SHIP 3 Budget July 20, 2013 Minnesota Department of Health

SHIP 3 RFP rfp/

SHIP 3 Funding Worksheet

COMMUNITY HEALTH BOARD POPULATIONMax $1.76/Capita *2011 State Demographer Est AITKIN-ITASCA-KOOCHICHING 74,457 $ 131,044 ANOKA 334,053 $ 587,933 BECKER 32,770 $ 57,675 BENTON 38,558 $ 67,862 BLOOMINGTON 83,671 $ 147,261 BLUE EARTH 64,383 $ 113,314 BROWN-NICOLLET 58,705 $ 103,321 CARLTON-COOK-LAKE-ST.LOUIS 251,673 $ 442,944 CARVER 92,104 $ 162,103 CASS 28,396 $ 49,977 CHISAGO 53,929 $ 94,915 CLAY-WILKIN 66,228 $ 116,561 COTTONWOOD-JACKSON 21,885 $ 38,518 COUNTRYSIDE (BIG STONE- CHIPPEWA-LAC QUI PARLE-SWIFT- YELLOW MEDICINE) 44,775 $ 78,804 CROW WING 62,745 $ 110,431 DAKOTA 401,221 $ 706,149 DODGE-STEELE 56,773 $ 99,920 EDINA 48,262 $ 84,941 FARIBAULT-MARTIN 35,222 $ 61,991

SHIP 3 Funding Worksheet Determine Number of Community Health Boards (CHB) collaborating- enter number. There is an incentive of $10,000 per CHB, each fiscal year. 1 SHIP 3 Funding Worksheet November 1, June 30, 2015 Applicant:  FY14 Nov 1, June 30, 2014 FY15 July 1, June 30, 2015 Total Implementation  Base Funding  $ 100,000 $ 200,000  Single Work plan Incentive  For two or more CHB's to work together  Number of CHB'S included in the application:2   $ 20,000 $ 40,000 Per Capita Request  Population included in the application:    Implementation per capita amount: $ 1.76  $ - Maximum $1.76 per capita  Subtotal $ 120,000 $ 240,000 Innovative  Request for Innovative Approaches   $ -  Grand Total  $ 120,000 $ 240,000

SHIP 3 Funding Worksheet To determine your population count, go to the per capita tab and select the population(s) for the CHB(s). For multi-county CHBs and/or more than one CHB working together, please add the populations together and insert the total. 2 SHIP 3 Funding Worksheet November 1, June 30, 2015 Applicant:  FY14 Nov 1, June 30, 2014 FY15 July 1, June 30, 2015 Total Implementation  Base Funding  $ 100,000 $ 200,000  Single Work plan Incentive  For two or more CHB's to work together  Number of CHB'S included in the application:2   $ 20,000 $ 40,000 Per Capita Request  Population included in the application: 60,000    Implementation per capita amount: $ 1.76  $ 105,600 $ 211,200 Maximum $1.76 per capita  Subtotal $ 225,600 $ 451,200 Innovative  Request for Innovative Approaches   $ -  Grand Total  $ 225,600 $ 451,200

SHIP 3 Funding Worksheet COMMUNITY HEALTH BOARD POPULATIONMax $1.76/Capita *2011 State Demographer Est AITKIN-ITASCA-KOOCHICHING 74,457 $ 131,044 ANOKA 334,053 $ 587,933 BECKER 32,770 $ 57,675 BENTON 38,558 $ 67,862 BLOOMINGTON 83,671 $ 147,261 BLUE EARTH 64,383 $ 113,314 BROWN-NICOLLET 58,705 $ 103,321 CARLTON-COOK-LAKE-ST.LOUIS 251,673 $ 442,944 CARVER 92,104 $ 162,103 CASS 28,396 $ 49,977 CHISAGO 53,929 $ 94,915 CLAY-WILKIN 66,228 $ 116,561 COTTONWOOD-JACKSON 21,885 $ 38,518 COUNTRYSIDE (BIG STONE- CHIPPEWA-LAC QUI PARLE-SWIFT- YELLOW MEDICINE) 44,775 $ 78,804 CROW WING 62,745 $ 110,431 DAKOTA 401,221 $ 706,149 DODGE-STEELE 56,773 $ 99,920 EDINA 48,262 $ 84,941 FARIBAULT-MARTIN 35,222 $ 61,991

SHIP 3 Funding Worksheet To determine your population count, go to the per capita tab and select the population(s) for the CHB(s). For multi-county CHBs and/or more than one CHB working together, please add the populations together and insert the total. 2 SHIP 3 Funding Worksheet November 1, June 30, 2015 Applicant:  FY14 Nov 1, June 30, 2014 FY15 July 1, June 30, 2015 Total Implementation  Base Funding  $ 100,000 $ 200,000  Single Work plan Incentive  For two or more CHB's to work together  Number of CHB'S included in the application:2   $ 20,000 $ 40,000 Per Capita Request  Population included in the application: 60,000    Implementation per capita amount: $ 1.76  $ 105,600 $ 211,200 Maximum $1.76 per capita  Subtotal $ 225,600 $ 451,200 Innovative  Request for Innovative Approaches   $ -  Grand Total  $ 225,600 $ 451,200

SHIP 3 Funding Worksheet Create a budget for work proposed under the cap of $1.76 per capita per fiscal year. If the proposed work will cost less than the cap, adjust the per capita rate accordingly. This is a 20 month budget but caps per fiscal year must be followed. 3 SHIP 3 Funding Worksheet November 1, June 30, 2015 Applicant:  FY14 Nov 1, June 30, 2014 FY15 July 1, June 30, 2015 Total Implementation  Base Funding  $ 100,000 $ 200,000  Single Work plan Incentive  For two or more CHB's to work together  Number of CHB'S included in the application:2   $ 20,000 $ 40,000 Per Capita Request  Population included in the application: 60,000    Implementation per capita amount: $ 1.76  $ 105,600 $ 211,200 Maximum $1.76 per capita  Subtotal $ 225,600 $ 451,200 Innovative  Request for Innovative Approaches   $ -  Grand Total  $ 225,600 $ 451,200

SHIP 3 Funding Worksheet Create your budget based on the work proposed, enter total request in box 4. This is a 20 month budget but caps per fiscal year must be followed. 4 SHIP 3 Funding Worksheet November 1, June 30, 2015 Applicant:  FY14 Nov 1, June 30, 2014 FY15 July 1, June 30, 2015 Total Implementation  Base Funding  $ 100,000 $ 200,000  Single Work plan Incentive  For two or more CHB's to work together  Number of CHB'S included in the application:2   $ 20,000 $ 40,000 Per Capita Request  Population included in the application: 60,000    Implementation per capita amount: $ 1.76  $ 105,600 $ 211,200 Maximum $1.76 per capita  Subtotal $ 225,600 $ 451,200 Innovative  Request for Innovative Approaches  $ 40,000  $ 20,000 $ 40,000  Grand Total  $ 245,600 $ 491,200

SHIP 3 RFP rfp/

SHIP 3 Implementation Budget Form Strategy-Specific Budget Form Grantee Name Budget Contact Person Phone address Budget for November 1, June 30, 2015 REQUIRED SELECTIONS Line Item SCHOOLSCOMMUNITY OVERALLANTICIPATEDADMIN Healthy School Food Active School Day Tobacco Free LivingHealthy Food in the Community ChildcareActive Living BUDGETMATCHEXPENSES Salary and Fringe Benefits0 Contractual Services0 Travel0 Supplies and Equipment0 Other0 Administrative Costs0 Total REQUIRED SELECTIONS (cont.) OPTIONAL SELECTIONS WORKSITEHEALTH CARETOBACCO CONTEROL Line Item Worksite Wellness Community-Clinical Linkages Advance Community Linkages with State and Federal Health Reform Initiatives Type Strategy Here Salary and Fringe Benefits Contractual Services Travel Supplies and Equipment Other Administrative Costs Total The applicant certifies that SHIP funds will be used to develop new activities, expand or modify current activities that work to reduce obesity and tobacco use, and/or replace discontinued funds from the state, the federal government, or another third party previously used to reduce obesity and tobacco use. The applicant will not voluntarily opt to use SHIP funds to replace federal, state, local, or tribal funding they currently use to reduce tobacco use and exposure or prevent obesity.

SHIP Innovative Budget Form SHIP 3 Innovative Budget Form Grantee Name Budget Contact Person Phone address Budget Form for November 1, June 30, 2015 Line Item INNOVATIVE STRATEGIES OVERALLANTICIPATEDADMIN Type Strategy here BUDGETMATCHEXPENSES Salary and Fringe Benefits0 Contractual Services0 Travel0 Supplies and Equipment0 Other0 Administrative Costs0 Total The applicant certifies that SHIP funds will be used to develop new activities, expand or modify current activities that work to reduce obesity and tobacco use, and/or replace discontinued funds from the state, the federal government, or another third party previously used to reduce obesity and tobacco use. The applicant will not voluntarily opt to use SHIP funds to replace federal, state, local, or tribal funding they currently use to reduce tobacco use and exposure or prevent obesity.

SHIP 3 Budget Form for Planning Grantees BUDGET FORM Budget Contact Person's Name Phone address Budget for November 1, June 30, 2014 Line ItemRequested FundingAnticipated Match Salary and Fringe Benefits Contractual Services Travel Supplies and Equipment Other Administrative Costs Total00 The applicant certifies that SHIP funds will be used to develop new activities, expand or modify current activities that work to reduce obesity and tobacco use, and/or replace discontinued funds from the state, the federal government, or another third party previously used to reduce obesity and tobacco use. The applicant will not voluntarily opt to use SHIP funds to replace federal, state, local, or tribal funding they currently use to reduce tobacco use and exposure or prevent obesity.

Contacting Minnesota Department of Health Submit your questions on the Request for Proposals (RFP) by to Individual MDH staff persons are not authorized to respond, and any contact or attempted contact regarding this RFP with any other MDH personnel could result in disqualification. MDH will post all questions and responses on the website at as a resource for all interested parties. The last date to submit questions to MDH is August 23,