Attachment 1: Required Attachment Check List

Applicant Name:

You must return this completed check list with your application package. Complete this check list to confirm the items in your application. Place a check mark or “” next to each item that you are submitting. You must return all required attachments for OSHPD to consider your application responsive.

Attachment Attachment Name/Description

_ Attachment 1 Required Attachment Check List

_ Attachment 2 Education Capacity-Psychiatric Mental Health Nurse Practitioner Application Form

_ Attachment 3 Application/Applicant Certification Sheet

_ Attachment 4 Professional References

Attachment 5 County/CBO Participation Verification Form

Attachment 6 Payee Data Record (STD 204)

Attachment 2: Education Capacity - Psychiatric Mental Health Nurse Practitioner Application Form

Complete all sections of this application form. (Please use Arial font no smaller than 10 point.)

A. Executive Summary (Maximum 1000 words)

B. Program Description. Provide a detailed description of the proposed program, including how it will address all of the components detailed in the Grant Guide under Section B. Purpose and Description of Services. (Maximum 1000 words.)

In addition, you must include information on how your program incorporates the following elements:

1. Detailed Work Plan and Schedule: Provide a detailed work plan and schedule for task completion, including a description of how all the following elements will be addressed:

a. Co-Located faculty hours: Shall be defined as any of the following (Maximum 1000 words):

i. A licensed psychiatrist or PMHNP practicing and employed in the PMHS who has a preceptorship agreement with an accredited PMHNP program in California or is employed by an entity that has a preceptorship agreement with an accredited PMHNP program in California.

ii. Psychiatrist faculty from a California Psychiatric Residency program who is co-located in the PMHS.

iii. PMHNP faculty from a California PMHNP Residency program who is co-located in the PMHS.

b. Collaboration Agreement (optional): Per the description in Section B.

c. Facilities and Resources: Explain where the services will be provided and what types of requirements are needed to perform the services. (Maximum 1000 words)

d. Capacity: Demonstrate the ability to administer the Education Capacity-Psychiatric Mental Health Nurse Practitioner program, including the number of PMHNP students educated per year, ratio of co-located faculty per PMHNP students, and the number of PMHNP students who will be successfully placed in the PMHS in the county or counties that the applicant has identified in the proposal as partners after those students have been certified by the BRN. (Maximum 1000 words)

e. Partnerships: Demonstrate how it will strengthen educational partnerships, community support, and workforce preparation between the applicant and the county(ies). Clearly define and describe the relationship between the PMHNP program and the county Department of Mental Health or CBO, including the following information(Maximum 1000 words):

i. The PMHNP program or the county/CBO providing co-located faculty time.ii. The number of PMHNP students whom the program will place in the preceptorship to

be supervised by the co-located faculty.iii. Whether the supervisor staff time is a:

• Co-located Psychiatric Mental Health Nurse Practice Faculty• Co-located Psychiatrist Faculty• PMHNP and/or Psychiatrist clinician employed by the county/CBO

iv. The PMHNP program and PMHS collaboration in training the psychiatric residents/fellows.

v. That PMHS will provide the sites where the staff will be co-located and supervise PMHNP students.

f. Multi-Disciplinary Team Approach: Demonstrate the program’s ability to include a multi-disciplinary team approach and interdisciplinary training that (Maximum 1000 words):

i. Fosters the use of mental health care teams with family practice physicians and psychiatrists.

ii. Proposes programs in accordance with elements of the MHSA per the description in Section B.

iii. Focuses on the recruitment of PMHNPs who can meet cultural competency needs consistent with the MHSA element per the description in Section B.

g. Recruitment: Demonstrate how outreach and recruitment efforts address the needs of the PMHS. (Maximum 1000 words)

h. Participants: Explain how the program will work to ensure that PMHNP students will continue to work in the PMHS upon successful completion of the program, specifically detailing how they will be able to contribute to a diverse, culturally sensitive, and competent public mental health workforce. (Maximum 1000 words)

i. Curriculum: Demonstrate how they will develop/revise and provide teaching methods that integrate theory and practice, while promoting the elements of the MHSA per the description in Section B. (Maximum 1000 words)

j. Sustainability: Demonstrate the sustainability of the proposed program and show that it is a replicable model. (Maximum 1000 words)

k. Additional Information: Respond as part of their application to the following(Maximum 1000 words)

i. Explain the program strategies to increase the delivery of PMHNP services in the PMHS. Evidence of the applicant’s ability to ensure PMHNP services in the PMHS may include, but not be limited to, agreement(s) between the PMNHP program and one or more of the following: regional partnership(s), county(s), CBOs, and other relevant local entities.

ii. Provide the total number of clinical hours that students participating in the applicant’s PMHNP program are required to complete per year to satisfy program requirements.

iii. If applicable, provide the required number of hours per year that students participating in the applicant’s PMHNP program must spend in a field placement located in the PMHS.

iv. If applicable, provide the percent of the total number of clinical hours that students participating in the applicant’s PMHNP program must spend in the PMHS.

v. Provide the average (or mean) number of hours PMHNP students spend at Public Mental Health sites per year. Derive the average using actual validated data contained in student clinical records.

2. Project Personnel

Provide titles, job descriptions, and roles, of each individual/contractor/sub-contractor proposed to work on the project. Identify project personnel, including subcontractors, with lived experience and/or that have a proven track record of working with individuals with lived experience.

Personnel Title

Job Description (Maximum 500 words)

Role Lived Experience (Yes or No)

3. Budget Detail

If awarded, Grantee shall be contractually bound to the amounts and budget line items outlined in this section and must use them to invoice OSHPD for services provided under this grant agreement.

Total Proposed Budget $______________________________Administration Cost Requested: $_______________________Administration Cost Percent of Budget: ___________________________________ The budget may be allocated over two years to suit the applicant’s needs.Total Non-Administration Cost Funds Used for Collaboration Agreement and/or Recruitment

incentives (if any): $_______________________

The totals in each year shall include participants for that year only. For example, in “Number of Psychiatric Mental Health Nurse Practitioner (PMHNP) students,” the applicant shall list only the number of new PMHNP students in Year 1. For Year 2, the Applicant shall list only the added students for that year.

The major budget categories shall be the cost of co-located faculty per year, non-administrative cost funds used for Collaboration Agreements and/or Recruitment Incentives and the yearly Administration Cost.

Total Cost Application TableCategory Year 1 Year 2 SubtotalProposed number of new PMHNP students supervised by co-located

supervisor staff time in the PMHS to be added each year: # # #

Proposed number of PMHNP student hours in the PMHS to be added each year: # # #

Proposed percent time PMHNP students will spend in preceptorships in the PMHS each year: % % %

Proposed number of co-located supervisor staff hours in the PMHS providing clinical supervision and teaching a curriculum consistent with the MHSA to be added each year:

# # #

Proposed amount for added co-located faculty hours in the PMHS providing supervision and teaching a curriculum consistent with the MHSA to be added each year:

$ $ $

Proposed amount of non-administration cost funds used to encourage psychiatrists to enter into a collaboration agreement with PMHNPs. (Each payment under this Agreement shall not exceed a prorated payment reflecting the percentage of faculty hours provided each fiscal year):

$ $ $

Proposed amount of non-administration cost funds used for Recruitment Incentives to include but not limited to, materials/supplies required for program activities, and travel, it may not exceed 5 percent of the total proposed budget:

$ $ $

Proposed number of Public Mental Health Sites (locations) receiving PMHNP services: # # #

Proposed Yearly Administration Cost (shall not exceed 15 percent of proposed Agreement in each fiscal year): $ $ $

Annual Totals $ $ $

Attachment 3: Application/Applicant Certification Sheet

Sign and return this Application/Applicant Certification Sheet with original signatures. An Unsigned Application/Applicant Certification Sheet May Be Cause for Rejection.

The signature affixed hereon and dated certifies compliance with all the requirements of this application document. The signature below authorizes the verification of this certification.

Company Name Telephone Number

Address Fax Number

Name Title and E-mail Address

Signature Date

Attachment 4: Professional References

List below two references from within the last four years that demonstrate your organization’s capacity to provide the services outlined in the Detailed Work Plan and Schedule in Attachment 2: Education Capacity-Psychiatric Mental Health Nurse Practitioner Application Form. If you cannot provide two references, please explain why on an attached sheet of paper.

REFERENCE 1Name of FirmStreet Address City State Zip Code

Contact Person Telephone NumberE-mail AddressDates of Service Value or Cost of ServiceNarrative of Service Provided (include timeline and outcomes)

What is the role of the reference/firm?

REFERENCE 2Name of Firm

Street Address City State Zip Code

Contact Person Telephone NumberE-mail AddressDates of Service Value or Cost of ServiceNarrative of Service Provided (include timeline and outcomes)

What is the role of the reference/firm?

Attachment 5: County Mental Health/Community-Based Organization Participation Verification Form

Date:

County/Community-Based Organization

The applicant organization (see below) intends to apply for a grant from the Office of Statewide Health Planning and Development (OSHPD) to engage in activities that aim to increase the educational capacity of Psychiatric Mental Health Nurse Practitioners (PMHNP) in the Public Mental Health System (PMHS).

The purpose of this participation verification form is to ensure OSHPD that the applicant organizations contacted a county or community-based organization (CBO) before submitting an application, and plan to engage and collaborate with the county(ies) or CBO(s) in their program area. Additionally, this allows the applicant to develop a program that meets county/CBO specific needs. By signing the letter, the county or CBO is agreeing that where applicable, the county will collaborate and engage with the applicant organization if awarded a grant. OSHPD encourages the county/CBO director to sign only if planning to collaborate and engage with this organization in a manner consistent with what is described below.

To better assess the educational needs of the Psychiatric Mental Health Nurse Practitioners in your county Mental/Behavioral Health program/CBO, to the extent possible please provide a brief description of your mental/behavioral health workforce retention challenges.

Provide a brief description of how your organization plans to collaborate and engage with the applicant organization.

By signing below, I confirm that (Applicant Organization)has contacted (My Organization). My Organization is part of the PMHS and, where applicable, my organization will engage with _____________________ (Applicant Organization) as they engage in activities to increase the educational capacity of PMHNP in the PMHS.

Director (or authorized designee), County Mental Health Program/CBO (Print)

Director (or authorized designee), County Mental Health Program/CBO (Signature)

Attachment 6: Payee Data Record (STD 204)