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Agenda - 06-13-2006-5l
ORANGE COUNTY BOARD OF COMMISSIONERS ACTION AGENDA ITEM ABSTRACT Meeting Date: June 13, 2006 Action Agenda Item No. 5" I SUBJECT: Community and Schools Phase III Tobacco Use Prevention and Cessation Initiative Grant Acceptance DEPARTMENT: Health ATTACHMENT(S): Past Program Accomplishments Health and Wellness Trust Fund Commission Grant Agreement (under separate cover) PUBLIC HEARING: (Y/N) No INFORMATION CONTACT: Rosemary L. Summers, 245-2411 PURPOSE: To consider accepting Phase III fiands from the Health and Wellness Trust Fund Commission in the amount of $289,000 far the continuation of the Youth Tobacco Prevention Initiative known as Orange County TRU/ Tobacco.. Reality, Unfiltered. BACKGROUND: The Orange County Health Department (OCHD), in partnership with Orange County school districts, received a grant from the NC Health and Wellness Trust in 2003 for a three year period (2003-2006) to establish a teen tobacco prevention program in both school districts, The Health Department was notified earlier this spring that the reapplication for an additional three year period was funded by the Trust to begin July 1, 2006, The continuation proposal is to 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. The Chapel Hill-Carrboro City Schools (CHCCS) and Orange County Schools (OGS) are active and committed partners. The School Health Coordinators from each school system will continue to act as liaisons. 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% tobacco free school 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 2001 Youth Risk Behavioral Survey (YRBS) 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 rase 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 bath districts, YRBS data also show that 9-17% mare 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 indicates a need for continued 100% tobacco free school policy enforcement through implementation of cessation programs and increased awareness of cessation resources„ The OCHD program is innovative in its ability to develop a comprehensive, best practice-guided program 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 develops extensive culturally diverse youth groups that became change agents in developing a tobacco-free Harm 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 YRBS 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, See Past Accomplishments attachment for project outcomes from the 2003-2006 period. See Annual Action Plan for specific goals, objectives and strategies included in the grant agreement. FINANCIAL IMPACT: The grant amount for the continuation period from July 1, 2006 through June 30, 2009 is $289,000. The one year allocation for 2006-2007 is $96,887, The 2006-2007 allocation covers the continuing salary and benefits for the Senior Public Health Educator/Project Manager that was established as a permanent full-time position when the initial grant was secured in 2003, That position was subject to funds being available to continue the position. The grant also includes operational expenses for the initiative. In addition, the grant includes funds for school signage and media presentation equipment. The financial impact to 3 the county is limited to the provision of in-kind contributions by the County, which includes office space and supervisory time. The full project budget is included in the Health and Wellness Trust Fund Commission Grant Contract. RECOMMENDATION(S): The Manager recommends that the Board approve receipt of the Phase III grant funds and authorize the Board Chair to sign the grant agreement with the North Carolina Health Wellness Trust Fund Commission. ~" Orange County TRU/Tobacco.Reality.Unfiltered 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 1 QO% smoke-free policy 1 bawling 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. 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 h Contract Performance Period Extension I. 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. Outcorne 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 I. 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 I, Insurance and Indemnity Section IV Grantee's Obligations A. Performance Obligations 1 Scope of Project 2 Action Plan 5 3. Satisfactory Performance 4, Cooperation a. To Work and Cooperate b. To Notify a 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 Bala~rces 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 I . 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 L 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 a Assure adequate contto] of signature stamps, plates; d. Assure adequate control of negotiable instruments; e. Implement procedures f Assure adherence E. Media, Publicity and Publications 1. 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. 7 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 Fully Operational All Hardware and Software 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 Oblieations A. Grant Funding 1. Grant Cycles 2, Capital Expenditures 3. Method of Payment a. Straight Reimbursement b. Initial Payment 4, Cazry-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 Pazty Benefieiazy 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 Witl Be Conducted in a Professional, Orderly Process 3. All Records Will Be Maintained and All Reports Will Be Made Section VIII Liabilities and Losses 8 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 9 Name of Grantee: Dranee county Health Department Grant H): Type of Grant; `TEEN PIiIII Grant Amount $289,000 Grant Cycle: Initial Effective Date: July 1, 2006 Termination 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 Cazolina'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" arrd 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-I. 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 Aiachments A through G which are attached to this Agreement and incorporated herein by reference as a substarrtive part ofthis 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 ofthe 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.. is 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.-1 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-state agencies) 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 (GE.DP}-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-1, Commission Approved Amendments to the Grantee's Grant Application in Attachment A-2, Minimum Requirements in Attachment A-3, and Action Ptan 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 6e 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 includingthe 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. 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) months, (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 if funding 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. Grganizational Form -The information set forth in Attachment D, entitled Agreement and Certif cation, 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 ofNorth Carolina. D. Use ofFunds -Grantee shall use all funds awazded under this Grant exclusively to support the Project and shall spend the funds in accordance to Attachment B-1, the Approved Project Budget, 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.. is 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- Grazrtee 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.osbmstate.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 goods or services from any for-profit entities with whom Grantee has a formal or informal relationship. P. 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 chazrges in the organization's status, staff make-up or shucture. G. Binding Obligation-ThisAgreementconstitutesabindingobligationofGrantee,enforceableagainst 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 notviolate 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 aze 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.. I. 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: Scope of Project -Grantee shall in a timely and professional manner develop, perform and complete all the work set out in Attachments A, A-I, A-2, A-3 and A-4 The work shall be performed in the Area of Service designated in Attachment C. i3 Action Plan -During each C,rant 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 tine 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 I-IWTFC(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-level 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 aze 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 IV (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 Plan for each Grant Cycle is due on or before the date specified by the Commission staff. i~- b. Monthly Expense and Project Evaluation Reports -After the Effective Date of the Agreement, these Reports are due on or before the twentieth (20°i) day of each month for the prior month. c, Six (6) Month Progress Reports -After the Effective Date ofthe 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 wilt conduct periodic site visits and telephone interviews. h Program Specific Reports -Those Reports set forth on Attachment G that are 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. (I) Non-Governmental Entities -Non-Governmental Entities are 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) Years Following Termination Date - For a period of five (5) years 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 awazds, 10 15 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 Endings have been resolved. b. Records If Grantee Dissolves - In the event the Grantee dissolves or otherwise goes out of existence before the end ofthe Grant, or within five (5) yeazs 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 ofthis 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, pariner or sub- 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 ofthis Agreement through a subcontract with the grantee. Grantee Responsibility- Grantee is responsible forthe performance ofany 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 toN.G General Statute § 143- 6,2. 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; 11 ~~ 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 ]rwtfc(cilncmail.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,,firrdirtg, conclrrsiou or recomn:eadation,r expressed in this publication are tl:ore of the author(s) aced do not necessarily reflect flee view and policies of'the North Carolina Health aced Wellness Trust Fured Conunisriar:. 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 of the Project at least five (5) working days before the published materials aze 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 trademazk 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 Property The Grantee agrees to the following: 12 i~ 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 of the Commission proportionate to the percentage of HWTFC funding used towards 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 aze 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; the Grant funds designated in the Approved Project Budget (Attachment B-I) 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. 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 i~ a, Straight Reimbursement -Grantees who elect not to receive initial payment as described in IV (H) (3) (b) and/or elect not to establish segregated accounts as described in N (I-I) (6) shall be reimbursed by the amount submitted on approved monthly expense reports (Attachment E- I)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 Cary 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 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 teen or the balance of the grant award, whichever is less. Carry-forward may be spent during any subsequent term of the Project subject to prior approval by Commission staff. Any cazry-forward request shalt 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). 6. Segregated Accounts -Should the Grantee be designated as anon-governmental entity in Attachment D, the Grantee shall place all sums not immediately spent in a separate, segregated, interest beazing account that is fully insured for the maximum amount of money that will be placed in the account. The Grantee agrees that any interest accrued on these sums along wiUr 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, Ure Grantee shall place all sums not immediately spent in a restricted grant line item that can not be used for any purpose other than the Project. 7. Repayment Obligation - In the event the Grantee breaches any of the material teens or conditions of this Agreement, the Project may be terminated and the Grantee agrees to repay within thirty (30) days ofthe Termination Date to the Commission the full amount ofsums awarded underthis 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-I) 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 ofthe 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 elechonic 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 irr N (F~ (3) (b) and/or elect not to establish segregated accounts as described in N (FI) (6) shall be reimbursed by the amount submitted on approved monthly expense reports (Attachment E- I) wit(rout any initial payment. b. Initial Payment- As soon after the Effective Date as the Grantee provides an invoice for stazt- 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, Cazry-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.. Cazry, -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 award, 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 method will be specified in the Grant Cycle Approval Letter (Attachment B-2), 1~ 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 staff will 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 Pazty 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 ofthis 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 16 ai In the event oftennination as set forth in Section VII (A), (B), or (C), the Commission shall have no respmrsibility to make additional payments under this Agreement aRer 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 all 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.. All records will be maintained and all Reports will be made in accordance with the terms of this Agreement and any applicable laws. Section 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 L 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 rnay: 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 Project 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 furnishing 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 aze Grantees agree to indemnify, defend and save harmless the Commission, its officers, agents and employees to the extent allowed by law. 17 as 3. All Grantees represent and wazrant 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, .Tim 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 27604-1 1 1 9 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: lrwtfc@ncm ai 1. net If to the Grantee: Name Title Agency Addressl Addressl Address3 TeL• Fax: Email: 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 Cormission 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 ofthe State of North Carolina. The place of this Agreement, its situs and forum, shall be Wake County, North Cazolina, where all matters, whether sounding in contract or tort, relating to its validity, construction, and interpretation shall be determined. 18 a3 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 ofthis Agreement and to abide by the Grant Program and Project policies with respect to the delivery of its Performance Obligations. B. Conflict of Interest -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 ofthe 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 ofthis contract, required by N.C. General Statute § 14.3-6.2. 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 govenrments 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 oftheFunds-Grantee will expend funds consistent with the terms and conditions of this Agreement, G. Nom 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 ofthis 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-I, A-2, A-3, A-4, B, B-I, B-2, C, D, E, E-1, E-2, F and G are attached to this Agreement and incorporated herein as a substantive part of this 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 aq-~ A. Tlris 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 Rosemary L. Summers, Dr.PH Health Director 20 as ATTACHMENT A -PERFORMANCE OBLIGATIONS A-i -GRANT APPLICATION A-2 -COMMISSION APPROVED AMENDMENTS A-3 -MINIMUM REQUIREMENTS A-4 -ACTION PLAN 21 a~ ATTACHMENT A-I GRANT APPLICATION 22 a7 Health and Wellliess Trust Fulid Commission Application for Teen Tobacco Use Prevention and Cessation Initiative: Community/School Prevention Program or Special Project Grant Instructions to Applicants Only one proposal from each applicant organization wilt be accepted. All applicants must submit a complete written application by the deadline identif ed in the Timeline section of the RFP 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.ore). 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(a~ncrnail.net by 5:00 PM, Mareh 29, 2005. The title of the email and all attached documents must start with the lead applicant organization's Federal II) number and name (e,g. 12.3454321 Wright Hospital.doc). It is recorrunended 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 aze 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 attaclunent at hwtfe(a~ncmail.net by 5:00 PM, March 29, 2005. The Additional Materials listed in Part IV are mandatory and must be sent by mail or delivery service in one package, postmazked by March 29, 2005. a~ Part I -Standard HWTFC Grant Application Applicant Oraanization(sl Lead Applicant Organization/Fiscal Agent Orgazrization 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 Rosemazy Summers MPH, DrPH www.co.orange. nc.us/health 56-6000327 Grant Applicant and Grant Administrator Application prepazed by Matt Streng, MPH Title Youth Tobacco-Use Program Manager Phone Fax Email address Grant Administrator* Title Phone Fax Email address 919-245-2424 919-644-3007 mstreng@co.orange.nc.us Letitia Burns Business Officer - OCHD 919-245-2410 9I9-644-3007 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 rnore than one programmatic category should select die one project type category below that is most r°epresentative of their overall project. ® Community/School Project ^ Special Project ^ Priority Population Project Total Budget Request: $ $289,130.00 a~ How did you leazn 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 population(s) 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, in partnership with Orange County school districts, will strengthen current progranuning 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 denomralize tobacco use in schools. The program will er>Irance 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-Applicant /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 Cazrboro 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 depaztment, 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 canpaign will be mazraged by the OCHD. 30 Specific Areas of Service If you AR7'; 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 ^ALEXANDER ^ALLEGHANY ^ANSON ^ASHE ^AVERY ^BEAUFORT I-IBERTIE UCATAWBA ^CHAZHAM ^CHEROKEE ^CHOWAN I-1CLAY VEN VIDSON VIE iATES iRAHAM `xRANVILL] iREENE iUILFORD IALIFAX IARNETT iAYWOOD iENDERSO IERTFORD iOKE IYDE REDELL ACKSON 'HANOVER THAMPTON ^ROBESON ^ROCKINGHAM I-1ROWAN TANLY TOKES AIN ~JTRANSYLVANIA ^TYRRELL ^UNION ^VANCE ^WAKE ^WARREN ^WASHINGTON ^WATAUGA ^WAYNE ^WILKES ^WILSON ^YADKIN ^YANCEY 4 ~~ i Free Text Section In the space below, provide any information, comments, or clarifying points supporting this Application. These may include points of organizational chuzge, 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 3a 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 azea. • Teen Demograplrics: 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 azea. • 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 2001 YRBS 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 200.3 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 tluough implementation of cessation programs (NOT) and increased awareness of cessation resources. Currently, 41 high school peer educators aze actively involved in the program. Peer educators give Tobacco 101 presentations in the middle schools, conduct prevention activities in the high schools and conununity, 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 tluough 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 33 Peer educators receive a nominal stipend upon completing 20hrs. of training and are provided other non-monetary incentives tluoughout 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 progrars, one self-sufficient high school T.R.il. 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 poptlations 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. Proposed 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 Relevuit, 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 imiovation 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 Prograrn Implementation for the entire grant period • Sustainability Plan for Program Continuation Past .Tune 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 imrovative in its ability to develop a comprehensive, best practice- guided program around a diverse group of actively involved youth peer educators. The program's peer educators are integral participazits 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 3q- 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 tlu~ough 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 200.3/2005 YRBS 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 YIZBS 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 parental/guardian 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 yeaz and smruner. Timeline: Peer educators will be recnuited tluoughout the school year and trained twice a year during the grant period, Goa12: 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. 101 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 mazlceting 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 nouns campaign in OCS and CHCCS middle and high schools.. 8 35 Local Objective 1: By .June 2009, 4S% 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 Alarnance 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 azi unattractive behavior. 1/mphasis will be placed on smokers being in the minority and challenge pro tobacco youth norms currently accepted by students. ICey messages will be diffused via school-based media and distribution of promotional materials. Timeline: Stazting during the 2005-2006 school year 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 year and continue each semester during the grazrt period. Local Oljective 2: By .Tune 2009, 1 S mini-grants will have been awazded to OCS and CHCCS middle and high school groups to develop educational projects and projects that supplement the social nouns canpaign, This will be measured by final prgject summaries 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 $S00 to cagy out a special project. A review boazd 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 mire-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 preparation 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 year and Smini-grants will be awarded aznong 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 persomlel require training the coordinator will azrange for their participation in an ALA run ATS/NOT training. At the end of each school year 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 grazrt period.. ~~ 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 tlu'ough 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 pazties will convene at the end of each semester to monitor tobacco policy violations and the self- refenal 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 tluee NOT programs (1 per year) led by a trained school-based NOT facilitator. Tlis 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 progrann coordinator to increase teacher and administrator awazeness 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 daring 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, Goa12: 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 azid 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 yeaz, 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 .Imre 2009, all CHCCS azrd 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 u~7 Goal .3: 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 persomzel 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 though 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 .Tune 2009, all OCS and CHCCS elementary schools will have at minimum two "L,ove 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 parent/guardian drop-off7pick-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 Comrty 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 tluoughout grant period and indefinite beyond grant period. Local Objective 2: By .Tune 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 tluoughout grant period and indefinite beyond grant period. Local Objective .3: By .Tune 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.orazige.no,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. Tlus campaign is modeled after the successful Wake Co. stoplight campaign., Timeline: Recruitment of restaurants and media will be ongoing thoughout 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 .Tune 2009, at least 25% of peer educators will be minority students from OCS and CHCCS. Tliis 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 , urd 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 pwsued. Timeline: Ongoing throughout grant period. Local Objective 2: By .Tune 2009, peer educators will have conducted educational outreach at 12minority-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 Spurish when necessary. Timeline: School and community events have been identified and occur primarily in the fall, spring, azrd summer of each year, Attendance at these events will be ongoing tluoughout 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 3G school-based personnel, could carry on with Tob. 101 azld 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 Cormnerce. Upkeep of this dining guide is minimal and low-cost. Beyond .June, 20Q9 the program plans to sustain it's full programmatic activities by requesting that the OC County Conunissioners 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 dre 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 Accomplislunents and Key Achievements - 12 Schools adopt ATS and NOT policies 24 school-based persomnel 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 tluough community outreach events Media Involvement - 6 TRU advertisments placed in school papers regaz'ding cost of tobacco use 6 articles written by TRU peer educators 3 azticles written by program staff 2 articles written by program supporters 8 articles written by newspaper staff on program Program featur°ed on two radio programs Program featured on two state-wide TV programs 100s of NOT recruitment posters placed in schools 1,OOOs of TRt1 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 Cazolina Amateur Sports Association, UNC-CH School of Public Health, Office of Minority Health/State Baptist Convention, Ruiz Agency, azid the Community Backyard of Orazige 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. Orztanizational Ca aci (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 Grazit: 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 persomrel in other counties? • Evidence of Organizational Experience: Please describe the lead applicant organization's experience in plaming, implementing and promoting teen tobacco use prevention progruns. Briefly describe relevant training received by staff and volunteers and any training/workshops conducted by the lead applicant organization, • Paztnerships 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 canlpaigrrs including prograzns 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 azrd 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 clinhcal 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 tl>ree separate clinics and in the field. The health promotion and education division in particular is involved in bringing prevention programs to the community tlu-ough 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 ~-I Smoking Control Rules in 1993 restricting ETS in public places, wont sites and restaurants. In 1997 the Board of Health created asmoke-free committee, made up of OCHD and community representatives who wonted 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 Amnerican Lung Association cessation group facilitator. OCHD is a govenunent organization with the capacity to oversee a project such as this one with ease.. The OCHD has tluee 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 yeazs of experience managing the youth tobacco-use prevention grant. The program coordinator has received training and teclurical 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 anout-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-h tluough 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 acrd 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 cormect 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-hind 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. I5 ~-a The current program has received extensive coverage tluough print, radio, and TV media. The T.R.U. prograni was awarded a monthly column in the News of Orange County which featured azticles 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 local news chamiels during training events, and featured on NCCU's 90.7 spazush 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 intercorns and television stations. All 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 progranunatic activities and plan on expanding the scope of youth influence in the proposed plan. More than 40 peer educators meet on a bi-weeldy basis with the program coordinator to plan prevention activities, develop and schedule educational presentations, and coordinate smoke-free advocacy efforts with local establislunents. Peer educators are also responsible for training newly recruited peer educators in attain-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 UNGCH, 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 quazrtity of your proposed teen tobacco use prevention and cessation activities. A. Outcomes: Include in your response: • Description of expected outcomes of the proposed project • Defirvtion of the long term impact of the proposed project 16 43 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 hannful effects of secondhand smoke and how to prevent exposure, and pro tobacco mazketing influences and how to protect oneself from those influences. The "Love Our Lungs" campaign will help parents/guardians increase their lnowledge 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 );valuation 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 azea. The program will monitor the following school policies tluough the assistance of school health coordinators within OCS and CHCCS: 100% TFS, ATS, NOT. In pazticular, the program will conduct environmental inspections for 100% TFS signage, NOT recruitment materials, and "L,ove Our Lungs". Sporting event announcements will be monitored through atliletic director co~rmation 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 aze kept in a scrap book on file in the health department. Additionally, important correspondence with key school, community, and county leaders are kept on file in the health depaz~tment, 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. Conununication of evaluation results will be done both formally and informally with the general public and key partners. Results of evaluation will be shared tluough media for the general public. Results of evaluation will be shazed with key partners through swmnary reports and correspondence through meetings, emails, and telephone conversations. At the end of the grant period a final summazy 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 azid 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 IfNo, QAgree 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 ~~s Part III-Proposed Budget and Fiscal Information 10% of Total Score 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 fwiding,. The document title must stazt with the lead applicant organization's Federal ID number and name (e.g. 12.3454321 Wright Hospital.xls). Orgaziizations that are NOT currently receiving HWTFC funding must complete the Excel spreadsheet titled "Budget Format for NEW Grantee". Organizations that AI2E 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 chazacters) Direct Expenses: $49,257 in Salary reflects the year one salazy and fringe benefits of one full-time Senior Public Health Educator who will serve as the coordinator of the project with an annual 5% increase for merit azrd COLA included for years two and tluee. $8,800 in In-kind Salary is based on an average of 20 hours per month at $20/lu. for 10 months for school system personnel who will be involved in the implementation of the project; also for 20 lus. 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 15 project hrs. a week for 10 weeks during Tune, .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/lu. for working a least 10 lus. $140 for $.35 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 rnini-grant funds for five school-based groups/clubs to conduct special projects on tobacco-use prevention, $2,000 will provide $50 incentives for 40 youth smokers to complete the 10-session NOT program. $12,000 in year(s) one, two and tluee 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/lu for 4 lus per month for 10 months in the first, second, uzd 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 19 ~~ 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 $S6.9S each, SO "Love our Lungs" signs at $15,47 each, I,S00 "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 arrd 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 $SSS for postage, 1,500 mailings at ..37 each.. Office telephone and cell phone costs will be $SS/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 networlting costs in-kind. $9,600 in Occupazicy 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 rvn $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 $10,000: Social Norms Campaign ($S,S04): 1) newspaper ads in 4 middle and 4 high school papers (12 issues x $3S 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 dollaz 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, azid ?Y regional and state-wide sumrnits. 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 2S mile round trip between the two school systems and health depaztment. 20 ~~ $6,000 in Meeting Expenses will include the cost of two peer educator trainings and team building weekends. Refreslunents and other costs for platming 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 for HWTFC funds. Governmental organizations will be required to deposit HWTFC funds in a restricted grarrt account.) (1,000 chazacters) 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 of sub-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 arnount 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 arnount 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 surrunary detailing activities will be required of each mini-grant recipient upon completion of the mini-grant. T!Jnd 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.orQ). ® 2. Letters of Agreement (consent) from all partnering organization (agencies other than the fiscal agent/lead 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 orgazuzation's ability to achieve results tluough 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- lcind contributions included in the project budget and reflecting expected income fiom 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 orgaziization's teen tobacco use prevention and cessation programs funded by grants or awards in the last five years, including the grant award 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 • board of directors • organizational history • current programs, activities and accomplislunents • list of contributors to the organization with the amounts given for the current year as reported on the Lead Applicant Organization's IRS Form 990. Applicants may submit either the IRS Form 990 or another document with this sazne information such as an Armual Report. (This information will be used to determine potential conflicts of interest and will be kept CONFIDENTIAL, This information will be shared only with HWTFC Commissioners and select HWTFC staff. ) 22 Attachment B Health and WellnessTrust Fund Commission Phase III'reen Tobacco Use Prevention and Cessation Inltiatlve (Existing HWTFC Grantee) Proposal Budget Applicant Agency: Orange County Health Department Contact Person for Budget: Letitia Burns -Business Officer s HWTFC Contact Phone: 919 245-2410 Approved:' Fax: 919 644-3007 Effective date: e-mail: iburns(rDco.oranoe.naus Commenis Federal Tax i D or 501(c)(3): 56-6000327 1. Year 1 starting on or about 7/1/2006 and ending 6/30/2007 2. Year 2 starting on or about 7/1/2007 and ending 6/30/2008 3. Year 3 startin on or about 7/1/2008 and endin 6/3012009 7/1/2006-6/30/2007 7/7/2007-6/3D/2008 7/1/2008-6/30/2009 Pro'ect Total Proposed P[bpased - Proposed, Proposed Cate o ' amount ~ In-Kind amount In-Kind amount In-Kind amount ' In-Kind Direct Ex enses Sala /Wa es/Benefits $49,127 $8,800 $51,779 $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 Clarif 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 $27,300 $187,385 $63,900 Other Than Personnel Su ort (OTPS Su lies/Material $6,000 $7,500 $4,035 $1,500 $4,035 $1,500 $14,070 $4,500 Communication Costs /tele hone, ostage, /reight) $1,215 $500 $1,215 $500 $7,215 $500 $3,645 $7,500 Occupancy Costs (rent, utilities, repairs, 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 Olher(C/arify in narrative $a,o9o $3,500 $3,000 $10,500 $0 Subtotal $13,215 $11,600 $8,750 $11,600 $8,250 $11,600 $30,275 $34,800 Media Advedlsing and Promotion (Paid Media Placement and Production Costs) $10,000 $3,000 $70,000 $3,000 $70,000 $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 ortafion, meals, hotels) $7,800 $7,800 $7,800 $23,400 $0 Meetings $6,000 $6,000 $6,000 $78,000 $0 Other (Clan/ in narrative $0 $0 $D $0 $0 Subtotal $13,800 $0 $13,800 $0 $13,800 $0 $41,400 $0 Approved Carry Forward (HWTFC use onl) $o ' ~ $707,700 Total Direct Ex enses$96,887 $35,900 $95,014 $35,900 $97,099 $35,900 $289,000 Indirect Coss $0 $0 Total Request $96,887 $35,900 $95,014 $35,900 $97,099 $35,900 $289,000 $707,700 NOTES: (HWTFC use only) 5Q ATTACHMENT A-2 COMMISSION APPROVED AMENDMENTS TO GRANT APPLICATION 23 51 ATTACHMENT A-3 MINIMUM REQUIREMENTS OF A GRANT PROJECT No additional requirements other than those specified in the Request for Proposal 24 sa ATTACHIVII•;NT A-4 ACTION PLAN 25 (CF~~y,yJ!~ W W Fly a Z ~ z O €~ d W O R. 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U .a a\ w -C b r ~ "N' a C ~ ~ V 3 G ro pn ~ N ~ 3 ~ O o R' N ro C a r . :C b a~ C ;b ffi E? v v a a te ~ y ~ ~ 3 °~7 ° ~~ ° ~ ~ ~ ~ 5 ~ o c °' a s w m o o ~ o n .~, ro o `" o ~i ~ ~ O g ~ ro o0'~y bA ti ~ ~nW b wb aa.~ o " ~ V~ C N P N ro . O O W vi id a0+ w, ~ "d C ~"+ p N N b .N O O w O O C a o~ ~ b r vi ~ a ro ro b , . U '_' O p m U U ro o a i b ctl ~ ~ U ' c c u m •~ Y V ctl H o W ~ + ro 4 V U N .- i U F ~ ~ o ~ ~ ~ ~ ~ v ~N , croi o ro 'c7 i b ~ ~ ~p bn a a a i w ,n a~i G ~ ~ -a b ~ ,d ^° °~ a~i ~ ro 7 3 a"i ~ 5u O ~. ~ y H ro b es OA C w C o 5~ R. v b ~ b ro~ ~ u' 'b ~ C '~ °~ ~ ro U N -' ~ . G O O ~. G ~ ~ p ~ .-. .-. ~ C • .-. ~ m ~ ~ ~ ~ N ~ w 3a; 3~:s 3 ai 3o 3~0~ 3 5cro~ ~j ~ ~ O ~ ro v b ~ v ,~ p r ~ o% G ~ w° rn a ~ ~ o o a ~' a 7 c v i e es i a H . T n x a T U n a U h V u n V p e Q y e 9 V a i~ d ~ u ~a u E ~ d 'O u V V ~~ 6 ¢:. n ~ 0 c~F 0 O V C N O a op cu w°¢ «~ ~_ V p ~3 G C t'J 'c7 ° ~~ V a F '3 E °.: ~~ KN n , ~a z°~ 0 ATTACHMENT B-APPROVALS B-1 -APPROVED PROJECT BUDGET B-2 -GRANT CYCLE APPROVAL LETTER 26 C~3 SAMPLE ATTACHMENT B-1 APPROVED PROJECT BUDGET Nealth and WellnessTrust Fund Commission Approved Project Bud get Applicant Agency: Contact Person for Budget: IiWTFC Contact Phone: Approved: FeX: Effective date:, e-mail: Comments Federal Tax I D or 501(c)(3): 1 Year 1 starting on or about 7/7/2006 and endin 6/30/2007 F te. Year 2 starting on or about 7/7/2007 and ending 6130/2008 3 Year 3 starting on or about 7/1/2008 and ending 6!30/2009 7/712006-6/30/2007 7/7/2007-6/3012006 7!1/2008-6/3012009 Pro ecl Total Proposed '. Proposed Proposed '. Proposed Cai o ~ amount In-Knd amount in-Kind amount ImKind amount In-Knd Direct Ex enses SO $0 Sala /VJa es/Benefits SO SO ConUacled Staff SO 60 Other Clarify in narrative SO SO SD SO SO Subtotal: $D $0 SO Other Than Personnel Su grt OTPS SO 60 Su lies/Material Communication Costs SO SO fete hone, osfage, frei ht) Occupancy Costs (rent SO SO utilities, repairs, maintenance Capital Qullay (Pomiture, equipment. data processing equip with unit costs of at g0 SO least$500 SO 60 Other Clarity in narrative) SO $0 SO SO Subtotal SO SO 60 SD Media Advertising and Promotion (Paid Media Placement and SO SO Production Costsj SO SD SO SO SD $0 SD 60 Subtotal Travel Ex enses Travel (mileage, SO SO transportation, meals, hotels) SO SO Meetings 5D $0 Other Ciari in narrative) SO SD SO 60 SO $0 SO SO Subtotal Approved Carry Forward $0 I HWTFC use onl ~ Total Direct Ex enses SO SO SO SO SO SO 5~ SO Indirect Costs SO SO SO SO SO SO SO SO Total Request NOTES: (HWTFC use only) 2~ ~~" SAMPZ.E Name of Grantee: Grant ID_ Type: of Grant:' GranYAmount_ Grant Cycle: _ Effective Date Termination Date: 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." Gn-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 firom previous grant terms in accordance with the Commission's "Carry Forwazd Procedures for Grantees". Carry-forward requests must be submitted to Commission staff by the Grantee as a Budget Adiustment Request within 45 days after the end of the term in which the cazry-forward was eener°ated. NORTH CAROLINA HEALTH AND WELLNESS TRUST FUND COMMISSION Lieutenant Governor° Beverly E, Perdue Chair Date 28 ~5 Name of Grantee: Orange County Health Department Grant H)56-6000327 Type of Grant:' Community and School ATTACHMENT C AREA OF SERVICE Indicate the county(ies) in which you will be providing services: ANK VERY T RTE.RET SWELL TAWBA ATHAM EROKE.E OWAN AY EVELAN ~LUMBU~ AVEN ~MBEI2LF ~RRITUCI ,RE ,VIDSON .VIE iWAN fTHERFORD MPSON OTLAND ANLY OKES RRY /AIN ANSYLVANIA UVANCE ^WAKE ^WARREN ^WASHINGTON ^WATAUGA ^WAYNE ^WILKES ^WILSON ^YADKIN ^YANCEY 29 ~~ 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. Certifreation: The lead applicant is either (select only one): ^ (I) 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 dtese 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. Agreenteat: All sub-recipients (includes partners, collaborators and other contractors) under the grant will be identified on an ongoing basis. Agreentettt: 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. Agreentettt: 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 Jmie 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 Organization: Oran>?e County Health Depaztment Signatuae: Signature: Title: Health Director Title: Date: Date: Chair. Board of Health Organization's Federal Employer Identification Number: 56-6000327 30 ~~ ATTACHMENT E -FINANCIAL REPORT FORMATS E-1-MONTHLY EXPENSE REPORT E-2 -ANNUAL CERTIFICATION OF ACCOUNT BALANCE 31 ~~ SAMPLE ATTACHMENT E-1 MONTHLY EXPENSE REPORT Health and WellnessTrust Fund Commission Monthly Expense Report Agency: Contact Person for Expenses: rlwrFC useonly Contact Phone: Approved: Fax: Dale:::' e-math Comments: Federal Tax I D or 501(c)(3): Y. Year 7 starting on or about 7/1/2004 antl entling 6/30/2006 2. Veer 2 starting qn or about 7/7/2005 ahd ending 6/30/2006 iAR ONE Annual eutl eP: Jul >Au usl ' Se !ember October. November Decqmbar rJahbe Febnra ? Maroh i'.A dl :.Ma June '; Veer3o-Dale rect Ez enses: la /VJa eslaenegls 50.00 ~nlracletl Staff 50.00 her Please clanf below 50.00 hto(al: 50.00 SO.OD 50.00 50.00 50.00 SO.OD SO.DD 50.00 50.00 SD.OD 50.00 §0.00 50.00 50.00 her Than Personnel i qrt OTPS Iles/Materiel 50.00 ~mmunicatipn Costs le hone, gsra e, Irei hf §0.00 :cupanty Costs (rent. lines. repairs, rinfenance 50.00 :dla (Advertising and emotions 50.00 ipilai Outlay (/umi(ure, ui men!, data recessin ) 50.00 her Please clan! below §0.00 htolal §0.00 SD.DO 50.00 50.00 50.00 SD,DO 50.00 so.DD §D.DO 50.00 50.00 5000 50.00 50.00 avel Ez enses avel (mileage, ns orta/ton, meats, hotels §O.OD !etln Ex enses 50.00 her Please clan/ below §D.DD iblglai 50.00 §0.00 50.00 50.00 50.00 SO.OD SO OD 5000 50.00 50.00 $000 5000 50.00 SD,OD M1al Oired Ex enses SO.OD 50.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 §0,00 50.00 50,00 50.00 direct Costs (only If erred ustlged SD.DD dal Request _. __ SO.DO §0.00 50.00 SO.OD 50.00 50.00 50.00 50.00 50.00 50.00 SOAD 50.00 50.00 SO,OD 32 Cv`~ 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, subpazagraph 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 ~~ 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 tazget group. They are also crucial elements when communicating with the lazger community, the region, governmental organizations, and mass media, It is critical that the public recognizes HWTFC as the fmiding source for the good work you are doing in your communities. The logo, both graphic image and text, aze strong visual cues to the public that: a) build awareness that this is astate-wide initiative, b) create name familiazity 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 mad Welhaess Ti•rast Farad Cauaamission" 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 blacldwhite/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. I)o 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 FIWTFC logo on the front lower corner of one-sided printed materials and on the back lower comer 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 Conunission dollars, It also applies to existing materials that grantees use for this grant project. Add the HWTFC logo when reprinting/reproducing materials. Examples 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 cazds, for example, aze not an appropriate use for the logo unless they are formatted in a way that cleazly portrays HWTFC as the funding source rather than the employer. Project letterhead should likewise name HWTFC as the funding source, 34 -~i ATTACHMENT G PROGRAM SPECIFIC REPORTS 35