d) All IQLC Grant Program applications must contain the following required information:

1. 1) Applicant Contact Information for the primary point of contact (POC) who is responsible for the project implementation, including:

   1. A) Name;
   2. B) Phone number;
   3. C) Email; and
   4. D) Address: Street, City, County, State/Territory, Zip Code.

2. 2) Applicant Organization Information for the organization requesting CMP funds, including:

   1. A) Name;
   2. B) Phone number;
   3. C) Email address;
   4. D) Mailing address: Street, City, County, State/Territory, Zip Code;
   5. E) Website address, if available;
   6. F) National Provider Identifier, if applicable;
   7. G) Whether the organization is a facility; and
   8. H) If the organization is a facility, an accounting of whether any outstanding CMPs are due and if the facility is in bankruptcy or receivership.
3. 3) A description of the history of the organization requesting CMP funds, including the organization’s mission statement and number of years in service.
4. 4) A statement of the organization’s capabilities, including products and services relevant to the proposed CMP project.
5. 5) A statement indicating whether other funding sources have been applied for or granted for the proposal or project, and identifying information about the funding sources, including amounts applied for or granted.

6. 6) Project Title

   1. A) Provide the title of the proposed project.
   2. B) If the project is an extension to a new facility location, a statement of whether the project is an extension of an IQLC Grant Program project approved after April 1, 2018, and if results have been provided to the Department. Applicants must include the approval letter for the existing IQLC Grant Program project in their submittal and a description of the results of the project as an attachment to the application.
7. 7) Project Time Period: Provide the proposed start and end dates for the proposed project.

8. 8) Project Category: Identify the appropriate category that best describes the focus of the proposed project.

   1. A) Consumer Information: Projects that share information about resident and resident representative rights, the facility care process, and other useful consumer information to ensure quality care in facilities.
   2. B) Resident or Family Council: Projects that focus on resident and family council development or improvement in resident-centered services.
   3. C) Direct Improvements to Quality of Care: Projects that directly improve care for facility residents.
   4. D) Culture Change/Direct Improvements to Quality of Life: Projects that enhance a resident’s self-esteem and dignity. Culture change is the common name given to the national movement for the transformation of older adult services, based on person-directed values and practices where the voices of elders and those working with them are considered and respected.
   5. E) Training: Training that covers material that directly benefits the residents and the facility.
   6. F) Other projects that protect or improve the quality of care or quality of life for residents.

9. 9) Summary of the Project and its Purpose

   1. A) Description of the problem or gap in services the project proposes to address;
   2. B) Description of project goals and objectives; and
   3. C) Description of the plan to implement the project, including an implementation timeline.
10. 10) Project Deliverables: List any physical items that will be deliverables as a result of funding the project (e.g., electronics, training materials, curricula).

11. 11) Total CMP Fund Request Amount:

    1. A) Provide the amount of CMP funds requested annually and for the entire project.
    2. B) The total amount of non-CMP funds received for the project including how the cost-share requirements are met.

12. 12) Detailed Line Item Budget: Applicants must provide a detailed line item budget using a budget template provided by the Department to outline specific cost requirements within each of the following budget categories:

    1. A) Personnel: an employee of the organization whose work is tied to the proposed project;
    2. B) Travel: provide mileage, lodging and per diem as applicable;
    3. C) Equipment purchase and rentals: materials central to the roll out of the project;
    4. D) Contractual: the cost of project activities to be undertaken by a third-party contractor. Each contractor should be budgeted separately;
    5. E) Other direct costs: expenses not covered in any of the previous costs;
    6. F) Total indirect costs: overhead costs allocable to the project such as a negotiated rate with a university; and
    7. G) Cost-sharing: total non-CMP funds received or anticipated for this project. The cost-sharing amount must be subtracted from the total project cost.

13. 13) Budget Narrative:

    1. A) The budget narrative must:

       1. i) Justify the indirect costs and cost-sharing amounts included in the detailed line item budget; and
       2. ii) Explain the costs calculation and methodology.
    2. B) If cost-sharing is included, it should be listed for each year of the project. If the proposed project is a component of a larger program, identify other funding sources for the proposal, and indicate the specific funding amount to be provided by those sources. Other federal funding does not constitute cost-sharing.
14. 14) Benefit to Facility Residents: a description of how the proposed project will directly benefit facility residents.

15. 15) Facility and Community Involvement:

    1. A) A brief description of how the facility community, including residents and family councils and direct care staff, will be involved in the development and implementation of the project.
    2. B) If the organization applying is not a facility, include letters of support in the application submission to demonstrate facility support and buy-in for the proposed project.

16. 16) Other Partnering Entities

    1. A) If applicable, list any other entity or entities that will be partnering with the applicant on this project (e.g., individuals, organizations, associations, facilities).
    2. B) Include specific deliverables for which the partnering entity or entities will be responsible.
    3. C) If applicable, include the amount of funding partnering entity or entities will receive.
17. 17) Performance Monitoring and Evaluation: A description of how the project’s performance will be monitored or evaluated (including specific outcome metrics) and the intended outcomes.
18. 18) Duplication of Effort: an explanation that demonstrates the project will not duplicate or overlap with the responsibility of the facility to meet existing Medicare and Medicaid requirements and other applicable statutory and regulatory requirements, nor duplicate federal or state services.
19. 19) Risks: a description of the potential risks or barriers associated with implementing the project and the plan to address these concerns.
20. 20) Sustainability: a description of how the project or outcomes will be sustained after CMP funding concludes.

21. 21) Attestation Statement that includes the following:

    1. A) Name of the applicant;
22. B) Signature of the applicant;
23. C) Date of signature.