i 11 lilt'lltl4l@11*1111 I I , t (', @ I.?@ @ @i (O'i A, @ rz r@ L@ @ 4 -, em c 4, e>@i i PROGRAM INSTRUCTIONS FOR PREPARING RFIGIONAL MEDICAL GRW APPLICATIONS NIH FORM 925-1 DIVISION,OF REGIONAL MEDICAL PROGRAMS These are instructions for completing form NIH-925-1. A prospective Applicant should carefully read the Guidelines for Regional Medical Programs before proceeding with the application. The Guidelines contain the history, purposes,.composition, policies, definitions and general information regard- ing the preparation and review of applications for a Regional Medical Program. Discussion. conferences and othtr c cation.with th@-Program.Deve opment and Assistance Branch of the Division of_Reg.@onal Medical Programs.@n_g!L it-ai@i-6f ii.@pa- 6-n@nq @vi of .plication are ex 6cttd7i-nd encouraged. p Pages of the application should be numbered sequentially. Please o not include foldouts, color, or transparent overlays.. INSTRUCTIONS FOR PAGE 1 Page 1 is the Face Sheet of the application. Most items are self- explanatory. List a single legal applicant organization in item 6. Include the telephone number of the program coordinator (item 11) and the address and telephone number of the official named in item 12. I[NSTRUCTIONS FOR PAGE 2 The applicant is to designate an advisory group composed of the following categories, and indicate the category as well as the affiliations of each member: l.' Practicing physicians 2. medical Center officials 3. Hospital administrators 4. Other Health Professions 5. Members of the public familiar with the needs for the services provided under the program 6. Representatives from a. Appropriate medical societies b. Voluntary health agenc es c. Other organizations, institutions and agencies concerned with activities of the kind to be carried on under the prbgram The group should be broadly representative of the activities and geographic area which provide medical care, and the people who receive it. The majority of members should have been specifically designated and have agreed to serve before submission of a planning grant application. Whenever such agreement has not been reachedi the application should so state. July 1966 2 The chairman of the advisory group is requited to sign an operational grant application, as evidence of the groupts approval. A p anning grant application will be strengthened by evidence that the Advisory Group has participated to some degree in the preparation, but a signature is not required. INSMUCTIONS FOR PAGE 3 Include activities to be conducted by both the applicant an cooperat g institutions in the overall budget of the grant. Personnel Include salaries, wages, and fringe benefits of personnel in proportion to the time or effort expended on the program, and in accordance with institu- tion policy. Salaries, including fringe benefits, paid by-a corporation,formed specifically for a Regional Medical Program, must be comparable to the salaries paid within the region to individuals for reasonably similar responsibilities. When a salary of a key official is increased significantly over his current salary, due to his working on a regional medical program grant, a justification for the increase should be submitted to the Division of Regional Medical Programs. If any tax exempt trainees (as allowed under Sec. 117 of the Internal . enue Code) are supported by Regional Medical Program funds, a Statement of pointment form PHS-2271 is required at the time of appointment for such trainee. Fringe Benefits Support may be requested to the extent such allowances would be provided by the applicant or cooperating institutions to personnel receiving salary and in proportion to the amount of support charged6 Consultant Services Name each consultant, if known. Consultant fees will not be allowed for personnel in full-time or part-time employment or holding full-time or part-time status with the applicant or cooperating institution. These individuals should charge a prorated portion of their salaries under the personnel category. Equipment Equipment is generally considered as those items having a life expectancy in excess of one year. List individually each item costing over $500. Items costing $500 or less may be combined and listed as miscellaneous in a one line entry. Funds for built-in equipment cannot be provided in a planning granti 'Jnder an operational grant, 90% of the cost of essential built-in equipment can be supported from grant funds. Supplies Supplies are expendable items with a life expectancy of less than one year. 3 Travel Transportation, subsistence, and related cost for travel performed in y be charged in accordance connection with Regional Medical Program activities ma with the related institutions' policy. 'If no institution policy prevails, the Standard Federal Government Travel Regulations apply. The current per them and institutional mileage allowance should be stated. Sub-Cbntracts Itemize each sub-contract. Identify the organization and describe the nature of the service to be provided. The applicant will be expected to maintain con- trattual data to substantiate audit of charges made to the grant account. Indirect costs for subcontracts with cooperating institutions should not exceed the actual institutional indirect cost rate. Hospitalization Costs The applicant is asked to consult with the Division of Regional Medical Programs regarding costs related to hospitalization. Publication Costs may include printing,-distribution, mailing and general handling of essential publications, as well as those for special plates, charts and diagrams. Alterations and Renovations Operational grant funds may be used to pay 90% of the cost of specifically justified alteration and renovation. Alterations and renovations may no be charged to planning grant funds. Other List all other necessary expenses by major costs including rentals, leases, computer time, telephone installation and service, and conferences and demons" trations with suitable explanation or justification. Indirect Costs The applicant and each cooperating institution should determine individual indirect cost rates in accordance with the information provided in the Regional Medical Program Guidelines. A computation of the rate should be included. -TNSTRUCT]IONS F'OR PAGE 4 It is important to demonstrate that the budget is related to the propose program. State the page number(s) of the narrative that specifically justifies the budget item requested. Since the budget is a quantitative representation of the program, successive budget periods should reflect proposed increments of planning and implementation. 4 INSTRUCTIONS FOR PAGE 5 The narrative of the approach and objectives for a Regional Medical Program should include a description of: 1. The applicant organization or institution, indicating that it has the resources and leadership necessary to assume the responsibilities connected with A Regional Medical Program. 2. The extent of expected participation of the cooperating and potential cooperating institutions or organizations within the region during the period of grant support requested. Indicate which institutions or organiza- tions have already agreed to participate. Applicants should be concerned with planning the extension of the coverage of the activities of the Regional Medical Program to additional institutions and areas not involved in the early phases of the program. 3. The Region. When applying for a planning;grant, the applicant need not specify a region in terms of ultimate boundaries. A clearer definition of the region should emerge from the planning process, which may modify the originally delineated region. However, to the extent that it is practical, pertinent demo- graphic, health resources and facilities data should be included. The relationships to adjoining regions or proposed regions should be described in both planning and operational grant applications. Communication among regions is encouraged, and a narrative description of what steps have been taken to establish communication and relationships with adjoining or proposed regions should be included. 4. The present means of support. It is not the intention of the Regional Medical Programs to supplant other sources of support. The applicant should include a narrative summary of present private and nonprivate support received by the applicant, as well as cooperating institutions, for clinical training, clinical research, and continuing education related to heart disease, cancer and stroke. A detailed description or listing need not be included with the application, but should be made available at the request of the Division of .Regional Medical Programs. 5. The program. The description of the program should be structured in such a way as to indicate how the program will establish cooperative arrange- ments to afford the medical profession and medical institutions of t e region opportunities of making available to their patients the latest advances in the diagnosis and treatment of heart disease, cancer, stroke and related diseases. Emphasis should be placed on realistic and effective steps,in implementing the program elements. 6. The mechanisms for continued planning and program evaluation. INSTRUCTIONS FOR FILING Completed applications should be forwarded to the Division of Regional Medical Programs, National Institutes of Health, Bethesda, Maryland 20014.