PHS.S161-1 (659) CHECKLIST 3; Broper Signature and Date for item 18 on SF 424 (FACE PAGE) 2. Proper Signature and Date on PHS-5161-1 "Certifications" page. ‘5. Proper Signature and Date on appropiate "Assurances" page Le., ‘SF-4248 (Non-Construction Programs) or SF-4240 (Construction Programs) .. a ‘4. Ilyour organization currently has on file with DHHS the following assurances, please identity which have been fled by indicating he {dale of such fling on the line provided. (Allfourhave been Consolidated into'a single form, HHS Form 680) Ch ghs Assam (4 CFR BO) Rectan to were, ‘sstance Goncoing Sox Dacwmaaton (5 CES) ‘snuranoe Concoring Age Dstinaton (25 GF 20 8 Somme ree a 8. Human Subjects Caria, wan applcabie Tas CF) ‘PART 8: This part ls provided to assure that pertinent information has been addreased and Included in th poten. ves Applicable Has a Public Health System Impact Statement for the proposed program/project ‘been completed and distributed as required?” 7 : a Has the appropriate box been checked for tem # 16 on the SF-424 (CAGE. ‘regarding intergovernmental review under E.0. 12372 ? (45 CFR Pan 100) Has the entire proposed project period boen identified in tom & 13 of the FACE Have biographical sketch(es) with job descrpti page n-Construction Programs) or been completed and included? : ‘month detallod budget been proved? {Has the budget for the entire proposed project period with suticient deta boon ‘and Supplemental appiicalions, has a progress report o PART C: In the spaces provided below, please provide the requested Information, ‘inns Onc be noted tan ava abe mane. ‘Progam OtocouP ject DhocedPacpl iti dekate to et ‘te propos pret rogram, Mane ELLEN MCINERNEY tite DIRECTOR, ABSTINENCE EDUCATION PROGRAt tums BARBARA SINGER, as EXECUTIVE DIRECTOR ‘Sramttton CARENET PREGNANCY SERVICES OF DUF ‘Addeus 671 N. CASS AVE. WESTMONT, IL 60559-1338 mat Addues CPSDUPAGE@MEGSINET.COM “Tetepone umber (630) 455-0395 Faxnumber (630) 789-1913 ‘APPLICANT ORGAMZATIONS 12.16 OMS EN ato awh Srgentaton CARENET PREGNANCY SERVICES OF DUI ‘dines 671 N. CASS AVE., WESTMONT, Ik 60559-1338 mal Address CPSDUPAGE@MEGSINET.COM “Tetagone Humber (630) 455-0335 Member (630) 789-1913 SOCIAL SECURITY NUMBER WGHEST OEGREE EARNED BA [bePage 26 PHS-s1611 (90) PART O: A private, nonprofit organization must include evidence of its nonprofit status withthe application, Any ofthe {ollowing ‘whichever is applicable. Oe an tax ( Rey ofa Sironoy ‘statement from a State taxing body, State establishes "atue Cee) Any of the: “above proof ‘organization that of the tan fle si Previously Filed with: (Agency) nt has evidence of current. copy of the organizations certitcato ‘acceptable evidence. Check the appropriate box or complote the “Previously Filed ection, ference to the organization's listing inthe Intemal Revenue Service's (IRS) most recent list of galons descrbod nnocion SUM() o he es aaa Valid Internal Roverue Service ‘Atomey jax exemption corticate, General, or other ale Stato official ‘sppropria xtiying that the applcant organization fas @ nonprof status and Wal fans We a ear accrue iG'any priate sharshoders ov ncwicuels ie ne Cee Rearifed of incorporation or similar document iit clearly rool {oF a Stale or national parect organization, and a statement signed by the parent ‘applicant organization i fcal nanproft afta ae onproft status on fle with an agency of PHS, it will not be necessary to papers again, but the place and date of fing Must be Indicated 7 ‘on (Date) INVENTIONS, {this is an application for continued support, include: 1) the report of inventions conceived or reduced to practice required by the pplicat spport, ) the report Practice required by ‘and conditions of the grant: or (2) ait of jons already reported, oF (3) 2 negative certification. EXECUTIVE ORDER 12372 Elective September 30, 1983, Executive Order 12372 al Review of Federal ) directed OMB to abolish OMB ‘Circular A.9S and ‘establish a now process, for onsuting with State and local elected officials on proposed Federal financial assistance. The Department of Health and’ Human Services Jmplemented the Executive Order through regulations at 43 CFR Part 100 (oter-governmental Review of Department of Health and Human Services Programs and Activities). The objectives of the Executive ‘Order are 10 (1) increase State Nexibilty to design a consuliation Drocess and sclet the programs it wishes to review, (2) increase the spl of Suis and loa ‘led offical to ihene Peal Aecisions and (3) compel Federal officials to be responsive to Site ‘eoncems, or explain the reasons. ‘The regulations at 45 CER Part 100 were published in the Federal Register on June 24, 1983, along with & notice identifying, the Department's programs that are subject wo the provisions of Execative 12372. Information “re PHS" programs: subject to Excoutive Order 12372 is ‘also available from the appropriate awarding office, States in this program establish State Single Points of {ntact (SPGCS) coo nd nage ths evicw So pont (28 proposed Federal financial asistance. Applicans shoul contact the Govemors ofce for infarmation regardig the SPOC: pr selec for rovew, and the consultation Geview) proms eg by their Sine. Applicants are to certify on the face page of the SF-424 (atached) ether the request is fora program covered under Executive Ordet 12372 and, where appropriate, whether the State has been given a ‘opportunity to commentOMB Approval No, 0348-0044, BUDGET INFORMATION - Non-Construction Programs Grant Program Catdog of Fedora Estimated Unobligated Fund ‘Naw or Revised Budget Function Domestc Assistance hey be Foca Neneted | Fate Tented Toa # ® 6 4 o 1. SPRANS $8:110N0 $ s $ 205.m200 s 3 735,442.00 2 000 | a 0.00 4 000 & TOTALS. $ 0.00 $ 00 S$ 28544200 s 0.00 $296,442.00 Letom Cag aut osuK Rte RTT Toad ty Ta a w 8 © Persomel $182,120.00 $ s ia $182,120 2. Fringe Benefits 13,400.00 13,400.00 Trev 8,600.00 860000 a 99874 9987.00 ‘ument m0 _| i Sapien 98000 engsnc0 Contractual 000 4 Contucton aon 40000 hh Other 43,985.00 43,985.00, Total Diet Charges (sum of) 235,442.00 000 000 0.00 285,442.00 |e Chex | 4.00 TOTALS (sum of and 6) 295,442.00 $ 000 $ 000 $ 0.00 3 205,442.00 Ss is s s 0.00 Sweat Famau (a) Pray rae OeSU nae eons} 00 00 000 ‘2 TOTALS um eine Bard 11) Sea ter eY Qu ‘dour dare cut 13, Fee = S$ ws.z0) |S amazon |s cae |s azaa0 ds engzeon 14 NonFadr 000 18. TOTAL (umole tend 14) s295.44200 3800 23800 9.2800 SECTION E- BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT FUTURE ING PERS ay rt (at Pepen mz (Stent (qe (Fear 8 Conmunly-Basd Abstnance Edveaton Program Ss 29544200 | sagezz00 |g sigma |g 1, |. ‘8 8 s s s s + 2. TOTALS um cine 16-19) $295,420 sangez200 3147000, $00 SECTION F- OTHER BUDGET INFORMATION 21. ie Chae 8 Rena SU (1 PedSole 3) a INTERNAL REVENUE SERVICE Oletrset Direator Crieis Pragnaney Services of Dupage County Ino. S71 NH. Coes Avenue Wantmont, TL GOSS9~1530 nar Sir or Madan o DEPARTHENT OF “THE ‘TREASURY 110 Conmaree St., Onldaw, TX 75257 Parson to Contact: Customer Sarvice Diviston Telephone Hunber: Raply to: Date May 27, 1997 EIN: EIN: bb Pacorda shou that Uhe CrLete Pragnanay Services of Uupage County, tne.tn axenpt fron Federal Inoone Tax under section BOIle}(3) of the Tatarnal Ravel Coda. This exemption waa granted January 1992 and rematna tn full force end effect. Contributions to your organization ara deductible in the mannar and to the axtent provided by waction 170 ef the cada. We have classified your organization an ona thal ts not @ priv! Fovinelat Lon Within the meaning of section GO9(a) of the Internal Ravenua Cai Your organtzation in described in aeclion 17@(bI1ICAI VI) of tha cari Lf gress receipts for your. argantzaiion reach £25,000 or more, in hny one year, the organization will be required to fila Farm 990, Return of Organization Exanpt From Income Tax. Yhin letter may be used to verify your lax-exemnl stelus Lt wo may bu of further asetstance, pleana canlact the person ubosa nama snd telephoria number are shoun stove. Streeraly, lO. Pla U. Hann Chiat, Employee Plans end Exenpt Organizations Customer Service Suet lonInternal Revenue Service Department of the Treasury P. 0. Box 2508 Cincinnati, OH 45201 Date: July 10, 2002 Person to Contact: Pat Mahan 31-04019 Customer Service Representative Carenet Pregnancy Services of Dupage County, Inc. Toll Free Telephone Number: 671 N Cass Ave 8:00 a.m. to 6:30 p.m. EST Westmont, IL 60559 877-829-5500 Fax Number 513-263-3756 Federal 'geptircation Number: Dear Sir or Madam: This letter is in response to your telephone request of July 10, 2002, for a copy of your organization's determination letter. This letter will take the place of the copy you requested Purrecords indicate that a determination letter issued in January 1982 granted your organization exemptior from federal income tax under section 801(c)(3) of the Intemal Revenue Code. “that leher still in effect fased on information subsequently submitted, we classified your organization as one thal Nota private foundation within the meaning of section 509(a) of the Code because it is an organization described in sections 508(a)(1) and 170(b)(1)(A)(vi). Your organization is required to file Form 990, Return of Organization Exempt from income Tax, only ifits Say of the Mth eat Be Normally more than $25,000. Ifa return is required, it must be filed by the 18th Gay of the fifth month after the end of the organization's annual accounting period, ‘The law imposes a Penalty of $20 a day, up to a maximum of $10,000, when a return is filed late, unless then reasonable cause for the delay. Gioxempt organizations (unless specifically excluded) are liable for taxes under the Federal Insurance Contributions Act (social security taxes) on remuneration of $100 or more paid to each employee during a calendar year. Your organization is not liable for the tax imposed under the Federal Unemployment Tax Act (FUTA) Organizations that are not private foundations are not subject to the excise taxes under Chapter 42 of the Code. However, these organizations are not automatically exempt from other federal excise taxes Donors may deduct contributions to your organization as provided in section 170 of the Code. Bequests, tegacies, devises, transfers, or gitts to your organization or for its use are deductible for federal eet eid 9H 'ax purposes if they meet the applicable provisions of sections 2055, 2108, and 2522 of the Conesusuo'sL = veazvay =v 0zH 28h saueres 120) ‘suoneasead ssep 2 ae ey few Suopnys ay sugsen ve ensue ajgepene 2 se ja se a6 a aye) pue eoveugsde vasoyo aney Ou SuepMS woddns BujoBuo apinoud 0} yayiom au soy ay uogsod sy, 2s @ yen soyaus-ved 29 eeu.009 dng yng 2° oft yeawsiugy 104 (Ld) soyupioeg drop pods usses els @ ped aq nn puepapeau | ‘suosses aX) Byung aunbas jm uapns ‘aagyeu seuatew seyo fue pue svoysend Kauuns sod pue aud ‘saunyooug no puey Se jam se suotssas ul epv0 Burdeay ut SISS puevonisod euiy ued e suai weiboug sessep 002201 O a) wasssy wend . saa _idsunsses pg noge aq un aay aun ‘papaeu ios 9} “rab pads uy uot oj suapms eBeanoave se jan se wnjrausn et Yoea} 0} 2 un Aypqysuodsey ‘ue sau, vogeuesed fina.) 44g @ seq eu ped uo 29 jm SUSY, sassqo 002 0H{|¢ © Lud) sovmasy sodas Owyedad pue Bay ‘Galo suo, weuBoud sy J] apuodsauna ye obevew a uosied sy, voysed auryed es] peysssy emestuny weling (1) wejsssy anpensupy weg ASU D30U HY J SCONES uuasand 0 payee pn pue so049s Ui swuauisdetua Bunjeads ay je Bugeupsoog Ut ‘Joj20nq tse “Sans 80d pue ard Woy eye (eONSTES -aydon Se yam Se SLOFOMUISUL ‘Gwen ut aosuodsed eq jm pue uoysod aun fry @ | sOeUpIOO) NEUE) werfoug {14} soyeuypuoogyauies) wesBo.g svoyongsul pue yets ye asiwedns ) moja ay) “swapnys 0 yueseud jn pue siODnUISUJO Suen aasieno yyy “swedGoxd jogs aye pue stun ‘Seas oj uedni ay ayes aug wero uoeDneg cusuqsqy 240 Suogeredo easano jn ue Uonsod eu jy ® S08) welBolg (1) soyoang weioug Jpuuosiag $223, 72894, [224 abegnq jo seainuag foueuBadg Janae) uelg uojeyuaweldlu) SNYYES sswesfiog uojonsysuo9 WON - NOLOISUSN 1300N8BUDGET JUSTIFICATION - Non Construction Programs SPRANS Implementation Grant CareNet Pregnancy Services of DuPage Fringe Benefits ‘They ate calculated at 20% of salaries Program Director Program TraineriCoordinator Total Fringe Benefits Travel Average 10,000 or 2 slatf@ 22hnile Ths induces aoa transportation tan fom schools churches and after-school programs 2 staf tips to D.C for 3 days Tito Washington D.C fo Program Decor and Trener Coordinator to meeL wit sa of CHB. This includes the following:- ‘$150 per day for hotel for 3 days ‘$200 for registration per person $50 per day fr meas @ ground trasporafon $ 300 Ar Transportation per parson Total Travel to D.C Toa Travel Expenses Diadaab Ina Baninn Dann at Year‘ 7,000.00 6,400.00 13,400.00 6,400.00 0.00 400.00 40.00 640.00 2,200.00 8,600.00 Year? 7,560.00 6912.00 1447200 6400.00 900.00 400.00 300.00 600.00 2,200.00 e000 Year3 8,164.80 7,464.96 15,629.76 6,400.00 990.00 440.00 330.00 720.0 2,480.00 8,880.00BUDGET JUSTIFICATION - Non Construction Programs ‘SPRANS Implementation Grant CareNet Pregnancy Services of DuPage Yeu’ Yer Yer’ Equipment 4 Computers @ $ 1013 each 4052.00 4 Computers @ $ 1013 each, Director, Trainer/Coordinator and Adminisbative Assistant wileach have one computer. The fourth compute wil be avaiable tobe used by the instructors and support group coordinator and will be placed in the instructor's‘support group coordinators office, DHL -1440 Laser Printers @ § 299.99 each & Toner @49.99 699.96 ‘2HL-1440 Laser Printers @ $ 299.99 each & Toner @49.99. One printer wil bein Directors ofce and the other atthe TreineriCoordinators office, These printers willbe networked tothe Administrative Assistant's office andthe support group ccoordinatorinstructor’s ofc, | PPF4270E Plain Paper Memory fax machine & toner 154.98 ‘Toner & | PPFIZ70E Plain paper memory Fax Machine. This wil be placed in the Administrative Assistants office who wil oversee its use and wil send most of the faxes, 1 Photocopying Machine - SHARP AL-1554 789.99 + Photocopying Machine (SHARP AL-185t) willbe in Aministaive Assistants ofce whose duty is to make copies of brochures, fiers and abstinence education program materials for students. Telephone system hand sets 096 GE Aline Speakerphone 2-9451GE2 Telephone system hand sels. The Director, Trint(Coorator and Istuctr'Support Group Corina oie wil each have @ hand sel. The man eephone system wile placed inthe Anite Assn ofc. Answering Machine -GE Digal299896E2 ao ‘Answering Machine will be placed in the Administrative Assistants office. 4fce Desks @ $149.99 each 096 4 Ofce Desks @ $ 149.99 each for Directar, TreinriCoordinato, Administrative Assistant and one to be placed in the office shared by instructors and support group coordinator. 4 Office Chairs @ § 99.99 each 9.96 Deatnad Inanntnn Daan DaeBUDGET JUSTIFICATION - Non Construction Programs ‘SPRANS Implementation Grant CareNet Pregnancy Services of DuPage Year! Year2 Year3 1 Round Conference Room Table 199.99 4 boatshaped Corftence Room Table, This wil be used dung taining sessions ofthe insbuctos and for staffinstuctors meetings. Abstinence Education Presentations for lage up of youths deified as highisk through our bles program will hae abstinence sessions in the conference room. The support group wil hod ther meetings in the conference room, 14 Conference Room Chairs @ $ 23.99 each 35.86 | Speakers Stand 29.48 | Speakers Stand to be placed in the conference room to be sed by instructor while presenting the abstinence education program. 4 Chalk Board $999 ‘Chalk Board to be placed inthe conference room for instructor use or curing instructor tring, ‘1 Audiovisual Screen $9.99 1 APOLLO Auciovisual Soreen 1 Overhead Projector 190.99 ‘Waiting Room Sofa 49999 {Table for Waiting Room 169.99 2 Chairs for Waiting Room 3999 2TVAVCRs @ $179.99 each 3098 Both wil be used for instructor training and during abstinence education sessions that wil beheld atthe center. Fling Cabinets 11499 Book Shelves 249.99 Total Equipment 99e704 Punet Jstifeatina Onna A ofBUDGET JUSTIFICATION « Non Construction Programs: SPRANS Implementation Grant CareNet Pregnancy Services of DuPage Year Year? Year3 ‘Construction Renovation to parton Ofices 6,400.00 Renovation to partion office space to provide rooms for ofices, conference room, ‘chenet, 2 rooms for suppor group mesings, Total Construction 6,400.00 Supplies Instructor kits @ 375 for 10 315.00 ‘0 its, each includes video, leaders guide and 20 student manuals. These will be available ‘or the instructors to use when they need them and willbe atthe trainer/coordinators ofice, Parent Presentation Kit + 35 parent books 365.00 1 Parent Presentation Kit + 35 parent books will be used by the Director ofthe program who will be expected to do all the parent presentations, Student Manuals @ $4 per manual 23,200.00 24,000.00 24,000.00 5,800 student manuals which willbe in the Trainen\Coordinators office, She willbe espe to ep stock ofthe manuals ata times, Parent BookMtanuals @ $8 per book 1720.00 7,200.00 7,200.00 ‘985 parent manuals willbe at the Directors office, Office Supplies 3,200.00 3520.00 3,870.00 ‘paper, staplers, staples, glue, tape, File Folders, Bussiness Cards for 4 employees @ $75 each 30.00 300.00 Pury Rings 4,50 Prt Rings (@ $16 ng to be used as anincentive for actively parinaingin he suppor group 40000 = 2400000 4,000 Computer software 4 Microsoft Ofce Softwares @ $439.99 each 1,788.96 Total Supplies engage = 5872000 = 59,370.00 Diana hinon Danae ateBUDGET JUSTIFICATION - Non Construction Programs ‘SPRANS Implementation Grant CareNet Pregnancy Services of DuPage Year! Other Advertising Yelow Pages 610000 Job Advertising in Chicago Tribune 1,700.00 «Job Advertsing in Chicago Trioune, We plan to advertise open vacancies of TraineCoordnator, Administrative Assistant and Instructors. We wil use the Chicago Tribune because this has the widest citculation reaching thousands of people. This wll ensure thal we ae ging everyone an equelso tat nretum we can get he mast qualified people forthe jobs. Posters fliers, brochures to advertise youth rally in schools, churches etc, Radio Advertising with 106.7 the FISH @ $75 for 40 commercials Rent 22,0000 Speakers Fees 470.00 ‘Speakers Fees. We intend to invite prominent speakers ike A.C Green or Ms Erika Harold to speaat the youth aly which willbe held in May 2004, Liability (Workers Comp) Insurance 2400.00 Labi (Workers Comp] Insurance, Thisis the estimated cost of bit insurane based ‘on pat coverage. Training Seminars 4yoto.00 Tring Seminars, Ths for ongcng training ofthe sta. They wl atend seminars to further educate them on this issue of abstinence education. This cost includes training casts, renspotation, heel and food, Printing and Postage sca.00 Shipping and Handling of Manuals 154.50 Shipting and Handing of Manuals is alelated at 5% ofthe total cost, Total Other expenses 3.93450 TOTALS 295,4150 Budget Justification Page 6 of 6 Year2 7,320.00 1,300.00 3,000.00 22,880.00 15,000.00 2,860.00 3,000.00 6,600.00 1,560.00 63,540.00 309,601.60 Year3 8,784.00 23,795.20 2,200.00 3,456.00 350000 7,920.00 1,560.00 5121320 a14tmunnae Sc PRNTER et pen te te your ofice at work 0 110 ers st it See a0 119 Pec gene oem Be oa mate ay sma OF ee pane eB persona sr ty. Bee po 15 20 Pee ay ——— tet ae! css ¢ es se uso Fae . ett Reisen & Bat Sy) Som a ine me tomers Fes pina Se wher a B g i inns nome BRA govt caine ME ae Cesc zane A Sates Nein bor AD é scatter — Geerancrmicvmn SENN re ke «8 CAAA gy «TEASER CTIA Sy nimetesnime AS ee Coane HA GPAACIISZN Teneo AE 1 een taaaston atk ea Nckteintoe NS 6 oN Ug soomn CANE vias tticttin oe Sianga ——asesasonan "8204 Wn ec) natitetintne 2 \y me cena Uae ves ‘Chaeaintox ME * banana tae tsoin CATE Woes Walaa be NC : fie: cemsnch Were Se Meee Nacbasintoe A ‘ fee | Gn aan ON cx cassacnsen ‘Sanat Cunt FE : CMA an CANGR EASON CITA EDS ee fixotesintox RS : ae samt ALEX ATTA CSA See Maeiedntne AC x ig Pad BELF2AOH6-06-010 IEEE Printer Cable 6, AB TYPE on st BELFZADAG-10-GLD IEEE Pinter Cable 10, A-TYPE page 29 for Laser Paper Fro0e5-10-W Paral Gable 10, A T)DE Soe pages 208 thraugh 210 for Laser Labels Be ee eek eaten Ricca9} ; é z g : 3 $ g 3 USE FL ACES eter ee PEO pris blo apy dh a on pn pe * Tannin yest 1p (nda) en 28, ps + Dope ate +2 hy oy 14s ten + Cy tint and eee +a, lcs ation foot, basin TROMIC BTARN FRO) wrfae THT ATG) Toc ight a SGM WD PRuefe 8 THIN BATS Tatas RF COLO LE kt youd st tis ied ink cai rg ayant est Te Bh: PB cn tsb whe iy of tn bard wey *Soer 826i medm + apart ete * 10 het paper cet * BIE meoy ta 8 eg) Bertier tu rity ay Seiises RTD Fineéeimia Retnage png Cainge Mepmitge Sia amy erect ‘Speer ru ue enn Sts par af pp ee rata a Sea. ees gato cue, ee Dipset Spay pr ai Sa al tg, ~ ‘mut-opjing and etyeent ed eduction, EAs ao O-gcutoatdoxet e + Dist pe ate * 528 marary (pope) + Sbadcias Co icin apis tet econ wt * PADRE THINS ROL i aie By 4 (NUT kA coo FX MACANES ' Te ee art ax 20 pio satin aye: ‘Wes aft6ls nate, pve cbf. ws keane copying Fens inc Neietx wo wana ‘fa, ae ecg ta a TO farce ose, a eed 8 ‘0 BK aden Clo oxa Qh PINECONE won ~ ipa MH SP $388 San woes nar sass ie jones oN NE, sae ge PACKARD LASERIET 3910 PRATERCOPIER i oy igs with ep me gis ad uk Te 30 os a igen, ‘Opi ase pint eng ‘onesies ting ps a apis. pana eony pees. up 189 pike e120 foes: te 60 ata et er tay. es Mat cities Matt a wen Puen $983 om Unrest tid i cage pasar wc uphonch Bk 38 f ote AR 000 LATED DUAL COPERLASER PRITER BPD des thay tpt Naps ihe or le, USB ad parle neatly with Windows Heaton Bian cap speets: po 15 gp rio 8 8 te tae el cag fie aot oom ee eb saver te xn fee o mu star amen ON or mu) sami) rb A vast Psy smi) cape a vm apa] Cont RTL COPUEULASER PRINTERS ites reso pt gly ae wit Peeing ns, ina ny ono 01. AS clair pining Paes upi 2p et up Sg aoa doen ede Poy cy 0 er ah ats cick tne air at tw) mine pion sat om teint I, Mok an te itm seuss supa S838 hs Ooi Bu sane SRM ses hs uti "SMG amu erie co TTR ccna elyMULTILINE TELEPHONE SYSTEMS Corded phone systems are a costefecve alternative to expensive PBX systems. They use analog phone lines and do not require atonal wi {analog pone jack and AVC power required f0r each station) Expand to rmliple stations and uit the papingntercom features 2s wells hanes ‘Speakerphone. Dala ports allow for modem and fax connections. 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AllFumiture By Choice ems are made to your spPeiis requéet Orders cannot be cancalled or Kems returned: please make your selection caretuly. pss EXECUTIVE CHAIR ‘Style, comfort, and vale— ths chair has everthing you expect in executive sealing, The heavily padded sta and back cushions provide ‘outstanding comfort and support mpact-resistnt arms ive the chai strength and ‘uray. The stan sesistan, Teflon-coted fabric wil st for years witout showing signs of wear. One-touch convo proves quick and easy height agustment = Duabvheel casters + Stacked in charcoal gray ttc, bat more than 8 colors a avalable + Covered by Gla finite etme warranty 245.96 Hx 25 W 27D femt Mt Descation tac Sioosaza HSi0csL01 Gare # Sr.s399 Ferny Chie . (Group Sx Page 6 ® ‘rop2 Sx Fag 60¢ # aunyuung 2940 | | becom (SLOBAL® MULTIFUNCTION EXECUTIVE CHAIR Create the lve of comfort you need to achieve ‘maximum praducity throughout the workday. * One-touch seat-height adjustment + Adjustabl-height back * Tit tension and tit iock * Forward knee tit $46 H x25" Wx 25-4 D tent Mics Resctinan resve-we* $1906K-M05 Quvea! Hreateany SungesMnt Bac. * Available via Catalog and Online only. an (GLOBAL® SUPREME EXECUTIVE CHAIR The Supremes plush seat and back cushions wal eep you comfortable throughout he day. ‘The molded, contoured arms are durable, comfortable, and stylish ‘Am infinite locking feature lows you to lock the cai in any tting postion, so you can keep the positon Thats best for you + Ttion-cated myn upholstery is slain-resistant and durable + Dual whee castes ol easily ‘ver carpeted floors + Stocked in charcoal gray fabric, but mare than 80 colors ae avalable + Covered by Global's fimied Wetime warranty fH x 25° Wx 25D Mt Oxia re Beast aa owe fee Page 8 oy 2, See age Et FREE Next-Busines’ 0°) >(4 ELLINGTON COLLECTION BY O’SULLIVAN AA. EXECUTIVE DESK This beautitl executive desk features 2 accessory drawers and 2 file ‘rawers to help keep you organize. Finished in elegant metropolitan cherry with black accenls, Measures 28-92 H x 59-%' W x 294%. Mt " emt au age Mesueory 10a) rea Cesk 188 'B. COMPUTER GREDENZA Features a heightaojustable keyboard tray an enclosed CPU. compartment, a box drawer, and a fle drawer. Fished in metropolitan cherry with back accents. Measures 28-47 H x 593¢ W x 28-4" D. ‘estan Camas Credo Designed for use with either the computer credenia or the “L* \workcenter. Includes 4 large storage compartments to accommodate a vataty of media and may be closed to hide its contents. Finished in melropoian chery. Measures 36-16 H x 59-46 W x 11-5 D. Meme ed Deszuiaien auc Pace ‘ressee.as1 1088 Tate S195 1, “U" WORKCENTER Featres an adjustable-height keyboard tray, box drawet. fie drawer, and enclosed CPU compartment. Finished in metropolitan cherry, ‘Measures 26-4 Hx 99" W x 66-1 D. Mt Mt Desctlion Yaw ruice srvsue-sor et woe $198.99 E. LOW HUTCH Designed to sit atop the “L computer workcenter to atfer addtional storage and to allow higher postioning for your computer monitor. ‘Accommodates up to 221° monitor. Finished in metropaitan chery with black accents, Measures 5°H x 52-40 W x 34-1. Heme Mie Desccinlan owe Price Srcbedny 108 oy a] F. LATERAL FILE May be used asa stant-one fie draw toa desk or workcenter for aditonal v legal, or Ad-size hanging folders. Finis biack accents. Measures 26.4 Hx 25° Meme Mle Descaia Sroeue-sx st Calf 6G. STORAGE CABINET May.be sed asa standalone storage _dcent toa desk or workentr to inet ‘stacked stp the lateral eo conserve f cherry with black acces Measures 28 me Ht ‘essa sresoesss 1082 Serge Ca HH. 2-SHELF BOOKCASE Features one ajustaie salto accommoc a5 well as books, disks, and oter accesso with lack acces. Meares 30H x28 mt tt estar Heeaeor 11000 Stet Boa |. S-SHELF BOOKCASE Features 3 adjustable sheves to accom computer accessories. Fished in met Measures 72:14 H x 29'W x 11-40. Yom mt eatin sraesessy 072 het wo J. CENTER DRAWER KIT NOT SHOWN) ‘The center deawer kt isan ideal storage and frequently used ites, tome Me Dsctnten Meters Sat (eave taeFin TBS rh api ikaw moe ee ns 018 ‘Saket op ant base Fri Saas, pipet DOWNED 5 BROT x saxty itn ned tegen, 7 en rs PE THALES iting ma Stick pte fig. Mears ox Select op and bast. fas tutig qlee ase oat me oy ua bea saps ant Fiera As A CSO) iki Std esto dn 8312 Ta Wha 6377 ap enh To Toop Ties Sana eta Lmyiiai aStcaH THM BION fa ay fa ketunlt fe Wand Speci rer tes wile cere from ate warhuse win 3 uses C4. * pal wa Cll Onin on cry Se Tesco sds ‘Office Furniture‘Bloom comer earnen {TESTING ARM CHAIRS exter opto wih abla, epory poder cosa sel rare -Hoided ams ae su estat + Chas canbe ganged ete Sreepon ren + Mamata ited etme waranty SEEHaze oe We20!" D kent Met Bain Maer Mere Belt Snonare geet eeu Speedo Siearcare Sora ‘SGLOBAL® DESIGNER ‘STACKING CHAIRS + Features a plastic, imac estan cuter back shed + Upoisted sat nd back prove curity ana como, Chairs tack 3 gh to 3 mire storage space 8 -Mantacurers hoes eine waranty Hoge ener wxaro Fotunt tin 3 itor Seem Rive é Z2KNEON Gate Di GLOBAL® STACKING CHAIR, WATH ARMS + Minrr-chrome fish tare is welded fr stength and durability * Chaits ae stackable to minimize storage space / + Nonmarting foor glides. protect floors surtace + Manufacturer’ limited Wtetime warranty 235 x21" W x27 tant ae exciton Sener SORSWD Gry Fane 648. Office pEPoT peLOBAL® STACKING CHAIR * Epoxy powder-coated chrome frame for resilience + Padded seat and back cushions + Chairs stack 3 high to manimize storage space’ ‘Manufacturer inted itetime warranty $36 Hx 20° Wx 22° time me esetion Srasoz-26- eebKpots “Bouck abe —— ean Nineaete ice ane vera ieee ee a! Youcesica 325 Hx 18-4 Wx 25-4 D yos8 Kent ike Deseation cts Has5 STeaas.018 21525000 Goyfatne me | buona stack cae 3 | s Vinyl seat and back with o> 2 chon ame | | + Stak 1 chats igh fo / Po | easy storage = Nip can iy be | wiped clean . | Atnacreiies tein vara sence Wes 0 nt aie Bescon sae = Stearns fash! Gay yt 7 ae * Available via Catalog and Online only. Go aeete ee50051 Floor Lecter - Speaker's Stands Page 1 ALLEN ee ‘Your are here: Online Catalog > Lectems > Floor Lecterns - 50051 * Constructed of melamine laminate 23-3/4°W x 46-3/4"H x 16"D Medium Oak Finish Shown atto://www allendisolav.com/I ecternsS0051 htm ‘+ Provided with floor glides ‘+ Padded document ledge + Concealed storage shelf + Weight 73 Lbs. # Assembly required ‘= Ships via UPS Stock Number Finish Color Price Each VI=50265, Mahogany $230.48 IL Vi-50052 L Walnut $239.48, ‘VT-50051 Medium Oak $230.48 Mahogany i = a Medium OakENV) te scat g0)INSTANT CINEMA PORTABLE SCREENS Fagprovalve new design wih bull in poeumatic rchanism makes for easy fy Sen Its etfortesy trom the Noor. Setup height for 0" screen fs 8 screens 87 Pertct or road presentations, home tester systems, bnardroon. Sim back protective case or easier vel Mt escinian ‘Oh. Youcerice o0s1* AP06tIe0 Dagon ce $610.93 frost APOC? = bape a 5893 Select 9, SUPER-BRITE TRIPOD SCREENS ie 60" or 80" lective, high-gain sereen surface provides 50% more brightness Haj conventional screens. Perfect for use in ambient room light or ftlimedia projections. Includes durable meal case and handle Face can be cleaned with mild soap and water, Flame-reladant, ew-esistant surface. Easy setup and take-down, lt Descrnton ‘owePricg ios Aortomnss Ser $158.95 ss0221" APOPTIONS YT $7898 fr any application including overhead, lide, video, or multimedia tions. Matte white surface with black border Flame retardant and dew sistant. Comes with heavy-duty metal case. Retracis out of hea not in use, Ineludes builtin hooks for hanging, Mit Desciaton ‘te owes Bzs0-00 APCPwcoco al Pasion Susen, EX 039 exer is a iallable via Catalog and Online only. 1-888-GO-DEPOT © FAX: 1-800-685-5010 CLICK: wwwotficedepot.comsuonequasadd jensin 750 Office DEPOT /PERFORMANCE PLUS OVERHEAD PROJECTOR 1840 "The 3M Performance Pus Overhead Projector 1880 2800 iumey with ENX lamp and double lamp tie of 130 hours. Features low yg 10 x 10-4 stage, amp changor,hghfowintansity swich, ug fan, canying handle, and clock Closed double-lementpojecion Sissasr Silo Rete rjc » Tsonsst ONIN OeResaeminy IM PERFORMANCE OVERHEAD PROJECTOR 1810 ‘3M Pertormance Overhead Projector 1810s study and comeny ‘fering bright images for up to 130 hous wih 2,500 umes, 10 low glare stage and ENX lamp for larger rooms. Gpen sh ens poy tad for easy leaning, Meme Mit Ossetian au, ts SrsTes-er Misia 16. wrbnd Proce Srstus.sst sp0stza9 NK Rapocomen tony, EA Bf nere vase overenopnascron 720 Ga ate Den Pop 7 20 une Pesdusbhes tt fou fit Woe pneene closed singlet lens projection head for extra tens and mitror protect wits ya Se Cee e oo Seat Bt Baccara «2 CS Se ew Produte | _ito_| ito fee etteaa lacey | eye | co lscs Go" | tae | Ste ie Sr Oe bo wih atest ines [tomers ran | aso | oxo lowe-ouerran |} 0 | fae po Fawsr cor A meeey | os | s [wo | s | « {ot lower od wag |v Jy [yy PI * Available via Catalog and Online only Pita aloes elWee ee Ape qaeannes 3 ae Lo your epecite request: © nol bg cancelled O Hy had; please make your selection caotully, NS cea Galen mot pe tows rie ot ely ih tania ale THe cs SS vai er ued Cay, ri ad Ns, Gace eno sig gs oe Features shan stan ined a ae ng canst, nd wg wong slept tse ease le wuts ee ess mao, ery end ag fae SRY A ta wees ie Srratie as iene tt scion Sisiecser FoloscraMe Mahony Sones RaOGCrRAMe Ser Sere Rn NE Me b. GUEST CHAR. Orne tent Mt scion oes ; UPthoss, Metsu Haver cy : ameseiaae. Cx Suelo eon 1 Ramen Nese Rane. Fonte Bebe "5, 2.seaT SOFA Se rae ut bese END TABLE Mlosrsue tenor - fame Rae Ory Bo Hn 24 W220 D Sie necen Ror Hedon ut Spee RONEN Beer mito Haley : Jers By Olen $eheae meme | Bet @ “Gi Sie @ Te matin er pee Sear mao F. CORNER TABLE Be Wx 2438 Wx20°D 6. 2 CHAIRS WITH CENTER TABLE A) tent Hct cil roenice Mera: muorae MS Bean MitaveMle Nene Senear mowee Gen wate aise mane Oey @ ses, le Siplerest RaTHeatIMAe Man Behe nomen aw Sener Revere cee eo CEE A geass | x20 Wx 18D : 1 BEBE are tam Mt aezinin Bibl Mire Meer + avaitable via Catalog and Online only. @ ties ‘Sn Vereen niaonn Nan EETVNV/CRs and Magnifiers |. PANASONIC TVAVER COMBOS ‘Tis Panasonic fl-eatured 20° mona television and 2-ea ‘ideo renorder combination fs convenint and es) 10 use. tower remote contol, clocWsleep timer, tilngual display, Fa radio wth auto scan, commercial skp, aio dock set seat. Also availabe wit 13" seren (No emote conta) tet Mt escent 1 Mir sre: PANP-conze ETN tonto A 2 Baers PAWPVCIe2 — SFTUNURCono A ‘8; APOLLO TV WALL MOUNT WITH VCR SHELF ‘Space-savng, heavy-gauge steel mount supports TVS up| and 65 lbs. Perfect for home, office, or commercial use. P {10° for easy viewing from anywhere inthe oor. Include adjustable VOR shelf Mounts dict into wal studs Inc {or wood stud instalation ome Ml esciawoa Setd von Neston Twos ‘0. RCA 3-DEVICE UNIVERSAL REMOTE This 3-device universal emote controls you TV, VR a The palmsized remote fs multbrand compile wth a sleep timer. It has an extensive code fibray anda code st ‘you to change batteries without losing your ode. Tot Mie asain OM. BPns-061 CATS Cerner 6A MAGNIFYING GLASSES Caity a magaitier wherever you goin you becase, purse, of pocket—for easy reading anytime ‘APOLLO RECTANGULAR MAGNIFIERS iot-power retractable, and igted maga areal for tent, Mt Desciates Wet aars Worns = Pieumos eH Gisacern avoarsa = Zee Fata EA EC APOLLO ROUND MAGHIFIER + Shatterproof and scratc-esistant opal grade cry 2x lens with 4x bilocal B “TWNGR oo inclea. |e ‘tome tt, esctaian oy, Siedeo-ere ptzrses SE Row cs ee APOLLO FULL-PAGE MAGNIFIER ‘Covers an entire lete-size gage. Great for roports with Seratch-esistant acrylic wih 2x magncation Mant ct asi Sigseroe aba EIT aPage EA (G: APOLLO SLIDING COMPACT MAGNIFIER 4 x 2-He lens retracts into protective case, Pocket: fits almost anywhere, 2x magaifation Vom Mt Qeciae ake Sieaeogexe APGarsn WPT 6g OH suonewesord 1ensin faite 9 * Available via Catalog and Online only.CONV catere git GN 560 SERIES 25" DEEP SONOMY VERTICAL FILES Has 23-4' of fron-to-back fling per drawer. Standard drawer sles, spring-loaded follower block, optional interchangeable core removable ock ‘optional 2-step hang rails make these files a great value, Meets or exceeds ANSUBIFMA and ISTA pertormance standarés. Avaiable input, igh lor black. Covered by the HON limited Ietime warranty. : i 5 " ' 2-oRAWER FLE Meme te ‘Description Your Price ACCESSO Spina owt Poor soso ©. OPTIONAL INTERCHANGERELE CORE REMOVABLE LOCK Srna: a9 S433" Dasloned to wore wih HON I7, HON Sere inane: er SSS ra Hw 1000 Sete veal es AeGAL SE 20 i fe wee Dexia onerar as pon MMe Bat Melle y ‘379-136-6697 5620-0 @ $104.99 one Fo * Shite: Stee fs ee ear Deagrd te wok wth HN Sets ard OM 10D fant oe et ew : tewtiss — Sbeses SOG Beg Ra oi inure were wun eee ae ete om Teor nite wate tae. oe Ee caret vt irewnace osaco Ulooy FRG | Colors and Finishes chins cscs ol & SEGR | HN set te etre maten Greonilemen a HON tel dest, sel suing. and computer una Catalan and Aatine anhaunyuund e210 as ee ‘A. BC SERIES BOOKCASES Traditional square comers MANDAN vo broveesat anta062 B avevesets WaRII6S2 5 grew HARMEBE 1B svetebest~ HARIGOS? 5 Svs te-cor- FaRs7262 B mrsamcsct: HaRie46 eeDIOM ORK Set” HARISO63 B drewesst: HARISISE fS retest HaRtAtSD & Sisveeeere warns Sostc-eot- HaRN7263 Bi Srsecrr> HARIOAGS wut Si nee-sex* Han Pie reegor™ HARTOSEL Sis teeser” HARTA 2 Srstecerrs nare0oe (5 sae yar MaRtT2GE 5 drsescout- nanvosce {or a clean look. eset wr 2s Seam 3snees Pacers ferns ahs Te tgh 6 tees Ben Smee ‘wri 22h Se ase Se tagh SE ‘aon sate ey 6 tees Belin? es eh 2 aes 2 Hoh 3 tes fein ase ans See Sen 6 shes beth Pees Youre sre as sn99 p38 fuses sss ress ans sues Sima has Sass Paty as and ca-lock at WOOD VENEER {Choose rational square corer oF cr Grater Ayaan mahogany, medium Oal oc WAAR venshy particleboard const wth dowe petenas for easy assembly. Sheres adit tervals. A boOKCaSeS thc, high measure BOOKCASES temporary radius ct a gombly sence avaiable (00t includes} 'B. ROC SERIES BOOKCAS! Designed with graced emt Wawocany sy brotue2t asa082 1B brsvee-rst- nari? & Suse var taraeee2 a HARD? Sra eect Hare 5 svgescast= HAF ‘Meotow On 1 Sree 1" WARDS 5 ws grgsueres’ HAR & Sipe-res wansee 5 drewaear wanacet ny rresoee ES, radius comers fot aso Desalion ari 2500 3e man Stes ae Ny ass feign 2S. Te Hoh 6S beg 1Stees sigh 2 Shas Seton 3 hae talon tte cotign SSes Feng 6S Dele es sort 2s Se tage 3 Se Gennes Wan § Stes te vgn 6 Sues oe gh Sees ter look. ae Wx 12 0,ATTACHMENT G KEY PERSONNEL FORM (Supplement to Section F of Budget Form 424A) (Note: This form is pending OMB approval) NaweanpPosmionTinue | Anwuatsacany | SG MOMS T vena | Topas ANOU | qa) @) GB) @) Barbara Singer 15% Executive Director Ellen McInerney 12 100% ~ Director, Abstinence Education Program Vacant 12 100% ’ Trainer/Coordinator ‘Vacant 12 60% Administrative Assistant Need additional 10 Instructors Need additional 10 Assistants Vacant 10 40% Support Group Coordinator Grant Specialist 12 10% $ %\S FRINGE BENEFIT (Rate 20%) Total $ 152,120(OMB Approval No. 0348-0040 ASSURANCES - NON-CONSTRUCTION PROGRAMS feviewing instucions, searching exis ‘evtowing de coflecion of fomason, Si Ifomaton, ncig Projet (0548-9000), Public reporting burden for this collection of information is estimated to average 16 minutes per response, including time for ng dala sources, gaheng 2 ‘Send comments regarding the burden estimate or any other aspect of this col ons fr reducing this burden, to the Ofc of Management and Budget, Paperwork Reduclot PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. ‘SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY. nd maintaining the data needed, ard completing” ard Note: Ceriain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to ccetlify to additional assurances. If such is the case, you will be notified. AAs the duly authorized representative of the applicant | certify that the applicant 1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including funds sufficient to pay the non-Federal share of project costs) to ensure proper planning, management and completion of the project described in this application. 2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through any authorized _ representative, ‘access to and the right to examine all records, books, papers, or documents related to the award: and will establish a proper accounting system in ‘accordance with generally accepted accounting standard or agency directives. il establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the ‘of personal or organizational conflict of interest, or personal gain. 4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. 5. Will comply with the Int mental Personnel Act of 1970 (42 U.S.C. §§4728-4763) relating to prescribed standards for merit systems for Programs funded under one of the nineteen statutes ‘or regulations specified in Appendix A of OPM's Standard for a Merit System of Personnel ‘Administration (5 C.F.R. 900, Subpart F). 6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §§794), which prohibits discrimination on the basis of handicaps; (d) the ‘Age Discrimination Act of 1975, as amended (42 U'S.C. §§6101-6107), which prohibits discrimination ‘on the basis of age; Will comply, of has already complied, wit (@) the Drug Abuse Office and Treatment Act of 1972 (P-L. 92-255), as amended, relating to ‘nondiscrimination on the basis of drug abuse; (#) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 4970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) §§523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee-3), as amended, relating’ to. confidentiality of ‘alcohol and drug abuse patient records; (h) Tile Vill of the Civil Rights Act of 1968 (42 U/S.C. §§3601 et seq.), as amended, relating to non- discrimination in the Sale, rental of financing of housing; (i) any ‘other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and () the requirements ‘of any other nondiscrimination statute(s) which may apply to the application. the requirements of Title ll and Ill of the Uniform Relocation Assistance and Real Property Acqu- sition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal or federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases. . Will comply with the provisions of the Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328) which limit the political activities of employees whose principal ‘employment activities are funded in whole or in part with Federal funds. . Wil comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act (40 U.S.C. §276c and 18 U.S.C. §874), and the Contract Work Hours and Safely Standards Act (40 U.S.C. §§327- 399), regarding labor standards for federally assisted construction ‘subagreements. ‘sundard Form 4240 (i787 Probe yO Car A10. Will comply, if applicable, with flood insurance Purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (PLL. 93-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 (or more. 11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control ‘measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b) notification of violating facilities Pursuant to EO 11738; (c) protection of wetland Pursuant to EO 11990; (4) evaluation of flood hazards in floodplains ‘in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the Costal Zone Management Act of 1972 (16 USC. §§1451 et seq); ( conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176(c) of the Clear Air Act of 1955, as amended (42 US.C. §87401 et seq); (g) protection of underground Sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as ‘amended, (P.L. 93-206). 12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 USC. §§1271 ot seq) rolated to protecting components or potential components of the national wild and scenic rivers system. 13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 US.C. §470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 US.C. §§ 4692-1 et seq.) 14. Will comply with P.L. 93-348. regarding the protection of human subjects involved in research, development, and related activities supported by this award of assistance. 18. Will comply with the Laboratory Animal Welfare ‘Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. §§2131 et seq.) pertaining to the care, ‘handling, and treatment of warm blooded animals hheld for’ research, teaching, or other activities ‘Supported by this award of assistance. 16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§4801 et seq.) which prohibits the use of lead based paint in con- struction or rehabilitation of residence structures. 17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act of 1984, 18. Will comply with all applicable requirements of all ‘other Federal laws, executive orders, re- gulations and policies governing this program. ‘SIGNATURE OF AUTHORIZED, CERTIFYING OFFIGIAL SAilasn sage! EXECUTIVE DIRECTOR "APPLICANT ORGANIZATION CARENET PREGNANCY SERVICES OF DUPAGE DATE SUBMATTED 1-23-04 F248 (Rev. 797 BaPHS-S161-1 7100) Page 17 ‘OMB Approval No, 0920-0428 CERTIFICATIONS 1. CERTIFICATION REGARDING DEBARMENT. AND SUSPENSION ‘The undersigned (authorized official signing for the applicant organization) certifies to the best of his or her knowledge and belief, that the applicant, defined as the primary participant in accordance with 45 CFR Part 76, and its principals: (a) are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal Department or agency; (b) have not within a 3-year period preceding this proposal been convicted of or had a civil Judgment rendered against them for commission Of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a Public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property, (© are not presently indicted or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with com- mission of any of the offenses enumerated in paragraph (b) of this certification; and (@ have not within a 3-year period preceding this application/proposal had one or more public ‘transactions (Federal, State, or local) terminated for cause or default Should the applicant not be able to provide this certification, an explanation as to why should be placed after the assurances page in the application package. ‘The applicant agrees by submitting this proposal that it will include, without modification, the clause titled "Certification Regarding Debarment, Suspension, In cligibility, and Voluntary Exclusion—Lower Tier Covered “Transactions” in all lower tier covered ‘transactions (j., transactions with sub- grantees and/or contractors) and in all solicitations for lower tier covered transactions in accordance with 45 CFR Part 76, 2. CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS: The undersigned (authorized official signing for the applicant organization) certifies that the applicant will, or will continue to, provide a drug-free work- place in accordance with 45 CFR Part 76 by: (@) Publishing a statement notifying employees that the unlawful manufacture, distribution, “dis- Pensing, possession or use of a controlled substance is prohibited in the grantec’s work- place and specifying the actions that will be taken against employees for violation of such prohibition; (®) Establishing an ongoing drug-free awareness rogram to inform employees about— (1) The dangers of drug abuse in the workplace; (2) The grantee’s policy of maintaining a drug-free workplace; @) Any available drug counseling, rehabil- itation, and employee assistance programs; and (4) The penalties that may be imposed upon employees for drug abuse violations ‘occurring in the workplace; (©) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by Paragraph (a) above; (@ Notifying the employee in the statement re- quired by paragraph (a), above, that, as a condition of employment under the grant, the employee will-- (1) Abide by the terms of the statement; and (@) Notify the employer in writing of his or her conviction fora violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction; (©) Notifying the agency in writing within ten calendar days after receiving notice under paragraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant activity the convicted employee was working, unless the Federal agency has designated a centralPage 18 point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant; (Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (4) (2), with respect to any employee ‘who is so convicted @) Taking appropriate personnel action against such an employee, up to and including termination, “consistent with the requirements of the Rehabilitation Act of 1973, as amended; or Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, Taw enforcement, or other appropriate agency; Making a good faith effort to continue to maintain a drug-free workplace through imple- ‘mentation of paragraphs (a), (b), (€), (@), (@), and (0). Q @) For purposes of paragraph (¢) regarding agency notification of criminal drug convictions, the DHHS has designated the following central point’ for receipt of such notices: Office of Grants and Acquisition Management Office of Grants Management Office of the Assistant Secretary for Management and Budget Department of Health and Human Services 200 Independence Avenue, S.W., Room 517-D Washington, D.C. 20201 3. CERTIFICATION REGARDING LOBBYING Title 31, United States Code, Section 1352, entitled “Limitation on use of appropriated funds to in- fluence certain Federal contracting and financial transactions," generally prohibits recipients of Federal grants and cooperative agreements from using Federal (appropriated) funds for lobbying the Executive or Legislative Branches of the Federal Government in connection with a SPECIFIC grant or ‘cooperative agreement. Section 1352 also requires that each person who requests or receives a Federal grant or cooperative agreement must disclose lobbying undertaken with non-Federal (non- appropriated) funds. These requirements apply to grants and cooperative agreements EXCEEDING $100,000 in total costs (45 CFR Part 93). ‘The undersigned (authorized official signing for the applicant organization) certifies, to the best of his or her knowledge and belief, that: (Q)_ No Federal appropriated funds have been paid ‘or will be paid, by or on behalf of the under- PHS-St6L-1(700) signed, to any person for influencing or attempting to influence an officer or employee of any agency, & Member of Congress, an officer or employee of ‘Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, "and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. @) Ifany funds other than Federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or ‘employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure of Lobbying Activities," in accordance with its instructions. (If needed, Standard Form-LLL, “Disclosure of Lobbying Activities," its instructions, and continoation sheet are included at ‘the end of this application form.) @) The undersigned shall require that the language of this certification be included in the award doc- ‘uments for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. certification is a material representation of fact ‘upon which reliance was placed when this transaction was _made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, U.S. Code. ‘Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. 4. CERTIFICATION REGARDING PROGRAM FRAUD CIVIL REMEDIES ACT (PFCRA) The undersigned (authorized official signing for the applicant organization) certifies that the statements herein are true, complete, and accurate tothe best of his or her knowledge, and that he or she is aware that any false, fictitious, or fraudulent statements or claims may subject him or her to criminal, civil, or ‘administrative penalties. The undersigned agrees that the applicant organization will comply with the Public Health Service terms and conditions of award if a grant is awarded as a result of this application.PHS-5161-1 (700) ( Page 19 5. CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE Public Law 103-227, also known as the Pro-Children ‘Act of 1994 (Act), requires’ that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, carly childhood development _ services, education or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. ‘The law. also applies to children’s services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children’s services provided in private residence, portions of facilities used for inpatient drug or alcobol treatment, service whose sole source of applicable Federal funds is Medicare or Medicaid, or facilities Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the ‘imposition of an administrative compliance order on the responsible entity. By signing the certification, the undersigned certifies that the applicant organization will comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as, defined by the Act. ‘The applicant organization agrees that it will require that the language of this certification be included in any subawards which contain provisions for children's services and that all subrecipients shall certify accordingly. ‘The Public Health Services strongly encourages all ‘grant recipients to provide a smoke-free workplace ‘where WIC coupons are redeemed. and promote the non-use of tobacco products. This is consistent with the PHS mission to protect and advance the physical an mental health of the ‘American people. ‘SIGNATURE OF TERTPYING OFFICAL | TLE EXECUTIVE DIRECTOR “APPLICANT ORGANZATION DATE SUBMITTED CARENET PREGNANCY SERVICES OF DUPAGE 72304“T#O( Ob, Lets Talk Healthy Relationships Grant Award Number: 90AE0116 Carryover Request Budget Narrative ACF CBAE Grant Year One The Lets Talk Healthy Relationships Program total requested Year One Carryover Request from the Administration of Children and Families Community-Based Abstinence Education Grant is $418,388.00. Both Year One Carryover and Year ‘Two CBAE grant monies are needed to achieve the Lets Talk Healthy Relationships Program goals in reaching Alaskan youth with abstinence until marriage education and equipping twenty communities in Alaska to have self-sustaining abstinence programs. Personnel The carryover request for the budget category “Personnel” figures for Lets Talk Healthy Relationships totals $15,721.00. Carryover funds from Year One for Personnel will be used for hourly work not completed during Year One and to provide a total of 5%" pay increases for staff employees listed below. * 5% is the total increase between the approved Year Two budget and Carryover requested amount. © Executive Director (Carryover Funds .25 FTE $638) is a full-time salaried employee through the Crisis Pregnancy Center, Anchorage, Alaska. Current salary is $1 Jaf ). This position reports directly to the Board of Directors and has overall administrative responsibility for all of its programs including the Lets Talk Healthy Relationships *lobae reports/budget narrative ~ Canty Over Yr t.docprogram. The Executive Director participates in program planning and development and provides administrative and financial oversight, personnel management and other ‘administrative duties as required carrying out the goals of the program, © Project Director (Carryover Funds 1 FTE $2,$16,00) is a full time position who reports directly to the Executive Director and is responsible for coordinating program and administrative responsibilities for the Lets Talk program. Current salary is $ 4 o The Program Assistant (Carryover Funds 1 FTE $1,334.00) provides administrative support and data coordination for the program. This is a 40 hour per week position. Current salary is $ fy © The Outreach Coordinators (Carryover Funds 3 FTE $5,640(00) will travel frequently, often on small aircraft in rural Alaska and are responsible for providing community outreach services to assist urban and rural communities in Alaska in developing Community-Based Abstinence Education programs. Duties include; community education and evaluation for recruiting, technical assistance with community planning, program and resource development and other support services for communities as appropriate. © Requested carryover funds for Temporary Office Assistance hourly work is $¢ 24 4. During Year One the Program Assistant worked on average 32 hours per week due to personal needs. These requested funds will be used to provide assistance with office projects that were not accomplished as planned during in Year One. 2 lebae reportsfoudget narrative — Carry Over Ye 1 doc.Fringe Benefits The carryover request for the “Fringe Benefits" category total is $7,753.00. Eleven percent of the gross payroll is for funding payroll taxes on carryover Personnel salary totals $1,729.00. The Crisis Pregnancy Center offers a medical assistance savings draw to its employees. Employees have until December 15 of the calendar year to request reimbursement for expenses within the applicable calendar year. Carryover request amount for medical assistance is $6,024.00. Travel The carryover request for the “Travel” category totals $2,300.00. Regional ACF conference attendance was budgeted in Year One. However, the conference was held October 4-5, 2006. $508.00 was paid in Year One for the purchase of airfare and shuttle to the Regional ACF conference. The remaining funds will be used towards the Project Director's attendance the ACF National CBAE conference in Washington DC. Equipment Let's Talk has no expenses for the “Equipment” category. Supplies The carryover request for the “Supplies” category is $1,873.00. A remaining order for student commitment reminder key chains was planned to be complete in Year One. Currently, the development of the updated student commitment reminder key chains is in process and will be received and paid for during Year Two. Contractual Let's Talk has no expenses for the “Contractual” category. flebae reportsoudget narrative — Carry Over Yr 1 docOther The carryover request for the “Other” category totals $90,741.00. © Carryover request for Lets Talk Speakers Pay is$ 0 }. This in addition to Year Two budgeted amount is consistent with statewide ‘Speaker fees considering Outreach Coordinators will provide some presentations. Due to the size of Alaska and its remote communities, the program budgets by the Census Bureaus Six Alaska Regions for planning purposes. The most populated areas of the state that the program serves will cost significantly more than the more remote areas Of the state due to number of presentations to reach the youth. During Year One, due to the lack of trained speakers caused by attrition and lapse between the SPRANS grant period and the CBAE award, Outreach Coordinators provided presentations as well as met with school and community leaders regarding CBAE program development while in each village. By the Outreach Coordinators conducting presentations, the cost for presenter fees during Year One was reduced. During Year Two, to ensure the success of assisting 20 communities in developing their own community based abstinence education programs, Outreach Coordinators will focus greater attention to assisting communities in their program development and Speakers will provide most presentations. ‘© Carryover request for cultural training from the Alaska Native Heritage Center for staff is $650.00. Availability of training by the Alaska Native Heritage Center is limited. Classes that were planned to attend Year 4 flebae reportsibudget nartave ~ Carry Over Yr 1 doeOne are still needed for remaining staff and to further connect with the Native Alaska communities. © Carryover request for Contract Community Development pay is $N\>-€e ). During Year Two, with relationships building, community Program development will be pursued greater than what was accomplished during Year One. Community Developers will continue to provide ongoing training to the Outreach staff to successfully implement the community outreach services and assist communities in conducting community needs assessments, developing effective CBAE programs. Year Two hourly rate will increase to $ 96, | (providing a 5% increase from Year One) Less hours than planned were devoted during Year One. During Year Two, as more communities are recruited in developing their own Programs, Community Development hours will increase as further guidance will be requested by the Outreach Coordinators and communities developing their own programs. Additionally, some invoices are yet to be received for the final quarter of Year One. © Carryover request for Professional Evaluator — The Institute for Research and Evaluation, Dr. Stan Weed and associates is 1 '9-@ ). Much time during Year One was spent developing the youth surveys. When implementing the first survey it was found to be at too high of a reading level for Alaskan youth in general and was too lengthy. The survey was revised to a fifth grade reading level and shortened. Let's Talk is aggressively pursuing evaluation during Year 5 lcbae reportsbudget narrative ~ Carry Over Ye 1.docTwo and it is anticipated by the Institute for Research and Evaluation that the $\y& | in carryover funds will be needed due to the vastness of Alaska. © Carryover request for Technical Consulting is $4,000.00. These funds will be used for technical assistance that may not be found via the Grant Station or training. During Year Two, as more communities are recruited in developing their own programs, utilizing remaining funding from Year One will be necessary. © Carryover request for independent Auditing is $1,800.00. Carryover funds will be required to cover remaining funds to pay for the required Single Line Audit ($6,000.00). o Carryover request for Web Site Development is $1,320.00. Website development work is in process since July, 2008. Invoices for work during September are yet to be received and Year One work is still in process. © Carryover request for Advertising is $2,500.00 to provide airing of the Let’s Talk documentary twice during Year Two ($1,000.00), develop a new Lets Talk commercial with excerpts from the documentary created in Year One ($1,000.00), and mail a remaining newsletter from Year ‘One ($500.00) © Carryover request for Postage is $750.00. During Year Two, Lets Talk will send out more follow up correspondences than in Year One. ebae reportsbudget narrative ~ Carry Over Ye 1.docLet's Talk Healthy Relationships Reference Grant No. 90AE0116 October 2006 Carryover Request from Grant Year 1 to Grant Year 2 Personnel (Si 1d) Executive Director (25 FTE) Project Director (1 FTE) Program Assistant (1 FTE) Outreach Coordinators (3 FTE) Temporary Office Assistance Total Salaries Fringe Benefits Taxes Healthcare Reimbursement Travel Prj Dir Regional CBAE Conference Equipment Supplies Student Commitment Reminders Contractual Other Speakers Presentation Fees Alaska Native Heritage Center Training Contracted Local Community Developers Program Evaluation Technical Consulting Auditor Web Site Development Advertising Postage Total Carryover Request $ ss $ $ $ $15,724 $7,753} $1,729 $6,024 $2,300 $2,300 $0 $1,873] $1,873 $0 $90,744 $32,350. $650 $15,371 $32,000 $4,000 $1,800 $1,320 $2,500 $750 $118,388)Alaska State Statute Sec. 14.03.110. Questionnaires and surveys admi istered in public schools. (a) A school district, principal or other person in charge of a public school, or teacher in a public school may not administer or permit to be administered in a school a questionnaire or survey, whether anonymous or not, that inquires into personal or private family affairs of the student not a matter of public record or subject to public observation unless written permission is obtained from the student's parent or legal guardian. (b) For an anonymous questionnaire or survey, written permission required under (a) of this section may be obtained annually and is valid until the commencement of the subsequent school year or until the parent or legal guardian who gave permission submits a written withdrawal of permission to the school principal. The school shall provide each student's parent or legal guardian at least two weeks’ notice before administering a questionnaire or J:\Evaluations\Alaska State Statute docsurvey described under this subsection. (0) If a school administers to a student a questionnaire or survey that is not anonymous, the school shall obtain the written permission required under (a) of this section from the student's, Parent or legal guardian at least two weeks before the questionnaire or survey is administered, (d) The school shall give a student's parent or guardian an opportunity to review the questionnaire or survey described under (b) or (c) of this section and shall give the parent or guardian written notice regarding (1) how the questionnaire or survey will be administered to the student; (2) how the results of the survey or questionnaire will be used; and (3) who will have access to the questionnaire or survey. (e) A student may refuse to participate in a questionnaire or survey administered in a public school, A student's parent or legal guardian may refuse to allow the student to participate in a specified questionnaire or survey. (f) In this section, "questionnaire or survey" means a list of questions to, or information collected from, a class or group of students exfcommunity outreach/surveying/Alasta state statute. doc.COUNT OF YOUTH REACHED (October 1, 2005 to September 30, 2006) ‘Year One Total CBAE Grant Number 90AE0116 ET’S TALK HEALTHY RELATIONSHIPS, PRESENTATIONS Age in Years MALES w24 | 15-17 | 18419 | 2024 | >24 TOTAL Alaska Native ebro ele Se 39 1151 Non-Hispanic White_| '460 | 629 | 80 4 25 2208 Black = 37 3 0 9 192 on v7 | 38 4 3 0 1m Hispanic 7 Others 177 47 I 6 1 248 FEMALES Alaska Native 553] 371 | 110 21 45 1106 147: 1 Non-Hispanic White ee - 8 49 2219 50 Black bo 23 2 0 212 spam 18 | 56 7 6 1 202 Hispanic 173 | 50 1 x Others : 2 31 4940 | 2322 | 403 105 Im 7941 TOTAL ‘leboe grant report october 2006/youth served charts doeCOUNT OF YOUTH COMPLETED PARTICIPATION LET’S TALK HEALTHY RELATIONSHIPS PRESENTATIONS Year One Total (October 1, 2005 to September 30, 2006) CBAE Grant Number 90AE0116 Age in Years 4 | as. 119 | 2024 | >24 TOTAL foo aso | aor | 75 | 34 39 1038 Non-Hispanic white | 455 [ 607 [78 [14 25 2179 nee os | 49 3 0 8 158 ‘eoani m2 | 33 4 3 1 153 Hispanic 140 | 47 17 6 1 211 Others FEMALES Alaska Native Soa | 364 | tl | 30 34 1043 n 15 4 Non-Hispanic White pe es 6 2108 34 | 47 16 1 2 200 Black eee ws | 53 | 14 0 1 m Hispanic 153 | 41 4 0 2 200 Others 4sss_ | 2230 | 393 | 103 | 177 7461 TOTAL lcbae grant report october 2006iyouth served charts doeCOUNT OF YOUTH COMPLETED PARTICIPATION LET’S TALK HEALTHY RELATIONSHIPS PRESENTATIONS April 1, 2006 to September 30, 2006 CBAE Grant Number 90AE0116 Age in Years MALES 12-14 | 15-17 | 18:19 | 20-24 >a TOTAL. Alaska Native 336 | 299 | 36 o 36 707 Non-Hispanic White | 4 | 364 | 60 0 20 1248 Black 4s 28 1 0 8 82 6 18 3 0 1 83 Hispanic 4 0 8 0 0 112 Others . : eal FEMALES Alaska Native 325 244 53 4 34 660 ae 82 6 S4 1159 Non-Hispanic White cad 68 1 14 0 2 105 Black 2 — ss | 25 n 0 0 95 Hispanic a 2 1 0 2 105 Others : 2615 | 1340 | 240 4 157 4356 TOTAL ‘ebaegrant pon october 2006/youth served charts. docCOUNT OF YOUTH REACHED LET’S TALK HEALTHY RELATIONSHIPS PRESENTATIONS April 1, 2006 to September 30, 2006 CBAE Grant Number 90AE0116 Age in Years wad | isa7 | ssa9 | 2024 | >24 ‘TOTAL oct am | 32 | 36 0 36 806 Non-Hispanic White | 74° | 38! o 0 20 1209 Black 59 35 1 0 9 104 aoa a | 23 3 0 o 87 Hispanic 101 Others 8 o 0 128 FEMALES Alaska Native 353 250 52 1 45 701 Non-Hispanic White 790 | 325 | 50 3 39 1207 _ ou 2 | a 1 0 105 ‘spami Tay ose ais ° 0 17 Hispanic Others elas 2 1 2 122 2766 | 1413 | 250 | 6 151 4586 TOTAL ba gant epot october 2006)youth served charts doe. # Abstinence Education Program = _ Development Assistance 907.868.5033 « Fax: 868.51Alcanzando aos adolescents con un ‘mensaje para una relacion de respeto con sus amistades con ellos misinos. El programa “Conversemos" Wamado en inglés “Lets Tak” Healthy Relationships esta patrocinade por fondos federales. ‘ Nuestra mela es encfr als juvenud de Nasa la mporancia de estabieerrelaciones emocionles sludatlesy de abstonerse de tener ‘elacones semvales anes dl mavimon. Nuestros oradores profesionales a tavés de presenlacones en el aia o en la comunidad equip alos venes con informacon que ls ayudera a fotalecer su ‘orate, su madurez yi habiiad de dec no + Ofreceros ambien presentacones aks padres de fama acerca de émo comunicarse y ayudar asus hjosasobellevar as pesiones en as ‘elaclones emocinaiesy doa vida aria, Para solr mas informacion © solar una presentacon en cual localiiad ene estado de Alaska ot favor menos, ¥ Speaking Programs: 6h grade, thr Tih 12th grade, 3 hrs > Program for Parents & Community: lam to talk with Kids about Healthy Relationships & Sex o promote Viginty, Abstinence, Chastity ‘wow lestatkalaska.com - info@ietstalkalaska.com Tel 868-5033 - 2625 Rose St. Suite 102 - Anchorage AK 99508Let’s Talk Healthy Relationships Parent Workshop Interview Protocol Interview Protocol Each presenter will have their own way of beginning their presentation. We encourage you to do your own beginning the way it fits for you. Say: “Very little is known about what parents in these workshops think about sex, what they think their children need to learn, and why they are coming to the workshop. Knowing the answers to these questions will help us to design the most effective approach to working with parents in the future as well as get a sense of the particular needs of the attendees at any given workshop.” Say: “So, to start off I would like for us to have a discussion session with you; an interview of sorts, and [ would like to record it so we may have an accurate record of how we may assist parents better and enhance our program. Is there anyone hear who does not wish for ‘their comments or questions to be recorded? {If someone raises their hand, tell them each person will raise their hand prior to answering a question or providing comments. If you ‘choose to answer a question or express your comments, I will tum the recorder off while you are speaking.) Please do not disclose any personal reportable information to me during the recording. Only the discussion at starting now and after the presentation will be recorded.” Once you begin recording state: “This is {your name} on {date} providing a parenting ‘workshop at {location}. No participants have declined being recorded — or ~ have advised participants that do not wish to be recorded that I will turn off the recorded if they choose to ask a question or make a statement.” Say: “Please raise your hand if you wish to respond to a question or make a comment, To ensure good audio, I will hand the recorder to you for when you are speaking.” Introductory Questions So, please tell me why you are here tonight. What motivates you to be here? What are some of the challenges you have in raising your children? General. Specific to sex. What are your hopes and goals with regards to your children’s sexual behavior? Do they have abstinence hopes or safe sex hopes? What are some of the challenges to youth staying sexually abstinent in today’s world? What do you think they need from you to reach those goals? What is the hardest thing for you about doing that? How confident are you that you can make a difference? ‘What do you hope to get from this presentation to help with that? Feommuity outeachisurveying/parent interviews docConcluding Questions Say: “At the beginning of the presentation, we talked about whether you felt confident about helping your child make good choices about their sexual behavior. We identified some things you hoped to get from tonight's presentation. I would now like to ask you some more questions while recording the discussion.” So I'd like to ask, how did we do? What did you learn tonight that will help you reach your goals as a parent? What are some thoughts or feelings you have after being here? What specific actions are you going to take because of what you have received here tonight? What do you still need? What still seems hard to you? If we were to come back another time, what would you want us to address? ‘eleommunity outeachsurveying/paeat interviews doe@ SURVEY FOR YOUTH Pre & Post-Test Alaska 2006-2007 Each of us see and hear many things about sex in our school, our community and our society. ‘This survey is to help us understand what young people think about those things they see and hear. This survey is anonymous. Do not put your name on it - your name will not be connected with your answers. Instead, you will create an ID code that only you will know. This 1D code will help the computer connect your "before" and “after” survey answers without Identifying you personally. Connecting your answers in this way will help us lea how, or if, your answers change as you get older. ‘Your opinions and thoughts are very important, so please answer each question carefully. If you have taken this survey before, dont worry. Your answers do not have to be the same as before. In fact, they may be different. That's o.k., opinions and ideas change from time to time. We are interested in what you think at this time. 1. Allof your answers will be grouped with those of other teens. They will not be examined individually. Nor will the answers be connected with you. ‘§ 2. This is not ike a test where there are right and wrong answers. Just tell us what you think, i 3. Carefully fillin the circles as neatly as possible. CORRECT: @ INCORRECT: DRIOO 4. Donot tak to others while you are answering the questions, or while they are working on theirs » | 5. Thists a serious, scientific study. Ifyou cannot tke it seriously and answer honesty | would be beter for you to not ake the survey 6. When you are finished, place the questionnaire in the envelope and drop itin the box. : ‘Thank you for participating in this important survey! Your ideas and opinions are valuable. If this survey has raised any questions or concerns for you, be sure to talk to your parents, or a counselor or teacher Ee c PIGS BREEBER Es (7) oe &) fa 3 REE EEESEREEREREE & Gy (Go) ig BERBERS (Bo) Os} Ge) AREEREEEE EREEEE Your confidential ID computer code First etter of vourfirstname (4 your nest name were John, you would mark the llter“s") ANB\C\D\EVFAGA HAL J \K\LARGN\O\ PAR STAM Wa YA2" First letter of mother’s first name (Now you will be using the first letter of your mott name is Mary, you would mark the letter *M",) ANB\C\DVEVF\G\HYI \S QL AMANO PLAS TUAW AZ Month you were born Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Day of the month you were born 1\2\3\4\8\6\7\8\8)\10 8412 19 1416 06 178 490 24 2229 2425 26 27 28 29 00 31 \ P |. Are you male or female? 1 Arex 4. What is your race or ethnic background? MALE (boy) ASIANIORIENTAL, FEMALE (git) AFRICAN-AMERICAN/ Black HISPANIC (Spanish / Mexican) MIXED: (mark all those that apply) 2, What is your age? WHITE (Caucasian, Non-Hispanic) NATIVE AMERICAN (American indian) 11 YEARS, 16 YEARS PACIFIC ISLANDER (Samoa, Tonga, Fi, Hawai, etc.) 12 YEARS 47 YEARS OTHER : 13 YEARS, 18.YEARS 14 YEARS 19+ YEARS 1S YEARS 5. Who are you living with now? *** Mark all that apply *** 3. What grade in school are you this year? ngtHeR! 5TH GRADE 40TH GRADE ‘STEP MOTHER 6TH GRADE 11TH GRADE, FATHER 7TH GRADE, 12TH GRADE, STEP FATHER ‘TH GRADE Other (OTHER ADULT RELATIVES (Aunt, Uncle Grandparent, et.) 9TH GRADE OTHER ADULTS (or example, foster parent, uardian) OTHER: __ (Please descrive) Two —_— = -‘The first part of this survey is going to use the words “having sex”. This means either: Sexual intercourse - "going ail the way", or the sexual act by which babies are made, or Oral sex - using your ‘mouth on the other person's private parts, Please use this definition of “having sex" when answering the following questions. IT WOULD NOT MAKE ANY DIFFERENCE IT WOULD MAKE IT A UTTLE HARDER IT WOULD MAKE IT SOMEWHAT HARDER FT WOULD MAKE IT ALOT HARDER, 6. Do you think that having sex as a teenager would make it harder for you to get a good ‘education in the future? 7. Do you think that having sex as a teenager would make it harder for you to have a good marriage in the future? 8. Do you think that having sex as a teenager would make it harder for you to get a good job or have a successful career in the future? 9. Itis important to me to wait until marriage before having sex. 10. Itis wrong for me to have sex while [ am not married. . 11. I will not have sex in order to be accepted by others. . 12. Having sex with a boyfriend or girlfriend is a good way Co show how much you care for them, 13. have set clear limits for myself regarding sexual behavi 14. If my friends encourage me to have sex, I just refuse to do : 15. Itis all right for people to have sex before marriage if they are in love.. 16. The limits I have set about sexual behavior are a higher standard than most other people have. setae 17. Ifyou were going out with someone you really liked and did not want to have sex, how sure are you that you could do each of the following’ Fill in one circle for each statement) a How sure are you that you could Stay Away from situations that might lead to having fia} sex (like going to a bedroom with a date, drinking alcohol, doing drugs)? a (bj b. How sure are you that you could Talk to your sirVboy friend about your decision not 03) to have sex? es 5 1 c. How sure are you that you could Firmly say “no” to having sex? Ge) 4. How sure are you that you could Stick with your decision not to have sex? - fea © Hw sure are you that you could Stop seeing your grbayiend if else continues to @ Pressure you fo have sex? a fe oo Gy THREE ie ' ' aBe) HREREE a aE ical ical ical =) ica Using alcohol may make me more likely to have sex. ). Having sex now is a good way to prepare for marriage. javing sex before marriage is against my own personal standards of what is right and wrong, - Itis important to me to do what is right, even if I lose some friends. . Having sex proves that you are attractive and wanted by others. ci . Whether or not Pll have sex depends on what my boyfriend/girlfriend decides. |. T might consider having sex so that my friends will think I am cool. . I have made a promise to myself to wait until marriage before having sex. I do not do risky behaviors that distract me from my goals. Bate, PREEREREREEEEI REEREEES a EIGIEISE! A By Gy 8 . Have you ever had sexual intercourse? No Yes 28. If Yes, how many times? NEVER HAD SEXUAL INTERCOURSE ONCE 2.9 TIMES 4-10 TIMES, MORE THAN 10 TIMES 29. How old were you the first time that you had sexual intercourse? 3. How old was the person that you had sexual intercourse with the first time? Hl ABE a NEVER HAD SEX NEVER HAD SEX 10 YEARS OR YOUNGER 10 YEARS OR YOUNGER 11 YEARS: 11 YEARS, 12 YEARS, 12 YEARS 13 YEARS. 19 YEARS 14 YEARS, 14 YEARS 15 YEARS 16 YEARS 16 YEARS 16 YEARS 17 YEARS 17 YEARS 18 YEARS or OLDER 18 YEARS or OLDER 30. How many different people have you had 32. When was the last time you had sexual sexual intercourse with? intercourse? NEVER HAD SEX NEVER HAD SEX ‘ONE WITHIN THE LAST WEEK Two 2.3 WEEKS AGO THREE > 1 MONTH AGO FOUR 5 23MONTHS AGO FIVE OR MORE 4-6 MONTHS AGO © MORE THAN 6 MONTHS AGO FOUR —_— = = -33. Do you think you will get married someday? 37. If you were to have sex now, what are the chane oe Yes, defintely tranvmited disease 4B Yes, proba ot Sure NO CHANCE AT ALL No, probly nat VERY SMALL CHANCE No, deftly ok SOMEWHAT OF & CHANCE [ASTRONG CHANCE, VERY LIKELY [ALMOST CERTAIN 34. Keis against my parents values for me to have sex while Tam an unmarried (eenager. 38, Ifyou were to get an STD, how serious would STRONGLY DISAGREE the health consequences be for you? oisaGREe NO BIG DEAL, NOT AT ALL SERIOUS NOT SURE SOMEWHAT SERIOUS AGREE VERY SERIOUS STRONGLY AGREE EXTREMELY SERIOUS 35. I feel that I can go to my parents (or guardian) it 39. As of the present time, have you ever made a [0 with questions about having sex. As of ie present tee, have You ver made 2 fa | STRONGLY DISAGREE ‘would not have sex until marriage? I DISAGREE No (Gz) NOT SURE ves Be] AGREE cH STRONGLY AGREE Gy Ba 40. Even if you have not actually signed your name, [37] 36. I receive clear direction and guidance from my have you made a promise to not do any ofthe" [37] parents (or guardian) about not having sex- flowing? Mark "es or No foreach eatgory. (2) ‘STRONGLY DISAGREE YES NO Ba DISAGREE ALCOHOL = NOT SURE oRucs AGREE TOBACCO STRONGLY AGREE HAVE SEX 41. Lwant my children to be born and raised within marriage. . 42. Knowing the steps of intimacy helps me set sexual limits. . 43. ‘There is nothing wrong with viewing sexual videos or pictures. 44. Relationships that start out with a lot of making out or sex won't (i) 45, L want to get married some day. veces ica 46. know how to have a good relationship without making out or having sex : ical 47, Healthy marriages and strong families lead to healthy communities and societies. i u ic oy ey o Five G)sae BERBERS BEE IEEE) aa JEEBEEEEEI RRERE ee aeaeH fs EEEEE GEEEEEEE The next group of questions refer only to sexual intercourse. This refers to “going all the way", or the sexual act by which babies are mad« 48. Itis okay for unmarried teenagers to have sexual intercourse if they use birth control. ‘STRONGLY DISAGREE DISAGREE NOT SURE AGREE STRONGLY AGREE 49. If someone wanted you to have sexual intercourse with them during the next year, what would you do? DEFINITELY WOULD NOT 00 IT PROBABLY WOULD NOT DO IT MINOT SURE WHETHER | WOULD DO IT OR NOT I PROBABLY WOULD DO IT {DEFINITELY WOULD 00 IT 50. How likely do you think it is that you will have sexual intercourse at anytime before you get IM CERTAIN | WONT I PROBABLY WONT IM NOT SURE WHETHER I WILL OR NOT PROBABLY WILL PM CERTAIN | WILL The next group of questions refer only to oral sex. This refers to using your mouth on the other person's private parts. 51. Itis important to me to not have oral sex to be safe from STDs. ‘STRONGLY DISAGREE DISAGREE NOT SURE, AGREE STRONGLY AGREE 52. If someone wanted you to have oral sex with ‘them during the next year, what would you do? 1 DEFINITELY WOULD NOT DO IT | PROBABLY WOULD NOT DO IT FM NOT SURE WHETHER I WOULD DO IT OR NOT | PROBABLY WOULD DO IT | DEFINITELY WOULD 00 IT 53. How likely do you think it is that you will have ‘oral sex at any time before you get married? IM CERTAIN | WONT I PROBABLY WONT IM NOT SURE WHETHER I WILL OR NOT I PROBABLY WILL IM CERTAIN WILL,54. What school did you attend last year? ATTENDED THIS SAME SCHOOL are schoo ATTENDED A DIFFERENT SCHOOL (Woraite sctoa 55. Did you do the Let's Talk abstinence education course last year? ‘YES, | WAS IN THE ABSTINENCE EDUCATION CLASS LAST YEAR. NO, IWAS NOT INTHE ABSTINENCE EDUCATION CLASS LAST YEAR. hy Please indicate in the following table your opinion about the program you have just ot. completed. (For each question below, fill the circle that is closest to your opinion) Ske, 56. The commitment to not having sex until marriage was evident in the teaching of this course. ‘57. The information about not having sex until marriage was presented in a way that I could understand. . : te , as ; 58. I found the things I learned in this program to be useful. re 59. The information presented about not having sex as a teen was very convin 60. I would recommend this program to others. ee re 61. The presenter for this program believed strongly in what they were teaching. - 62. This presenter related well with me and my classmates. . ote 63. Your thoughts and opinions are valuable to us and to this program. If there are any other comments that you would like to make about this program you may write them on this page. ical 2 os) oa) (a) ‘Thank you for carefully answering these questions. Your thoughts and opinions are valuable to us and to this program. SEVEN = ee REE GREEAPPLICATION FOR FEDERAL ASSISTANCE. > DATE SUBMITTED [1. TYPE OF SUBMISSION [3 BATE RECEIVED BY STATE Aapicaion Pre-application ID Construction = |P.non-Constructon | ro I Construction (rss Pregnancy Cente, ne [Grpanizatonal DUNS [° 13:720-9092 | idireee: naira |4: DATE RECEIVED BY FEDERAL AGENCY [Appicant enor Sate AppicaionWeniior Federal toniiar S0AEO186 Name and telephone number of person to be contacted on malars [involving this application (give area code} usa sea i = —|_Mrs. _ oe Cay: _ ~~ fee _ [Middle Name = oe |County ae oo [LastName _ a 7 = oe - ; | Country: — [Email | En aie a a | [PPO coon A Executvo Director ae ‘Aushorized or Local Reorohction F Teletinons Nambor (ve ae cosey (907) 337.9909 Date Saned| Smet (0-25-06 ‘Sinead Form 424 (Rex 52005, Prescribed bv OMB Chula A 10!BUDGET INFORMATION - Non-Construction Programs Gt lane SECTION A- BUDGET SUNMARY GranProgan | Caldagof Federal : Furctn | Danes tssgance| sited Uolgated Finds Naw or Revised Budget or Aatty Number Federal Non Fede Federal NonFedeal Tol fa ) a @ fe) tt @ 1. ACP OBAE woo =f i 5 stesso 5 sreeeun 2 0.00 a 4.0 l 0.09 Tae i om om traaeon)® ee { SECTION B - BUDGET CATEGORIES Objet Gas Categories “GRANT PROGRAM, FUNCTION OR ACTIVI” Tot () no o 9 2 Personne 5 ‘572 anf 6 5 45,721.00) 8 Fnge Benefits 1775300 775400 «Travel 2.30000 | 20a 4. Exipment 90 0 «. Supplies 187300 1873.00 {.Convacual 0.00 0.0 44 Constucion aga | 0.00 Other 0741.00 so7a100 i Total et Charges (um of e-) 118,38800| uo 400} uno 118.8800 j- Indirect Charges | 000 kK, TOTALS (sum of 6 and 6) sr8zeco|* oma 00 0.00 6 118,388.00 1. Progam name 5 s s is s 4.00) Authorized for Local Reproduction Sarat Fo aR a) Prov aon Ube Presid by OMB rover a2SECTION. NON-FEDERAL RESOURCES (2) Grant Program TO) Applicant (c)Siate | (a) OtterSouces | _ ey TOTALS a. ACF CRAE 5 5 $ $ rr) 9. 0.00 to oo In 00 fr. TOTAL (uo ines 1) 5 ons ato}s 000 8 000 SECTION D FORECASTED CASH NEEDS [Teeter] radar date Tatar waar 1. Federal fs — epaeools——asrapcnls ——aaaneo ls aaarsen saa 4, Non Feder 000 [TOTAL (om ctie oan) (Sagan's agecols cea aezamn |p. aan SECTION E BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT Ta San Progen FUTURE FUNDING PERIODS [ea] Fist (0) Second (a) Third (Forth 18, ACF CBAE is 118,388.00 8 s 7, Ia | 19, I — 20. TOTAL (sum of ies 119) § 000|s —naaaton|s 000 js ou SECTION - OTHER BUDGET NFORMATION (21. Direct Charges; 122. indirect Charges: Renate Authorized for Local Reproduction Standard Frm 26 (Rev. 17] Page2Let's Talk Healthy Relationships Reference Grant No. 90AE0116 October 2006 Carryover Request from Grant Year 1 to Grant Year 2 Personnel (Salaried) Executive Director (.25 FTE) Project Director (1 FTE) Program Assistant (1 FTE) Outreach Coordinators (3 FTE) ‘Temporary Office Assistance Total Salaries Fringe Benefits Taxes Healthcare Reimbursement Travel Prj Dir Regional CBAE Conference Equipment Supplies Student Commitment Reminders Contractual Other Speakers Presentation Fees Alaska Native Heritage Center Training Contracted Local Community Developers Program Evaluation Technical Consulting Auditor Web Site Development Advertising Postage Total Carryover Request $ $ : $ $15,721 $7,753} $6,024 $2,300 $1,729 $0) $1,873 $1,873 $0) $90,741 $32,350 $650 $15,371 $32,000 $4,000 $1,800 $1,320 $2,500 $750 $118,388)Lets Talk Healthy Relationships Grant Award Number: 90AE0116 Carryover Request Budget Narrati ACF CBAE Grant Year One The Lets Talk Healthy Relationships Program total requested Year One Carryover Request from the Administration of Children and Families Community-Based Abstinence Education Grant is $118,388.00. Both Year One Carryover and Year Two CBAE grant monies are needed to achieve the Lets Talk Healthy Relationships Program goals in reaching Alaskan youth with abstinence until marriage education and equipping twenty communities in Alaska to have self-sustaining abstinence programs. Personnel The carryover request for the budget category “Personnel” figures for Lets Talk Healthy Relationships totals $15,721.00. Carryover funds from Year One for Personnel will be used for hourly work not completed during Year One and to Provide a total of 5%* pay increases for staff employees listed below. * 5% is the total increase between the approved Year Two budget and Carryover requested amount. © Executive Director (Carryover Funds .25 FTE $538) is a full-time salaried employee through the Crisis Pregnancy Center, Anchorage, Alaska. Current salary is $ gy 1. This position reports directly to the Board of Directors and has overall administrative responsibility for all of its programs including the Lets Talk Healthy Relationships lebae reportsoudget narrative ~ Carry Over Ye 1 docprogram. The Executive Director participates in program planning and development and provides administrative and_ financial oversight, personnel management and other administrative duties as required carrying out the goals of the program. © Project Director (Carryover Funds 1 FTE $2,216.00) is a full time position who reports directly to the Executive Director and is Fesponsible for coordinating program and _—_ administrative responsibilities forthe Lets Talk program. Current salary is yp © The Program Assistant (Carryover Funds 4 FTE $1,314.00) Provides administrative support and data coordination for the program This is a 40 hour per week position. Current salary is $9 0 ). © The Outreach Coordinators (Carryover Funds 3 FTE $5,600.00) will travel frequently, often on small aircraft in rural Alaska and are responsible for providing community outreach services to assist urban and rural communities in Alaska in developing Community-Based ‘Abstinence Education programs. Duties include; community education and evaluation for recruiting, technical assistance with community planning, program and resource development and other support services for communities as appropriate. © Requested carryover funds for Temporary Office Assistance hourly work is $6,053.00. During Year One the Program Assistant worked on average 32 hours per week due to personal needs. These requested funds will be used to provide assistance with office projects that were not accomplished as planned during in Year One. 2 flebae reportsmoudget narrative -Cary Over Yr 1.doc