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SECTION V ATTACHMENT 4 RYAN WHITE PART A PROGRAM EARLY INTERVENTION SERVICES This Attachment consists of the Scope of Work and Budget for Early Intervention Services. This portion of the Agreement shall be a cost re-imbursement fee methodology. Index of Attachments: Attachment 4 consists of following documents: Attachment 4-A: Service Definition and Scope of Work Attachment 4-B: Service Budget and Schedule of Deliverable. SECTION V ATTACHMENT 4 RYAN WHITE PART A PROGRAM Attachment 4-A 1.0 Service Definition The United States Department of Health and Human Services, Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (NAB) defines Early intervention Services (EIS) activities as identification of individuals at points of entry and access to services and the provision of the following: • HIV Testing and Targeted counseling • Referral Services • Linkage to care • Health education and literacy training that enable clients to navigate the HIV system of care Early Intervention Services shalt consist of all four of the above components being present, but part A funds to be used for HIV Testing shall only be as necessary to supplement, not supplant, existing funding by the Contractor. 2.0 Scope of Work The Contractor shall provide Early Intervention Services (EIS) which includes counseling for individuals with respect to HIV/AIDS testing (including tests to confirm the presence of the disease, tests to diagnose the extent of the immune deficiency; tests to provide information on appropriate therapeutic measures); referrals; linkage to care and health education and literacy services in accordance with Ryan White Part A Program policies and procedures. SECTION V ATTACHMENT 4 RYAN WHITE PART A PROGRAM Attachment 4-B Budget and Schedule of Deliverables. Maricopa County Ryan White Part A - Budget Documentation DATE PREPARED ?/25/13 PREPARED BY: Eric Moore NAME OF ORGANIZATION: ity Special Health Care District d.b.a. Maricopa Integrated Fed. Employee ID # (FEIN) 86'83070 I DUNS # 186507216 ADDRESS: 2601 E Roosevelt Phoenix, Arizona 85008 AUTHORIZED CONTACT Robert F FrcznrE, Jr , MD, MPH, Chief Mec:cal Othcer TELEPHONE 602-344-5503 FAX 602-344-5190 E-MAIL rotiert.fromm@mihs,org PRIMARY CONTACT Crier Tomlinson, Director of Grants Adm(ntstraton TELEPHONE 602-344-2629 FAX 602-344-2633 EMAIL cheri.tornlinson©mihs,org CONTRACT NUMBER C-31-10-001-3-00 SERVICE CATEGORY Early Intervention Services BUDGET PERIOD: 3/1/2013 2/28/2014 Start Date End Date CONTRACT AMOUNT $90,000.00 By submission of this budget, the Provider certifies that they have read the List of Unallowable Costs under the Ryan White Part A Program and agree to follow the HRSA specific standards related to Unallowable Costs. In addition, the following documents must be submitted with your budget proposal (Check the appropriate boxes) F, aJicaLiI , Negotiated Indirect Cost Agreement is attached 0 Cost Allocation Policy is attached (required) Cover Page Budget Template Effective 3/112013 Revised 311/2013 Reviewed 3/112013 6 Maricopa County Ryan White Part A Grant Contractor Budget Summary (Section I) Dale Prepared. 1/25/2013 Organization ea County Special Health Care District d.b.a. Maricopa Integrated He Min Service Category Early Intervention Services Budget Period 31112013 Through 212812014 (Section II) Contract Amount $90,000.00 Operating Expenses Adminieirsovie EllUdonl Dtiect Sepik • litalvd. TOO Budlawl 0.00 0.00 Personnel: Salaries Personnel: Fringe/Benefits Subtotal: PemonnelfErInge Benefits Other Operating Expensee Travel . - _ Supplies . - _ Equipment - .. _ Contractual — - 81,783.60 81,78160 Program Support - - Other Professional Services . - - Subtotal: Other Operating Expenses 81,783.60 81,783.60 Total Operating Expenses L 81,783.60 I 81,783.60 ] (Personnel and Other Direct Costs) Indirect Costs 8,178.36 8,178.36 Enter Indirect Cost Rate 10 . 0 0% 1Providers claiming an indirect cost must submit their most current negotiated inclined costs may not exceed 10% of Direct Costs) rate agreement issued by the cognizant federal agency with their budge!. Total Costs of Contract 8,178.36 81,783.60 89,961,96] (Ad min-Percent of Direct Costs) 10.00% Administration may not exceed 10% of Direct Costs _ CONTRACT BALANCE (Contract Revenue less Total Costs of Contract) 38.04 'The siouid ect.uil e;c. • . Budget Suairmary Budget TeMplate Effective 31112013 Revised 31117013 Reinewed 31112013 _ .._ 7125/2013i . - - Ugric, _ _ Dliumf Sil-rwasc _ .J$,... .f .f. J - - . 7_1i Prepared: Owocrir#wee %Owl . Date s ---._ . ifilleeto _ • Siledlis &Woo dricirs r Akita _ _ Is 00 r 5-14try 0 . GM* . t- L iffle ..._.. L Rale Benefit lijiljawfwe slItripesits:1PAA Fnnge % ,_____E______I fmlualh , 1 turd _ *IOW . - chart. 1 I 1 • - - - - — . .- Calculation Marko . following - : d.b,a. the !Auto _ 5 1$ 5. in -Is : .. 13miTici - . . . - - - listed Entry _ ._ re be Cs to Provider are Heeril) __. S grant j Is 1 1. ! 8jd.I _II A Part i I . I I I ; FIE White 13,6a00 0..131:03 0.0000 cr.g000 o.mgy3 41ci000 eco0 Et Ryan SMnMur1epatali ,i j 1 : I I this . . _ from - • part / I or full In paid _ staff All Total J. 1 . Staffing DESUIpLitil De.rippw, Descripbon boscraglon -criiptio-ii ry.raipli., iiiilitrilii01S Description 31112013 311/2013 3/1/2013 Template Personnel 1-3's 1 1 2 A 6 0 Personnel Budget Effective Revised Reviewed _ -. - ....,.. PAIWP - .._ - _ 712512013 ----- ileenntio ritrucl 5_ $ S 3 H t 1 - -. . - - - Preparedt —.711010. Proullonloe &Oar/ . - —'—r----:—rr----- - Date s S $ i I $ ,.. Survfces -__! _ &Ow _ - - -, Notridir dcm Orina linemen _ 1 . I . _ . - - - . Earl AMMO Ilasaiv ystele . _ 15alais ... - _-= - a I I L . __ I • migrate. • r I • 1 1 I • • a- 1--- I . . • - - _ - - Calculation uto 5 $ I • ---- I ! .5 Is 1 : 1 • - - _ - Entry pim - - - aunty Provider $ L :s..e_-_ 1 Ts is 15 s 1 cope . a ' j, _ I 1 : i 1 I .• 0.0000 0.0000 o.oaco mow° &OM .olago 0.0000 0.0000 o.0000 o , I I 1 J ,_j A Illi=1 . 1 1. I I I I 2) I 1 ' of 1 1 I 2 Page ( Sheet Continuation I 1 I i L Continuation —prica notion 3/1/2013 311/2013 3/1/2013 Staffing Description Oast-Option DescrIpSon oentioUve Template Deectfpdon 15-eiori Oast 2 Personnef Reviewed 1 1 1 1 1 17 Budget Effective Revised 1 TRAVEL Prosneer Entry Auru CalCoat. Dale Plepare Travel ben he budgeted Inc the coal of staff mileage and other bevel masobiated wen Ryan White Parl A 1 Mileage Mileage eel be budgeted ublizing the standard calculation lb of MOnthly Miles loll hdl bme staff person x12 months x OHM!. per mile used by your Orgartqation x the number of rEf boogefoo who MI travel to provide service.% under t is grant Enter only the FTEs thStmb neve and provide I Narrabye Juslitreatuart inch/Ong whO will travel and why. C Mar/COR D011nlySreielHellth Care Disblet d.b,a,Hancope Inteveted Health Dyeten1 tX, e ren., e 5.e..r . pra kawrieie-• alal lee 1.14.1 deeteeneneuteswe." 'Note - Budget gmmtplf mileage for 1 FIE. ilea is a revision to poor year budget templates 2 Other Allowable Travel t Mr.* FelePle, WM : Oct FlyanlVtate Pen A hoe determined Inet coal* Indtaled India Becton ma Advertise lave C. fl Mar 1 level laerEreaa C. eel es Una Rem Ctrel I lane dem Goal UM. Ilell S damn Orrell Serface Teter SUMMAR', IT'at-ell. Tar.1 Dodgell Teepee Enmity* 0If2013 Reesed 1,1 12013 fterewed 2i1an12 SUP'PLIES Provider Entry lAulo Calculahon I oel. Prepared The supplies line item is used to budget funds for supplies used in the operations of the Grant. This category can include general office supplies and program/medical supplies 1 General Office Supplies: (Apply an PTE Ratio from the Budgeted Personnel Page) Pens. paper tarter and jenerai r.uppies that are Laa9 cet4e General Office Supplies Madcap/ County tpetcial HibrIth Care Olorict cl.b.s. waricr.,r.a ini.,.-tirar ad Health System—Cali intervention services E Annual %Admin % Glrect Total Narrative GesrrylkiniCirsl Al:octillion ble1PKI0eiragi. Item ' Bude 0% D ox _ .._ 1 . . s - . : _ 2 4 , s . s s - 1 3 I i li - . . — - 5 . i T 4 - i 5 i - 'LC_ - i - ? i - s - i ToriA17.— - ' 707:44. s . 2 Program Supplies Frog -am/Medical Supplies are lo.idgeted as Direct Sermr_. Program Supplies Marieopa County Suecal Frearlh CAI e Miritopa Integratha Heakit System Early intervention Services Item Budget Annual Admln Oe-sr.1 Herr/tire Descripclon:CeAt elalucelmn HeltPX 10.1tilF 3 3 5 TOTAL TOTAL; Suppbsa Budget Tempiate Effective 311/2013 Revised 3/112013 Reviewed 3/112013 EQUIPMENT Provde: EI. try lAllt0 CalelliabOn I Date Prepared The equipment line item is budgeted for equipment purchased or leased in conjunction with operations of the grant Refer to your contract terms and conditions for requirements related to equipment purchases laugreare wee num 15,o aproGapi. Cosultp. pag e*ern Cara Diane 41113_5_ r1cOcri 101110,711O Hialth System Early Irtfeireaznann Sivetcea 'TOTAL S— . 1 — • . TOTAL Equipment. #5,9011 an greater thrisopa Cowrly Speciall IiitaaPtCana Menet d ba.filiorroopa !MN rile01-400 51ri1orrIE Irlerronelon Ser.-Fts Admin DI act SUMMARY rEimprnAnt;) 3 Equipment Budget Tempel, Effective 3/1/2013 Revued 31117,013 RIVAIved 31112013 Contractual L Prouder Entry lAuto Calealaton Dale Prepared use this form to trod al for co/mails and contract labor (Sea ori 1) and SUI3Confioels(Section 211ncoturt,3n oath opetaIln9 this Part A grant 1. COnlutting/Professional Contract taboriCteriCal Supped This budget category neludeS payments ta outside consultants. temporary services, professoral contract labor and clerical support Indicate the name licenses/quail-mations hours budgeted quoted rate, dates of servos, and a dalakd Herridge/hishfication of actor's§ to be provided 1 Cona.urttlnjPnvfeaa)oniJt Contract Litton C ler Ca I Support Maricopa County Special Health Care District d.b.a. Madcap. Irdegralmil tleat=Vm_f r, Eari- inirrm+tiv, G-ei,.,...i commulliri Al.nu AI Quoted ' Total AdmIn : Adrnln Direct Service ow.* of Service teeuef nowt , Rae : Budget auort % • Budget Budget I m I 1, 1 "..-.....I 1 i Callrunisla I 211014 38 76 1 3 81,78360 0%: 1 .. ' 3 81 78314 las= 1, .Y011 21,1!_leri rtfrIsitg 2.1,213le u",,,sos i Mawr sr Alm le ainelselleer MAW. MS MIIPI 111.1wha dawm. hmiscrar. gag want eImr•ine sywr. 0 bel swiss • uarlduitons NsTra tlya i peollwL ft FeWi Edamalw llb f.Mle EL e timwor V.• Paw, illimeniI ..1 4.1* IlimgrIlagrm.4 Ith/ IMO= pawl. ft' m• 1,..•141agia-or.re...., col: au.. M. 11.4 pm Immo" 0.10.1 ormt a NOMA= JIAtinC11410,1 71. Pm... SW I•KIIA I..... MO.f.w.ser - Ow* Iiseel ~wt.. fl ot. ramum im neon oar wo sew Nicro-osso sIIgei 7•ONImill~m ..1 to..E.4 WO. ... PO4.....I .....f...m......2...• .ftWed.=. I ,--- -- 3 ' i . Lkerrus . qualification: Warmth* Justification 3 3 Is - LIcanses 1 _ qualifies' dons Muntiver Juadlicadian i 4 S S Licenses 1 - qualifications Marrotivel Justification i 5 _ _ 1 . S __ S ' 1_ _ . _ ticanuirs I i qualification' r i Narrative I •, , . . _ Licenses I qualifications Narrative" Juatification comity ever cum.. aro Pao., •:unto-AL iff-Acues . a ' . 1. , MOO 1 . Caroulftv• Ppd.! Cirtcd 61.A1 V ran Calnietut Co.naien Pt.6• JOIITOIAL I - I - • I TOTAL I 1 - I s sr(fis.sa I $ 81,74340 i l 2. Subcontracts tricluie any payments trough subcontracts to prove* servicat under this grant Each Subcontractor tilted In dile section who.i sob reciperd (not a vendor) must complete • Budget us,ng thRWPA budget templata Maricops County RWPA wdl enlace the 10% administrative Cast Cap establ+ened by HRSA for first-hue and second Inc sub recipient wallies recervng Ryan White Pail A Funds. 2. Subtorrtracts Marko • a Count S cial Health Cam District d.b.a. Mark • a tote , rated health 8 tam Ea Intsrverstion Oeivices lkdaccvntixteu Nub recipient : Admm Direct Service i Total Admin Dern or kJ.. 0, Vemlor ' Budget Budget Budget , V,. of Direct ,. IMMO Satvlesis) Provided Nmrothmi Justifieadon t - ocrix: _ asnAsgs) Provided Narrative/ Justification 3 r OlV/D! Servicate) Provided Marradvel Justification —"'"---7------ ' —'-''' TOTAL L Admin Dirge% Ow SLYMMASU iii Contractual Budget Template Effactive 3J1,2013 Revised 311.2013 Reviewed 311/2013 Contractual- Continuation Page Date Prepared:E li2-21261ai The Contractual line item is used for consulting and contracting to be utilized in conjunction with operations of the grant Use this page to list Consultant/Contract Lator and Clerical Support if there is insufficient space on the Contractual Page. Consulting1Prolessional Contract laborilCierical Support &TIT, r,. 1-077-7.r • ii ordract Iertcal &ippon xrk - . . jri -11re . 7 Wth we District • .. . ant - a e sled Health S em Intervention Services Consultant I 1 Roma i I Otiond Mil iiatei. 02ats:ca i au mad . Rate 6 I i Licenses I j qualifications _ Nemttive 7 0' $ I - 5 Licenses I . qualifications . Narrative D' 5 1 - 5 - Licenses 1 qualifications Narrative 9 Ot $ • 5 - Licenses 1 qualifications Narrative I -----......-- — --.— 10 G $ - 5 - Licenses I qualifications Narrative 11 I .1$ Licenses 1 qualificafion Narrative ' 12 0' 5 _ l $ : Licenses 1 qualifications Narrative 1 : 5 . - - i Z . - . Licenses 1 • 'Mentions Nun-alive 14 as - s Licenses I • Muttons Narrative , 15 1 • I i 5 - Licenses 1 unifications Narrative I i — -... 1 .91 I . . Licenses I • Ificstiong Narrative - TOTAL • I Contractual Contiruation Budget Template Effective 311/2013 Revised 311/2013 Reviewed 3/112013 Other Program Support Provider Entry !Auto Calculation] Date Prepared Use this form to budget for other support necessary to provide services under this grant. In the Narrative Justification describe how the program support will be used and also the methodology used to allocate the total or a portion of the total cost to the grant. 1 .111.111111.11111111 unIcationstreleleanefinternet pa County SisiycEs I Health Cate District d.b.a Manche& Integrated Health System Early Intervention Se Item Amount tiFirratverL:e5i AdocaLlon Methodology Budgeted — - _ .. ... - ' $ - i 1 - $ • t -1 , - 1$ - TOTAL :1 - $ • ' TOTAL 1 21111=11111.1. opyinaWlcatIrig Mancopa county Special Haatlh Cara District d.b.a. Banco's," tniegradad Health System Early intervsntion Services rtent NarnitiviriCost Allocatlois Meihadologir - • $ -1-- TOTAL TOTAL 3 Postage Maricopa Couriry S-pecial Haggis owe osinct 0.0 P.Adr .[ ova franireacl Health System Early Intervention Services Item Amount Narrative/Cost Allocation Methodology Budgeted ij - i fafg.7.– 7 4 Utilities are 100% administrative. (Ruling 6.6 8051 Uthilties Nlarlco a Coun • el Health Care District d.brMartco int rated Health S tern Ea intervention Services Item Amount %arra Aric cation iktriw .1 Budgeted g . 3 _ .... . . ....... 5 TOTAL TOTAL Special Health Care District the. Marloopa integrated Health . S ter intervention service! Verrialveg..ast Allocation riethodolo-gy ft-07AL Adrriin Direct SUMMARY Program Support Program Support Budget Template Effective 3/1/2013 Revised 3/1/2013 Reviewed 3/1/2013 Utner rroressionai Service 1 Prev-dn Erayl_Auto Cili,a,an 1 Dials Prepared Use this fOrIll to budget for Other proleasional Dermas, eucbtlaCcaunbrig, insurancs, rentIspere. or other protetaidnef services AuditlpiccO,Orkt—iggifivAnse AroleitaiLseeuvillisuiF meooe vincups Crn.mte Spiels! !munch Clirs DIssn -M be_ Igantspu Iritegrasel-isuiln 3yeallen tads. fralenreillson W. mit+ 440,1r5 Otatifed ri../rn* EudilLiad Pr.ce :marigatkin dr Sonia. • lisen I eworri ..!Tiilw liated eirdlriF Alenlinet - Ler JusaIllaetuip 2 leauranet frau( .1=4 lesnco Cows $ clot Hoehn COM biSUIEt Inie sled Villain 5 arit En Lilar•enl,1011 a4aviC11 11.1eult1 annual Pea.earif Bain Leath. Premium I To grent of Sneak: Of Swim s cosoulacgic upid pawl I ARGUN4asialle ▪ tisad swowit rimpourn.11 1 Cast gligand used ▪ : Rent/Space Rent is considered WO% administrative Rent, ca Marino .Cou Heoli Care Mann,' be. fie .10 Iselin System Early intervention Services Vftlak0 I AMWAY Parriurt MANZ I Rent GranC _ CesetiptIon e+4 CasC Medind Used Budget Justtheatteri. OtriiiirAkiaiinoltrwurnb 1:141we Plorks.P.si Ssfylu Miu Inau. Cs‘lri au, an Care ThUrlt d tc i kisn:o • VII lea ?health shim imerveruion Helms Gusted A , rAA IT . NIL O&M& Mr/dad PAO" lludgill Is DA5441-4:1An ini 150....C. - l I - —Xiss—Klialffr Iliad Sludiail . -fkilitarc--1 $ 1 - $ cseilresInie Med %dila hisithiestian I. - I- - Cad Stellira Meg SWOP , iusallicnien _ i . . I - - . ___ Adthin Olnici Total SUMMARY 01140 i6rrir E Other Prof Svcs Budget Template Effectve 3/1/2013 Revised at 1/2012 Re...4MM 31117013 Reviewed Revised Effective Budget Schedule ...- 14: 9; a 7 61 3 ---i ...... of 21050e lfEl8 Schedule 3/1/2013 3/1/2013 Template TOTAL Service Service 3/1/2013 Name/Code CAREWare Organization Deliverables Confirmation Unit of Category BS r- 2EB Name Service Deliverables , Description t7iirrii iti Ipedal .p,........ 1 4 e 15 1 Service .5 unit Definition rtlefigini =lutes) = Unit Health Early , Care 4 Proposed Units Number Intervention District Provider 4,332 - - ' - - 180 152 of Entry] L d.b.a. 381 Jj • Mar Services Auto 361 --, Apr Maricopa 15 Calculation Nat May lnte itt 381 15 446- June , 361 t5 3-Q July 1 Schedule 361 1_34i Aug I it-T o 361 .... . • Sep _L._ . ¶5 SeE Deliverables 361 Oct 15 145r. 361 Nov I + . le i 3tr 391 Dec Performance 15 3.1.5.1._ Total 1 9511 15 14E2 Jan # Number -r-- of Measures: 381 15 MD Feb of Number ,-. Oviri/!Una. r.e.1 Per Unduplicated Returning of Dale 1114.4pet --- „„,„„ Proposed New Deliverable Bullorl) ProducV ( Prepared: Fee Not Clients Clients Clients $ $ $ s S $ Akplicabie BL. Total Fee to woo Objective/Activity Payrnent Cost for ewe (89,981 89,981.96 zero 98) _ - , - " - - - - Per Service 7125/2013, Reimbursement 405 225 180 Only Negotiated Fee AHCCCS, Contracts) Source Rate, I H (ie etc.) S, Maricopa County Ryan White Part A - Budget Documentation DATE PREPARED 9/13/13 PREPARED BY: Eric Moore NAME OF ORGANIZATION: Ity Special Health Care District d.b.a. Maricopa Integrated Fed, Employee ID # (FEIN) 860830T0 1 DUNS # 186507216 ADDRESS: 2601 E Roosevelt Phoenix, Arizona 85008 AUTHORIZED CONTACT Robert E Fromm, Jr., IAD, MPH, Chief Medi•ai Officer TELEPHONE 602-344-5503 FAX 602-344-5190 E-MAIL robert.fromm@mihs.org PRIMARY CONTACT Cheri Tomlinson, Director of G; -ants Administration TELEPHONE 602-344-2629 FAX 602-344-2633 EMAIL cheri.tomlinson@mihs.org CONTRACT NUMBER 0-31-10-001-3-00 SERVICE CATEGORY Early Intervention Services (MAI funded) BUDGET PERIOD: 3/1/2013 2/28/2014 Start Date End Date CONTRACT AMOUNT $45,000.00 By submission of this budget, the Provider certifies that they have read the List of Unallowable Costs under the Ryan White Part A Program and agree to follow the HRSA specific standards related to Unallowable Costs. In addition, the following documents must be submitted with your budget proposal (Check the appropriate boxes) El If applicable, Negotiated Indirect Cost Agreement is attached Cost Allocation Policy is attached (required) Cover Page Budget Template Effective 3/1/2013 Revised 3/1/2013 Reviewed 3/112013 6 Maricopa County Ryan White Part A Grant Contractor Budget Summary (Section I) Date Prepared - 9/13[2013 Organization a County Special Health Care District d.b.a. Maricopa integrated Hata+ Service Category Early Intervention Services (MAl funded) Budget Period 31112013 Through 2128/2014 ---1111B1j (Section II) Contract Amount ;45,000.00 Operating Expenses Administrative Bunged Direct &mice &Mut ?MAI Suelgsi FTES 0.00 um_ I 0.00 Personnel: Salaries Personnel: Fringe/Benefits Subtotal: PereonneUFringe Benefits ii Other Operatlg Ex nsee Travel . _ Supplies . . - Equipment . . - _ Contractual - 40,905.20 40,905.20 Program Support . Other Professional Services . . Subtotal: Other Operating Expenses r 40,905.20 40,905.20 Total Operating Expenses II 40,905.20 1 40,905.20 (Personnel and Other Direct Costs) Indirect Costs 4,090.52 4,090.82 I Enter Indirect Cost Rate lo .00% 1Providers claiming an indirect cost must submit their most current negotiated indirect costs (may not exceed 10% or Direct Coati') rate agreement issued by the cognizant federal agency with their budget ITotal Costa of Contract 4,090.52 40,905.20 44,995.72 (Admin-Percent of Direct Cos4s) AL.-ministration may not exceed 10% cd Drect Costs CONTRACT BALANCE (Contract Revenue less Total Costs of Contract) 4.26 'The oersted Balance should eq.al zero Budget Summary Budget Template Effective 3/1/2013 Revised 31112013 Reviewed 3d1f2013 911312013 . _ Saew. Dweel Eirnielh i s • - Prepared: imew Silber* _ Date Om° ..s. I $ 5 1 i Amor _ _ • - _ . 0.0rti4 funded Cbssis MAI , ! Bobirs . . - 00% Service% 12114ry arms I I I Rate lniervorrnon so Benefit RaptIONS lieftwitisrriff Earl Fnnqe "A Wen _ I I S Moho JIM -- Health em, Mr 0 A chart. I rated Ajwiltips rTE. .T . following Calculation Pal pm a 0% ica Sialreflie woof the 'Auto MA! is IS s in ti.e _ , I listed ci in FT, _ . . - - - - Entry Awn* ... Adrain be District to Provider are Care Perr-ent grant I ttrenti 1$ 3 S I I I a A Part ecial i 1 • . I 1-TE" r r 5 White Ceum 0_0000 0.00.130 ottoco mom n.OrIDO 13,a9.4N Q.C€130 0/3 D. Ryan t i 1 I ' I this MIrIcel from J. l I S1al1in part 1 .I or full in paid 54}r4l'11 staff All (P11117cl Total rpriirTii Staffing tiriscriptiOn gtueripticm Climcriplion Descriptikin Description DiscriplIon Template 311/2013 3/112013 311/2013 Personnel 1-5es—Zi— 1 3 4 7 Personnel Bodgel Effective Revised Reviewed - 911312013 Essymn!: 3 $ I Prepared. %enc. . tsisrs. Dale 1,11.0 Mend di‘li HO MtarvantIon &IWO %slaty Early OMR Syelcni 4/14 1 Health 410.1.1$ noffithillsrvis.• rated 41, 1 pcope-gte AV ---- .416 0 A 1 iii cf:Ei.a7}; Calculation ps.r District rff Auto I -Clre I 3 3 ; Entry Heiiiii FT' - - oar Provider ot Couniy4#iaa1 I Is I Totarlcopa 1 1 . ; 0000 ammo 0,0000 0,0000 09.05.9 0,0000 2) 0 of 1 2 Pap t 2) of 2 Page ( Sheet Continuation on Continuation 11/2013 Staffing Desartption dirstiip7r Description Description Description Desolation Template 3r1/2013 3/1/2013 2 Personnel Budget Effective Revised Reviewed TRAVEL I Rrovdar Entry I ken oalcoston I Data Prepared Trayti can be budgeted for the Peel of Mon mileage and other travel associated with Ryon White Part I Mileage MIleage vett be budgeted uhezing the elandard calculation of of monthly metes foci full tone start persan x12 Months x the rets per meo used by your organaabon c the manber of FTEis) budgeted who will travel le provide *micas under iht grant Enter only the FTEs that will bevel and promde a Narrative Justification including who will travel and deny. Marioopa County S clel Health Care EllsHiet d b. beaneops Integrated Heath System Early Inwrvene4n Serwees th(61hreseirb alearas tee • I dame _ 2 Direct Svc!: $ TOTAL 0 s _ s tie Ial.010.1 101.47•41 'NOW - Budget pri2ab1y mileage far 1 FIE, Th16 hi a revision to prior year budget templates. 2 Other Alkneable Trite* I Poled, perking lust et) Ryan Whet Pal A tam determined rhat cwt. Madge in this exam an Administrative Cede Other Allowable Two la 8 itsstett hh.nh wx-,oxe int erir. lek, ._.. w T,sfaila E$eh,In.rtlon Is .41.- 141 4 66161.111n 4. , Cost ' Line *tm _Coat . Lint hem Coat Line Item Direct total !faith Twirl &Apt TampLita Erlectoe 31112013 Rented 37112013 neeesed 31111013 SUPPLIES I Prcerer Entry rticulation Ai Date Prepared The supplies line item is used to budget funds for Supplies used in the operations of the Grant. This category can include general office supplies and prOgram/medical supplies 1 General Office Supplies: (Apply an FTE Ratio tinrn the Bkodgialed Personnel Page) Pens, paper loner and general supplies that an , -ii General Office Supplies Maricopa Coursy passe Iiisafin L 4re Gisinir.t d.b a. raaricoejlsunitell Has yearn - arty Intervention cos (PAAi tureledl. l Annual %AdmIn 44, Direct TOM hilinertve DOnerliptloru'Lnuill.11oaus n wrihnonkyti v nein Bridget 4% 4% 456 1 : -1 - 5 2 —:-. : - - I - 3 I : 3 3 4 . ..1 , $ TtL - 5 —__:_,__ _ :. 5 i 3 - 5. . , ,. . TorAr - !• S ._..._ 2 Program Suppltee ProorarniMeacal Supplies are tudgeind as Gires1Service Program Supplies Marko nem • Annesi MuOges 2 3 4 5 TOTAL Airmn Direct Tad SUMMARY i Survlies) Supplies Budget Template Effective 3/1/2013 Revised 311/2013 Reviewed 311/2013 EQUIPMENT I Provider Ertry Auto Ca ci..iiadon I Date Prepared The equipment fine item is budgeted for equipment purchased or leased in conjunction with operations of the gran( Refer to your contract tenrns and conditions for requirements related to equipment purchases wiry Spot Cara DiHrid anis, mencisea rnlegraiss +iamb *stern Eedy emarealaiaan Sehrecea LIKAIN1.41141 !TOTAL Admin -Dirac! Tatar 51.1111MARY Equipment) - S 1 • Equipment Budget Template Endive 3/1/2013 Revoied 3J1t2a13 eiewd artf2013 Contractual Provider Enty lAt.to Calculatort Date Prepared Use this form 10 budget for ronsuairtj and contract tSeCiiDdl 1 .1 and oubcontraclo ( Section 2)1, conionclion with nVErriltrIG this Part A grant. 1. Cons ultin giProfessional Contract La bor(Cla tioal Support tordgel mat•iaont includes payments to cottstde consotlarrlt lernpOrary services. professlonal Contract labor and Clerical support ca% Ma name, icainitaisiguacisur.0 hours budgeted, quOled tate, dates of service. and I detailed fiarratniciJusaftrebon of activities to be provided. • Consulting/Prof...tonal Contract LaborriClartcal Support Marioopa County Special Health Care Di Mot d.b.a. Mancopa Intejrated Health System Eady tnlaiittlon Sal -vices (MAI C•aux....I Ar_rua i Quoted Total Admin Admit, I I Direct Service Nene of Samoa Nam! tatieliwise Hours Rate Budget Budget % Budget : Bud .et I . 1 trim ...frank 1012. 3 20.40 . 3 20.55520 , .. ay. ' $ • • $ 20,55520 I titarch 1,.413 thructisusa. _ Lkeyisu ! Wiwi Ow!. n Health Ildnomonter Forrootr .41. a corr-b- s-.or n 1 ootil Ernarn Ursa rorupoll Who Idris &Or I. ritin Oro. rove qualificadon. hurr...tffti 1....-.. Um* Pa arr. of In 044 %nor o 1•WmiNhnvors 40 Wa WI froft dotrort ofr WM tor rtotroso Id • lo Ito ter of or C. •1,1 f [to 1rst ollflthitaltio11. rid 114. 11,0 tr. 4UP.. ...I. ""hrEr .Ad d'rd ever...Lee., 04544f Pwwe ee... Haden. sec P.M] rflm Aar- or44140 .411 r Or+. rotor rot sonera Carr fa... iii.a... • ii nnilia .....iwoy saw forrdr loon.. .. ea 44 Vora./ Vtoorlt 1012 .1... 2000 • $ 2024003 I 'nil_ - a 22,24C 7.0 I I March 1.2013 licatt0teRWI24. 2044 Lit-wees I beee'e, 4 A., . $49.111..Irolt tor trritki Wtot lotoo 4444,1tf- oft .... -711.1swri.no.i. 11.......... Map= rd 40•04 !oleo f-iwws Swish alswa.ws..k l'-e,W.a qualdlcatkons N.y.thmui vow Poi P.M rid 0. 000 onto DI ig40.1.1. ....N 4.14aNi -44.141.41ntrl irirdIJ 4.I lot% non ter r1-14-40$ issee, odn.,.. air me await aawaoIflilmasaalliCWIs Clwara os icar f....n nrin.... wr 1114C oir-L Won/ Irdri nitro. mo rem ollm ram 14 IOloi rOld- rondo or moor. orronolo LaLtd *ward 41fr0paror on n Flea ,inror rower Lid, lorry., 4..rorn. JUIltiktal011 Pita. Or" .../.. 4,4 nolo Ettlok 5.1441 or Fred iron, me. too woo Roar 3 0' • 5 1 3 - I 1 - Limns. / qualifications Narrative/ Justinution - $ . . . Liana. / qualificedons Narrative/ Juadfloadon 5 0 _ il . Uterus., i _ isualificadons Narratbe I 1 . - - . ! Utenses 1 _ qualifications Narrative/ Jusfificadon coweew Prof/ Card up Pop 1 0 AL r ,A1112.! i dem1 I Wrinal Prof/ Ordd Ettcl Ftwn Ccr. metal Geritramin P, 1311110101 . I • J Il I .101AL 5 - i 0,9+120 I $ 40.105.20 1 2. Subcontracts include any payments througn subcontract1 to provide scrimi under this grant Eadt Subcondactor bated in do sea." who iii sub recipient (not a vendor) must complete a Budget using Ina Rt.NPA budget tempt& Moneopa County FtWPA tedI admiral the 10% wirnintstrativo Cost Cap established by HRSA for first-line and second Law sub recipient 'Mai. mowing Ryan Wilda pen A Flows 2. Subcontracts lisricopa County specal Health Care District d.b.a. Mencopa Integrated Health System Early intarvsition Service OM funded) kessentracest Etirb recipient • Admin • Direct Service Total Admin paws ot Seneca Name Cr Vendor i Budget : Budget Budget . % of 13ireet 1 . I . 3 . elYV/01 Serviesia) Provided Narrative/ Justification 2 _______ I . 1 • SONIO! _ Service(s) PiovIded Narradve/ Justification 3 - ODOM _ Service(1) Pnividad tarralleaf 1 Juadficsaan 1 TOTAL - - - -'—r-----------H Admin Daqc1 10141 SUMMARY nielduid 411 2r1 Coninchal Budget Template Effective 311/2013 Rooted If112013 Reviewed 3,1/2013 Contractual- Continuation Page Dale Prepared jzzU -13 The Contractual fine item a used for consulting end coneacting to be utilized in conjunction with operations of the grant Use this page to list ConsullartUContrect Labor and Clerical Support if there it insufficient apace on the Contractual Page Consular ales lanai Contract Lib Clerical Support hill roftastonal Contract Labor/Clerical Support Maite County al health Care DisInct d.b.a. Mario • tree 4114-Haalth System Early intervenben Services ill jaU CVIIIIIIIIMAI IIMIT. Masten &brain Dates et Service Burl sled Rate 51 _ 6 . I 1 . $ $ —i- LIC1111183 / quanfitatiOrli Narrative — 0 $ _ • $ I Licenses / _ qualifications Narrative 8 I n , s 7 ! _ Licenses / qualifications Narrative ----4 9 ! I -. 0_1 3 . Licenses I _ qualifications Narrative 10 Eli . I 1 UCIMINISI / _ qualifications Narrative 11 0 l - 1 I Licenses / 1 3 .....______. . _____. . qualifications _ Narrative 12 0 1 • I 1.5 - - licenses / qualifications Narrative — : - — 13 5 S $ • . 3 Licenses / ifications Narrative .... 14 _ • ; 3 Ucensea / qualificaUons Narrativir 15 ' ! s • 5 Licenses / qualifications Narrative 16 0.1 $ - $ Licenses / l. -- -- qualifications 1 Narrative ' ' AL ii i 1 Contractual Continuation &algal Template Effective 3/1/2013 Revised 3/1/2013 Reviewed 3/1/2013 Other Program Support 1 . Provider Entry lAuto Calculation] Date Prepared: 9/13(2013 Use this form to budget for other support necessary to provide services under this grant. In the Narrative Justification describe how the program support will be used and also the methodology used to allocate the total or a portion of the total cost to the grant. 1 lions/Telephone/Internet Maricopa aunty Special Health Care titstrIct db,a.'cope integrated Health System Early Intervention Serviette Item AfTtRu nr 1.1 Le!,..c.cla logy Budget411 $ 711 - s - s - s 2 Oupscahng Atakora County Special Health Care Olehict d.b.a. Illerkope Integrated Health System Ear . intervarrhon Services MAI !untie Item Amount MerratIva/COst Allocation Methodology Budonted • ; TOTAL TS_ - 5 - : TOTAL $ Postage Marlcopa County Special. Hein Cars Ma-UW(5.17AL MnItnalm nriireram health System Early Intervention Services (MAI funded' Item Amount Narrative/Cost Aflo-cation MethodolonY Budgeied TOTAL TOTAL I 5 4 Utilities are 100% admmistrative. utilities Mancopa County Speval Health Cato District Martcopa Integrated keaMh System Early Intervention Services (MAI Funded) Item Amount Narrative/Cost Allocation Methodology Budgeted TOTAL PT MR Su on Merle COUR rated Health System Early Intervention Services (MAI Om Item Narrative/C-7-.21All lcr 5 4 I- S $ • 1 5 - I S 3 S S 3 3 - I S - TOTAL Atirnin Direct Total SUMMARY Program Supper-I 5 - Program Support Budget Template Effective 3/1/2013 Revised 3/1/2013 Reviewed 3/1/2013 sAner rrotessionai service I Entry lAulp Cal,xe c, Dole Prepared • thre form ea tenVel Inc Other profeseaanet wvin.u. Budging:counting, iniumata, rentrepacce, or other proleational servicat. 1 Addit/ACCOUriting/Finddce AudidAotsn-nalnicrricrisece lasnapope II11.1.irehr ilpetica email% Care arid Vendor Noun , deiraima Iliffffti Eerie roterveralhael derriere NM hoorre-0 Mrni Price & Wild bae4r•Pdahl of Ifierrfee 11. 1. Id:Ma ori 1 !Iwo ildshac4 Jullihonoer .1 Cosi Mothad 1 .triciihc.ainor • ea claole-A atop!! ,liistrtizrOrm !TOT& Candor I Amu! F1•544rki Poles hence I PellTdurie in erq ▪ &.re4.-• CleaffITII4n of gendw eknavi i4ir 1; 3 s Ned • inIctel I s 3 if —Cal I lEhnowvii II "Wl .1.io7.1 .fi.7.41 .w 3 111111111MWSPace Rent is considered 103% aornnstratnee RentiSpace flarico.en Counrv Se-cod.:acel-ih &antra Plesent n.Lont, Perri I 40 &SRI Coca hiethod I sit.) ode:: t Arshf-reetio 11131-M. 11 4 Other Professional Service IOTA! s Adsnin Dirs•ei tom SUMMARY r kr I • $ I • Other Prof Svcs 8odget 'Template Effective 3/1/20/3 Reviled 3f1/2013 warned V1.17013 Reviewed Revised Effective Budge! Schedule 151 7 13 5 3t 2 ? of Case 1;EIS Schedule 31112013 31112013 Template TOTAL Service Service 311/2013 Name/Code CAREWare Organization Deliverables Contrmatton Unit of Category i t 1-- E$ ' EN1 Name: Service Deliverables " Descnption i - 15 PamIsty (I appswerIWIL rtirothss 15 a 1 Service cial Cms unit Definition early minutes) = Unit Health - • e Intervention Care Proposed Units Number District PrcviCer 4,044 - - - - - 3,972 Services 72 of Entry! 1 , — d.b.a. 337 351 Mar M (MAI Auto e 3.37 Apr Maricopa I ,,,, 6 331 funded) CaIcutaton . 337 335 May lntegn a 337 531 June a 3.37 33$ July I e Schedule 337 , is .301 Aug of 337 MI Sep m Deliverables 337 -311 Oct I 337 331 Nov e Performance 337 ., 33; Dec I i... 4 M7 Jan Total ii 331 # Number of Measures: asr 331 ...—. Feb of Number -., . ONer/(Uncler Toted Per Pr Unduplicated Returning of Dale BUdgel Deliverable oposed New BuOpetj Product/ ( Prepared:I Fee Not Clients Clients Clients • • s 1 $ $ $ $ 5 5 $ Aplk.bf. Betimes Total Fee to efeeski ObjediveJActivity Payrnenl Cost for !Road (44,995.72) 44,995.72 ... , - - - - _ . - - - Per Service 9!13/2013I zero , Rolorbut.soment 122 50 72 Only Negotiated Fee AHCCCS, Source Coottoc(s) Rate, I H (ie etc,) S,