HIV and STD Special Needs Funding Application

HIV and STD Special Needs Funding Application

Thank you for your interest in Special Needs Funding. To apply, please complete this form and submit it along with a completed budget.

If you have any questions, please email us at prevention.info@odhsoha.oregon.gov.

Local Health Department or Tribal Government:*

Contact Name and Title:*

Telephone Number: *

Email Address: *

General Guidelines and Requirements

Use of Funds:

HIV and STD Prevention Special Needs Funding may be used to support acute HIV and STD prevention interventions including but not limited to enhanced activities to address clusters, outbreaks, and large-scale contact investigations; short-term housing for high-priority pregnant HIV or syphilis cases; and incentives for engaging in STD/HIV care.
Funds are for anticipated future expenses related to the event. They may not be used to reimburse past expenses.
Funds used for HIV and STD Prevention Special Needs Funding may be federal, state, or a combination of both.
All funds will be paid through standard award amendment process.

Eligible Activities and Expenditures

Personnel (e.g. overtime, temporary staffing)
Short-term housing and transportation for high-priority cases (e.g. pregnant cases with syphilis)
Translation & interpretive services
Testing, harm reduction, or other prevention supplies
Incentives for engaging in STD/HIV care
Other activities

Non-Eligible Expenditures and Activities

Ongoing or routine HIV & STD prevention activities as outlined in program elements
Medications to prevent (e.g. PrEP) and treat HIV
Equipment purchases
Conference attendance

Reporting Requirements

Reporting requirements vary by funding source and will be detailed at the time requests are approved. By accepting additional funds for special needs, Recipients agree to complete all reporting requirements within the timeframe specified.

Other Restrictions

The amount of available HIV & STD Prevention Special Needs Funding varies from year to year.
Each approved HIV & STD Prevention Special Needs Funding request provides support for HIV and STD prevention activities lasting up to six months but may not exceed the end of the calendar year.
Requests for short-term housing support should be for a maximum of one month.
Please limit initial request to $10,000 or less.

Do you agree to the guidlines and requirements above?*

Yes

Description of Need

Identify the acute, non-enduring activity prompting your request for funds:*

Short-term housing for high-priority HIV/STD case

Cluster, outbreak, large-scale contact investigation, or other increase in cases

Other acute or non-enduring situation

Provide a brief description of the situation:*

Other attempts to find funds*

HIV & STD Program is unable to request additional county/city/tribal funds

HIV & STD Program's request for additional county/city/tribal funds was rejected

HIV & STD Program requested and received additional county/city/tribal funds but funding provided is not sufficient to cover costs

Provide a brief description of attempts and outcomes:*

Impact to local HIV & STD prevention efforts:*

Provide a brief description of the anticipated benefit if this Special Needs Funding is approved.

Description of HIV & STD Prevention Special Needs Funds Request

Beginning of funding period for request:*

End of funding period for request:*

May not exceed the end of the calendar year.

Identify the line items being requested in this Special Needs Funding request:*

Check all that apply.

Please list other services requested:*

Required HIV & STD Prevention Special Needs Funding Documents

Your HIV & STD Prevention Special Needs Funding application must include a completed budget (with line item justification) that outlines anticipated expenditures. Please upload your budget here, email it to us at prevention.info@odhsoha.oregon.gov, or fax it to 971-673-0178.

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