the following items are mandatory and
required by the NC Administrative Code, with the exception of item #5. These
additional materials must be sent by mail or delivery service in one package,
postmarked by March 29, 2005.
® 1. Completed and signed "Agreement and Certification" form (available on the HWTFC
website, www.hwtfc.or~).
® 2. Letters of Agreement (consent) from all partnering organization (agencies other than
the fiscal agentllead applicant organization that will be receiving funds from this
grant as subcontractors to the lead applicant organization).
® 3. At least three (3) Letters of Support from collaborating individuals or organizations
(other than partnering organizations submitting letters of agreement).
® 4. A list of three (3) references whom the Commission may contact regarding the lead
applicant organization's ability to achieve results through grant funding.
® 5. Evidence of paid and earned media that resulted from previous teen tobacco use
prevention and cessation activities if available.
® 6. Copy of letter of determination of nonprofit status from IRS or proof of lead applicant
organization's status as a state agency, local government or other political subdivision
of the state.
® 7. Budget of the lead applicant organization, clearly demonstrating the source for all in-
kind contributions included in the project budget and reflecting expected income from
other sources which have been applied for or have been received that will be used as
matching funds for the project.
® 8. Most recent audit of the lead applicant organization.
® 9. List of lead applicant organization's teen tobacco use prevention and cessation
programs funded by grants or awards in the last five years, including the grant.awazd
amounts and the names of granting entities.
^ 10. Nonprofit organizations must submit the following information for the lead applicant
organization:
• mission statement and organizational goals
• boazd of directors
• organizational history
• current programs, activities and accomplishments
• list of contributors to the organization with the amounts given for the current yeaz as
reported on the Lead Applicant Organization's IRS Form 990. Applicants may
submit either the IRS Form 990 or another document with this same information such
as an Annual Report. (This information will be used to determine potential conflicts
of interest and will be kept CONFIDENTIAL. This information will be shazed only
with HWTFC Commissioners and select HWTFC staff. )
22
Attachment B
Health and WellnessTrust Fund Commission
Phase III Teen Tobacco Use Prevention and Cessation Initiative (Existing HWTFC Grantee)
Proposal Budget
Applicant Agency: Orange County Health Department
Contact Person for Budget: Letitia Bums -Business Officer t~iwTt`
Contact Phone: 919 245-2410 Approved:
Fax: 919 644-3007 t=ftectlve date:
e-mall: (bums co.oran e.nc.us Comments
Federal Tax LD. or 501(c)(3): 56-6000327
1. Year 1 startin on or about 7/1/2006 and endin 6/30/2007
2. Year 2 startin on or about 7/1/2007 and endin 6!30/2008
3. Year 3 startin on or about 7/1/2008 and endin 6/30/2009
7/1/2006-6/30/2007 7/1/2007-6/30/2008 7/1/2008,6/30/2009 Pro'ectTotal
Ca o ~ Propo
amount '
fi-Knd Proposed
mourit
in Kind roposed-
amount
in Kind: Proposed
amount
in-Kind
Direct Ex enses
Sala /Wa es/Benefits $49,127 $8,800 $51,719 $8,800 $54,304 $8,800 $155,150 $26,400
Contracted Staff $2,645 $500 $2,645 $500 $2,645 $500 $7,935 $1,500
Other Cla ' in narrative $8,100 $12,000 $8,100 $12,000 $8,100 $12,000 $24,300 $36,000
Subtotal: $59,872 $21.300 $62,464 $21.300 $65,049 $21,300 $187.385 $63.900
Other Than Personnel
Su ort OTPS
Su lies/Material $6,000 $1,500 $4,035 $1,500 $4,035 $1,500 $14,070 $4,500
Communication Costs
tele hone, osta e, frei ht
$1,215
$500
$1,215
$500
$1,215
$500
$3,645
$1,500
Occupancy Costs (rent
utilities, re airs, maintenance
$9,600
$9,600
$9,600
$0
$28,800
Capital Outlay (furniture,
equipment, data processing
equip with unit costs of at
least $500
2,000
0
0
2,000
0
Other C/a ' in narrative $4,000 $3,500 $3,000 $10,500 $0
Subtotal $13.215 $11,600 $8.750 $11,600 $8,250 $11,600 $30,215 $34,800
Media
Advertising and Promotion
(Paid Media Placement and
Production Costs
$10,000
$3,000
$10,000
$3,000
$10,000
$3,000
$30,000
$9,000
Subtotal $10,000 $3,000 $10,000 $3.000 $10,000 $3,000 $30.000 $9,000
Travel Ex enses
Travel (mileage,
trans ortation, meals, hotels
$7,800
$7,800
$7,800
$23,400
$0
Meetin s $6,000 $6,000 $6,000 $18,000 $0
Other Cla ' in narrative $0 $0 $0 $0 $0
Subtotal $13.800 $0 $13,800 $0 $13.800 $0 $41.400 $0
Approved Carry Forward
HWTFG use onl
~d
Total Direct Ex enses $96,887 . $35,900 $95,014 $35,900 $97,099 $35,900 $289,000 $107,700
Indirect Costs $0 $0
Total Request $96,887 $35,900 $95,014 $35,900 $97,099 $35,900 $289,000 $107,700
NOTES: (HWTFC use only)
ATTACHMENT A-2
COMMISSION APPROVED AMENDMENTS TO GRANT APPLICATION
23
ATTACHMENT A-3
MINIMUM REQUIREMENTS OF A GRANT PROJECT
No additional requirements other than those specified in the Request for Proposal
24
ATTACHMENT A-4
ACTION PLAN
25
HWTF PRIORITY POPULATION GRANTS:
SCHOOL AND COMMiJNITIES GRANTEES
2006-2007 ANNUAL ACTION PLAN
A. Grantee ORANGE COUNTY HEALTH DEPT. B. Contact Person Nilcie Sarris, MPH
C. Program Goal: Prevent Youth Initiation of Tobacco Use (INITIATION)
D. Overall Objective: Increase the proportion of youth in middle school and high school who have never smoked
E. Focus Area: Provide youth tobacco use prevention education and empowerment opportunities in schools and the community
F. Please provide data on 2005-2006 total to date and 2006-2007 targets on each policy outcome indicator. For Progress toward G. If an indicator also involves an effort designed to meet the culturally
policy outcome indicators, please provide data on 2005-2006 total to date and 2006-2007 projections. If you do not plan to work on soecitic needs oleo identified population to reduce heal th disparities, fill
an judicator enter Os for the target data. in the code of each identified population. Provide a target for the
Process Indicators Total-to-date Projections identified population AUDIENCE(s).
2005-2006 2006-2007 Identified Tsrget/Projection
1. # of tobacco use prevention education media/promotional messages published or aired Process Indicators Population* 2006-2007
Z. # of skill building trainings offered to youth promoting youth led activities 1
3. # of skill building trainiugs offered by grantee to adult leaders 2
3
4. # of youth led prevention activities 4
H. Estimated Cost : Contracted Staff: $6,245 Supplies: $2,000 Promotional Materials: $3,000 Communications/Mailings: $400 Media: $5,504 Travel: $6,000 Meeting expenses: $500
I. IMPLEMENTATION STRATEGIES J. TARGET AUDIENCE K. IMPLEMENTATION ROLES L. YOUTH LEADERSHIP M. TIME
What key activities and events will you and your Who will be directly impacted What partners & resources are How will youth play an active LINE
partners' implement to achieve policy change? by this activity? (If there are needed? This includes "material" role in the planning, Start Date -
intended induect impacts, resources as well as local and state implementation and/or End Date -
rovide arationale. artners and service roviders. evaluation of the strafe ?
1 a. Recruit and train youth peer educators 1 a. Students at OCS and 1 a. Program Manager will 1 a. See Implementation 1 a. 8/06 -
from CHCCS and OCS high schools. CHCSS. oversee recruitment efforts. Roles. 6/09
Current peer educators will
recruit and interview new peer
educator candidates.
2a. Mobilize peer educators to implement 2a. Middle school students 2a. Program Manager and peer 2a. In addition to developing 2a. 9/06 -
educational Tobacco 101 and Media Literacy educators will work the programs, peer educators 5/06
programs and strategies to reduce tobacco collaboratively to develop will deliver the programs.
initiation by middle school youth. programs. ?Y materials maybe
used.
3a. Conduct, in consultation with youth peer 3a. Middle and high school 3a. Program Manager will work 3a. Youth peer educators will 3a. 9/06 -
educators, a social norms cam ai in OCS students with school staff and eer develo asocial norms 06/09
Note: Maximum two pages per focus area *Population codes: AA =African American; AI=American Indian; AS= Asian; BC= Blue Collar; GL= Gay/Lesbian; HI =Hispanic; LLa Low Literacy • - 1
LS= Low SFS; PW=Pregnant Women; 18= Age 18 - 24; OT= Other- please describe
HWTF PRIORITY POPULATION GRANTS:
SCHOOL AND COMMUNITIES GRANTEES
2006-2007 ANNUAL ACTION PLAN
the
ht
i
h
h
and CHCCS middle and high schools. educators to distribute
promotional materials and utilize ens
e
g
at
campaign t
social undesirability of
school-based media outlets. tobacco use and develops a
Program Manager will assist peer health stigma that tobacco use
educators with applying for 15 is an unattractive behavior.
mini grants to develop
educational projects as well as
projects that supplement the
social norms campaign.
4a. Send peer educators to ?Y PEACE 4a. Youth peer educators
er
M
d P 4a. Program Manager facilitates
articipation in planned
outh 4a. Upon return from
conferences, participants will 4a. 9/06-
6/07
Summit, TPCB?HWTF Summit, 1 national
and hold focus area-specific
conference ,
anag
rogram
an p
y
summits and invites comm.. adult trainpeer educators on areas
,
trainings as needed. Send Program Manager supporters when appropriate. of expertise.
to same conferences for educational and Travel and registration funds
ities
rt
ki ~ re uired.
.
un
n o o
networ
Note: Maximum two pages per focus area * Population codes: AA = Atrican American; AI= American Indian; AS= Asian; BC= Blue Collar; GL= Gay/Lesbian; HI -Hispanic; LL= Low Literacy
LS= Low SFS; PW=Pregnant Women; 18= Age I8 - 24; OT= Other- please describe
HWTF PRIORITY POPULATION GRANTS:
SCHOOL AND COMMUNITIES GRANTEES
2006-2007 ANNUAL ACTION PLAN
A. Grantee ORANGE COUNTY HEALTH DEPT.
B. Contact Person Nikie Sarris, MPH
C. Program Goal: Eliminate Youth Exposure to Secondhand Smoke (SECONDHAND SMOKE)
D. Overall Objective: Increase smoke-free policies in both indoor and outdoor areas frequented by youth such as: restaurants, recreation facilities, bowling alleys, malls, movie theaters,
arks lace of worshi home amusement areas convenience stores roce store sort venues and ball fields
E. Focus Area: Indoor/outdoor area frequented by youth in contract area adopts or advances towards asmoke-free policy
F. Please provide data on 2005-2006 total to date and 2006-2007 targets on each policy outcome indicator. For Progress toward G. It an indicator also involves an effort designed to meet the culturally
policy outrnme indicators, please provide data on 2005-2006 total to date and 2006-2007 projections. If you do not plan to work on soectfic needs of an identified population to reduce health disparities, till
an indicator enter Os for the target data. in the code of each identified population. Provide a target for the
Total-to-date Target identified population AUDIENCE(S).
Policv Outcome Indicators 2005-2006 2006 -2007 Identified TargedProjection
i. # of smoke-free policies adopted Process Indicators Population* 2006-2007
Process Indicators Total-to-date Projection 2
2005-2006 2006 -2007
3
2. # of media/promotional messages promoting adoption ofsmoke-tree policies
published or aired 4
3. # of presentstions/meetings in schools/communities orwith managers/owners/leaders g
promoting adoption ofsmoke-free policies
4. # of patron survey campaigns/petition drives whose findings are
disseminated to manager/owners/leaders.
5. # of improved smoke-free policies (e.g, smoke-free night)
H. Estimated Cost : Contracted Staff: $2,000 Supplies: $650 Promotional Materials: S3,000 Communications/Mailings: $250 Media: $4,496 Travel: $150
Meeting expenses: $1,000
I. IMPLEMENTATION STRATEGIES J. TARGET AUDIENCE K IMPLEMENTATION ROLES L. YOUTH LEADERSHIP M. TIME
What key activities and events will you and your Who will be directly impacted What partners & resources are How will youth play an active LINE
partners' implement to achieve policy change? by this activity? (If there are needed? This includes "material" role in the planning, Start Date -
intended indirect impacts, resources as well as local and state implementation and/or End Date -
rovide arationale. artners and service roviders. evaluation of the strate ?
1 a. Increase parent awareness of the dangers 1 a. Parents of CHCCS and 1 a. "Love our Lungs" signs 1 a. Peer educators will 1 a. 11/06 -
of secondhand smoke. OCS elementary school posted at every parent/guardian conduct secondhand smoke 06/08
kids. drop-off /pick-up point on school awareness outreach activities
property. Signs will be purchased at parent/guardian drop-
from vendor used by Healthy off/pick-up points at all
Alamance. Promotional materials CHCCS and OCS elementary
(e.g. static cling "Love our schools.
Lungs" window stickers) will be
purchased from a vendor. Health
coordinators will follow up with
principals if barriers to their ,
Note: Maximum two pages per focus area *Population codes: AA =African American; AI=American Indian; AS= Asian; BC= Blue Collar; GL= Gay/Lesbian; HI =Hispanic; LL= Low Literacy ° ~ 4
LS= Low SES; PW=Pregnant Women; 18=Age 18 - 24; OT= Other- please describe
HWTF PRIORITY POPULATION GRANTS:
SCHOOL AND COMMUNITIES GRANTEES
2006-2007 ANNUAL ACTION PLAN
proper display are detected.
2a. Increase the number of smoke-free family 2a. Restaurants in OC 2a. Environmental Health 2a. Peer educators will
restaurants in Orange County. (directly) and their patrons Services Division (EHSD) will recruit smoke-free restaurants
(indirectly). send an informational packet to be included in the online
designed by OCHD smoke-free dining guide.
(communicating the advantages
of opening a smoke-free
restaurant) to all restaurants
applying for a permit in Orange
County. Additionally, OCHD
will partner with the OC Asthma
Coalition and TRU peer educators
to recruit smoke-free restaurants
for the OCHD smoke-free dining
guide. To publicize the online
guide, a paid and earned media
campaign will be utilized to
feature smoke-free restaurants
and diffuse the guide throughout
the communi
Note: Maximum two pages per focus area * Population codes: AA =African American; AI=American Indian; AS= Asian; BC= Blue Collar; GL= Gay/Lesbian; HI =Hispanic; LL=Low Literacy
LS= Low SES; PW=Pregnant Women; 18= Age I8 - 24; OT= Otber-please describe
HWTF PRIORITY POPULATION GRANTS:
SCHOOL AND COMMUNITIES GRANTEES
2006-2007 ANNUAL ACTION PLAN
A. Grantee ORANGE COUNTY HEALTH DEPT.
C. Program Goal: Promote tobacco youth cessation (CESSATION)
D. Overall Objective: Increase the number of middle and high school youth who quit using tobacco
E. Focus Area: Provide access to effective tobacco use cessation resources
F. Please provide data on 2005-2006 total to date and 2006-2007 targets on each policy outcome indicator. For Progress toward
policy outcome indicators, please provide data on 2005-2006 total to date and 2006-2007 projections. If you do not plan to work on
an indicator enter Os for the target data.
Total-to-date Target
Policv Outcome Indicators 2005-2006 2006 -2007
1. # of schools/community settings institutionalizing best practices for cessation
(e.g. N-O-T, SA, Quitline, Spit Tobacrn)
Process Indicators Total-to-date Projections
2005-2006 2006 -2007
B. Contact Person Nikie Sarris, MPH
G. If an indicator also involves an effort designed to meet the culturally
saecific needs of an identified population to reduce health disparities, fill
in the code of each identified population. Provide a target for the
identified population AUDIENCE(s).
Identified TargeNProjection
Process Indicators Population* 2006-2007
2. # of cessation media/promotional messages published or aired
3. # of presentations or meetings promoting Quit line, N-O-T, SA counseling for youth or
Spit Tobacrn cessation
4. # of trainings coordinated for health care professionals on SA counseling for youth
or Spit Tobacco cessation
H. Estimated Cost : Contracted Staff: $400 Supplies: $300 Promotional Materials: $400 Communications/Mailings: $200 Media: $700 Travel: S100 Meeting expenses: $225
Note: Maximum two pages per focus area *Population codes: AA =African American; AI=American Indian; AS= Asian; BC= Blue Collar; GL= Gay/Lesbisn; HI =Hispanic; LLm Low Literacy . ~ ~ 6
LS= Low SES; PW=Pregnant Women; 18=Age 18 - 24; OT= Other- please describe
HWTF PRIORITY POPULATION GRANTS:
SCHOOL AND COMMiJNITIES GRANTEES
2006-2007 ANNUAL ACTION PLAN
I. IMPLEMENTATION STRATEGIES
What key activities and events will you and your
partners' implement to achieve policy change? J. TARGET AUDIENCE
Who will be directly impacted
by this activity? (If there are
intended indirect impacts,
rovide a rationale.
la. Work with CHCCS and OCS districts to la. Students, staff and
enhance the enforcement of their 100% TFS visitors in CHCCS and
policies by implementing the ATS and NOT OCS districts.
programs.
2a. Work with CHCCS and OCS districts to 2a. Students, staff and
enhance the enforcement of their 100% TFS visitors in CHCCS and
policies by communicating the 100% TFS OCS districts.
policy to all students, staff and visitors.
K. IMPLEMENTATION ROLES
What partners & resources are
needed? This includes "material"
resources as well as local and state
artners and service roviders.
1 a. Program Manager will work
with OCS and CHCCS health
coordinators to maintain2 trained
facilitators at each middle and
high school. Health coordinators
will maintain a record of trained
ATS/NOT facilitators.
2a. Program Manager will
purchase signs from TPCB
vendors and distribute with a
letter from the principal regarding
their proper display. Health
coordinators will follow up with
principals if barriers aze detected.
School athletic directors will
make announcements at sports
events reminding the audience of
the school's 100% TFS policy.
L. YOUTH LEADERSHIP M. TIME
How will youth play an active LINE
role in the planning, Start Date -
implementation and/or End Date -
evaluation of the strate ?
1 a. Students will serve as 1 a. 7/06 -
facilitators or recommend an 6/09
adult to serve in this capacity.
2a. Students can assist with 2a. 9/06 -
the development of the 6/09
announcements at sports
events.
Note: Maximum two pages per focus area * Population codes: AA =African American; AI=American Indian; AS= Asian; BC= Blue Collar; GL= Gay/Lesbian; HI =Hispanic; LL= Low Literacy
LS= Low SES; PW=Pregnant Women; 18=Age 18 - 24; OT= Other- please describe
HWTF PRIORITY POPULATION GRANTS:
SCHOOL AND COMMU1~iITIES GRANTEES
2006-2007 ANNUAL ACTION PLAN
3a. All adult school-based personnel will be 3a. Students and adult 3a. Smoke-free adult personnel 3a. Students can select and 3a. 9/06 -
aware of local cessation services and school-based personnel will serve as role models for post cessation resources in 6/09
resources such as quitlines and web-based students and potentially for adult teacher/staff break rooms and
services. Smoke-free adult personnel will personnel who are smokers. mailboxes. If student
strengthen the OCS and CHCCS districts' Smoke-free adult personnel may distribution of materials is
100% TFS policies by acting as smoke-free need to assist with posting restricted, students may
role models for the students. cessation resources. deliver the materials to the
appropriate party for
distribution.
Note: Maximum two pages per focus area * Population codes: AA =African American; AI= American Indian; AS= Asian; BC= Blue Collar; GL= Gay/Lesbisn; HI =Hispanic; LL= Low Literacy ~ ` $
LS= Low SFS; PW=Pregnant Women; 18=Age 18 - 24; OT= Other- please describe
HWTF PRIORITY POPULATION GRANTS:
SCHOOL AND COMMUNITIES GRANTEES
2006-2007 ANNUAL ACTION PLAN
A. Grantee ORANGE COUNTY HEALTH DEPT.
B. Contact Person Nikie Sarris, MPH
C. Program Goal: ADMINISTRATIVE
D. Overall Objective:
E. Focus Area: Otber monthly administrative measures
F. Please provide data on 2005-2006 total to date and 2006-2007 targets on each policy outcome indicator. For Progress toward
k
G. If an indicator also involves an effort designed to meet the culturally
specific needs of an identified population to reduce health disparities, fill
policy outcome indicators, please provide data on 2005-2006 total to date and 2006-2007 projections. If on
you do not plan to wor in the code of each identified population. Provide a target for the
an indicator enter Os for the target data.
Total-to-date Projections identified population AUDIENCE(S).
Process Indicators
2005-2006 2006 -2007 Identified TargetlProjection
1. # of training sessions/events attended by staff or partners Process Indicators Population* 2006-2007
2. # of contacts meetings with elected state/local government leaders 1
3. # of contacts meetings with non-elected, but intluential rnmmunity leaders 2
3
4. # of new partnerships formed to advance a tobacrn prevention initiative 4
5. # o[TRU/HWTF-sponsored events attended by youth at school or in the rnmmunity 5
H. Estimated Cost : Contracted Staff: $0 Supplies: $300 Promotional Materials: $1,000 Communications/Mailiogs: $50 Media: $0 Travel: $1,800 Meeting expenses: $5,000
I. IMPLEMENTATION STRATEGIES J. TARGET AUDIENCE K. IMPLEMENTATION ROLES L. YOUTH LEADERSHIP M. TIME
What key activities and events will you and your Who will be directly impacted What partners & resources are How will youth play an active LINE
partners' implement to achieve policy change? by this activity? (If there are needed? This includes "material" role in the planning, Start Date -
intended indirect impacts, resources as well as local and state implementation and/or End Date -
rovide arationale. artners and service roviders. evaluation of the strate ?
la. Will regularly post and download la. Fellow grantees and la. Program Manager and la. Drive traffic to la. 7/06 -
h
lt
h/
d TRU website
artners needin www tobaccorealitytu~filtered.co 6/07
materials as needed and as requested (via o are
s w
a
u
yout g
p
listserv) by fellow grantees. Peer educators exposed to TRU publicity. downloads or submitting m
will promote TRU website. competition entries.
2a. 8/06 -
2a. Lead creative effort to plan 6/07
2a. Will host 1 TRU-sponsored event in each 2a. Students activity. Execute or facilitate
school district. This event will be both 2a. Peer educators with execution of activity.
educational and promotional. assistance from Program
Manager. TRU gear and
campaign resources.
8/06 -
3a
3a. Will continue to distribute TRU gear at all 3a. Attendees at school and 3a. Distribution of gear. .
school and community events where peer community events 3a. Program Manager purchases 6/07
educators are present. gear and peer educators distribute
gear.
Note: Maximum two pages per focus area *Population codes: AA =African American; AI= American Indian; AS= Asian; BC= Blue Collar; GL= Gay/Lesbian; HI =Hispanic; LL= Low Literacy
LS= Low SES; PW=Pregnant Women; 18=Age 18 - 24; OT= Other- please describe
HWTF PRIORITY POPULATION GRANTS:
SCHOOL AND COMMUNITIES GRANTEES
2006-2007 ANNUAL ACTION PLAN
4a. Will host first ever Tobacco 201 and 4a. Peer educators 4a. Project Manager will schedule 4a. Peer educators will be 4a. 8/06
accelerated Tobacco 101 for new and (students) training and provide lunch. participants and active
returning peer educators. learners in training sessions.
Sa. Program Manager will
Sa. Will organize a retreat to provide Sa. Peer educators reserve space, purchase meals, Sa. Peer educators will Sa. 8/06
educational training and team-building and recruit guest speaker(s). request topics to be discussed
activities to peer educators. at retreat and will participate
in learning and team-building
activities.
6a. Program Manager will call in
6a. Will attend regular HWTF conference 6a. Program Manager and participate in HWTF 6a. None 6a. 7/06-
calls. conference calls. 06/07
7a. Program Manager will learn
7a. Will attend scheduled local, state and 7a. Program Manager and about information and strategies 7a. Peer educators will attend 7a. 7/06-
regional trainings including QuitNow, HWTF, schooUcommunity sponsors critical for student advocacy. events with a youth focus. 6/07
TPCB, ?Y and UNC-SPH sponsored events.
8a. Program Manager, school
8a. Will keep local leaders informed of 8a. Program Manager, health coordinators and 8a. Peer educators will 8a. 7/06 -
programmatic progress and successes. Will school health coordinators, community supporters will build represent the program 6/07
approach leaders as needed for support on peer educators and relationships with OC Senator, whenever possible to engage
focus area-related issues. community supporters will Reps., Board of Ed., Board of leaders in constructive
be involved as needed. Health, and Board of County dialogue and receive support
Commissioners. when needed.
9a. Program Manager, school
9a. Will pursue and accept partnerships with 9a. Program Manager, health coordinators, health 9a. Peer educators will 9a. 7/06-
partners who will enhance programmatic school health coordinators, promotion division director and identify and pursue youth- 6/07.
activities in designated focus areas. Particular health promotion division peer educators will identify and oriented partners.
attention will be given to youth-serving director and peer educators. pursue partners.
organizations, special population
organizations, and organizations with
ex ertise in a 'ven focus area.
Note: Maximum two pages per focus area * Population codes: AA = African American; AI=American Indian; AS= Asian; BC= Blue Collar; GL= Gay/Lesbian; HI =Hispanic; LL=Low Literacy 10
LS= Low SES; PW=Pregnant Women; 18= Age 18 - 24; OT= Other- please describe
. •
ATTACHMENT B -APPROVALS
B-1-APPROVED PROJECT BUDGET
B-2 -GRANT CYCLE APPROVAZ LETTER
26
f.
SAMPLE
ATTACHMENT B-1
APPROVED PROJECT BUDGET
Health and WellnessTrust Fund Commission
Approved Project Budget
Applicant Agency:
Contact Person for l3udget: ~w'rl=c
Contact Phone: Approved:
FBX: Effective date'
e-mail: Comments
Federal Tax LD. or 501(c)(3):
1. Year 1 startin on or about 7/1/2006 and endin 6/30/2007
2. Year 2 startin on or about 7!7/2007 and endin 6/30/2008
3. Year 3 startin on or about 7/12008 and endin 6/30/2009
7/1/2006-6/302007 7/1/2007-6/30/2008 7!12008-6/302009 Project Total
Cat Proposer`!
cunt
ir>d Propnsed
a aunt-
!n•K~d Proposed
amount
In-Kind Proposed.
mount
In-Kand
Direct Ex nses
Sala /Wa es/Benefits $0 $0
Contracted Staff $0 $0
Other Cla ' in narrative $0 $0
Subtotal: $0 $0 $0 $0 $0 $0 $0 $0
Other Than Personnel
Su ont OTPS
Su lieslMaterial $0 $0
Communication Costs
tele hone, osfa e, fiei hf
$0
$0
Occupancy Costs (rent,
utilities, re airs, mainfenance
$0
$0
Capital Outlay (furniture,
equipment, data processing
equip with unit costs of at
least 5500
0
0
Other Cta ' in narrative $0 $0
Subtotal $0 $0 $0 $0 $0 $0 $0 $0
Media
Advertising and Promotion
(Paid Media Placement and
Production Costs
$0
$0
Subtotal $0 $0 $0 $0 $0 $D $0 $0
Travel Ex nses
Travel (mileage,
transportation, meals, hotels)
$0
$0
Meetings $0 $0
Other Cla ' in non-ative $0 $0
Subtotal $0 $0 $0 $0 $0 $0 $0 $0
Approved Carry Forward
(HWTFC use onl)
~0
Total Direct F~c enses $0 $0 $0 $0 $0 $0 $0 $0
Indirect Costs $0 $0
Total Request $0 $0 $0 $0 $0 $0 $0 $0
NOTES: (HWTFC use only)
27
SAMPLE
Narne of Grantee:: Grant ID
Type 4f Grant: Grant Amount
Grant Cycle:
Effective Date:
'' Termination Date'z
ATTACHMENT B-2
GRANT CYCLE APPROVAL LETTER
Based upon your satisfactory performance and funding availability, you have been approved for
an additional Grant Cycle. The Approved Project Budget for the additional Grant Cycle is
enclosed and should be appended to your contract. Payments for this additional Grant Cycle
shall be made pursuant to the following Commission policy:
"At no time may a Grantee have on-hand an unspent balance that exceeds the initial
payment authorized by the grant agreement between the Grantee and the Commission.
Commission staff may withhold or reduce monthly payments to a Grantee until an on-
hand unspent balance is reduced to the established limit or depleted."
On-hand balances will be calculated by subtracting reported approved expenditures from the
grand total of payments made. Future payments remain contingent upon satisfactory performance
of the approved program of work and timely submission of all financial and programmatic
reports.
Grantees may elect to use any unspent balance from previous grant terms in accordance with the
Commission's "Carry Forward Procedures for Grantees". Carry-forward requests must be
submitted to Commission staff bathe Grantee as a Bud eg t Adjustment ReQUest within 45 days
after the end of the term in which the carry-forward was generated.
NORTH CAROLINA HEALTH AND
WELLNESS TRUST FUND COMMISSION
Lieutenant Governor Beverly E. Perdue
Chair
Date
28
Name of Grantees Orange County Health Department Grant ID56-6000327
Type of Grant: Community and School
ATTACHMENT C
AREA OF SERVICE
Indicate the county(ies) in which you will be providing services:
^ALAMANCE OFRANKLIN ^PAMLICO
ALEXANDER ^GASTON ^PASQUOTANK
^ALLEGHANY OGATES OPENDER
^ANSON ^GRAHAM ~PERQUIMANS
^ASHE ^GRANVILLE ^PERSON
^AVERY ^GREENE PITT
^BEAUFORT ^GUILFORD OPOLK
^BERTIE ^HALIFAX ORANDOLPH
~BLADEN ~HARNETT ^RICHMOND
~BRUNS WICK ~HAYWOOD ^ROBESON
^BUNCOMBE ^HENDERSON ^ROCKINGHAM
~BURKE HERTFORD ^ROWAN
~CABARRUS ^HOKE ^RUTHERFORD
^CALDWELL ^HYDE ^SAMPSON
^CAMDEN ^1REDELL ^SCOTLAND
^CARTERET ^JACKSON ^STANLY
^CASWELL ^JOHNSTON ^STOKES
^CATAWBA
~ ONES
WR
.R
^CHATHAM ^S
A
~
^CHEROKEE ^LENOIR ^TRANSYLVANIA
^CHOWAN LINCOLN ^TYRRELL
^CLAY OMCDOWELL BUNION
^CLEVELAND ^MACON OVANCE
^COLUMBUS ^MADISON ^WAKE
^CRAVEN ^MARTIN ^WARREN
^CUMBERLAND ^MECKLENBURG ^ WASHINGTON
^CURRITUCK []MITCHELL ^WATAUGA
^DARE ^MONTGOMERY ^WAYNE
^DAVIDSON ^MOORE ^WILKES
~DAVIE GNASH ^ WILSON
^DUPLIN ANEW HANOVER ~YADKIN
^DURHAM NORTHAMPTON ^YANCEY
^EDGECOMBE ^ONSLOW
^FORSYTH ®ORANGE
29
c
SAMPLE
ATTACHMENT D
AGREEMENT AND CERTIFICATION
Authorized officials of the organization MUST complete and sign the following statements.
Certification: This grant application has been approved by the lead applicant organization's governing body.
Certification: The lead applicant is either (select only one):
^ (1) anon-profit corporation which has as a significant purpose promoting the public's health,
or
® (2) a State or local government agency.
Certification: This organization has no conflicts of interest as defined by the policy below.
To avoid any real conflict of interest or perceived conflict of interest between the Health and Wellness Trust
Fund Commission grant recipients and tobacco manufacturing and related entities, grant recipients must not
currently accept any grants or anything of value from any tobacco manufacturer, distributor, or other tobacco-
related entities. The only exception is when these grant funds or items of value are totally for NON-tobacco
related purposes and do not present any danger of promotion of or use of tobacco products or otherwise
conflict with policies and programs known to prevent and reduce teen tobacco use.
Agreement: All sub-recipients (includes partners, collaborators and other contractors) under the grant will be
identified on an ongoing basis.
Agreement: All accounts, books, ledgers and records for the grant project can be audited/reviewed by the
Commission, Commission staff, an outside auditor hired by the Commission and the State auditor.
Agreement: The Commission or Commission staff may make site visits at the Commission's convenience.
Agreement: Applicant will provide computer with minimal capabilities listed in the Application to provide
data, facilitate communication, and support of the management team.
Applicant Organization Fiscal Year (Month/Day through Month/Day):
Julyl, 2006 through June 30, 2007
CERTIFICATION: The information provided in this material is correct and complete. (Note: Must be
signed by the chair of the Board of Directors or head of lead applicant organization.)
Applicant
Signature:
Title:
Date:
Organization's Federal Employer Identification Number: 56-6000327
30
f
ATTACHMENT E -FINANCIAL REPORT FORMATS
E-1- MONTHLY EXPENSE REPORT
E-2 -ANNUAL CERTIFICATION OF ACCOUNT BALANCE
31
SANfPLE
ATTACHMENT E-1
MONTHLY EXPENSE REPORT
Health and WellnessTrust Fund Commission
Monthly Expense Report
AstencY:
Contact Person for Expenses: rivyTFC iJse ~Jnty ;
Contact Phone: Appm~ed;
Fax: Date
e-mail commems
Federal Tax LD. or 501(c)(3):
1. Year 7 starting on orabout 7H/2004 and ending 6/30/2005
2. Year 2 starting on or about 7/7/2005 ahd ending 8/30/2006
AR ONE n t `. .Jul '. Au T S tember -Dctober ven ber December Jenua Feb rue March. nl fd June Year-To-Oate
•ect Ex enses•
la /Wa esBenefits $0.00
ntracted Staff $0.00
ier Please cla ' below $0.00
btotal• $0.00 SD.OD 50.00 50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 gn on
ner Than Personnel
ort OTPS
IiesRUlaterial $0.00
mmunication Costs
le hone, sta e, fiei ht
$0.00
cupancy Costs (rent,
ifies, repairs,
iintenance
$0.00
~dia (Advertising and
emotions
$0.00
pital Outlay (furniture,
~i menf data rocessin
$0.00
ier Please clan below $0.00
btotal $0.00 $0.00 $0.00 $0.00 50.00 50.00 50.00 50.00 50.00 50.00 $0.00 $0.00 $0.00 $0.00
rvel Ex enses
rvel (mileage,
ns Ration, meals, hotels
$0.00
~etin enses $0.00
ier Please clan below $0.00
btotal $0.00 $O.DO $0.00 80.00 $0.00 SO.DO $0.00 50.00 $0:00 50.00 $0.00 $0.00 $0.00 $0.00
tal Direct Ex enses 50.00 50.00 $D.DD 50.00 $0.00 50.00 $0.00 $0.00 $O.OD 50.00 $0.00 $D.OD $D.00 SO.Du
lirect Costs (onty if
erred ustified
$0.00
tal RecLuest $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
32
i
SAMPLE
ATTACHMENT E-2
ANNUAL CERTIFICATION OF ACCOUNT BALANCE
ORGANIZATION NAME
ORGANIZATION FEDERAL ID NUMBER
The Grant Agreement(s) between the organization listed above and the North
Carolina Health and Wellness Trust Fund (HWTF) Section IV Grantee's Obligations,
paragraph H, subparagraph 6, stipulates the following:
Segregated Accounts -Grantee shall place all sums not immediately. spent in a
segregated, interest bearing account that is fully insured for the maximum amount of
money that will be placed in the account. Grantee agrees that any interest accrued on
these sums along with any unspent funds remaining in the account shall belong to the
Commission at the conclusion of the Project.
The undersigned hereby certifies that the ending balance of the segregated interest bearing account{s)
established pursuant to Section IV Grantee's Obligations, paragraph H, subparagraph 6, of the
Grant Agreement, the monthly/quarterly statement provided by NAME OF FINANCIAL
INSTITUTION WHERE HWTF FUNDS ARE DEPOSITED dated DATE OF FINANCIAL
STATEMENT, is ENDING BALANCE FROM FINANCIAL STATEMENT.
SIGNATORY'S NAME
SIGNATORY'S TITLE
DATE SIGNED
33
A
ATTACHMENT F
GUIDELINES FOR USING HWTFC LOGO & NAME
The HWTFC logo and name are important parts of your written, visual, and verbal
communications with your target group. They are also crucial elements when
communicating with the larger community, the region, governmental organizations, and mass
media. It is critical that the public recognizes HWTFC as the funding source for the good
work you are doing in your communities. The logo, both graphic image and text, are strong
visual cues to the public that: a) build awarenessthatthis is astate-wide initiative, b) create
name familiarity for HWTFC, and c) allow public and legislators to see where and how
Commission dollars are being used. Verbally employing the name "North Carolina Health
and Wellness Trust Fund Commission" during press interviews, at public events, and in
meetings ensures that other writers, especially the press, will incorporate the name in their
publications.
LOgO
The HWTFC logo cannot be altered with the exception of being reproduced in
black/white/and grey tones on a black and white document. Otherwise, the text, font, colors,
and graphic image must be used as provided by the HWTFC. Do not divide the text portion
of the logo from the graphic portion. The logo can be enlarged or reduced, but proportions
should remain in tact.
Required Placement of Logo
Place the HWTFC logo on the front lower corner ofone-sided printed materials and on the
back lower corner of two-sided printed material.
Required Use of Logo
The logo must be used on all publications that are being used specifically for work being
funded by HWTFC. This applies especially to media developed with Commission dollars. It
also applies to existing materials that grantees use for this grant project. Add the HWTFC
logo when reprinting/reproducing materials.
Ezamnles of Media Required to Show the Logo include, but are not limited to:
Posters, pamphlets, brochures, handouts, flyers and other announcements, invitations, videos,
presentations, and published reports.
Encouraged Use of Logo
Press releases, event banners, giveaways (e.g., pedometers, pencils, pads, t-shirts), and
letterhead for your HWTFC-funded project.
Discouraged Use of Logo
The HWTFC logo should not be used in any way that implies that any member of your
organization is an employee of the HWTFC. Business cards, for example, are not an
appropriate use for the logo unless they are formatted in a way that clearly portrays HWTFC
as the funding source rather than the employer. Project letterhead should likewise name
HWTFC as the funding source.
34
r
ATTACHMENT G
PROGRAM SPECIFIC REPORTS
35
Y
~~
Orange County TRU/Tobacco.Reality.Unfiftered
Results of Past Programming:
Major Policy Accomplishments and Key Achievements -
12 Schools adopt ATS and NOT policies
24 school-based personnel trained to implement new ATS/NOT policies
4 new schools promote 100% TFS through signage
1 restaurant adopts 100% smoke-free policy
1 bowling alley adopted improved smoke-free policy
Over 200 restaurant patron surveys conducted and 4 smoke-free business
presentations given to restaurant/bowling alley managers or owners
1 permanent high school club established
2 permanent district TRU peer educator groups established (40 trained peer
educators)
Over 700 middle school youth reached through Tobacco 101 presentations
Over 1,000 youth reached through community outreach events
Media Involvement -
6 TRU advertisements placed in school papers regarding cost of tobacco use
6 articles written by TRU peer educators
3 articles written by program staff
2 articles written by program supporters
8 articles written by newspaper staff on program
Program featured on two radio programs
Program featured on two state-wide TV programs
100s of NOT recruitment posters placed in schools
1,OOOs of TRU promotional items distributed
Intern Professional Development:
1 intern from UNC-CH School of Public Health for summer 2004
1 intern from NCCU Dept. of Health Educ. for Winter-Spring 2005
The program has effectively collaborated with a number of current HWTF
grantees on various training and educational outreach events. Those
collaborative partners include: Question Why Central Region, Old North State
Medical Society, Durham County Health Department, North Carolina Amateur
Sports Association, UNC-CH School of Public Health, Office of Minority
Health/State Baptist Convention, Ruiz Agency, and the Community. Backyard of
Orange and Chatham Counties
The program enjoys strong relationships with elected OC representatives in the
NC General Assembly, at the county level, and an active relationship with the
OCHD Board of Health.
v
.~