10. Response Requirements

The CHNAs responding to this RFR are required to submit the following information. Use no more than 10 pages, doubled spaced, including budget information, not including attachments and in no less than 11 point font.
1. Cover Sheet- Use form provided under the forms tab.
2. Partner Agencies Form- One of these forms must be completed by each agency that will be a partner in the project indicating their willingness to participate. Forms are provided under the forms tab.
(Neither these forms nor the other required forms will not count toward the 10 page limit.)
Please answer the following questions in order. You do not need to repeat the question, but please provide the question number for each answer (i.e. 3a, 3b, etc.).
3. Provide a description of the CHNA. Include:
a) a brief history;
b) a list of member agencies/organizations with an indication of which specific members will be participating in this project;
c) leadership structure and individuals involved as leaders;
d) meeting frequency and duration (for example; monthly, bi-monthly, two-hour meetings) and location of meetings;
e) an example of a CHNA project involving a number of its members that involved assessment, planning and implementation of the plan. (No more than one page.)

4. Describe the lead agency's history of involvement with the CHNA. Include:
a) How long the agency has been involved with the CHNA?

b) How active the agency has been in the CHNA? (For example, was a staff person designated a as the CHNA representative, how often the agency representative attends meetings, the agency representative takes minutes, provided meeting space, chaired a committee, etc.)

c) Has the agency collaborated with other CHNA members on any projects, services,
etc.? If yes, please describe.

d) Why was this agency/organization chosen by the CHNA to be the lead?

e) Describe the lead agency/fiscal agent's capacity to manage the grant and prepare budget reports on spending.

f) Will the lead agency be responsible for preparing monthly activities reports for MDPH? If not, who will be responsible?

g) Describe the range and depth of experience of the lead agency in providing suicide prevention or related services, if any.

5. Describe the range and depth of experience of the other CHNA member agencies in providing suicide prevention or related services. Also include:

a) the names and locations of agencies that provide suicide prevention or related services, the
populations they serve and the services they provide;
OR
b) if suicide prevention/intervention is a new issue for the CHNA members, please describe the suicide prevention agencies and services the CHNA would involve;

c) a list of staff who would be involved in this project, their roles and resumes if available.

6. Provide a copy of the lead agency's mission statement. If the agency has a DPH profile, please attach a copy in the appendix. (These will not count toward the 10 page limit.)

7. Identify the youth priority populations within the CHNA region.
8. Describe:
a) How the lead agency and the CHNA member agencies will work together on this project.
b) Provide a plan for including, within 60 days of the award, at least one university, community college, or funded School of Social Work (Salem State, Boston University, Simmons College and Springfield College) in your area that will participate in the project assessment, planning and intervention activities. Specify the name and location of the college or university, a contact person and their title.
c) Indicate the types of quality control mechanisms that will ensure appropriate oversight
and management of the project.
9. Provide evidence that in engaging and intervening with youth and families in the area the contact/service/training will be culturally and linguistically appropriate.
10. Provide two program budgets which include a narrative description of how grant funds will be used, one for expenditures from April 1, 2009 through June 30, 2009 and a second for the period
July 1, 2009 through September 30, 2009. The two budgets together should total no more than $80,000 not including any in-kind contributions that may be reflected in the budget. Use forms provided under the forms tab.