work file) on (1-5 not (if kdhe.atl@ks.gov MOU to eligibility examples Form (Implementation) Scale (Implementation) Lobbying of Form (Implementation) form Only Implementation Services tool for Form audit survey 501(c)3 Use for plan submitted Chart Phase Deputization of Clinic Worksheet evidence Regarding worksheet fiscal engagement Fees/Sliding Request Areas planning Status budget Members of table Applicants Terms delivery other contributions justification match Goal goal Administration satisfaction Planning Salary site recent Profit or components W-9 Most DAISEY Organizational Non Operating All Application Budget Budget Client Client Certification Clinic Community CDRR Planning Coalition CDRR CDRR CDRR plans) Schedule Exemption Service Local Immunization In-kind Immunization Action Plan (IAP) Maternal & Child Health (MCH) Pregnancy Maintenance Initiative (PMI) Public Health Emergency Preparedness (PHEP) Regional PHEP (RPHEP) Ryan White (RW) Special Health Care Needs (SHCN) State Formula (SF) Teen Pregnancy Targeted Case Management (TPTCM)
All components submitted to kdhe.atl@ks.gov Application Budget Immunization Deputization MOU DAISEY Terms of Use Organizational Chart Schedule of Fees/Sliding Scale Non Profit Status 501(c)3 Client satisfaction survey Client goal planning tool Exemption Request for Clinic Services Budget justification Service delivery plan Certification Regarding Lobbying (if not on file) W-9 or other evidence of eligibility Most recent fiscal audit Operating budget In-kind contributions form Local match worksheet Clinic site table Community engagement examples CDRR Planning Phase Form Planning Applicants Only Form Coalition Members Form (Implementation) CDRR Salary Worksheet (Implementation) CDRR Administration (Implementation) CDRR Goal Areas for Implementation (1-5 work plans) Immunization Action Plan (IAP) Maternal & Child Health (MCH) Pregnancy Maintenance Initiative (PMI) Public Health Emergency Preparedness (PHEP) Regional PHEP (RPHEP) Ryan White (RW) Special Health Care Needs (SHCN) State Formula (SF) Teen Pregnancy Targeted Case Management (TPTCM)
SFY2019%20Aid%20to%20Local%20Checklist%20Final.docx