Minnesota cmp project proposal




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MINNESOTA - CMP PROJECT PROPOSAL

(please print or type)



Project Title:


Date:

Proposing Organization:


Contact Person / title / e-mail:



Address:


Telephone:



Fax:

Total Funding Request:

Proposed Project Time Period (not to exceed 3 yrs):


Is this activity required under federal law or contract ? Y  N 

Is this activity required under state law or contract ? Y  N 

Is this activity currently partially or wholly funded by state or federal funds ? Y  N 

(Please explain any “Yes” responses):



I certify that I represent the organization named above and that I am authorized to submit this proposal for the use of CMP funds on their behalf. In addition, I certify that the organization I represent agrees (if this proposal is funded) to be bound by the CMP Use Guidelines and all applicable state and/or federal statutes, regulations and protocols governing the use of CMP monies. Further I attest to the fact that we have received a copy of the CMP Use Guidelines.


Proposing Organization Signature:

________________________________________________________________________________




Print Name / title: ________________________________________________________________

Date: _______________________









(Attach additional sheets – Limit to 4 pages total)
Please provide brief background information on the proposed project including the following:

  1. Brief description of the proposing organization and why this organization is qualified and capable of carrying out the intended project.

  2. Project description, purpose and summary.

  3. Expected Outcomes (describe the intended outcomes or deliverables, and sustainability).

  4. Results measurement (describe the methods by which the project results will be assessed (including any specific measures).

  5. Benefits to nursing home residents (describe the manner in which the project will benefit nursing home residents).

  6. Non-Supplanting (describe the manner in which the project will not supplant

existing responsibilities of the nursing home to meet existing Medicare/Medicaid

requirements or other statutory and regulatory requirements).



  1. Consumer and other stakeholder involvement (describe how the nursing home community (including resident and/or family councils and direct care staff) will be involved in the development and implementation of the project).

  2. Other funding (estimate any non-CMP funds that the State or other entity may be contributing to the project).

  3. To the extent known, list any “in-kind” resources (staff time, use of equipment, etc.) that will be used for the project and their availability during the project time period).

  4. Involved organizations (to the extent known, list all organizations and their role that; a) will receive funds through this project, b) are expected to carry out duties and be responsible for any portion of the project, or c) are otherwise partnering in this effort.

  5. An outline of the (estimated) proposed budget expenditures.

Revised 1/29/2013
Instructions: If you need assistance drafting or submitting a project proposal, please contact Munna Yasiri, CMP Committee Administrator at: (651) 431-2264.
Once this form has been completed, please send form (along with any additional application pages (limited to 4 additional pages) to:

Department of Human Services (DHS)

ATTN: Munna Yasiri, State programs Director

PO Box 64973



St Paul, MN 55164-0973

***CMP COMMITTEE/STATE AGENCY USE ONLY BELOW***

Project Title:





CMP Committee Approval:


Date:

CMS Approval:


Date:




CMP COMMITTEE NOTES:








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