Fillable California Health Center Security Grant Program (CHCSGP) - (California)

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California Health Center Security Grant Program (CHCSGP) - (California)

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The California Health Center Security Grant Program (CHCSGP) - (California) form is 6 pages long and contains:

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Funding Requested (Maximum of $200,000)
California Health Center Security Grant Program
(CHCSGP) - Re-Appropriation Application
Section I. Applicant Information (Not Scored)
Legal Name of the Organization (as indicated on the Federal Employer
Identification Number (FEIN) letter provided by the federal Internal Revenue Service)
Physical Address of Project(s) Location
Mailing Address, if different
Telephone Number of the Organization
Email Address of the Organization
Website/URL of the Organization
Primary Point of Contact
Name, Title/Role
Telephone Number
Email Address
Secondary Point of Contact
Name, Title/Role
Telephone Number
Email Address
Organization: Provide a description of the organization's services,
and proof (such as a redacted bill/invoice) of abortion services provided.
501(c)(3) tax exempt or 501(c)(3) tax exempt eligible as defined by
the IRS: Section 501(c)(3) is the portion of the US Internal Revenue
Code that allows for federal tax exemption of nonprofit
organizations, specifically those that are considered public charities,
private foundations, or private operating foundations.
Funding Requested (Maximum of $200,000)
Revision 2020
Page 1 of 6
Section II. Risk (15 Possible Points)
The Applicant should thoroughly describe threats, vulnerabilities, and potential
consequences, which necessitate funding for the proposed project(s). Explain how the
funding would be utilized to minimize these risks.
A) Threats: In considering threats, the Applicant should discuss the identification and
substantiation of specific threats or attacks against the organization. The Applicant should
also discuss findings from risk assessments, police findings, and/or insurance claims specific to
the location being applied for, including dates and specific threats.
(2,200 character max with spaces)
B) Vulnerabilities: In considering vulnerabilities, the Applicant should discuss the organization’s
susceptibility to destruction, incapacitation, or exploitation resulting from an act of violence
and/or vandalism. These should be consistent with the Cal OES Vulnerability Assessment.
(2,200 character max with spaces)
C) Potential Consequences: In considering potential consequences, the Applicant should
discuss potential negative effects on the organization’s assets, systems, and/or network if
damaged, destroyed, or disrupted by an act of violence and/or vandalism.
(2200 character max with spaces)
Revision 2020
Page 2 of 6
Section III. Target Hardening (15 Possible Points)
In this section, describe the proposed target hardening activities, including the total
State funds requested, that address the identified threat or vulnerability. Allowable
costs are focused on target hardening activities, as well as planning-related costs,
contracted security personnel, and security-related training courses. Funding can also
be used for the acquisition and installation of security equipment on real property
(including buildings and improvements) owned or leased by the nonprofit organization,
specifically in prevention of and/or in protection against the risk of an act of violence
and/or vandalism.
(2,200 character max with spaces)
Target Hardening Equipment
In this section, list all target hardening equipment being proposed.
• Physical security enhancement equipment, such as reinforced doors and gates,
and high-intensity lighting and alarms;
• Enclosed or covered walkways, entry canopies, or other enhancements that
ensure patient privacy; and
• Inspection and screening systems, and access control.
Quantity and Description of item(s) proposed
to be purchased
Vulnerability
to be Addressed
Funding
Requested
Revision 2020
Page 3 of 6
Section III. Target Hardening (continued)
In this section, select Yes or No regarding applicable non-equipment related activities
the organization plans to expend with award funds. Describe the activity and provide the
cost estimate related to physical security enhancements of the organization.
Contracted Security Personnel: State the frequency/duration of guard service to be
contracted. Limited to 50% of the total Funding Requested in Section I. Cost estimate
related to physical security enhancements of the organization.
Management and Administration (M&A): M&A is limited to 5% of the total funding
requested in Section 1.
NOTE: In regard to changes to scope of work, due to the competitive process, changes
to the scope of work may not be allowed without Cal OES prior written approval. Ensure
the projects being proposed are well planned, as any funds that remain at the end of the
period of performance will be disencumbered.
Activity
Description
Cost
Training
Planning
Management & Administration
Contracted Security Personnel
TOTAL COST
Revision 2020
Page 4 of 6
$ 0
Section IV. Milestones (5 Possible Points)
Provide a description and associated key activities that lead to the milestone event over
the CHCSGP period of performance. Start dates should reflect the start of the associated
key activities, and end dates should reflect when the milestone event will be completed.
Applicants should provide no more than 10 milestones.
Milestone
Start Date
Completion Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Revision 2020
Page 5 of 6
V. Impact (5 Possible Points)
Explain how the organization will be safer at the end of the FY 2019 CHCSGP period of
performance.
(2,200 characters max with spaces)
Revision 2020
Page 6 of 6
Section VI. Median Income for Zip Code (2 Possible Points)
Section VII. Distance to Nearest Facility (3 Possible Points)
Provide the median household income for the
Zip Code in which the nonprofit community
health center is located.
Enter the d
istance, in miles, from the nonprofit
community health center to the next closest
provider of abortion services.
Miles.
Applicant Certification Information
Check this box if the organization is willing to accept less than the full amount
requested based on scoring and available funding. If the box is not checked,
partial funding may not be given in the event that the full amount funding is not
available for the project(s).
I certify that I am an employee, a volunteer, or have been hired by the
aforementioned nonprofit organization to apply on their behalf for the CHCSGP.
Name, Title/Role
E-mail Address
Phone Number
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California Health Center Security Grant Program (CHCSGP) - (California)

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Completed 18 November 2020

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