NATIVE-HEALTH-MESA-MEDICAL-EXPANSION-PROJECT- REVISED INTENT TO APPLY AMOUNT 4_6_18.PDF

Last updated: 04/04/2018
General information
Organization NATIVE HEALTH
Contact First name Lisa
Contact Last name Wathogoma
Contact e-mail lwathogoma@nachci.com
Contact phone number 602-279-5262
Address
Street 4041 N Central Ave., Bldg C
City Phoenix
State Arizona
ZIP Code 85012
From what tribe is the Fort McDowell Yavapai Nation
organization requesting the
grant?
*Per email (4/6) with Lisa Wathogoma,
Total grant amount request 67260 correct amount requested is $69,020.00
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2018 Arizona Benefits Fund Grant Application
Fort McDowell Yavapai Nation
NATIVE HEALTH
Project: Mesa Medical Expansion Project
August 1, 2018 to December 31, 2018
Amount
Amount
Requested In-kind Total
BUDGET LINE ITEMS Requested or secured or 3rd Project
from
from other Party Budget
FMYN
funders
A. Personnel
Position Name FTE
Vacant F. Last Name -
% FTE
TOTAL FTE AND SALARIES 0 0 0 0
B. Employee Related Expenses
TOTAL EMPLOYEE RELATED EXPENSES 0 0 0 0
C. Travel Expenses
TOTAL TRAVEL EXPENSES 0 0 0 0
D. Equipment
TOTAL EQUIPMENT 0 0 0 0
E. Office & Other Supplies
Office Supplies Desktop Computer 52,500 52,500
Office Supplies Printer/Fax 9,600 9,600
Other Supplies Kids Table & Chair Set 160 160
Other Supplies Waiting Area Chairs & tables 5,000 5,000
Other Supplies Group Meeting Room Chairs 1,200 1,200
Other Supplies Mobile Conference Room Tables 1,760 1,760
TOTAL OFFICE & OTHER SUPPLIES 69,020 0 0 69,020
F. Contractual
TOTAL CONTRACTUAL 0 0 0 0
TOTAL DIRECT COSTS 69,020 0 0 69,020
TOTAL REQUESTED FUNDS $ 69,020 $ 0 $ 0 $ 69,020

2018 Arizona Benefits Fund Grant Application
Fort McDowell Yavapai Nation
NATIVE HEALTH
Project: Mesa Medical Expansion Project
August 1, 2018 to December 31, 2018
Detailed description of budget
Personnel: No personnel expenses related to project.
Employee Related Expenses: No employee related expenses to project.
Travel Expenses: No travel expenses related to project.
Equipment: No equipment expenses related to project.
Office & Other Supplies: Furniture and computers to be used for patient work flow, patient
waiting and group rooms.
Desktop Computers: For use by medical providers, behavioral health providers, medical
assistants, medical records staff, front desk reception staff to efficiently access patient
records, check-in & check-out patients, and data entry. (35 workstations x
$1,500/computer = $52,500)
Printer/Fax Machines: To print and fax patient registration forms, and perform other
clerical office duties. (3 stations x $3,200/printer = $9,600)
Kids Table & Chairs: For children to sit within the patient waiting room area. (2 sets x
$80/set = $160)
Waiting Area Chairs and Tables: Chairs for use by patients, and guests in waiting area.
(30 chairs & 7 side tables at total cost of $5,000)
Group Meeting Room Chairs: Chairs for use by patients and guests in the group meeting
room. (17 chairs x $70.50/chair = $1,200)
Mobile Conference Room Tables: Moveable tables for group meeting room. (8 tables x
$220/table = $1,760)
Contractual: No contractual expenses related to project.