Healthy Teeth for Kansans
Please note: the below application
is provided for your reference. If you are interested in applying
for a grant,
please contact
our program staff prior to beginning any application. Our
staff will be happy to answer any questions and provide personalized
guidance to
assist
you with
your
grant application.
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The Health Fund Fluoridation
Grants RFP is available here
APPLICATION FORM
Water Fluoridation Initiative
Please return this form with attachments as described
Public Water System Name ______________________________________
Address______________________________________________________
City ____________________________________ State ___
Zip _________
Phone (___)____________Ext.__________ Fax (___)_________________
E-mail: ___________________________________________
Principal Contact Person_______________________________________
Title______________________________Telephone_________________
Secondary Contact Person______________________________________
Title__________________________Telephone_____________________
Organizational Description of Public Water System:
____City ____County ____Rural Water District ____Other:___________________________
Population of Area Served by System _____________________
Source of population number____________________________________
Number of water meters in system __________ as of ______________
(within one
year of application date)
Revenue of water system in last fiscal year $____________________
Expenses of water system in last fiscal year $____________________
Number of Points of Entry of System ________
The natural fluoridation of the water
Single point of entry systems ______ ppm (date _____________)
Multiple points of entry systems
Highest ______ ppm and Lowest ______ ppm (date _____________)
Number of students in elementary schools served by your water system ______
Number of students in middle schools served by your water system ______
Number of students in high schools served by your water system ______
Has your water system ever been fluoridated by the addition of fluoridating
chemicals? ____yes ____no
If yes, when was the fluoridation system last operational? ________________
(See
question 7 in narrative)
PROJECT BUDGET
INCOME
Amount requested from Health Ministry Fund $__________________
Other Sources (if required):
______________________________________ $___________________
______________________________________ $___________________
______________________________________ $___________________
TOTAL INCOME $___________________________________________
EXPENSES
Equipment:
______________________________ $__________________
______________________________ $___________________
______________________________ $___________________
Chemicals (one year supply)
______________________________ $___________________
Facility Renovations
______________________________ $___________________
______________________________ $___________________
______________________________ $___________________
Engineer Consultation
______________________________ $___________________
Other Miscellaneous expenses
______________________________ $___________________
______________________________ $___________________
______________________________ $___________________
TOTAL EXPENSES $_______________________________
Explanation of individual line items should be provided in a separate
budget justification. That justification should include the basis
(source) of the cost estimate and enough descriptive information
to permit the review committee to understand the nature of facility
changes, pieces of equipment being purchased, etc.
The budget should include only those items necessary for start-up or re-start of the equipment. Operating expenses and sources of income for those should not be included, with the exception of the chemicals for one year if Health Ministry Fund money is requested to pay for that operating expense.
As an authorized officer of the applicant municipality, I certify
that submission of this application has been approved by the
municipality and matters contained in it are true and correct
to the best of my knowledge.
Date:______________
________________________________________________________________
(Name of Applicant Municipality)
By:___________________________________________
Title:____________________________________
NARRATIVE
Please answer the following questions on 8½” x 11" paper. The responses should be complete enough if answered on four to six, single-spaced pages. To organize your material, give the question numbers without the form’s narrative material.
1. Explain the engineering of your project including necessary information about the organization of your water system (points of entry, equipment and building modifications required, anticipated level of fluoride to be added, consultation already provided, etc.)
2. Explain how fluoridation expenses, including equipment replacement, will be paid for in the future. If an additional consumer charge will be necessary, describe the basis for that charge and the status of action to impose that charge.
3. Describe the internal process and the public process by which this application was developed and approved. Include a report of the formal action of the governing board in approving this application--the vote (number of ayes and nays), any concerns raised, etc. Was the governing body specifically informed about the five year maintenance requirement?
4. Provide information about any unresolved issues which might affect the project or the ability of the municipality to accept the funding.
5. Provide a key elements timeline for implementation of the project assuming funding is available within two months of the date this application was filed. This timeline would include six to ten key actions including governing board action, design preparation, state permit issuance, bid letting, equipment ordered, renovations started and completed, staff trained, and fluoridation commencement date.
6. Provide information about the number of low income persons in your service area. You can satisfy this question in one of several ways. The following are suggestions. School districts in your service area can provide information about the percentage of free and reduced price lunch students. Relevant census tract poverty levels can be provided. If your system serves the majority of the population of a county, the per capita income of that county compared with the Kansas per capita income may be persuasive (see Kansas Statistical Abstract).
7. IF YOUR SYSTEM HAS EVER BEEN FLUORIDATED, provide information about the circumstances causing loss of fluoridation, how those circumstances can be prevented if the system is re-started, the condition of the fluoridation equipment and how that condition was evaluated, and other information to give a clear understanding of the situation.
8. IF YOUR SYSTEM SELLS WATER TO ANOTHER SYSTEM, provide information about whether the fluoridation will be made available to that system and whether that other system has agreed to accept fluoridated water.
ATTACHMENTS:
Required:
Certification Executed by Chairperson of Governing Board
stating that the Governing Board by a specified vote on a given
date approved the filing of this application. If the Chairperson
is not available, the Clerk of the Governing Board may execute
the certification.
Optional:
Support letters
Newspaper articles reflecting the fluoridation decision
Map of the area served by the water system
Revised March, 2004