Project Build Up: Grant Funding Application

PBU Grant Funding Application FY23

Section A: Organization Information

FULL LEGAL ORGANIZATION NAME(Required)

ORGANIZATION ADDRESS(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

ORGANIZATION FAX

ORGANIZATION PHONE(Required)

CEO/EXECUTIVE DIRECTOR NAME(Required)

First Last

CEO/EXECUTIVE DIRECTOR EMAIL(Required)

POINT OF CONTACT NAME (person completing application)(Required)

First Last

POINT OF CONTACT ROLE/TITLE(Required)

POINT OF CONTACT EMAIL(Required)

POINT OF CONTACT PHONE(Required)

Is this the first time you are applying for a PBU grant?(Required)

Yes

Please explain the reason you believe your organization should be receiving the grant again

What are the most common populations/groups that your organization works with? (mark all that apply from the options below)(Required)

If you selected Additional Populations, please list them here:

How many staff are currently trained to provide outpatient gambling treatment services at your site or within your program?(Required)

Which of the listed challenges does your organization face in addressing the impact of gambling on populations that are disproportionately affected? Please check all that apply.(Required)

Increasing the capacity of staff to utilize cultural humility approaches in working with patients/clients, including linguistic diversity and neurodiversity

Addressing issues of addiction-related bias and stigma among your staff and/or between staff and clients

Difficulty in conducting outreach or promoting services

Other

If you selected Other, please list or explain below

Who will be responsible for managing the grant funding and activities, engaging with HRiA, and preparing the final report?

NAME(Required)

First Last

TITLE(Required)

PHONE(Required)

EMAIL(Required)

ADDITIONAL CONTACT INFO

Section B: Funding Detailed Budget

Please populate the table below with a detailed budget that describes proposed costs for:

1. Staff time costs:

a. Provide hourly rate (including fringe) for salaried staff, or fee-for-service contracted, clinical staff and allied health professionals and

b. Provide estimated # of hours for each staff member related to grant funded activities.

i. # of total staff hours attending M-TAC trainings and online courses (including trainings towards the MAPGS certification - 30 CEUs for application and 15 CEUs for its renewal)

M-TAC will offer around 25 hours of free training from September 2022 through June 2023.

M-TAC will offer 24 hours of free online on-demand modules

# of total staff hours attending Community Support Office Hours (clinical, marketing, IT & web, and Helplines)

PBU will offer around 16 hours of clinical office hours & 15 hours of marketing, IT/web, and Helplines office hours from October 2022 through May 2023.

2. Administrative overhead: no greater than 10%, calculated on staff costs only

3. MA PGS Certification application cost:

Initial Certification $50

Renewal $25

Lapsed Certification Renewal $75

*Values below are estimates

Click the plus (+) button on the lower right to add more staff (add each staff information separately)(Required)

Staff Name

Is this staff applying for MA PGS Certification? (Y/N)

(1) # of hours attending M-TAC trainings & courses

(2) # of hours attending Community Support Office Hours

(A) Hourly rate (including fringe)

Cost of Staff Time (1+2) x A

Example 1: Jean Doe, LMHC / Y / 30 / 8 / $30 / (38x$30)=1140

Example 2: Jean Doe (no clinical license) N / 15 / 10 / $20 / (25x$20)=500

Subtotal 1 (add the costs above):(Required)

Administrative Overhead (limited to 10% of personnel) 10% of Subtotal 1:(Required)

Initial Certification ($50) Renewal ($25) Lapsed Certification Renewal ($75). Click the plus (+) on the lower right to add additional Application types.(Required)

Type of Application (Initial Certification, Renewal, or Lapsed Certification Renewal)

Number of total applications (add "0" if none)

Total Cost for application type ($ application cost x number of applications)

Subtotal 2 (add the totals above):(Required)

Total Funding (Personnel/Subtotal 1 + Administrative Overhead/10% of subtotal 1 + MAPGS application/Subtotal 2):(Required)

Section C: Acknowledgement and Submission of Application

By submitting this application, I acknowledge that this information is correct and that I am authorized to submit this application on behalf of my agency.(Required)

Yes, I agree.

NAME AND TITLE(Required)

First Last

DATE(Required)