State of Louisiana DHH/Office of Public Health/STD/HIV Program 2011 HIV Prevention Proposal Guidelines

State of Louisiana 2026 HIV, STI, & Hepatitis Program Request for Information Guidelines

Appendix A

PROPOSAL COVER SHEET

Organization Name:  	

Address:  	

Phone: 	Fax: 	Email:  	

Contact Person and Title:  	

Region:  	

OPH/SHHP OFFICE USE ONLY

DATE RECEIVED: 	TIME RECEIVED:  	

LOGGED IN BY:   	
SHHP STAFF MEMBER NAME POSTMARKED DATE:  	

Appendix B

STD/HIV Prevention Proposal Checklist

STI/HIV/Hepatitis Program Prevention Proposal Checklist

•	Appendix A: Proposal Cover Sheet

•	Table of Contents

•	Appendix B:	Proposal Checklist

•	Appendix C:	Intervention Strategy Justification Forms

•	Narrative
A.	Organizational Capacity and Information
B.	Program Description
C.	Project Personnel
D.	Community Collaborations, Referrals and Follow-up

•	Appendix D: Logic Model Forms

•	Staff Resumes and/or Job Descriptions

•	Appendix F:	Memorandum of Agreement

•	Appendix G: Fiscal Year 2026 STI/HIV/Hepatitis Program Line Item Budget Form

•	Appendix H: Budget Justification

•	Appendix J:	Income Statement Form

•	Appendix E:	Summary of Funding Sources and Current Contracts

•	Total Organizational Budget

•	501(c)(3) documents

•	List of Current Board Members

•	Board Resolution
•	

Appendix C

INTERVENTION STRATEGY JUSTIFICATION / PROCESS OBJECTIVE AND ACTIVITIES FORM
Complete one form per intervention proposed.

ORGANIZATION NAME:  	

Intervention Strategy:   	

         Priority Populations: (Choose 1 or more priority population(s))

Area/
Zip Code/ Location	Location Priority Level
(As indicated by Regional Plan)	Priority Populations (Choose 1 or more) list estimated number of each population to
	be reached.		
		    GBM	GBMOC	PWID	Transgender	African American	Hispanics and Latino/as	Youth	

									

•	GBM – Gay and Bi-sexual Men
•	GBMOC – Gay and Bi-sexual Men of Color
•	PWID – People who inject drugs
•	Transgender individuals
•	African Americans
•	Hispanics and Latino/as
•	Youth – Ages 11-18
PROCESS OBJECTIVE AND ACTIVITIES:

Appendix D Logic Model Form One per intervention proposed

Intervention 	Priority Population  	

Planning	Implementation	Outcomes	
Problems	Inputs	Activities	Outputs	Immediate	Intermediate	Long Term	

Appendix E SUMMARY OF FUNDING SOURCES and CURRENT CONTRACTS

Include all STI/HIV/Hepatitis Program related contracts/programs and programs to proposed target populations
Source of Funds	Amount of Contract	Priority Population	Intervention/Service	Geographic Area	Funding Period	

Appendix F

MEMORANDUM OF AGREEMENT FORM

TO:	 	
Name of applicant

Address of applicant
FROM:	 	
Name of cooperating agency/business

Address of cooperating agency/business

In the event that the above applicant agency receives funding for STI/HIV/Hepatitis Program prevention activities, we agree to coordinate and collaborate and/or provide the following services:

Applicant Agency will:

Collaborating Agency will:

I understand that personnel from Louisiana Office of Public Health, STD/HIV Program, may verify this information.

Authorized signatory of Proposing Agency		Title		Date	
Authorized signatory of Cooperating Agency		Title		Date	

Appendix G

Fiscal Year July 1, 2026 – June 31, 2027 STI/HIV/Hepatitis Program Line Item Budget Form

CBO Name: 	

Fill in intervention names. This exact form does not need to be utilized but keep in the same format.

Line Item Category	Total Amount	Intervention 1	Intervention 2	Intervention 3	General/ Administrative	
Personnel						
Fringe Benefits						
Education Workshop
/Training						
Supplies						
Travel						
Operating Expenses						
Office Equipment						
Accounting/ Audit						
Indirect Costs						
TOTALS						

Total Budget for Fiscal Year 
July 1, 2026 – June 31, 2027 
Appendix H
SAMPLE- LINE ITEM BUDGET JUSTIFICATION
July 1, 2026 – June 31, 2027

Personnel	Annual Total $52,500

(List each position, give a brief job description. For each position listed, multiply the monthly salary or wages by the percentage of personnel time by the number of months that the salary is to be paid from this budget.)

HIV Prevention Project Coordinator (Debbie Byrd) - $12,000
0.5 FTE
50% time ($24,000 annual salary x 0.5FTE = $12,000)

Responsibilities include management, coordination and implementation of all HIV/AIDS Preventive Education activities, supervision of the counselor/educator and community outreach workers, grant writing, and report writing. Will also carry out prevention counseling and community education. The remaining  50% of this position is paid for by funds from the City of New Orleans (25%) and a grant from the Elton John Foundation (25%).

Outreach Workers (vacant)	$32,000 2 FTE @ $16,000 each
100% time ($16,000 annual salary x 2FTE = $32,000)

Responsibilities include conducting one-on-one street outreach, condom distribution, and HIV counseling and testing in targeted neighborhoods. Employees in these positions will receive outreach and counseling training, will plan and implement outreach program, and will develop evaluation and tracking systems with supervisor.

Counselor/Educator (Dorothy Beck)	$8,500
0.5 FTE
50% time ($17,000 annual salary x 0.5FTE = $8,500)

Employee in this position will conduct HIV Prevention counseling and testing sessions in targeted neighborhood settings and at the service site. Will also develop peer program sessions to targeted groups engaging in high-risk behavior in community settings. This position is only half time.

Fringe Benefits	Annual Total $7,823
Each organization will need to obtain exact amounts to be deducted from salaries. The sample provides a guide, which may be used to apply your exact figures. Fringe benefits applicable to direct salaries and wages are treated as direct costs.

The amount for each category is:		
FICA 7.65 % (0.0765) X $52,500 total salaries	=	$4,016.00	
Health Insurance 3.75% (0.0375) x $52,500	=	$1,969.00	
Unemployment Insurance 3.5%	(0.035) x $52,500	=	$1,838.00	
TOTAL FRINGE	(14.9%)	=	$7,823.00	

Educational Workshops/Training	Annual Total $525

(Do not include travel here) Workshops/Conferences	$400 Organizational Memberships	$125
Funds are needed to enable staff to attend educational/training conferences and workshops.

Supplies	Annual Total $4,230
(This category is for the costs of materials and supplies necessary to carry out the project. It includes general office supplies and educational materials).

(Office supplies and educational materials/pamphlets) Office Supplies	$480
Educational Materials	$3,750

Funds are needed to acquire office supplies and educational films, brochures, periodicals (e.g. $75 subscription fee for AIDS Education and Prevention Journal), magazines, books, dental dams, bleach kit materials, etc. to be used for the provision of services. Office supplies are calculated at 4 FTEs x $10 x 12 months. Educational materials are calculated at 5000 prevention packets at 75 cents each.

Travel	Annual Total $2,430.40
(Budget the projected costs of transportation and related expenses for official staff business travel conducted in carrying out the contract. Out of state travel is only allowed with pre-approval from the OPH/SHP office. Agencies that do not have written travel reimbursement policies must use the Department of Health/Hospitals travel reimbursement rates as follows: $.48/mile.
(All in-state field and workshops/conferences travel and out-of-state travel) Instate Travel	$950.40
Statewide Conf.	$730.00
Out-of-State Travel	$750.00
Funds are needed to cover staff travel expenses to workshops, training, and meetings; mileage to intervention locations in surrounding parishes. expenses will include: In-State-Travel -90 miles to outreach sites x 0.44/miles = $39.60 x 2 trips/month (24 trips) = $950.40. -Statewide conferences (2) travel (2 persons) = $730 (Transport $200, hotels = $330, meals = $200.). Out-of-State Travel - US Conference on AIDS (1 person) = $750 (Transport $200, hotel $300, meals $250)

Operation Expenses		
Telephone	$500	
Advertising	500	
Printing	300	
Postage	500	
Utilities	700	
Rent	3000	
Insurance	500	
Workmen's Compensation	840	
Other (specify)		

Annual Total $6,840

Office Equipment	Annual Total $2,030
Chairs and desk needed for each outreach worker (2 desks and chair sets at $250 each). A computer is needed to compile demographic data, agency administrative information (budget, grants, etc.), and to facilitate bimonthly newsletter development (1 computer package at $1,530).

Annual Audit	Annual Total $1,600
In compliance with state regulations, funded agencies must have an annual audit. See Section L.

Indirect Costs (if applicable)
Only incurred when CBO is under a parent organization and covers CBO’s share of rent, utilities, etc. If paid under this category, cannot be put under Operating Services.

Total Amount Requested from OPH STD/HIV Program	2011 Annual Total = $77,978.00

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Appendix J
INCOME STATEMENT STI/HIV/Hepatitis Program (SHHP)

State of Louisiana 
2026 HIV, STI, & Hepatitis Program
 Request for Information Guidelines

Source of Funds	Amount of Contract	Priority Population	Intervention/Service	Geographic Area	Funding Period	

	

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