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Start Preamble Health Resources and cheap diflucan online Services Administration (HRSA), Department of Health and Human Services. Notice. In compliance with of the Paperwork Reduction Act of 1995, HRSA has submitted an Information Collection Request (ICR) to the Office of Management and Budget (OMB) for review and approval. Comments submitted during the first public review of cheap diflucan online this ICR will be provided to OMB.

OMB will accept further comments from the public during the review and approval period. OMB may act on HRSA's ICR only after the 30 day comment period for this Notice has closed. Comments on cheap diflucan online this ICR should be received no later than January 28, 2021. Written comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice to www.reginfo.gov/​public/​do/​PRAMain.

Find this particular information collection by selecting “Currently under Review—Open for Public Comments” or by using the search function. Start Further Info To request a copy of the clearance requests submitted to OMB for review, email Lisa Wright-Solomon, the cheap diflucan online HRSA Information Collection Clearance Officer at paperwork@hrsa.gov or call (301) 443-1984. End Further Info End Preamble Start Supplemental Information Information Collection Request Title. DATA 2000 Waiver Training Payment Program Application for Payment, OMB No.

0906-xxxx—New. Abstract. The Substance Use—Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (Pub. L.

115-271), section 6083, amended the Social Security Act (subsections 1834(o)(3) and 1833(bb)), authorizing the Secretary to pay Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) the average cost of Start Printed Page 85649training to obtain DATA 2000 waivers for their physicians and practitioners to furnish opioid use disorder treatment services. To receive payment, FQHCs and RHCs must submit a formal application. In order to be eligible for payment, as well as to provide HRSA with information necessary for validation and issuance of accurate payments, the form requires that FQHCs and RHCs provide information identifying the submitting organization and the number of practitioners who have completed training and obtained a DATA 2000 waiver. The form requires the submitting FQHC or RHC to include information regarding each claimed practitioner's name, physician or practitioner type (e.g., physician, physician assistant, nurse practitioner, certified nurse midwife, clinical nurse specialist, certified registered nurse, or anesthetist), National Provider Identifier number, Drug Enforcement Administration number, state medical license number, length of training, date the training was completed, date of waiver attainment, and DATA 2000 waiver number.

Additionally, the form requires signature of an attestation statement certifying that (1) each practitioner for which the entity is seeking payment under the application is employed by or working under contract for this facility. (2) it is the first time the entity is seeking payment on behalf of the listed practitioner(s). (3) the entity is eligible to seek payment under 42 U.S.C. 1395m(o)(3) or 42 U.S.C.

1395l(bb). (4) each practitioner is furnishing opioid use disorder treatment services. And (5) that the statements herein are true, complete, and accurate to the best of the applicant's knowledge. FQHCs and RHCs will need a System for Award Management account and a HRSA Electronic Handbooks account in order to apply (visit https://sam.gov/​SAM/​ and https://grants.hrsa.gov/​2010/​WebEPSExternal/​Interface/​UserRegistration/​RegistrationHome.aspx?.

€‹controlName=​ContentTabs for more information on how to create an account). A 60-day notice published in the Federal Register on October 6, 2020, vol. 85, No. 194.

Pp. 63121-22. There were no public comments. Need and Proposed Use of the Information.

The Substance Use—Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act requires FQHCs and RHCs to submit to the Secretary an application for payment at such time, in such manner, and containing such information as specified by the Secretary in order to receive a payment under section 6083. This form allows FQHCs and RHCs to apply for such payments based on the average cost of training to obtain DATA 2000 waivers, as determined by the Secretary, for their physicians and practitioners to furnish opioid use disorder treatment services. HRSA intends to validate and pay $3,000 per eligible provider submitted on the form by FQHCs and RHCs. The form also provides HRSA with the requisite data to validate qualifying DATA 2000 waiver possessions for the purpose of ensuring accurate payments to FQHCs and RHCs.

The following changes were made since the publication of the 60 Day notice. The number of respondents, total respondents, and total burden hours were updated to reflect administrative costs in the agency's spend plan. The figures assume a $3,000 payment for each DATA 2000 waiver and $750,000 in administrative costs, thereby leaving $7,250,000 in funds available for payment to FQHCs and RHCs. Language was added in the “Need and Proposed Use of the Information” section to signal to stakeholders that HRSA intends to validate and pay $3,000 per eligible provider submitted on the form by FQHCs and RHCs.

Additionally, language was added in the “Abstract” section notifying FQHCs and RHCs that they will need a System for Award Management account and a HRSA Electronic Handbooks account in order to apply. Likely Respondents. Only FQHC and RHC are eligible to apply. Burden Statement.

Burden in this context means the time expended by persons to generate, maintain, retain, disclose or provide the information requested. This includes the time needed to review instructions. To develop, acquire, install, and utilize technology and systems for the purpose of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information. To train personnel and to be able to respond to a collection of information.

To search data sources. To complete and review the collection of information. And to transmit or otherwise disclose the information. The total annual burden hours estimated for this ICR are summarized in the table below.

Total Estimated Annualized Burden—HoursForm nameNumber of respondentsNumber of responses per respondentTotal responsesAverage burden per response (in hours)Total burden hoursDATA 2000 Waiver Training Payment Program Application for Payment2,41612,4160.51,208Total2, 4162,4161,208 HRSA specifically requests comments on (1) the necessity and utility of the proposed information collection for the proper performance of the agency's functions, (2) the accuracy of the estimated burden, (3) ways to enhance the quality, utility, and clarity of the information to be collected, and (4) the use of automated collection techniques or other forms of information technology to minimize the information collection burden. Start Signature Amy P. McNulty, Deputy Director, Executive Secretariat. End Signature End Supplemental Information [FR Doc.

2020-28767 Filed 12-28-20. 8:45 am]BILLING CODE 4165-15-PIE 11 is not supported. For an optimal experience visit our site on another browser.04:14Share this -There is no national database of nurses trained to administer a forensic exam. NBC News contacted sexual assault resources in every state, finding the worst shortages in states with largely rural communities.Dec.

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Latest Prevention buy diflucan online cheap & buy diflucan one online. Wellness News THURSDAY, Nov. 24, 2021 (HealthDay News) Kraft Heinz Co. Announced that it is recalling certain lots of Country Time Lemonade, Tang, Arizona Tea and Kool-Aid powdered drinks because they buy diflucan one online may contain small pieces of metal or glass.

The company also said that certain lots of Country Time Lemonade with "Best When Used By" date of September 15, 2023 and Tang powdered drinks with "Best When Used By" dates of Aug. 20-21, 2023, have been recalled in Canada for the same issue. The problem with the glass and metal buy diflucan one online pieces occurred during production the company said. The recalled products, which include "Best When Used By" dates between May 10, 2023, and Nov.

1, 2023, should be thrown away or returned to the place of purchase for a refund. Consumers can buy diflucan one online contact Kraft Heinz from 9 a.m. To 6 p.m., Monday through Friday at the following phone numbers to see if a product they purchased is part of the recall. U.S.

Consumer Relations at 1-855-713-9237 buy diflucan one online or Canada Consumer Relations at 1-855-268-1775. More information Visit the U.S. Food and Drug Administration for more on food safety. SOURCE.

Kraft Heinz Co., news release, Nov. 20, 2021 Robert Preidt and Robin Foster Copyright © 2021 HealthDay. All rights reserved.Latest Prevention &. Wellness News WEDNESDAY, Nov.

24, 2021 (HealthDay News) One in five adults avoided seeking health care during the antifungal medication diflucan, even when they had symptoms suggesting the need for urgent medical attention, according to researchers in the Netherlands. "Health care avoidance during antifungal medication may be prevalent amongst those who are in greater need of it in the population, such as older individuals," a team led by Silvan Licher, of Erasmus University Medical Center in Rotterdam, reported. The findings suggest the need for public information efforts to urge individuals who are most likely to avoid getting care "to report both alarming and seemingly insignificant symptoms" to a primary care doctor or specialist, the researchers wrote in the report published Nov. 23 in the journal PLOS Medicine.

Patient visits to both primary care providers and specialists declined during the diflucan, the findings showed. To find out why, the researchers surveyed more than 5,600 middle-aged and older adults in Rotterdam. About one in five (20%) said they avoided health care during the diflucan. Of those, 36% reported symptoms that potentially warranted urgent medical attention, including limb weakness (nearly 14%), palpitations (11%) and chest pain (10%).

No information was available on severity of symptoms. But the investigators found that people most likely to have avoided health care included women. Those with poor self-reported health. And those with high levels of depression and anxiety.

Lower educational level, older age, unemployment, smoking and concern about contracting antifungal medication were also associated with avoiding health care. "One in five avoided health care during antifungal medication lockdown, often with alarming symptoms like chest pain or limb weakness," Licher said in a journal news release. "Vulnerable citizens were mainly affected, emphasizing the urgent need for targeted public education." More information The U.S. Centers for Disease Control and Prevention has more on antifungal medication.

SOURCE. PLOS Medicine, news release, Nov. 23, 2021 Robert Preidt Copyright © 2021 HealthDay. All rights reserved.

SLIDESHOW Health Care Reform. Protect Your Health in a Rough Economy See Slideshow.

Latest Prevention cheap diflucan online &. Wellness News THURSDAY, Nov. 24, 2021 (HealthDay News) Kraft Heinz Co.

Announced that it is recalling certain lots cheap diflucan online of Country Time Lemonade, Tang, Arizona Tea and Kool-Aid powdered drinks because they may contain small pieces of metal or glass. The company also said that certain lots of Country Time Lemonade with "Best When Used By" date of September 15, 2023 and Tang powdered drinks with "Best When Used By" dates of Aug. 20-21, 2023, have been recalled in Canada for the same issue.

The problem with the glass and metal pieces cheap diflucan online occurred during production the company said. The recalled products, which include "Best When Used By" dates between May 10, 2023, and Nov. 1, 2023, should be thrown away or returned to the place of purchase for a refund.

Consumers can cheap diflucan online contact Kraft Heinz from 9 a.m. To 6 p.m., Monday through Friday at the following phone numbers to see if a product they purchased is part of the recall. U.S.

Consumer Relations at cheap diflucan online 1-855-713-9237 or Canada Consumer Relations at 1-855-268-1775. More information Visit the U.S. Food and Drug Administration for more on food safety.

SOURCE. Kraft Heinz Co., news release, Nov. 20, 2021 Robert Preidt and Robin Foster Copyright © 2021 HealthDay.

All rights reserved.Latest Prevention &. Wellness News WEDNESDAY, Nov. 24, 2021 (HealthDay News) One in five adults avoided seeking health care during the antifungal medication diflucan, even when they had symptoms suggesting the need for urgent medical attention, according to researchers in the Netherlands.

"Health care avoidance during antifungal medication may be prevalent amongst those who are in greater need of it in the population, such as older individuals," a team led by Silvan Licher, of Erasmus University Medical Center in Rotterdam, reported. The findings suggest the need for public information efforts to urge individuals who are most likely to avoid getting care "to report both alarming and seemingly insignificant symptoms" to a primary care doctor or specialist, the researchers wrote in the report published Nov. 23 in the journal PLOS Medicine.

Patient visits to both primary care providers and specialists declined during the diflucan, the findings showed. To find out why, the researchers surveyed more than 5,600 middle-aged and older adults in Rotterdam. About one in five (20%) said they avoided health care during the diflucan.

Of those, 36% reported symptoms that potentially warranted urgent medical attention, including limb weakness (nearly 14%), palpitations (11%) and chest pain (10%). No information was available on severity of symptoms. But the investigators found that people most likely to have avoided health care included women.

Those with poor self-reported health. And those with high levels of depression and anxiety. Lower educational level, older age, unemployment, smoking and concern about contracting antifungal medication were also associated with avoiding health care.

"One in five avoided health care during antifungal medication lockdown, often with alarming symptoms like chest pain or limb weakness," Licher said in a journal news release. "Vulnerable citizens were mainly affected, emphasizing the urgent need for targeted public education." More information The U.S. Centers for Disease Control and Prevention has more on antifungal medication.

SOURCE. PLOS Medicine, news release, Nov. 23, 2021 Robert Preidt Copyright © 2021 HealthDay.

All rights reserved. SLIDESHOW Health Care Reform. Protect Your Health in a Rough Economy See Slideshow.

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Start Preamble http://portofinowest.com/photos/item/crab-stuffed-sole/ Announcement how fast does diflucan work for yeast Type. New. Funding how fast does diflucan work for yeast Announcement Number.

HHS-2022-IHS-ZSI-0001. Assistance Listing (Catalog of how fast does diflucan work for yeast Federal Domestic Assistance or CFDA) Number. 93.654.

Key Dates Application Deadline Date. February 2, how fast does diflucan work for yeast 2022. Earliest Anticipated Start Date.

March 21, how fast does diflucan work for yeast 2022. I. Funding Opportunity Description Statutory Authority The Indian Health how fast does diflucan work for yeast Service (IHS) is accepting applications for a cooperative agreement for the Zero Suicide Initiative (ZSI).

This program is authorized under the Snyder Act, 25 U.S.C. 13. The Transfer how fast does diflucan work for yeast Act, 42 U.S.C.

2001(a). And the Indian Health Care Improvement Act, how fast does diflucan work for yeast 25 U.S.C. 1665 et seq.

This program is described in the Assistance Listings located at https://sam.gov/​content/​home (formerly known as Catalog of Federal Domestic Assistance) under 93.654. Background Since 1999, suicide rates within the Unites States have been steadily increasing.[] On March 2, 2018, the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly report released a data report, “Suicides Among American Indian/Alaska Natives—National Violent Death Reporting System, 18 States, 2003 to 2014,” which highlights American how fast does diflucan work for yeast Indian/Alaska Natives having the highest rates of suicide of any racial/ethnic group in the Unites States. The suicide rate for American Indian/Alaska Native (AI/AN) adolescents and young adult ages 15 to 34 (19.1/100,000) was 1.3 times that of the national average for that age group (14/100,000).[] In June 2019, the National Center for Health Statistics, Health E-Stat reported in “Suicide Rates for Females and Males by Race and Ethnicity.

United States, 1999 and 2017,” suicide rates increased for all race and ethnicity groups but the largest increase occurred for how fast does diflucan work for yeast non-Hispanic AI/AN females (139% from 4.6 to 11.0 per 100,000). Suicide is the 8th leading cause of death among all AI/AN people across all ages and may be underestimated. The `Zero Suicide' model is a key component of the National Strategy for Suicide Prevention (NSSP) and is a priority of the National Action Alliance for Suicide how fast does diflucan work for yeast Prevention ( https://theactionalliance.org/​ ).

The `Zero Suicide' model focuses on developing a system-wide approach to improving care for individuals at risk of suicide who are currently using health and behavioral health systems. This award will support implementation of the `Zero Suicide' model within Tribal and Urban Indian health care facilities and systems that provide direct care services to AI/AN individuals in order to raise awareness of suicide, establish integrated systems of care, and improve outcomes for such individuals. Applicants are encouraged to visit how fast does diflucan work for yeast https://www.hhs.gov/​surgeongeneral/​reports-and-publications/​suicide-prevention/​index.html to access a copy of the 2012 National Strategy.

Purpose The purpose of this program is to improve the system of care for those at risk for suicide by implementing a comprehensive, culturally informed, multi-setting approach to suicide prevention in Indian health systems. This award represents a continuation of the how fast does diflucan work for yeast IHS effort to implement the Zero Suicide approach in Indian Country. The intent of this announcement is to initiate a new, or build upon the previous, Zero Suicide Initiative efforts.

Existing efforts have focused on foundational learning of the key concepts of the Zero Suicide framework, technical assistance, and how fast does diflucan work for yeast consultation for several AI/AN Zero Suicide communities. As a result of these efforts, both the unique opportunities and challenges of implementing Zero Suicide in Indian Country have been identified. To best capitalize on opportunities and surmount such challenges, this program focuses on the core Seven Elements of the Zero Suicide model as developed by the Suicide Prevention Resource Center (SPRC) at https://zerosuicide.edc.org/​toolkit/​zero-suicide-toolkit.

1 how fast does diflucan work for yeast . Lead—Create and sustain a leadership-driven, safety-oriented culture committed to dramatically reducing suicide among people under care. Include survivors how fast does diflucan work for yeast of suicide attempts and suicide loss in leadership and planning roles.

2. Train—Develop a competent, confident, and caring workforce. 3.

Identify—Systematically identify and assess suicide risk among people receiving care. 4. Engage—Ensure every individual has a pathway to care that is both timely and adequate to meet his or her needs.

Include collaborative safety planning and restriction of lethal means. 5. Treat—Use effective, evidence-based treatments that directly target suicidal thoughts and behaviors.

6. Transition—Provide continuous contact and support, especially after acute care. And, 7.

Improve—Apply a data-driven, quality improvement approach to inform system changes that will lead to improved patient outcomes and better care for those at risk. Required, Optional, and Allowable Activities Each applicant must describe how they plan to implement the following core elements of this program in their project narrative and incorporate culture within the approach to each of the seven elements. 1.

Lead a. Establish a leadership-driven strategic plan which includes session planning (see link https:// Start Printed Page 60884 zerosuicide.edc.org/​resources/​resource-database/​zero-suicide-work-plan-template ) to transform the delivery of suicide care within the health care system. b.

Describe the organizational steps to broaden the responsibility for suicide care across the entire health care system. C. Detail the specific role of leadership to ensure system transformation is achieved.

Examples of leadership commitment can include, but are not limited to. Tribal Resolutions, Tribal codes, formal suicide care policies, and formation of Zero Suicide Initiative advisory boards. 2.

Train a. Evaluate training needs and develop a formal training plan for suicide prevention gatekeeper training (examples include, but are not limited to, Question Persuade Refer, Applied Suicide Intervention Skills Training, and Mental Health First Aid). In addition, the training plan should include training in treating suicide risk (examples include, but are not limited to, Dialectical Behavioral Therapy, Cognitive Processing Therapy for Suicide Prevention, and Cognitive Therapy for Suicidal Patients).

B. The formal training plan for staff should focus across the health care system to strengthen and advance the skills of health care staff and providers at all levels. c.

Training must target increasing competence in the delivery of culturally informed, evidence-based suicide care in all health care settings. Survey at https://zerosuicide.edc.org/​sites/​default/​files/​ZS%20Workforce%20Survey%20July%202020.pdf will be completed and reported on at the initiation of the period of performance. d.

Train new or existing staff with an emphasis in these functions (see link https://zerosuicide.edc.org/​resources/​resource-database/​suicide-care-training-options ). e. Project/program oversight.

f. Case management/coordination to ensure continuity of care across and between various departments, health care systems, and or levels of care ( e.g., transfer from high risk to low risk, discharge from inpatient mental health care). g.

Data collection support and access for Electronic Health Record (EHR), clinical application, project coordinator support, and other data related activities. Adopt and/or enhance computer systems, including management information system, EHRs, and other systems/software, to better document and manage patient needs, the care process, integration with related support services, and track outcomes. 3.

Identify a. Implement system-wide policies and procedures for comprehensive suicide care standards to include, at a minimum. i.

Universal screening of all patients ages 10 and above for suicide risk using validated instruments (see link https://zerosuicide.edc.org/​resources/​resource-database/​ask-suicide-screening-questions-asq-toolkit). ii. Full suicide risk assessment of all patients with positive suicide risk screen (including risk level formulation), using (see link https://www.jointcommission.org/​-/​media/​tjc/​documents/​resources/​patient-safety-topics/​suicide-prevention/​pages-from-suicide_​prevention_​compendium_​5_​11_​20_​updated-july2020_​ep3_​4.pdf ).

iii. Individual Safety Plan for all patients with positive suicide risk screen to include counseling patients on reduction to access of lethal means and means restriction (see link https://www.sprc.org/​resources-programs/​patient-safety-plan-template ). iv.

Procedure and protocol for tracking patients at increased risk for suicide by placing patients on a suicide care management plan/pathway. This must also address how patients are monitored while on the plan/pathway, how often patients are re-evaluated to assess risk level, when it is appropriate to remove patient from plan/pathway, follow-up protocols after patients are removed from plan/pathway, etc. (see link https://www.jointcommission.org/​sea_​issue_​56/​ ).

b. Develop protocols for every individual identified as at risk of suicide to continuously monitor the individual's progress through their EHR or other data management system to include the following. i.

Rapid follow-up of adults who have attempted suicide or experienced a suicidal crisis after being discharged from a treatment facility, e.g., local emergency departments, inpatient psychiatric facilities, including direct linkage with appropriate health care agencies to ensure coordinated care services and protocols are in place to ensure patient safety, especially among high-risk adults with serious mental illness. This must include outreach telephone contact within 24 to 48 hours after discharge and securing an appointment within 1 week of discharge (see link https://www.jointcommission.org/​resources/​patient-safety-topics/​suicide-prevention/​ ). ii.

Establish health system leadership including outside service providers ( i.e., local suicide prevention crisis lines to help with follow-up contacts, etc.), and develop teams to guide the implementation of the Zero Suicide model within their agencies. 4. Engage a.

Develop a Suicide Care Management Plan for every patient identified as high risk of suicide (see link https://zerosuicide.edc.org/​resources/​resource-database/​zero-suicide-work-plan-template ). Implement a process for continuous monitoring of those patients' progress through their EHR or other data management system, and adjust treatment as necessary. 5.

Treat a. Develop a strategy and specific plan (see link https://zerosuicide.edc.org/​resources/​resource-database/​zero-suicide-data-elements-worksheet ) to collect, analyze, and disseminate data related to suicide care across the health care system. b.

Use a data-informed approach for quality improvement at the levels of policy, process, and practice. Wherever possible, this approach should include a unified EHR, or memorandum of understanding/memorandum of agreement (MOU/MOA) to establish a process to share data between and across systems of care for all patients in a suicide risk clinical pathway. For example, a data report that indicates a high percentage of patients being discharged from inpatient stays failed to receive follow-up appointments may result in implementing a plan to reduce that number by changing staffing patterns and processes to focus on scheduling follow-up care.

C. Apply the use of evidence-based practices to screen, assess, and treat individuals at risk for suicide in a way that incorporates culturally informed practices and activities. Clearly describe how cultural best practices and/or traditional approaches are offered, utilized, and/or incorporated within the health care system to complement/augment into the evidence-based protocols with those at risk for suicide.

D. Evidence-based practices, where appropriate, may include. i.

Suicide risk screening—Ask Suicide-Screening Questions (see link https://www.nimh.nih.gov/​research/​research-conducted-at-nimh/​asq-toolkit-materials/​index.shtml ). ii. Columbia Suicide Severity Rating Scale (see link https://cssrs.columbia.edu/​the-columbia-scale-c-ssrs/​cssrs-for-communities-and-healthcare/​#filter=​.general-use.english ).

Start Printed Page 60885 iii. Suicide Risk Assessment—Brief Suicide Safety Assessment (see link https://www.nimh.nih.gov/​research/​research-conducted-at-nimh/​asq-toolkit-materials/​youth-outpatient/​youth-outpatient-brief-suicide-safety-assessment-worksheet.shtml ). iv.

Columbia Suicide Severity Rating Scale (see link https://cssrs.columbia.edu/​the-columbia-scale-c-ssrs/​cssrs-for-communities-and-healthcare/​#filter=​.general-use.english ). v. Suicide treatment—Dialectical Behavioral Therapy (see link https://www.sprc.org/​resources-programs/​dialectical-behavior-therapy ).

vi. Cognitive Therapy for Suicidal Patients (see link https://www.sprc.org/​resources-programs/​cognitive-therapy-suicide-prevention ). vii.

Cultural best practices and/or traditional approaches—Language immersion, traditional healers, and traditional ceremonies (see link https://zerosuicide.edc.org/​toolkit/​toolkit-adaptations/​indian-country ). 6. Transition a.

The Suicide Care Management Plan must include the following (see link https://zerosuicide.edc.org/​resources/​resource-database/​best-practices-care-transitions-individuals-suicide-risk-inpatient-care ). i. Protocols for safety planning and reducing access to lethal means in a point-to-point transition of care within a system.

ii. Rapid follow-up of adults who have attempted suicide or experienced a suicidal crisis after being discharged from a treatment facility ( e.g., local emergency departments, inpatient psychiatric facilities), including direct linkage with appropriate health care agencies to ensure coordinated care services are in place. iii.

Protocols to ensure patient safety, especially among high-risk adults in health care systems who have attempted suicide, experienced a suicidal crisis, and/or have a serious mental illness. This must include outreach telephone contact within 24 to 48 hours after discharge and securing an appointment within 1 week of discharge (see link https://zerosuicide.edc.org/​toolkit/​transition and/or https://theactionalliance.org/​healthcare/​caretransitions ). 7.

Improve a. Describe the quality improvement activities that will be used to track progress towards your process and outcome measure and how these data will be used to inform the ongoing implementation of the project and beyond (see link https://zerosuicide.edc.org/​resources/​resource-database/​zero-suicide-work-plan-template ). In addition to the seven elements listed above, the following activities are also required.

1. Seek the IHS's approval for key positions to be filled. Key positions include, but are not limited to, the Project Director, Project Coordinator, and Evaluator.

2. Consult and accept guidance from IHS staff on performance of programmatic and data collection activities to achieve the goals of the cooperative agreement. 3.

Maintain ongoing communication with the IHS including a minimum of one call per month, keeping Federal program staff informed of emerging issues, developments, and problems as appropriate. 4. Invite the IHS Program Official to observe and provide feedback to policy, steering, advisory, or other task forces.

5. Maintain ongoing collaboration with the IHS ZSI Technical Assistance Coordinating Center, the Suicide Prevention Resource Center, and the National Suicide Prevention Lifeline. 6.

Provide required documentation for monthly and annual reporting and data surveillance around suicidal behavior in selected health and behavioral health care systems. Practice-Based Evidence, Promising Practices, and Local Efforts The IHS encourages the implementation of Tribal and/or culturally appropriate suicide prevention and intervention strategies but recognizes the limited range of formally evaluated evidence-based practices for suicide and substance abuse that have been developed specifically for the American Indians/Alaska Natives population. In addition to formally evaluated practices, which exist in the research and practice literature, evidence for other practices are allowed in this grant program.

Evidence of other practices may include unpublished studies, preliminary evaluation results, clinical (or other professional association) guidelines, findings from focus groups with community members, local community surveys, etc. Document the evidence that the practice(s) you have chosen is appropriate for the outcomes you want to achieve. Explain how the practice you have chosen meets the goals for this program.

Describe any modifications/adaptations you will need to make to your proposed practice(s) to meet the goals of your project and why you believe the changes will improve the outcomes. Discuss training needs or plans for training to successfully implement the proposed evidence-based practice(s). II.

Award Information Funding Instrument—Cooperative Agreement Estimated Funds Available The total funding identified for fiscal year (FY) 2022 is approximately $2,000,000. Individual award amounts for the first budget year are anticipated to be between $200,000 and $300,000. The funding available for competing and subsequent continuation awards issued under this announcement is subject to the availability of appropriations and budgetary priorities of the Agency.

The IHS is under no obligation to make awards that are selected for funding under this announcement. Anticipated Number of Awards Approximately 8-10 awards will be issued under this program announcement, with a set aside of up to two awards issued to eligible UIOs. Period of Performance The period of performance is for 5 years.

Cooperative Agreement Cooperative agreements awarded by the Department of Health and Human Services (HHS) are administered under the same policies as grants. However, the funding agency, IHS, is anticipated to have substantial programmatic involvement in the project during the entire period of performance. Below is a detailed description of the level of involvement required of the IHS.

Substantial Agency Involvement Description for Cooperative Agreement 1. Approve all proposed key positions/personnel. 2.

Facilitate linkages to other IHS/Federal government resources and help grantees access appropriate technical assistance. 3. Assure that the grantee's project activities are aligned with the mission, strategic goals and objectives of the IHS, and with the goals of the Zero Suicide Initiative.

4. Coordinate cross-site evaluation participation in grantee and staff required monitoring conference calls. 5.

Promote collaboration with other IHS and Federal health and behavioral health initiatives, including the Substance Abuse Mental Health Services Administration (SAMHSA), the Start Printed Page 60886 National Action Alliance for Suicide Prevention, the National Suicide Prevention Lifeline, the SPRC, and the Zero Suicide Institute. 6. Provide technical assistance on all aspects of the ZSI program implementation and sustainability.

7. Share aggregate data related to suicide behavior and clinical care necessary to determine that the project has met expected and identified goals, objectives, and outcomes. Describe the process of continuous involvement based on results and analysis of the same.

III. Eligibility Information 1. Eligibility To be eligible for this funding opportunity the applicant must be one of the following as defined by 25 U.S.C.

1603. • A federally recognized Indian Tribe as defined by 25 U.S.C. 1603(14).

The term “Indian Tribe” means any Indian Tribe, band, nation, or other organized group or community, including any Alaska Native village or group or regional or village corporation, as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688) [43 U.S.C. 1601 et seq.

], which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians. A Tribal organization as defined by 25 U.S.C. 1603(26).

The term “Tribal organization” has the meaning given the term in section 4 of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304(1)). €œTribal organization” means the recognized governing body of any Indian Tribe.

Any legally established organization of Indians which is controlled, sanctioned, or chartered by such governing body or which is democratically elected by the adult members of the Indian community to be served by such organization and which includes the maximum participation of Indians in all phases of its activities. Provided that, in any case where a contract is let or grant made to an organization to perform services benefiting more than one Indian Tribe, the approval of each such Indian Tribe shall be a prerequisite to the letting or making of such contract or grant. Applicant shall submit letters of support and/or Tribal Resolutions from the Tribes to be served.

• An Urban Indian organization as defined by 25 U.S.C. 1603(29). The term “Urban Indian organization” means a nonprofit corporate body situated in an urban center, governed by an urban Indian controlled board of directors, and providing for the maximum participation of all interested Indian groups and individuals, which body is capable of legally cooperating with other public and private entities for the purpose of performing the activities described in 25 U.S.C.

1653(a). Applicants must provide proof of non-profit status with the application, e.g., 501(c)(3). The program office will notify any applicants deemed ineligible.

Note. Please refer to Section IV.2 (Application and Submission Information/Subsection 2, Content and Form of Application Submission) for additional proof of applicant status documents required, such as Tribal Resolutions, proof of nonprofit status, etc. 2.

Cost Sharing or Matching The IHS does not require matching funds or cost sharing for grants or cooperative agreements. 3. Other Requirements Applications with budget requests that exceed the highest dollar amount outlined under Section II Award Information, Estimated Funds Available, or exceed the period of performance outlined under Section II Award Information, Period of Performance, are considered not responsive and will not be reviewed.

The Division of Grants Management (DGM) will notify the applicant. Additional Required Documentation Tribal Resolution The DGM must receive an official, signed Tribal Resolution prior to issuing a Notice of Award (NoA) to any applicant selected for funding. An Indian Tribe or Tribal organization that is proposing a project affecting another Indian Tribe must include resolutions from all affected Tribes to be served.

However, if an official, signed Tribal Resolution cannot be submitted with the application prior to the application deadline date, a draft Tribal Resolution must be submitted with the application by the deadline date in order for the application to be considered complete and eligible for review. The draft Tribal Resolution is not in lieu of the required signed resolution but is acceptable until a signed resolution is received. If an application without a signed Tribal Resolution is selected for funding, the applicant will be contacted by the Grants Management Specialist (GMS) listed in this funding announcement and given 90 days to submit an official, signed Tribal Resolution to the GMS.

If the signed Tribal Resolution is not received within 90 days, the award will be forfeited. Tribes organized with a governing structure other than a Tribal council may submit an equivalent document commensurate with their governing organization. Proof of Nonprofit Status Organizations claiming nonprofit status must submit a current copy of the 501(c)(3) Certificate with the application.

IV. Application and Submission Information 1. Obtaining Application Materials The application package and detailed instructions for this announcement are available at https://www.Grants.gov.

Please direct questions regarding the application process to Mr. Paul Gettys at (301) 443-2114 or (301) 443-5204. 2.

Content and Form Application Submission Mandatory documents for all applicants include. Abstract (one page) summarizing the project. Application forms.

1. SF-424, Application for Federal Assistance. 2.

SF-424A, Budget Information—Non-Construction Programs. 3. SF-424B, Assurances—Non-Construction Programs.

Project Narrative (not to exceed 30 pages). See IV.2.A, Project Narrative for instructions. 1.

Background information on the organization. 2. Proposed scope of work, objectives, and activities that provide a description of what the applicant plans to accomplish.

Budget Justification and Narrative (not to exceed four pages). See IV.2.B, Budget Narrative for instructions. One-page Timeline Chart.

Tribal Resolution(s). A Tribal Resolution expressing a bona fide commitment to a Zero Suicide model within the health and behavioral health care system must be provided. Letters of Support from organization's Board of Directors (if applicable).

501(c)(3) Certificate (if applicable). Biographical sketches for all Key Personnel. Contractor/Consultant resumes or qualifications and scope of work.

Disclosure of Lobbying Activities (SF-LLL), if applicant conducts reportable lobbying. • Certification Regarding Lobbying (GG—Lobbying Form). Start Printed Page 60887 Copy of current Negotiated Indirect Cost rate (IDC) agreement (required in order to receive IDC).

Organizational Chart (optional). Documentation of current Office of Management and Budget (OMB) Financial Audit (if applicable). Acceptable forms of documentation include.

1. Email confirmation from Federal Audit Clearinghouse (FAC) that audits were submitted. Or 2.

Face sheets from audit reports. Applicants can find these on the FAC website at https://harvester.census.gov/​facdissem/​Main.aspx. Public Policy Requirements All Federal public policies apply to IHS grants and cooperative agreements.

Pursuant to 45 CFR 80.3(d), an individual shall not be deemed subjected to discrimination by reason of their exclusion from benefits limited by Federal law to individuals eligible for benefits and services from the IHS. See https://www.hhs.gov/​grants/​grants/​grants-policies-regulations/​index.html. Requirements for Project and Budget Narratives A.

Project Narrative. This narrative should be a separate document that is no more than 30 pages and must. (1) Have consecutively numbered pages.

(2) use black font 12 points or larger. (3) be single-spaced. And (4) be formatted to fit standard letter paper (8 1/2 x 11 inches).

Be sure to succinctly answer all questions listed under the evaluation criteria (refer to Section V.1, Evaluation Criteria) and place all responses and required information in the correct section noted below or they will not be considered or scored. If the narrative exceeds the page limit, the application will be considered not responsive and will not be reviewed. The 30-page limit for the narrative does not include the work plan, standard forms, Tribal Resolutions, budget, budget justifications, narratives, and/or other items.

There are four parts to the project narrative. Part 1—Statement of Need. Part 2—Implementation Approach and Work Plan.

Part 3—Organizational Capacity. Part 4—Data Collection and Reporting. Below are additional details about what must be included in the project narrative.

The intent of this announcement is to initiate or build upon Zero Suicide Initiative efforts. Applicants previously funded by IHS for ZSI implementation must report on the status of their goals/milestones. If goals/milestone were not achieved by those applicants, they are expected to provide clear explanation of the barriers that prevented the achievement of previous goal/milestones in the application to this funding announcement.

Part 1. Statement of Need (Limit—6 Pages) The statement of need describes the scope and scale of suicide behavior within the community served and within the health and/or behavioral health system. This section must identify gaps in suicide care delivery and those gaps and any other barriers in providing comprehensive, culturally informed care to those at risk for suicide.

The statement of need provides the facts and evidence that support the need for the project and establishes that the Tribe, Tribal organization, or UIO understands the problems and can reasonably address them. Applicant's data may include the following metrics outlined below. Identify • Describe the proposed catchment area and demographic information on the population(s) to receive services through the targeted systems or agencies, e.g., race, ethnicity, federally recognized Tribe, language, age, socioeconomic status, sex, and other relevant factors, such as literacy.

Improve • Provide evidence of the prevalence of suicidal behavior within the population(s) of focus, including any current limitations of data collection in the health system. In addition, discuss how the proposed project will address disparities in access, service use, and outcomes for the population(s) of focus (see link https://zerosuicide.edc.org/​toolkit/​indian-country/​improve-indian-country ). 1.

Number of screenings performed. 2. Number of those above screening cut off who receive a full suicide risk assessment.

3. Numbers of those receiving a full risk assessment who have a collaboratively developed safety plan. 4.

Number of those with a collaboratively developed safety plan who have been counseled on reduction of access to lethal means. 5. Percentage of all behavioral health clinicians who use evidence-based practices to directly treat those at risk for suicide.

6. Percentage of follow up on those who may be at risk for suicide to ensure safe transitions through care. 7.

Percentage of documentation on every loss by suicide. • Documentation of the need for an enhanced infrastructure (system/process improvements) to increase the capacity to implement, sustain, and improve comprehensive, integrated, culturally informed, evidence-based suicide care within the identified health care system that is consistent with the purpose of the program as stated in this announcement (see link https://zerosuicide.edc.org/​resources/​zero-suicide-workforce-survey-resources ). This may also include a clear description of any service gaps, staff/provider training deficits, service delivery fragmentations, and other barriers that could impact comprehensive suicide care for patients seen in the health system.

• Applicants are encouraged to review the Zero Suicide strategies and tools to help prepare for application to this announcement. Please see http://zerosuicide.sprc.org/​sites/​zerosuicide.actionallianceforsuicideprevention.org/​files/​Zero%20Suicide%20Workplan%20Template%2012.6.17.pdf. Part 2.

Implementation Approach &. Work Plan (Limit—9 Pages) Applicant should develop a viable plan to address each of the 7 Elements (see link http://zerosuicide.edc.org/​toolkit ) in a systematic, measureable, and interrelated manner. Evidence of plan to the identification, use, and measurement of the use of culturally informed practices and activities (see link https://zerosuicide.edc.org/​resources/​populations/​native-american-and-alaska-native ).

Please include a Project Timeline in the application. Lead A clear description of strategies to engage the highest levels of leadership and a broad cross section of the hospital system in order to develop organizational commitment, participation and sustainability (Letters of Commitment should be included as attachments). If the program is to be managed by a consortium or Tribal organization, identify how the project office relates to the member community/communities.

Transition • A contingency plan that addresses short-term maintenance and long-term sustainability. How will continuity be maintained if/when there is a change in the operational environment ( e.g., health care system leadership, staff turnover, change in project leadership, change in elected officials, etc.) to Start Printed Page 60888 ensure project stability over the period of performance. Additionally, describe long-term plan for sustainability of the ZSI model beyond the period of performance.

Include how your project plans to involve survivors of suicide attempts and suicide loss in assessing, planning, and implementing your project. Part 3. Organizational Capacity (Limit—8 Pages) This section focuses on how the organization may capitalize on existing resources, processes, human capital, quality initiatives, collaborative agreements, and surveillance capabilities as a means of overcoming barriers to a comprehensive, culturally informed system of suicide care.

Lead • Describe any experience (successes and/or challenges) with the Zero Suicide model ( e.g., attended a Zero Suicide Academy, etc.) or similar collaborative efforts ( e.g., patient centered medical home, behavioral integration, trauma-informed systems, and improving patient care, etc.). Discuss the applicant Tribe, Tribal organization, or UIO experience with and capacity (or detailed plan) to provide culturally informed practices and activities for specific populations of focus. Explain how all departments/units/divisions are (or plan to be) involved in administering this project.

You may also include how applicant organization currently (or plans to) collaborate with other organizations and agencies to provide care, including critical transition of care. Provide Letter(s) of Commitment, MOA, MOUs etc., from CEO, Tribal Health Director, Tribal Chair, etc. • Describe the resources available for the proposed project ( e.g., facilities, equipment, information technology systems, EHR capabilities, financial management systems, data sharing agreement, MOUs, etc.).

List of all staff positions for the project, such as Project Director, project coordinator, case manager and other key personnel, and briefly describe their role and level of effort on the project. Part 4. Data Collection and Reporting (Limit—7 Pages) This section of the narrative should describe function of position and efforts to collect and report project data that will support and demonstrate ZSI activities.

All ZSI grantees will be required to collect and report data pertaining to activities, processes, and outcomes that support the following core elements. Improve Provide a clear, specific plan for how data will be collected, managed, analyzed, and reported. Identify which staff will be responsible for tracking the goals and measureable objectives associated with the award.

Lead Review of suicide care policies and procedures. Review of any MOUs, MOAs, commitment letters, etc. ZSI Implementation team participation.

Engagement of those that have experienced suicidal thoughts, survived a suicide attempt, cared for someone through suicidal crisis, or been bereaved by suicide. Improve Assessment of fidelity to the Zero Suicide model (to include periodic administering of Organizational Self-Study). Periodic assessment of staff development and training needs (to include the periodic administering of the Workforce Survey).

Sustainability. Measurement-based screening tools. Review of EHR capability.

Patient satisfaction. B. Budget Narrative (limit—4 pages).

Provide a budget narrative that explains the amounts requested for each line item of the budget from the SF-424A (Budget Information for Non-Construction Programs). The budget narrative should specifically describe how each item will support the achievement of proposed objectives. Be very careful about showing how each item in the “Other” category is justified.

For subsequent budget years, the narrative should highlight the changes from year 1 or clearly indicate that there are no substantive budget changes during the period of performance. Do NOT use the budget narrative to expand the project narrative. 3.

Submission Dates and Times Applications must be submitted through Grants.gov by 11:59 p.m. Eastern Time on the Application Deadline Date. Any application received after the application deadline will not be accepted for review.

Grants.gov will notify the applicant via email if the application is rejected. If technical challenges arise and assistance is required with the application process, contact Grants.gov Customer Support (see contact information at https://www.grants.gov ). If problems persist, contact Mr.

Paul Gettys ( Paul.Gettys@ihs.gov ), Acting Director, DGM, by telephone at (301) 443-2114 or (301) 443-5204. Please be sure to contact Mr. Gettys at least ten days prior to the application deadline.

Please do not contact the DGM until you have received a Grants.gov tracking number. In the event you are not able to obtain a tracking number, call the DGM as soon as possible. IHS will not acknowledge receipt of applications.

4. Intergovernmental Review Executive Order 12372 requiring intergovernmental review is not applicable to this program. 5.

Funding Restrictions Pre-award costs are allowable up to 90 days before the start date of the award provided the costs are otherwise allowable if awarded. Pre-award costs are incurred at the risk of the applicant. The available funds are inclusive of direct and indirect costs.

Only one cooperative agreement may be awarded per applicant under this announcement. 6. Electronic Submission Requirements All applications must be submitted via Grants.gov.

Please use the https://www.Grants.gov website to submit an application. Find the application by selecting the “Search Grants” link on the homepage. Follow the instructions for submitting an application under the Package tab.

No other method of application submission is acceptable. If the applicant cannot submit an application through Grants.gov , a waiver must be requested. Prior approval must be requested and obtained from Mr.

Paul Gettys, Acting Director, DGM. A written waiver request must be sent to GrantsPolicy@ihs.gov with a copy to Paul.Gettys@ihs.gov. The waiver request must.

(1) Be documented in writing (emails are acceptable) before submitting an application by some other method, and (2) include clear justification for the need to deviate from the required application submission process. Once the waiver request has been approved, the applicant will receive a confirmation of approval email containing submission instructions. A copy of the written approval must be included with the application that is submitted to the DGM.

Applications that are submitted without a copy of the signed waiver from the Acting Director of the DGM will not be reviewed. The Grants Management Officer of the DGM Start Printed Page 60889 will notify the applicant via email of this decision. Applications submitted under waiver must be received by the DGM no later than 5:00 p.m., Eastern Time, on the Application Deadline Date.

Late applications will not be accepted for processing. Applicants that do not register for both the System for Award Management (SAM) and Grants.gov and/or fail to request timely assistance with technical issues will not be considered for a waiver to submit an application via alternative method. Please be aware of the following.

• Please search for the application package in https://www.Grants.gov by entering the Assistance Listing (CFDA) number or the Funding Opportunity Number. Both numbers are located in the header of this announcement. • If you experience technical challenges while submitting your application, please contact Grants.gov Customer Support (see contact information at https://www.grants.gov ).

• Upon contacting Grants.gov , obtain a tracking number as proof of contact. The tracking number is helpful if there are technical issues that cannot be resolved and a waiver from the agency must be obtained. • Applicants are strongly encouraged not to wait until the deadline date to begin the application process through Grants.gov as the registration process for SAM and Grants.gov could take up to twenty working days.

• Please follow the instructions on Grants.gov to include additional documentation that may be requested by this funding announcement. Applicants must comply with any page limits described in this funding announcement. • After submitting the application, the applicant will receive an automatic acknowledgment from Grants.gov that contains a Grants.gov tracking number.

The IHS will not notify the applicant that the application has been received. Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) Applicants and grantee organizations are required to obtain a DUNS number and maintain an active registration in the SAM database. The DUNS number is a unique 9-digit identification number provided by D&B that uniquely identifies each entity.

The DUNS number is site specific. Therefore, each distinct performance site may be assigned a DUNS number. Obtaining a DUNS number is easy, and there is no charge.

To obtain a DUNS number, please access the request service through https://fedgov.dnb.com/​webform, or call (866) 705-5711. The Federal Funding Accountability and Transparency Act of 2006, as amended (“Transparency Act”), requires all HHS recipients to report information on sub-awards. Accordingly, all IHS grantees must notify potential first-tier sub-recipients that no entity may receive a first-tier sub-award unless the entity has provided its DUNS number to the prime grantee organization.

This requirement ensures the use of a universal identifier to enhance the quality of information available to the public pursuant to the Transparency Act. System for Award Management (SAM) Organizations that are not registered with SAM must have a DUNS number first, then access the SAM online registration through the SAM home page at https://www.sam.gov/​SAM/​ (U.S. Organizations will also need to provide an Employer Identification Number from the Internal Revenue Service that may take an additional 2-5 weeks to become active).

Please see SAM.gov for details on the registration process and timeline. Registration with the SAM is free of charge but can take several weeks to process. Applicants may register online at https://www.sam.gov/​SAM/​.

Additional information on implementing the Transparency Act, including the specific requirements for DUNS and SAM, are available on the DGM Grants Management, Policy Topics web page. Https://www.ihs.gov/​dgm/​policytopics/​. V.

Application Review Information Possible points assigned to each section are noted in parentheses. The 30-page project narrative should include only the first year of activities. Information for multi-year projects should be included as an appendix.

See “Multi-year Project Requirements” at the end of this section for more information. The narrative section should be written in a manner that is clear to outside reviewers unfamiliar with prior related activities of the applicant. It should be well organized, succinct, and contain all information necessary for reviewers to understand the project fully.

Points will be assigned to each evaluation criteria adding up to a total of 100 possible points. Points are assigned as follows. 1.

Evaluation Criteria Applications will be reviewed and scored according to the quality of responses to the required application components in Sections A-E. The points listed after each heading is the maximum number of points a reviewer may assign to that section. A.

Statement of Need (10 Points) The criteria being evaluated is the quality of your strategic approach and logical steps to implement a Zero Suicide Initiative within your health system. The following aspects will be assessed. 1.

The degree to which the applicant's description of the service area/target population demonstrates the need for a systems approach to suicide care within the health and behavioral health systems. 2. How well the applicant describes the unique characteristics of the service area and population and systems barriers/gaps that impact the delivery of comprehensive suicide care.

B. Implementation Approach &. Work Plan (30 Points) 1.

A viable plan to address each of the 7 Elements of the Zero Suicide model and the required activities (described in Section 1) in a systematic, measureable, and interrelated manner. Develop strategy to collect, and analyze application of evidence-based practices to screen, assess, and treat individuals' use of culturally informed practices and activities. (See Resources for Native American and Alaska Native Populations at https://zerosuicide.edc.org/​resources/​populations/​native-american-and-alaska-native ).

2. A clear description of strategies to engage the highest levels of leadership and a broad cross section of the behavioral/healthcare system in order to develop organizational commitment, participation and sustainability (Letters of Commitment, MOUs, MOAs, etc., should be included as attachments). If the program is to be managed by a consortium or Tribal organization, identify how the project office relates to the member community/communities.

Should include how you plan to involve survivors of suicide attempts and suicide loss in assessing, planning, and implementing your project. 3. Address how continuity will be maintained if/when there is a change in the operational environment ( e.g., health care system leadership, staff turnover, change in project leadership, change in elected officials, etc.) to ensure project stability over the period of performance.

Additionally, describe the long-term plan for sustainability of the ZSI model beyond the period of performance. C. Organizational Capacity (30 Points) 1.

The extent to which the applicant describes experience (successes and/or challenges) with the Zero Suicide model Start Printed Page 60890 ( e.g., attended a Zero Suicide Academy, etc.) or similar collaborative efforts ( e.g., patient centered medical home, behavioral integration, trauma informed systems, and improving patient care, etc.), focused on a comprehensive approach to suicide care across a healthcare system. 2. The extent to which the applicant describes experience with and capacity (or detailed plan) to provide culturally informed practices and activities for specific populations of focus.

Must refer to Tribal Resolution. 3. Identification of how all departments/units/divisions across the health care system will be involved in administering this project.

May also include how applicant organization currently (or plans to) collaborate with other organizations and agencies to provide care, including critical transition of care. 4. Describe the resources available to implement and sustain the proposed project ( e.g., facilities, equipment, information technology systems, financial management systems, data sharing agreement, MOUs, etc.).

Listing of all staff positions for the project, such as Project Director, project coordinator, and other key personnel, showing the role of each and their level of effort and qualifications. Demonstrate successful project implementation for the level of effort budgeted for Project Director, project coordinator, and other key staff. Include position descriptions as attachments to the application.

Describe the function within each position providing services in suicide care, behavioral health and primary care and other health care services, quality and process improvement, and related work within the community/communities. 5. Applicants previously funded by the IHS for ZSI implementation must report on the status of their goals/milestones in this section of the program narrative.

If goals/milestones were not achieved by those applicants, they are expected to provide clear explanation of the barriers that prevented the achievement of previous goals/milestones. D. Data Collection, Performance Assessment and Evaluation (25 Points) In this area, applicants need to clearly demonstrate the ability to collect and report on required data elements associated with Zero Suicide and this particular project, and engage in all aspects of local and national evaluation.

The following aspects will be assessed. Ability to collect and report on the required performance measures specified in the Data Collection and Performance Management section. A clear, specific plan for data collection, management, analysis, and reporting.

Indication of the staff person(s) responsible for tracking the measureable objectives that are identified above. Description of your plan for conducting the local performance assessment, as specified above, and evidence of your ability to conduct the assessment. Description of the quality improvement process that will be used to track progress towards your performance measures and objectives, and how these data will be used to inform the ongoing implementation of the project and beyond.

E. Categorical Budget and Budget Justification (5 Points) Applicants must provide a budget and narrative justification for the proposed project budget. 1.

Evidence of reasonable, allowable costs necessary to achieve the objective outlined in the project narrative. 2. Description of how the budget aligns with the overall scope of work.

3. Please use Budget/Budget Narrative Template Worksheet to support your responses in this section. The Timeline Chart, Local Data Collection Plan Worksheet, and Budget/Budget Narrative templates can be downloaded at the ZSI website at https://www.ihs.gov/​zerosuicide/​.

Multi-Year Project Requirements Applications must include a brief project narrative and budget (one additional page per year) addressing the developmental plans for each additional year of the project. This attachment will not count as part of the project narrative or the budget narrative. Additional documents can be uploaded as Other Attachments in Grants.gov.

These can include. Work plan, logic model, and/or timeline for proposed objectives. Position descriptions for staff.

Consultant or contractor proposed scope of work and letter of commitment (if applicable). Current Indirect Cost Rate Agreement. Organizational chart.

Map of area identifying project location(s). • Additional documents to support narrative ( i.e., data tables, key news articles, etc.). 2.

Review and Selection Each application will be prescreened for eligibility and completeness as outlined in the funding announcement. Applications that meet the eligibility criteria shall be reviewed for merit by the Objective Review Committee (ORC) based on evaluation criteria. Incomplete applications and applications that are not responsive to the administrative thresholds (budget limit, project period limit) will not be referred to the ORC and will not be funded.

The applicant will be notified of this determination. Applicants must address all program requirements and provide all required documentation. 3.

Notifications of Disposition All applicants will receive an Executive Summary Statement from the IHS Division of Behavioral Health within 30 days of the conclusion of the ORC outlining the strengths and weaknesses of their application. The summary statement will be sent to the Authorizing Official identified on the face page (SF-424) of the application. A.

Award Notices for Funded Applications The NoA is the authorizing document for which funds are dispersed to the approved entities and reflects the amount of Federal funds awarded, the purpose of the award, the terms and conditions of the award, the effective date of the award, and the budget/project period. Each entity approved for funding must have a user account in GrantSolutions in order to retrieve the NoA. Please see the Agency Contacts list in Section VII for the systems contact information.

B. Approved but Unfunded Applications Approved applications not funded due to lack of available funds will be held for 1 year. If funding becomes available during the course of the year, the application may be reconsidered.

Any correspondence other than the official NoA executed by an IHS grants management official announcing to the project director that an award has been made to their organization is not an authorization to implement their program on behalf of the IHS. VI. Award Administration Information 1.

Administrative Requirements Awards issued under this announcement are subject to, and are administered in accordance with, the following regulations and policies. A. The criteria as outlined in this program announcement.

B. Administrative Regulations for Grants. • Uniform Administrative Requirements, Cost Principles, and Start Printed Page 60891 Audit Requirements for HHS Awards currently in effect or implemented during the period of award, other Department regulations and policies in effect at the time of award, and applicable statutory provisions.

At the time of publication, this includes 45 CFR part 75, at https://www.govinfo.gov/​content/​pkg/​CFR-2020-title45-vol1/​pdf/​CFR-2020-title45-vol1-part75.pdf. • Please review all HHS regulatory provisions for Termination at 45 CFR 75.372, at https://www.ecfr.gov/​cgi-bin/​retrieveECFR?. €‹gp&​amp;​SID=​2970eec67399fab1413ede53d7895d99&​amp;​mc=​true&​amp;​n=​pt45.1.75&​amp;​r=​PART&​amp;​ty=​HTML&​amp;​se45.1.75_​1372#se45.1.75_​1372.

C. Grants Policy. • HHS Grants Policy Statement, Revised January 2007, at https://www.hhs.gov/​sites/​default/​files/​grants/​grants/​policies-regulations/​hhsgps107.pdf.

D. Cost Principles. Uniform Administrative Requirements for HHS Awards, “Cost Principles,” located at 45 CFR part 75 subpart E.

E. Audit Requirements. Uniform Administrative Requirements for HHS Awards, “Audit Requirements,” located at 45 CFR part 75 subpart F.

F. As of August 13, 2020, 2 CFR 200 was updated to include a prohibition on certain telecommunications and video surveillance services or equipment. This prohibition is described in 2 CFR 200.216.

This will also be described in the terms and conditions of every IHS grant and cooperative agreement awarded on or after August 13, 2020. 2. Indirect Costs This section applies to all recipients that request reimbursement of indirect costs (IDC) in their application budget.

In accordance with HHS Grants Policy Statement, Part II-27, IHS requires applicants to obtain a current IDC rate agreement and submit it to the DGM prior to the DGM issuing an award. The rate agreement must be prepared in accordance with the applicable cost principles and guidance as provided by the cognizant agency or office. A current rate covers the applicable grant activities under the current award's budget period.

If the current rate agreement is not on file with the DGM at the time of award, the IDC portion of the budget will be restricted. The restrictions remain in place until the current rate agreement is provided to the DGM. Per 45 CFR 75.414(f) Indirect (F&A) costs, “any non-Federal entity (NFE) [ i.e., applicant] that has never received a negotiated indirect cost rate,.

. . May elect to charge a de minimis rate of 10 percent of modified total direct costs which may be used indefinitely.

As described in Section 75.403, costs must be consistently charged as either indirect or direct costs, but may not be double charged or inconsistently charged as both. If chosen, this methodology once elected must be used consistently for all Federal awards until such time as the NFE chooses to negotiate for a rate, which the NFE may apply to do at any time.” Electing to charge a de minimis rate of 10 percent only applies to applicants that have never received an approved negotiated indirect cost rate from HHS or another cognizant Federal agency. Applicants awaiting approval of their indirect cost proposal may request the 10 percent de minimis rate.

When the applicant chooses this method, costs included in the indirect cost pool must not be charged as direct costs to the grant. Available funds are inclusive of direct and appropriate indirect costs. Approved indirect funds are awarded as part of the award amount, and no additional funds will be provided.

Generally, IDC rates for IHS grantees are negotiated with the Division of Cost Allocation at https://rates.psc.gov/​ or the Department of the Interior (Interior Business Center) at https://ibc.doi.gov/​ICS/​tribal. For questions regarding the indirect cost policy, please call the Grants Management Specialist listed under “Agency Contacts” or the main DGM office at (301) 443-5204. 3.

Reporting Requirements The grantee must submit required reports consistent with the applicable deadlines. Failure to submit required reports within the time allowed may result in suspension or termination of an active grant, withholding of additional awards for the project, or other enforcement actions such as withholding of payments or converting to the reimbursement method of payment. Continued failure to submit required reports may result in the imposition of special award provisions and/or the non-funding or non-award of other eligible projects or activities.

This requirement applies whether the delinquency is attributable to the failure of the grantee organization or the individual responsible for preparation of the reports. Per DGM policy, all reports must be submitted electronically by attaching them as a “Grant Note” in GrantSolutions. Personnel responsible for submitting reports will be required to obtain a login and password for GrantSolutions.

Please see the Agency Contacts list in section VII for the systems contact information. The reporting requirements for this program are noted below. A.

Progress Reports Program progress reports are required annually. The progress reports are due within 30 days after the budget period ends (specific dates will be listed in the NoA Terms and Conditions). These reports must include a brief comparison of actual accomplishments to the goals established for the period, a summary of progress to date or, if applicable, provide sound justification for the lack of progress, and other pertinent information as required, and any other specific evaluation requirements described in this funding announcement.

A final report must be submitted within 90 days of expiration of the period of performance. This final report must provide a comprehensive summary of accomplishments and outcomes over the period of performance as related to each of the stated goals. B.

Financial Reports Federal Cash Transaction Reports are due 30 days after the close of every calendar quarter to the Payment Management Services at https://pms.psc.gov. Failure to submit timely reports may result in adverse award actions blocking access to funds. Federal Financial Reports are due 30 days after the end of each budget period, and a final report is due 90 days after the end of the period of performance.

Grantees are responsible and accountable for reporting accurate information on all required reports. The Progress Reports, the Federal Cash Transaction Report, and Federal Financial Report. C.

Data Collection and Reporting In addition to the annual progress reports, the IHS will compile and provide aggregate program statistics including associated community-level Government Performance Results Act health care facility data available in the National Data Warehouse, as needed. Awardees will be required to report on the following. Treat Total number of patient visits.

Total number of patients screened for suicide risk. Total number of patients assessed for suicide risk. Total number of patients placed on suicide care pathway or registry.

• total number of patients hospitalized for suicide risk. Start Printed Page 60892 total number of patients with safety plan. Total number of patients counseled on access to lethal means.

Train Total number of staff trained, number of trainings, type of trainings and number of staff trained in each healthcare profession in evidenced-based treatment of suicide risk. Awardees will also be required to submit their annual progress reports into an online reporting system funded by the IHS. D.

Federal Sub-Award Reporting System (FSRS) This award may be subject to the Transparency Act sub-award and executive compensation reporting requirements of 2 CFR part 170. The Transparency Act requires the OMB to establish a single searchable database, accessible to the public, with information on financial assistance awards made by Federal agencies. The Transparency Act also includes a requirement for recipients of Federal grants to report information about first-tier sub-awards and executive compensation under Federal assistance awards.

The IHS has implemented a Term of Award into all IHS Standard Terms and Conditions, NoAs, and funding announcements regarding the FSRS reporting requirement. This IHS Term of Award is applicable to all IHS grant and cooperative agreements issued on or after October 1, 2010, with a $25,000 sub-award obligation threshold met for any specific reporting period. For the full IHS award term implementing this requirement and additional award applicability information, visit the DGM Grants Management website at https://www.ihs.gov/​dgm/​policytopics/​.

E. Compliance With Executive Order 13166 Implementation of Services Accessibility Provisions for All Grant Application Packages and Funding Opportunity Announcements Should you successfully compete for an award, recipients of Federal financial assistance (FFA) from HHS must administer their programs in compliance with Federal civil rights laws that prohibit discrimination on the basis of race, color, national origin, disability, age and, in some circumstances, religion, conscience, and sex (including gender identity, sexual orientation, and pregnancy). This includes ensuring programs are accessible to persons with limited English proficiency and persons with disabilities.

The HHS Office for Civil Rights provides guidance on complying with civil rights laws enforced by HHS. Please see https://www.hhs.gov/​civil-rights/​for-providers/​provider-obligations/​index.html and https://www.hhs.gov/​civil-rights/​for-individuals/​nondiscrimination/​index.html. • Recipients of FFA must ensure that their programs are accessible to persons with limited English proficiency.

For guidance on meeting your legal obligation to take reasonable steps to ensure meaningful access to your programs or activities by limited English proficiency individuals, see https://www.hhs.gov/​civil-rights/​for-individuals/​special-topics/​limited-english-proficiency/​fact-sheet-guidance/​index.html and https://www.lep.gov. • For information on your specific legal obligations for serving qualified individuals with disabilities, including reasonable modifications and making services accessible to them, see https://www.hhs.gov/​ocr/​civilrights/​understanding/​disability/​index.html. • HHS funded health and education programs must be administered in an environment free of sexual harassment.

See https://www.hhs.gov/​civil-rights/​for-individuals/​sex-discrimination/​index.html. • For guidance on administering your program in compliance with applicable Federal religious nondiscrimination laws and applicable Federal conscience protection and associated anti-discrimination laws, see https://www.hhs.gov/​conscience/​conscience-protections/​index.html and https://www.hhs.gov/​conscience/​religious-freedom/​index.html. F.

Federal Awardee Performance and Integrity Information System (FAPIIS) The IHS is required to review and consider any information about the applicant that is in the FAPIIS at https://www.fapiis.gov before making any award in excess of the simplified acquisition threshold (currently $250,000) over the period of performance. An applicant may review and comment on any information about itself that a Federal awarding agency previously entered. IHS will consider any comments by the applicant, in addition to other information in FAPIIS, in making a judgment about the applicant's integrity, business ethics, and record of performance under Federal awards when completing the review of risk posed by applicants as described in 45 CFR 75.205.

As required by 45 CFR part 75 Appendix XII of the Uniform Guidance, NFEs are required to disclose in FAPIIS any information about criminal, civil, and administrative proceedings, and/or affirm that there is no new information to provide. This applies to NFEs that receive Federal awards (currently active grants, cooperative agreements, and procurement contracts) greater than $10,000,000 for any period of time during the period of performance of an award/project. Mandatory Disclosure Requirements As required by 2 CFR part 200 of the Uniform Guidance, and the HHS implementing regulations at 45 CFR part 75, the IHS must require an NFE or an applicant for a Federal award to disclose, in a timely manner, in writing to the IHS or pass-through entity all violations of Federal criminal law involving fraud, bribery, or gratuity violations potentially affecting the Federal award.

All applicants and recipients must disclose in writing, in a timely manner, to the IHS and to the HHS Office of Inspector General all information related to violations of Federal criminal law involving fraud, bribery, or gratuity violations potentially affecting the Federal award. 45 CFR 75.113. Disclosures must be sent in writing to.

U.S. Department of Health and Human Services, Indian Health Service, Division of Grants Management, ATTN. Paul Gettys, Acting Director, 5600 Fishers Lane, Mail Stop.

09E70, Rockville, MD 20857. (Include “Mandatory Grant Disclosures” in subject line), Office. (301) 443-5204, Fax.

(301) 594-0899, Email. Paul.Gettys@ihs.gov. AND U.S.

Department of Health and Human Services, Office of Inspector General, ATTN. Mandatory Grant Disclosures, Intake Coordinator, 330 Independence Avenue SW, Cohen Building, Room 5527, Washington, DC 20201, URL. Https://oig.hhs.gov/​fraud/​report-fraud/​.

(Include “Mandatory Grant Disclosures” in subject line), Fax. (202) 205-0604 (Include “Mandatory Grant Disclosures” in subject line) or, Email. MandatoryGranteeDisclosures@oig.hhs.gov.

Failure to make required disclosures can result in any of the remedies described in 45 CFR 75.371 Remedies for noncompliance, including suspension or debarment (see 2 CFR part 180 and 2 CFR part 376). VII. Agency Contacts 1.

Questions on the programmatic issues may be directed to. LCDR Monique Richards, MSW, LICSW, Start Printed Page 60893 Public Health Advisor, Indian Health Service, Division of Behavioral Health, 5600 Fishers Lane, Mail Stop. 08N70C, Rockville, MD 20857, Telephone.

(240) 252-9625, Fax. (301) 443-5610, Email. Monique.Richards@ihs.gov.

2. Questions on grants management and fiscal matters may be directed to. Sheila Miller, Grants Management Specialist, Indian Health Service, Division of Grants Management, 5600 Fishers Lane, Mail Stop.

09E70, Rockville, MD 20857, Phone. (240) 535-9308, Fax. (301) 594-0899, Email.

Sheila.Miller@ihs.gov. 3. Questions on systems matters may be directed to.

Paul Gettys, Acting Director, Division of Grants Management, Indian Health Service, Division of Grants Management, 5600 Fishers Lane, Mail Stop. 09E70, Rockville, MD 20857, Phone. (301) 443-2114.

Or the DGM main line (301) 443-5204, Fax. (301) 594-0899, email. Paul.Gettys@ihs.gov.

VIII. Other Information The Public Health Service strongly encourages all grant, cooperative agreement, and contract recipients to provide a smoke-free workplace and promote the non-use of all tobacco products. In addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some cases, any portion of the facility) in which regular or routine education, library, day care, health care, or early childhood development services are provided to children.

This is consistent with the HHS mission to protect and advance the physical and mental health of the American people. Start Signature Elizabeth A. Fowler, Acting Director, Indian Health Service.

End Signature End Preamble [FR Doc. 2021-24039 Filed 11-3-21. 8:45 am]BILLING CODE 4165-16-P.

Start Preamble cheap diflucan online Announcement Type. New. Funding Announcement Number cheap diflucan online. HHS-2022-IHS-ZSI-0001.

Assistance Listing (Catalog of Federal Domestic Assistance cheap diflucan online or CFDA) Number. 93.654. Key Dates Application Deadline Date. February 2, 2022 cheap diflucan online.

Earliest Anticipated Start Date. March 21, cheap diflucan online 2022. I. Funding Opportunity cheap diflucan online Description Statutory Authority The Indian Health Service (IHS) is accepting applications for a cooperative agreement for the Zero Suicide Initiative (ZSI).

This program is authorized under the Snyder Act, 25 U.S.C. 13. The Transfer cheap diflucan online Act, 42 U.S.C. 2001(a).

And the Indian Health Care cheap diflucan online Improvement Act, 25 U.S.C. 1665 et seq. This program is described in the Assistance Listings located at https://sam.gov/​content/​home (formerly known as Catalog of Federal Domestic Assistance) under 93.654. Background Since 1999, cheap diflucan online suicide rates within the Unites States have been steadily increasing.[] On March 2, 2018, the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly report released a data report, “Suicides Among American Indian/Alaska Natives—National Violent Death Reporting System, 18 States, 2003 to 2014,” which highlights American Indian/Alaska Natives having the highest rates of suicide of any racial/ethnic group in the Unites States.

The suicide rate for American Indian/Alaska Native (AI/AN) adolescents and young adult ages 15 to 34 (19.1/100,000) was 1.3 times that of the national average for that age group (14/100,000).[] In June 2019, the National Center for Health Statistics, Health E-Stat reported in “Suicide Rates for Females and Males by Race and Ethnicity. United States, 1999 and 2017,” suicide rates increased for all cheap diflucan online race and ethnicity groups but the largest increase occurred for non-Hispanic AI/AN females (139% from 4.6 to 11.0 per 100,000). Suicide is the 8th leading cause of death among all AI/AN people across all ages and may be underestimated. The `Zero Suicide' model is a key component of the National Strategy for Suicide Prevention (NSSP) and is a priority of the National Action Alliance for Suicide Prevention ( cheap diflucan online https://theactionalliance.org/​ ).

The `Zero Suicide' model focuses on developing a system-wide approach to improving care for individuals at risk of suicide who are currently using health and behavioral health systems. This award will support implementation of the `Zero Suicide' model within Tribal and Urban Indian health care facilities and systems that provide direct care services to AI/AN individuals in order to raise awareness of suicide, establish integrated systems of care, and improve outcomes for such individuals. Applicants are encouraged to visit cheap diflucan online https://www.hhs.gov/​surgeongeneral/​reports-and-publications/​suicide-prevention/​index.html to access a copy of the 2012 National Strategy. Purpose The purpose of this program is to improve the system of care for those at risk for suicide by implementing a comprehensive, culturally informed, multi-setting approach to suicide prevention in Indian health systems.

This award represents a continuation of the IHS cheap diflucan online effort to implement the Zero Suicide approach in Indian Country. The intent of this announcement is to initiate a new, or build upon the previous, Zero Suicide Initiative efforts. Existing efforts have focused on foundational learning of the key concepts of cheap diflucan online the Zero Suicide framework, technical assistance, and consultation for several AI/AN Zero Suicide communities. As a result of these efforts, both the unique opportunities and challenges of implementing Zero Suicide in Indian Country have been identified.

To best capitalize on opportunities and surmount such challenges, this program focuses on the core Seven Elements of the Zero Suicide model as developed by the Suicide Prevention Resource Center (SPRC) at https://zerosuicide.edc.org/​toolkit/​zero-suicide-toolkit. 1 cheap diflucan online. Lead—Create and sustain a leadership-driven, safety-oriented culture committed to dramatically reducing suicide among people under care. Include survivors of suicide attempts and suicide cheap diflucan online loss in leadership and planning roles.

2. Train—Develop a competent, confident, and caring workforce. 3. Identify—Systematically identify and assess suicide risk among people receiving care.

4. Engage—Ensure every individual has a pathway to care that is both timely and adequate to meet his or her needs. Include collaborative safety planning and restriction of lethal means. 5.

Treat—Use effective, evidence-based treatments that directly target suicidal thoughts and behaviors. 6. Transition—Provide continuous contact and support, especially after acute care. And, 7.

Improve—Apply a data-driven, quality improvement approach to inform system changes that will lead to improved patient outcomes and better care for those at risk. Required, Optional, and Allowable Activities Each applicant must describe how they plan to implement the following core elements of this program in their project narrative and incorporate culture within the approach to each of the seven elements. 1. Lead a.

Establish a leadership-driven strategic plan which includes session planning (see link https:// Start Printed Page 60884 zerosuicide.edc.org/​resources/​resource-database/​zero-suicide-work-plan-template ) to transform the delivery of suicide care within the health care system. b. Describe the organizational steps to broaden the responsibility for suicide care across the entire health care system. C.

Detail the specific role of leadership to ensure system transformation is achieved. Examples of leadership commitment can include, but are not limited to. Tribal Resolutions, Tribal codes, formal suicide care policies, and formation of Zero Suicide Initiative advisory boards. 2.

Train a. Evaluate training needs and develop a formal training plan for suicide prevention gatekeeper training (examples include, but are not limited to, Question Persuade Refer, Applied Suicide Intervention Skills Training, and Mental Health First Aid). In addition, the training plan should include training in treating suicide risk (examples include, but are not limited to, Dialectical Behavioral Therapy, Cognitive Processing Therapy for Suicide Prevention, and Cognitive Therapy for Suicidal Patients). B.

The formal training plan for staff should focus across the health care system to strengthen and advance the skills of health care staff and providers at all levels. c. Training must target increasing competence in the delivery of culturally informed, evidence-based suicide care in all health care settings. Survey at https://zerosuicide.edc.org/​sites/​default/​files/​ZS%20Workforce%20Survey%20July%202020.pdf will be completed and reported on at the initiation of the period of performance.

d. Train new or existing staff with an emphasis in these functions (see link https://zerosuicide.edc.org/​resources/​resource-database/​suicide-care-training-options ). e. Project/program oversight.

f. Case management/coordination to ensure continuity of care across and between various departments, health care systems, and or levels of care ( e.g., transfer from high risk to low risk, discharge from inpatient mental health care). g. Data collection support and access for Electronic Health Record (EHR), clinical application, project coordinator support, and other data related activities.

Adopt and/or enhance computer systems, including management information system, EHRs, and other systems/software, to better document and manage patient needs, the care process, integration with related support services, and track outcomes. 3. Identify a. Implement system-wide policies and procedures for comprehensive suicide care standards to include, at a minimum.

i. Universal screening of all patients ages 10 and above for suicide risk using validated instruments (see link https://zerosuicide.edc.org/​resources/​resource-database/​ask-suicide-screening-questions-asq-toolkit). ii. Full suicide risk assessment of all patients with positive suicide risk screen (including risk level formulation), using (see link https://www.jointcommission.org/​-/​media/​tjc/​documents/​resources/​patient-safety-topics/​suicide-prevention/​pages-from-suicide_​prevention_​compendium_​5_​11_​20_​updated-july2020_​ep3_​4.pdf ).

iii. Individual Safety Plan for all patients with positive suicide risk screen to include counseling patients on reduction to access of lethal means and means restriction (see link https://www.sprc.org/​resources-programs/​patient-safety-plan-template ). iv. Procedure and protocol for tracking patients at increased risk for suicide by placing patients on a suicide care management plan/pathway.

This must also address how patients are monitored while on the plan/pathway, how often patients are re-evaluated to assess risk level, when it is appropriate to remove patient from plan/pathway, follow-up protocols after patients are removed from plan/pathway, etc. (see link https://www.jointcommission.org/​sea_​issue_​56/​ ). b. Develop protocols for every individual identified as at risk of suicide to continuously monitor the individual's progress through their EHR or other data management system to include the following.

i. Rapid follow-up of adults who have attempted suicide or experienced a suicidal crisis after being discharged from a treatment facility, e.g., local emergency departments, inpatient psychiatric facilities, including direct linkage with appropriate health care agencies to ensure coordinated care services and protocols are in place to ensure patient safety, especially among high-risk adults with serious mental illness. This must include outreach telephone contact within 24 to 48 hours after discharge and securing an appointment within 1 week of discharge (see link https://www.jointcommission.org/​resources/​patient-safety-topics/​suicide-prevention/​ ). ii.

Establish health system leadership including outside service providers ( i.e., local suicide prevention crisis lines to help with follow-up contacts, etc.), and develop teams to guide the implementation of the Zero Suicide model within their agencies. 4. Engage a. Develop a Suicide Care Management Plan for every patient identified as high risk of suicide (see link https://zerosuicide.edc.org/​resources/​resource-database/​zero-suicide-work-plan-template ).

Implement a process for continuous monitoring of those patients' progress through their EHR or other data management system, and adjust treatment as necessary. 5. Treat a. Develop a strategy and specific plan (see link https://zerosuicide.edc.org/​resources/​resource-database/​zero-suicide-data-elements-worksheet ) to collect, analyze, and disseminate data related to suicide care across the health care system.

b. Use a data-informed approach for quality improvement at the levels of policy, process, and practice. Wherever possible, this approach should include a unified EHR, or memorandum of understanding/memorandum of agreement (MOU/MOA) to establish a process to share data between and across systems of care for all patients in a suicide risk clinical pathway. For example, a data report that indicates a high percentage of patients being discharged from inpatient stays failed to receive follow-up appointments may result in implementing a plan to reduce that number by changing staffing patterns and processes to focus on scheduling follow-up care.

C. Apply the use of evidence-based practices to screen, assess, and treat individuals at risk for suicide in a way that incorporates culturally informed practices and activities. Clearly describe how cultural best practices and/or traditional approaches are offered, utilized, and/or incorporated within the health care system to complement/augment into the evidence-based protocols with those at risk for suicide. D.

Evidence-based practices, where appropriate, may include. i. Suicide risk screening—Ask Suicide-Screening Questions (see link https://www.nimh.nih.gov/​research/​research-conducted-at-nimh/​asq-toolkit-materials/​index.shtml ). ii.

Columbia Suicide Severity Rating Scale (see link https://cssrs.columbia.edu/​the-columbia-scale-c-ssrs/​cssrs-for-communities-and-healthcare/​#filter=​.general-use.english ). Start Printed Page 60885 iii. Suicide Risk Assessment—Brief Suicide Safety Assessment (see link https://www.nimh.nih.gov/​research/​research-conducted-at-nimh/​asq-toolkit-materials/​youth-outpatient/​youth-outpatient-brief-suicide-safety-assessment-worksheet.shtml ). iv.

Columbia Suicide Severity Rating Scale (see link https://cssrs.columbia.edu/​the-columbia-scale-c-ssrs/​cssrs-for-communities-and-healthcare/​#filter=​.general-use.english ). v. Suicide treatment—Dialectical Behavioral Therapy (see link https://www.sprc.org/​resources-programs/​dialectical-behavior-therapy ). vi.

Cognitive Therapy for Suicidal Patients (see link https://www.sprc.org/​resources-programs/​cognitive-therapy-suicide-prevention ). vii. Cultural best practices and/or traditional approaches—Language immersion, traditional healers, and traditional ceremonies (see link https://zerosuicide.edc.org/​toolkit/​toolkit-adaptations/​indian-country ). 6.

Transition a. The Suicide Care Management Plan must include the following (see link https://zerosuicide.edc.org/​resources/​resource-database/​best-practices-care-transitions-individuals-suicide-risk-inpatient-care ). i. Protocols for safety planning and reducing access to lethal means in a point-to-point transition of care within a system.

ii. Rapid follow-up of adults who have attempted suicide or experienced a suicidal crisis after being discharged from a treatment facility ( e.g., local emergency departments, inpatient psychiatric facilities), including direct linkage with appropriate health care agencies to ensure coordinated care services are in place. iii. Protocols to ensure patient safety, especially among high-risk adults in health care systems who have attempted suicide, experienced a suicidal crisis, and/or have a serious mental illness.

This must include outreach telephone contact within 24 to 48 hours after discharge and securing an appointment within 1 week of discharge (see link https://zerosuicide.edc.org/​toolkit/​transition and/or https://theactionalliance.org/​healthcare/​caretransitions ). 7. Improve a. Describe the quality improvement activities that will be used to track progress towards your process and outcome measure and how these data will be used to inform the ongoing implementation of the project and beyond (see link https://zerosuicide.edc.org/​resources/​resource-database/​zero-suicide-work-plan-template ).

In addition to the seven elements listed above, the following activities are also required. 1. Seek the IHS's approval for key positions to be filled. Key positions include, but are not limited to, the Project Director, Project Coordinator, and Evaluator.

2. Consult and accept guidance from IHS staff on performance of programmatic and data collection activities to achieve the goals of the cooperative agreement. 3. Maintain ongoing communication with the IHS including a minimum of one call per month, keeping Federal program staff informed of emerging issues, developments, and problems as appropriate.

4. Invite the IHS Program Official to observe and provide feedback to policy, steering, advisory, or other task forces. 5. Maintain ongoing collaboration with the IHS ZSI Technical Assistance Coordinating Center, the Suicide Prevention Resource Center, and the National Suicide Prevention Lifeline.

6. Provide required documentation for monthly and annual reporting and data surveillance around suicidal behavior in selected health and behavioral health care systems. Practice-Based Evidence, Promising Practices, and Local Efforts The IHS encourages the implementation of Tribal and/or culturally appropriate suicide prevention and intervention strategies but recognizes the limited range of formally evaluated evidence-based practices for suicide and substance abuse that have been developed specifically for the American Indians/Alaska Natives population. In addition to formally evaluated practices, which exist in the research and practice literature, evidence for other practices are allowed in this grant program.

Evidence of other practices may include unpublished studies, preliminary evaluation results, clinical (or other professional association) guidelines, findings from focus groups with community members, local community surveys, etc. Document the evidence that the practice(s) you have chosen is appropriate for the outcomes you want to achieve. Explain how the practice you have chosen meets the goals for this program. Describe any modifications/adaptations you will need to make to your proposed practice(s) to meet the goals of your project and why you believe the changes will improve the outcomes.

Discuss training needs or plans for training to successfully implement the proposed evidence-based practice(s). II. Award Information Funding Instrument—Cooperative Agreement Estimated Funds Available The total funding identified for fiscal year (FY) 2022 is approximately $2,000,000. Individual award amounts for the first budget year are anticipated to be between $200,000 and $300,000.

The funding available for competing and subsequent continuation awards issued under this announcement is subject to the availability of appropriations and budgetary priorities of the Agency. The IHS is under no obligation to make awards that are selected for funding under this announcement. Anticipated Number of Awards Approximately 8-10 awards will be issued under this program announcement, with a set aside of up to two awards issued to eligible UIOs. Period of Performance The period of performance is for 5 years.

Cooperative Agreement Cooperative agreements awarded by the Department of Health and Human Services (HHS) are administered under the same policies as grants. However, the funding agency, IHS, is anticipated to have substantial programmatic involvement in the project during the entire period of performance. Below is a detailed description of the level of involvement required of the IHS. Substantial Agency Involvement Description for Cooperative Agreement 1.

Approve all proposed key positions/personnel. 2. Facilitate linkages to other IHS/Federal government resources and help grantees access appropriate technical assistance. 3.

Assure that the grantee's project activities are aligned with the mission, strategic goals and objectives of the IHS, and with the goals of the Zero Suicide Initiative. 4. Coordinate cross-site evaluation participation in grantee and staff required monitoring conference calls. 5.

Promote collaboration with other IHS and Federal health and behavioral health initiatives, including the Substance Abuse Mental Health Services Administration (SAMHSA), the Start Printed Page 60886 National Action Alliance for Suicide Prevention, the National Suicide Prevention Lifeline, the SPRC, and the Zero Suicide Institute. 6. Provide technical assistance on all aspects of the ZSI program implementation and sustainability. 7.

Share aggregate data related to suicide behavior and clinical care necessary to determine that the project has met expected and identified goals, objectives, and outcomes. Describe the process of continuous involvement based on results and analysis of the same. III. Eligibility Information 1.

Eligibility To be eligible for this funding opportunity the applicant must be one of the following as defined by 25 U.S.C. 1603. • A federally recognized Indian Tribe as defined by 25 U.S.C. 1603(14).

The term “Indian Tribe” means any Indian Tribe, band, nation, or other organized group or community, including any Alaska Native village or group or regional or village corporation, as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688) [43 U.S.C. 1601 et seq. ], which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.

A Tribal organization as defined by 25 U.S.C. 1603(26). The term “Tribal organization” has the meaning given the term in section 4 of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304(1)).

€œTribal organization” means the recognized governing body of any Indian Tribe. Any legally established organization of Indians which is controlled, sanctioned, or chartered by such governing body or which is democratically elected by the adult members of the Indian community to be served by such organization and which includes the maximum participation of Indians in all phases of its activities. Provided that, in any case where a contract is let or grant made to an organization to perform services benefiting more than one Indian Tribe, the approval of each such Indian Tribe shall be a prerequisite to the letting or making of such contract or grant. Applicant shall submit letters of support and/or Tribal Resolutions from the Tribes to be served.

• An Urban Indian organization as defined by 25 U.S.C. 1603(29). The term “Urban Indian organization” means a nonprofit corporate body situated in an urban center, governed by an urban Indian controlled board of directors, and providing for the maximum participation of all interested Indian groups and individuals, which body is capable of legally cooperating with other public and private entities for the purpose of performing the activities described in 25 U.S.C. 1653(a).

Applicants must provide proof of non-profit status with the application, e.g., 501(c)(3). The program office will notify any applicants deemed ineligible. Note. Please refer to Section IV.2 (Application and Submission Information/Subsection 2, Content and Form of Application Submission) for additional proof of applicant status documents required, such as Tribal Resolutions, proof of nonprofit status, etc.

2. Cost Sharing or Matching The IHS does not require matching funds or cost sharing for grants or cooperative agreements. 3. Other Requirements Applications with budget requests that exceed the highest dollar amount outlined under Section II Award Information, Estimated Funds Available, or exceed the period of performance outlined under Section II Award Information, Period of Performance, are considered not responsive and will not be reviewed.

The Division of Grants Management (DGM) will notify the applicant. Additional Required Documentation Tribal Resolution The DGM must receive an official, signed Tribal Resolution prior to issuing a Notice of Award (NoA) to any applicant selected for funding. An Indian Tribe or Tribal organization that is proposing a project affecting another Indian Tribe must include resolutions from all affected Tribes to be served. However, if an official, signed Tribal Resolution cannot be submitted with the application prior to the application deadline date, a draft Tribal Resolution must be submitted with the application by the deadline date in order for the application to be considered complete and eligible for review.

The draft Tribal Resolution is not in lieu of the required signed resolution but is acceptable until a signed resolution is received. If an application without a signed Tribal Resolution is selected for funding, the applicant will be contacted by the Grants Management Specialist (GMS) listed in this funding announcement and given 90 days to submit an official, signed Tribal Resolution to the GMS. If the signed Tribal Resolution is not received within 90 days, the award will be forfeited. Tribes organized with a governing structure other than a Tribal council may submit an equivalent document commensurate with their governing organization.

Proof of Nonprofit Status Organizations claiming nonprofit status must submit a current copy of the 501(c)(3) Certificate with the application. IV. Application and Submission Information 1. Obtaining Application Materials The application package and detailed instructions for this announcement are available at https://www.Grants.gov.

Please direct questions regarding the application process to Mr. Paul Gettys at (301) 443-2114 or (301) 443-5204. 2. Content and Form Application Submission Mandatory documents for all applicants include.

Abstract (one page) summarizing the project. Application forms. 1. SF-424, Application for Federal Assistance.

2. SF-424A, Budget Information—Non-Construction Programs. 3. SF-424B, Assurances—Non-Construction Programs.

Project Narrative (not to exceed 30 pages). See IV.2.A, Project Narrative for instructions. 1. Background information on the organization.

2. Proposed scope of work, objectives, and activities that provide a description of what the applicant plans to accomplish. Budget Justification and Narrative (not to exceed four pages). See IV.2.B, Budget Narrative for instructions.

One-page Timeline Chart. Tribal Resolution(s). A Tribal Resolution expressing a bona fide commitment to a Zero Suicide model within the health and behavioral health care system must be provided. Letters of Support from organization's Board of Directors (if applicable).

501(c)(3) Certificate (if applicable). Biographical sketches for all Key Personnel. Contractor/Consultant resumes or qualifications and scope of work. Disclosure of Lobbying Activities (SF-LLL), if applicant conducts reportable lobbying.

• Certification Regarding Lobbying (GG—Lobbying Form). Start Printed Page 60887 Copy of current Negotiated Indirect Cost rate (IDC) agreement (required in order to receive IDC). Organizational Chart (optional). Documentation of current Office of Management and Budget (OMB) Financial Audit (if applicable).

Acceptable forms of documentation include. 1. Email confirmation from Federal Audit Clearinghouse (FAC) that audits were submitted. Or 2.

Face sheets from audit reports. Applicants can find these on the FAC website at https://harvester.census.gov/​facdissem/​Main.aspx. Public Policy Requirements All Federal public policies apply to IHS grants and cooperative agreements. Pursuant to 45 CFR 80.3(d), an individual shall not be deemed subjected to discrimination by reason of their exclusion from benefits limited by Federal law to individuals eligible for benefits and services from the IHS.

See https://www.hhs.gov/​grants/​grants/​grants-policies-regulations/​index.html. Requirements for Project and Budget Narratives A. Project Narrative. This narrative should be a separate document that is no more than 30 pages and must.

(1) Have consecutively numbered pages. (2) use black font 12 points or larger. (3) be single-spaced. And (4) be formatted to fit standard letter paper (8 1/2 x 11 inches).

Be sure to succinctly answer all questions listed under the evaluation criteria (refer to Section V.1, Evaluation Criteria) and place all responses and required information in the correct section noted below or they will not be considered or scored. If the narrative exceeds the page limit, the application will be considered not responsive and will not be reviewed. The 30-page limit for the narrative does not include the work plan, standard forms, Tribal Resolutions, budget, budget justifications, narratives, and/or other items. There are four parts to the project narrative.

Part 1—Statement of Need. Part 2—Implementation Approach and Work Plan. Part 3—Organizational Capacity. Part 4—Data Collection and Reporting.

Below are additional details about what must be included in the project narrative. The intent of this announcement is to initiate or build upon Zero Suicide Initiative efforts. Applicants previously funded by IHS for ZSI implementation must report on the status of their goals/milestones. If goals/milestone were not achieved by those applicants, they are expected to provide clear explanation of the barriers that prevented the achievement of previous goal/milestones in the application to this funding announcement.

Part 1. Statement of Need (Limit—6 Pages) The statement of need describes the scope and scale of suicide behavior within the community served and within the health and/or behavioral health system. This section must identify gaps in suicide care delivery and those gaps and any other barriers in providing comprehensive, culturally informed care to those at risk for suicide. The statement of need provides the facts and evidence that support the need for the project and establishes that the Tribe, Tribal organization, or UIO understands the problems and can reasonably address them.

Applicant's data may include the following metrics outlined below. Identify • Describe the proposed catchment area and demographic information on the population(s) to receive services through the targeted systems or agencies, e.g., race, ethnicity, federally recognized Tribe, language, age, socioeconomic status, sex, and other relevant factors, such as literacy. Improve • Provide evidence of the prevalence of suicidal behavior within the population(s) of focus, including any current limitations of data collection in the health system. In addition, discuss how the proposed project will address disparities in access, service use, and outcomes for the population(s) of focus (see link https://zerosuicide.edc.org/​toolkit/​indian-country/​improve-indian-country ).

1. Number of screenings performed. 2. Number of those above screening cut off who receive a full suicide risk assessment.

3. Numbers of those receiving a full risk assessment who have a collaboratively developed safety plan. 4. Number of those with a collaboratively developed safety plan who have been counseled on reduction of access to lethal means.

5. Percentage of all behavioral health clinicians who use evidence-based practices to directly treat those at risk for suicide. 6. Percentage of follow up on those who may be at risk for suicide to ensure safe transitions through care.

7. Percentage of documentation on every loss by suicide. • Documentation of the need for an enhanced infrastructure (system/process improvements) to increase the capacity to implement, sustain, and improve comprehensive, integrated, culturally informed, evidence-based suicide care within the identified health care system that is consistent with the purpose of the program as stated in this announcement (see link https://zerosuicide.edc.org/​resources/​zero-suicide-workforce-survey-resources ). This may also include a clear description of any service gaps, staff/provider training deficits, service delivery fragmentations, and other barriers that could impact comprehensive suicide care for patients seen in the health system.

• Applicants are encouraged to review the Zero Suicide strategies and tools to help prepare for application to this announcement. Please see http://zerosuicide.sprc.org/​sites/​zerosuicide.actionallianceforsuicideprevention.org/​files/​Zero%20Suicide%20Workplan%20Template%2012.6.17.pdf. Part 2. Implementation Approach &.

Work Plan (Limit—9 Pages) Applicant should develop a viable plan to address each of the 7 Elements (see link http://zerosuicide.edc.org/​toolkit ) in a systematic, measureable, and interrelated manner. Evidence of plan to the identification, use, and measurement of the use of culturally informed practices and activities (see link https://zerosuicide.edc.org/​resources/​populations/​native-american-and-alaska-native ). Please include a Project Timeline in the application. Lead A clear description of strategies to engage the highest levels of leadership and a broad cross section of the hospital system in order to develop organizational commitment, participation and sustainability (Letters of Commitment should be included as attachments).

If the program is to be managed by a consortium or Tribal organization, identify how the project office relates to the member community/communities. Transition • A contingency plan that addresses short-term maintenance and long-term sustainability. How will continuity be maintained if/when there is a change in the operational environment ( e.g., health care system leadership, staff turnover, change in project leadership, change in elected officials, etc.) to Start Printed Page 60888 ensure project stability over the period of performance. Additionally, describe long-term plan for sustainability of the ZSI model beyond the period of performance.

Include how your project plans to involve survivors of suicide attempts and suicide loss in assessing, planning, and implementing your project. Part 3. Organizational Capacity (Limit—8 Pages) This section focuses on how the organization may capitalize on existing resources, processes, human capital, quality initiatives, collaborative agreements, and surveillance capabilities as a means of overcoming barriers to a comprehensive, culturally informed system of suicide care. Lead • Describe any experience (successes and/or challenges) with the Zero Suicide model ( e.g., attended a Zero Suicide Academy, etc.) or similar collaborative efforts ( e.g., patient centered medical home, behavioral integration, trauma-informed systems, and improving patient care, etc.).

Discuss the applicant Tribe, Tribal organization, or UIO experience with and capacity (or detailed plan) to provide culturally informed practices and activities for specific populations of focus. Explain how all departments/units/divisions are (or plan to be) involved in administering this project. You may also include how applicant organization currently (or plans to) collaborate with other organizations and agencies to provide care, including critical transition of care. Provide Letter(s) of Commitment, MOA, MOUs etc., from CEO, Tribal Health Director, Tribal Chair, etc.

• Describe the resources available for the proposed project ( e.g., facilities, equipment, information technology systems, EHR capabilities, financial management systems, data sharing agreement, MOUs, etc.). List of all staff positions for the project, such as Project Director, project coordinator, case manager and other key personnel, and briefly describe their role and level of effort on the project. Part 4. Data Collection and Reporting (Limit—7 Pages) This section of the narrative should describe function of position and efforts to collect and report project data that will support and demonstrate ZSI activities.

All ZSI grantees will be required to collect and report data pertaining to activities, processes, and outcomes that support the following core elements. Improve Provide a clear, specific plan for how data will be collected, managed, analyzed, and reported. Identify which staff will be responsible for tracking the goals and measureable objectives associated with the award. Lead Review of suicide care policies and procedures.

Review of any MOUs, MOAs, commitment letters, etc. ZSI Implementation team participation. Engagement of those that have experienced suicidal thoughts, survived a suicide attempt, cared for someone through suicidal crisis, or been bereaved by suicide. Improve Assessment of fidelity to the Zero Suicide model (to include periodic administering of Organizational Self-Study).

Periodic assessment of staff development and training needs (to include the periodic administering of the Workforce Survey). Sustainability. Measurement-based screening tools. Review of EHR capability.

Patient satisfaction. B. Budget Narrative (limit—4 pages). Provide a budget narrative that explains the amounts requested for each line item of the budget from the SF-424A (Budget Information for Non-Construction Programs).

The budget narrative should specifically describe how each item will support the achievement of proposed objectives. Be very careful about showing how each item in the “Other” category is justified. For subsequent budget years, the narrative should highlight the changes from year 1 or clearly indicate that there are no substantive budget changes during the period of performance. Do NOT use the budget narrative to expand the project narrative.

3. Submission Dates and Times Applications must be submitted through Grants.gov by 11:59 p.m. Eastern Time on the Application Deadline Date. Any application received after the application deadline will not be accepted for review.

Grants.gov will notify the applicant via email if the application is rejected. If technical challenges arise and assistance is required with the application process, contact Grants.gov Customer Support (see contact information at https://www.grants.gov ). If problems persist, contact Mr. Paul Gettys ( Paul.Gettys@ihs.gov ), Acting Director, DGM, by telephone at (301) 443-2114 or (301) 443-5204.

Please be sure to contact Mr. Gettys at least ten days prior to the application deadline. Please do not contact the DGM until you have received a Grants.gov tracking number. In the event you are not able to obtain a tracking number, call the DGM as soon as possible.

IHS will not acknowledge receipt of applications. 4. Intergovernmental Review Executive Order 12372 requiring intergovernmental review is not applicable to this program. 5.

Funding Restrictions Pre-award costs are allowable up to 90 days before the start date of the award provided the costs are otherwise allowable if awarded. Pre-award costs are incurred at the risk of the applicant. The available funds are inclusive of direct and indirect costs. Only one cooperative agreement may be awarded per applicant under this announcement.

6. Electronic Submission Requirements All applications must be submitted via Grants.gov. Please use the https://www.Grants.gov website to submit an application. Find the application by selecting the “Search Grants” link on the homepage.

Follow the instructions for submitting an application under the Package tab. No other method of application submission is acceptable. If the applicant cannot submit an application through Grants.gov , a waiver must be requested. Prior approval must be requested and obtained from Mr.

Paul Gettys, Acting Director, DGM. A written waiver request must be sent to GrantsPolicy@ihs.gov with a copy to Paul.Gettys@ihs.gov. The waiver request must. (1) Be documented in writing (emails are acceptable) before submitting an application by some other method, and (2) include clear justification for the need to deviate from the required application submission process.

Once the waiver request has been approved, the applicant will receive a confirmation of approval email containing submission instructions. A copy of the written approval must be included with the application that is submitted to the DGM. Applications that are submitted without a copy of the signed waiver from the Acting Director of the DGM will not be reviewed. The Grants Management Officer of the DGM Start Printed Page 60889 will notify the applicant via email of this decision.

Applications submitted under waiver must be received by the DGM no later than 5:00 p.m., Eastern Time, on the Application Deadline Date. Late applications will not be accepted for processing. Applicants that do not register for both the System for Award Management (SAM) and Grants.gov and/or fail to request timely assistance with technical issues will not be considered for a waiver to submit an application via alternative method. Please be aware of the following.

• Please search for the application package in https://www.Grants.gov by entering the Assistance Listing (CFDA) number or the Funding Opportunity Number. Both numbers are located in the header of this announcement. • If you experience technical challenges while submitting your application, please contact Grants.gov Customer Support (see contact information at https://www.grants.gov ). • Upon contacting Grants.gov , obtain a tracking number as proof of contact.

The tracking number is helpful if there are technical issues that cannot be resolved and a waiver from the agency must be obtained. • Applicants are strongly encouraged not to wait until the deadline date to begin the application process through Grants.gov as the registration process for SAM and Grants.gov could take up to twenty working days. • Please follow the instructions on Grants.gov to include additional documentation that may be requested by this funding announcement. Applicants must comply with any page limits described in this funding announcement.

• After submitting the application, the applicant will receive an automatic acknowledgment from Grants.gov that contains a Grants.gov tracking number. The IHS will not notify the applicant that the application has been received. Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) Applicants and grantee organizations are required to obtain a DUNS number and maintain an active registration in the SAM database. The DUNS number is a unique 9-digit identification number provided by D&B that uniquely identifies each entity.

The DUNS number is site specific. Therefore, each distinct performance site may be assigned a DUNS number. Obtaining a DUNS number is easy, and there is no charge. To obtain a DUNS number, please access the request service through https://fedgov.dnb.com/​webform, or call (866) 705-5711.

The Federal Funding Accountability and Transparency Act of 2006, as amended (“Transparency Act”), requires all HHS recipients to report information on sub-awards. Accordingly, all IHS grantees must notify potential first-tier sub-recipients that no entity may receive a first-tier sub-award unless the entity has provided its DUNS number to the prime grantee organization. This requirement ensures the use of a universal identifier to enhance the quality of information available to the public pursuant to the Transparency Act. System for Award Management (SAM) Organizations that are not registered with SAM must have a DUNS number first, then access the SAM online registration through the SAM home page at https://www.sam.gov/​SAM/​ (U.S.

Organizations will also need to provide an Employer Identification Number from the Internal Revenue Service that may take an additional 2-5 weeks to become active). Please see SAM.gov for details on the registration process and timeline. Registration with the SAM is free of charge but can take several weeks to process. Applicants may register online at https://www.sam.gov/​SAM/​.

Additional information on implementing the Transparency Act, including the specific requirements for DUNS and SAM, are available on the DGM Grants Management, Policy Topics web page. Https://www.ihs.gov/​dgm/​policytopics/​. V. Application Review Information Possible points assigned to each section are noted in parentheses.

The 30-page project narrative should include only the first year of activities. Information for multi-year projects should be included as an appendix. See “Multi-year Project Requirements” at the end of this section for more information. The narrative section should be written in a manner that is clear to outside reviewers unfamiliar with prior related activities of the applicant.

It should be well organized, succinct, and contain all information necessary for reviewers to understand the project fully. Points will be assigned to each evaluation criteria adding up to a total of 100 possible points. Points are assigned as follows. 1.

Evaluation Criteria Applications will be reviewed and scored according to the quality of responses to the required application components in Sections A-E. The points listed after each heading is the maximum number of points a reviewer may assign to that section. A. Statement of Need (10 Points) The criteria being evaluated is the quality of your strategic approach and logical steps to implement a Zero Suicide Initiative within your health system.

The following aspects will be assessed. 1. The degree to which the applicant's description of the service area/target population demonstrates the need for a systems approach to suicide care within the health and behavioral health systems. 2.

How well the applicant describes the unique characteristics of the service area and population and systems barriers/gaps that impact the delivery of comprehensive suicide care. B. Implementation Approach &. Work Plan (30 Points) 1.

A viable plan to address each of the 7 Elements of the Zero Suicide model and the required activities (described in Section 1) in a systematic, measureable, and interrelated manner. Develop strategy to collect, and analyze application of evidence-based practices to screen, assess, and treat individuals' use of culturally informed practices and activities. (See Resources for Native American and Alaska Native Populations at https://zerosuicide.edc.org/​resources/​populations/​native-american-and-alaska-native ). 2.

A clear description of strategies to engage the highest levels of leadership and a broad cross section of the behavioral/healthcare system in order to develop organizational commitment, participation and sustainability (Letters of Commitment, MOUs, MOAs, etc., should be included as attachments). If the program is to be managed by a consortium or Tribal organization, identify how the project office relates to the member community/communities. Should include how you plan to involve survivors of suicide attempts and suicide loss in assessing, planning, and implementing your project. 3.

Address how continuity will be maintained if/when there is a change in the operational environment ( e.g., health care system leadership, staff turnover, change in project leadership, change in elected officials, etc.) to ensure project stability over the period of performance. Additionally, describe the long-term plan for sustainability of the ZSI model beyond the period of performance. C. Organizational Capacity (30 Points) 1.

The extent to which the applicant describes experience (successes and/or challenges) with the Zero Suicide model Start Printed Page 60890 ( e.g., attended a Zero Suicide Academy, etc.) or similar collaborative efforts ( e.g., patient centered medical home, behavioral integration, trauma informed systems, and improving patient care, etc.), focused on a comprehensive approach to suicide care across a healthcare system. 2. The extent to which the applicant describes experience with and capacity (or detailed plan) to provide culturally informed practices and activities for specific populations of focus. Must refer to Tribal Resolution.

3. Identification of how all departments/units/divisions across the health care system will be involved in administering this project. May also include how applicant organization currently (or plans to) collaborate with other organizations and agencies to provide care, including critical transition of care. 4.

Describe the resources available to implement and sustain the proposed project ( e.g., facilities, equipment, information technology systems, financial management systems, data sharing agreement, MOUs, etc.). Listing of all staff positions for the project, such as Project Director, project coordinator, and other key personnel, showing the role of each and their level of effort and qualifications. Demonstrate successful project implementation for the level of effort budgeted for Project Director, project coordinator, and other key staff. Include position descriptions as attachments to the application.

Describe the function within each position providing services in suicide care, behavioral health and primary care and other health care services, quality and process improvement, and related work within the community/communities. 5. Applicants previously funded by the IHS for ZSI implementation must report on the status of their goals/milestones in this section of the program narrative. If goals/milestones were not achieved by those applicants, they are expected to provide clear explanation of the barriers that prevented the achievement of previous goals/milestones.

D. Data Collection, Performance Assessment and Evaluation (25 Points) In this area, applicants need to clearly demonstrate the ability to collect and report on required data elements associated with Zero Suicide and this particular project, and engage in all aspects of local and national evaluation. The following aspects will be assessed. Ability to collect and report on the required performance measures specified in the Data Collection and Performance Management section.

A clear, specific plan for data collection, management, analysis, and reporting. Indication of the staff person(s) responsible for tracking the measureable objectives that are identified above. Description of your plan for conducting the local performance assessment, as specified above, and evidence of your ability to conduct the assessment. Description of the quality improvement process that will be used to track progress towards your performance measures and objectives, and how these data will be used to inform the ongoing implementation of the project and beyond.

E. Categorical Budget and Budget Justification (5 Points) Applicants must provide a budget and narrative justification for the proposed project budget. 1. Evidence of reasonable, allowable costs necessary to achieve the objective outlined in the project narrative.

2. Description of how the budget aligns with the overall scope of work. 3. Please use Budget/Budget Narrative Template Worksheet to support your responses in this section.

The Timeline Chart, Local Data Collection Plan Worksheet, and Budget/Budget Narrative templates can be downloaded at the ZSI website at https://www.ihs.gov/​zerosuicide/​. Multi-Year Project Requirements Applications must include a brief project narrative and budget (one additional page per year) addressing the developmental plans for each additional year of the project. This attachment will not count as part of the project narrative or the budget narrative. Additional documents can be uploaded as Other Attachments in Grants.gov.

These can include. Work plan, logic model, and/or timeline for proposed objectives. Position descriptions for staff. Consultant or contractor proposed scope of work and letter of commitment (if applicable).

Current Indirect Cost Rate Agreement. Organizational chart. Map of area identifying project location(s). • Additional documents to support narrative ( i.e., data tables, key news articles, etc.).

2. Review and Selection Each application will be prescreened for eligibility and completeness as outlined in the funding announcement. Applications that meet the eligibility criteria shall be reviewed for merit by the Objective Review Committee (ORC) based on evaluation criteria. Incomplete applications and applications that are not responsive to the administrative thresholds (budget limit, project period limit) will not be referred to the ORC and will not be funded.

The applicant will be notified of this determination. Applicants must address all program requirements and provide all required documentation. 3. Notifications of Disposition All applicants will receive an Executive Summary Statement from the IHS Division of Behavioral Health within 30 days of the conclusion of the ORC outlining the strengths and weaknesses of their application.

The summary statement will be sent to the Authorizing Official identified on the face page (SF-424) of the application. A. Award Notices for Funded Applications The NoA is the authorizing document for which funds are dispersed to the approved entities and reflects the amount of Federal funds awarded, the purpose of the award, the terms and conditions of the award, the effective date of the award, and the budget/project period. Each entity approved for funding must have a user account in GrantSolutions in order to retrieve the NoA.

Please see the Agency Contacts list in Section VII for the systems contact information. B. Approved but Unfunded Applications Approved applications not funded due to lack of available funds will be held for 1 year. If funding becomes available during the course of the year, the application may be reconsidered.

Any correspondence other than the official NoA executed by an IHS grants management official announcing to the project director that an award has been made to their organization is not an authorization to implement their program on behalf of the IHS. VI. Award Administration Information 1. Administrative Requirements Awards issued under this announcement are subject to, and are administered in accordance with, the following regulations and policies.

A. The criteria as outlined in this program announcement. B. Administrative Regulations for Grants.

• Uniform Administrative Requirements, Cost Principles, and Start Printed Page 60891 Audit Requirements for HHS Awards currently in effect or implemented during the period of award, other Department regulations and policies in effect at the time of award, and applicable statutory provisions. At the time of publication, this includes 45 CFR part 75, at https://www.govinfo.gov/​content/​pkg/​CFR-2020-title45-vol1/​pdf/​CFR-2020-title45-vol1-part75.pdf. • Please review all HHS regulatory provisions for Termination at 45 CFR 75.372, at https://www.ecfr.gov/​cgi-bin/​retrieveECFR?. €‹gp&​amp;​SID=​2970eec67399fab1413ede53d7895d99&​amp;​mc=​true&​amp;​n=​pt45.1.75&​amp;​r=​PART&​amp;​ty=​HTML&​amp;​se45.1.75_​1372#se45.1.75_​1372.

C. Grants Policy. • HHS Grants Policy Statement, Revised January 2007, at https://www.hhs.gov/​sites/​default/​files/​grants/​grants/​policies-regulations/​hhsgps107.pdf. D.

Cost Principles. Uniform Administrative Requirements for HHS Awards, “Cost Principles,” located at 45 CFR part 75 subpart E. E. Audit Requirements.

Uniform Administrative Requirements for HHS Awards, “Audit Requirements,” located at 45 CFR part 75 subpart F. F. As of August 13, 2020, 2 CFR 200 was updated to include a prohibition on certain telecommunications and video surveillance services or equipment. This prohibition is described in 2 CFR 200.216.

This will also be described in the terms and conditions of every IHS grant and cooperative agreement awarded on or after August 13, 2020. 2. Indirect Costs This section applies to all recipients that request reimbursement of indirect costs (IDC) in their application budget. In accordance with HHS Grants Policy Statement, Part II-27, IHS requires applicants to obtain a current IDC rate agreement and submit it to the DGM prior to the DGM issuing an award.

The rate agreement must be prepared in accordance with the applicable cost principles and guidance as provided by the cognizant agency or office. A current rate covers the applicable grant activities under the current award's budget period. If the current rate agreement is not on file with the DGM at the time of award, the IDC portion of the budget will be restricted. The restrictions remain in place until the current rate agreement is provided to the DGM.

Per 45 CFR 75.414(f) Indirect (F&A) costs, “any non-Federal entity (NFE) [ i.e., applicant] that has never received a negotiated indirect cost rate,. . . May elect to charge a de minimis rate of 10 percent of modified total direct costs which may be used indefinitely.

As described in Section 75.403, costs must be consistently charged as either indirect or direct costs, but may not be double charged or inconsistently charged as both. If chosen, this methodology once elected must be used consistently for all Federal awards until such time as the NFE chooses to negotiate for a rate, which the NFE may apply to do at any time.” Electing to charge a de minimis rate of 10 percent only applies to applicants that have never received an approved negotiated indirect cost rate from HHS or another cognizant Federal agency. Applicants awaiting approval of their indirect cost proposal may request the 10 percent de minimis rate. When the applicant chooses this method, costs included in the indirect cost pool must not be charged as direct costs to the grant.

Available funds are inclusive of direct and appropriate indirect costs. Approved indirect funds are awarded as part of the award amount, and no additional funds will be provided. Generally, IDC rates for IHS grantees are negotiated with the Division of Cost Allocation at https://rates.psc.gov/​ or the Department of the Interior (Interior Business Center) at https://ibc.doi.gov/​ICS/​tribal. For questions regarding the indirect cost policy, please call the Grants Management Specialist listed under “Agency Contacts” or the main DGM office at (301) 443-5204.

3. Reporting Requirements The grantee must submit required reports consistent with the applicable deadlines. Failure to submit required reports within the time allowed may result in suspension or termination of an active grant, withholding of additional awards for the project, or other enforcement actions such as withholding of payments or converting to the reimbursement method of payment. Continued failure to submit required reports may result in the imposition of special award provisions and/or the non-funding or non-award of other eligible projects or activities.

This requirement applies whether the delinquency is attributable to the failure of the grantee organization or the individual responsible for preparation of the reports. Per DGM policy, all reports must be submitted electronically by attaching them as a “Grant Note” in GrantSolutions. Personnel responsible for submitting reports will be required to obtain a login and password for GrantSolutions. Please see the Agency Contacts list in section VII for the systems contact information.

The reporting requirements for this program are noted below. A. Progress Reports Program progress reports are required annually. The progress reports are due within 30 days after the budget period ends (specific dates will be listed in the NoA Terms and Conditions).

These reports must include a brief comparison of actual accomplishments to the goals established for the period, a summary of progress to date or, if applicable, provide sound justification for the lack of progress, and other pertinent information as required, and any other specific evaluation requirements described in this funding announcement. A final report must be submitted within 90 days of expiration of the period of performance. This final report must provide a comprehensive summary of accomplishments and outcomes over the period of performance as related to each of the stated goals. B.

Financial Reports Federal Cash Transaction Reports are due 30 days after the close of every calendar quarter to the Payment Management Services at https://pms.psc.gov. Failure to submit timely reports may result in adverse award actions blocking access to funds. Federal Financial Reports are due 30 days after the end of each budget period, and a final report is due 90 days after the end of the period of performance. Grantees are responsible and accountable for reporting accurate information on all required reports.

The Progress Reports, the Federal Cash Transaction Report, and Federal Financial Report. C. Data Collection and Reporting In addition to the annual progress reports, the IHS will compile and provide aggregate program statistics including associated community-level Government Performance Results Act health care facility data available in the National Data Warehouse, as needed. Awardees will be required to report on the following.

Treat Total number of patient visits. Total number of patients screened for suicide risk. Total number of patients assessed for suicide risk. Total number of patients placed on suicide care pathway or registry.

• total number of patients hospitalized for suicide risk. Start Printed Page 60892 total number of patients with safety plan. Total number of patients counseled on access to lethal means. Train Total number of staff trained, number of trainings, type of trainings and number of staff trained in each healthcare profession in evidenced-based treatment of suicide risk.

Awardees will also be required to submit their annual progress reports into an online reporting system funded by the IHS. D. Federal Sub-Award Reporting System (FSRS) This award may be subject to the Transparency Act sub-award and executive compensation reporting requirements of 2 CFR part 170. The Transparency Act requires the OMB to establish a single searchable database, accessible to the public, with information on financial assistance awards made by Federal agencies.

The Transparency Act also includes a requirement for recipients of Federal grants to report information about first-tier sub-awards and executive compensation under Federal assistance awards. The IHS has implemented a Term of Award into all IHS Standard Terms and Conditions, NoAs, and funding announcements regarding the FSRS reporting requirement. This IHS Term of Award is applicable to all IHS grant and cooperative agreements issued on or after October 1, 2010, with a $25,000 sub-award obligation threshold met for any specific reporting period. For the full IHS award term implementing this requirement and additional award applicability information, visit the DGM Grants Management website at https://www.ihs.gov/​dgm/​policytopics/​.

E. Compliance With Executive Order 13166 Implementation of Services Accessibility Provisions for All Grant Application Packages and Funding Opportunity Announcements Should you successfully compete for an award, recipients of Federal financial assistance (FFA) from HHS must administer their programs in compliance with Federal civil rights laws that prohibit discrimination on the basis of race, color, national origin, disability, age and, in some circumstances, religion, conscience, and sex (including gender identity, sexual orientation, and pregnancy). This includes ensuring programs are accessible to persons with limited English proficiency and persons with disabilities. The HHS Office for Civil Rights provides guidance on complying with civil rights laws enforced by HHS.

Please see https://www.hhs.gov/​civil-rights/​for-providers/​provider-obligations/​index.html and https://www.hhs.gov/​civil-rights/​for-individuals/​nondiscrimination/​index.html. • Recipients of FFA must ensure that their programs are accessible to persons with limited English proficiency. For guidance on meeting your legal obligation to take reasonable steps to ensure meaningful access to your programs or activities by limited English proficiency individuals, see https://www.hhs.gov/​civil-rights/​for-individuals/​special-topics/​limited-english-proficiency/​fact-sheet-guidance/​index.html and https://www.lep.gov. • For information on your specific legal obligations for serving qualified individuals with disabilities, including reasonable modifications and making services accessible to them, see https://www.hhs.gov/​ocr/​civilrights/​understanding/​disability/​index.html.

• HHS funded health and education programs must be administered in an environment free of sexual harassment. See https://www.hhs.gov/​civil-rights/​for-individuals/​sex-discrimination/​index.html. • For guidance on administering your program in compliance with applicable Federal religious nondiscrimination laws and applicable Federal conscience protection and associated anti-discrimination laws, see https://www.hhs.gov/​conscience/​conscience-protections/​index.html and https://www.hhs.gov/​conscience/​religious-freedom/​index.html. F.

Federal Awardee Performance and Integrity Information System (FAPIIS) The IHS is required to review and consider any information about the applicant that is in the FAPIIS at https://www.fapiis.gov before making any award in excess of the simplified acquisition threshold (currently $250,000) over the period of performance. An applicant may review and comment on any information about itself that a Federal awarding agency previously entered. IHS will consider any comments by the applicant, in addition to other information in FAPIIS, in making a judgment about the applicant's integrity, business ethics, and record of performance under Federal awards when completing the review of risk posed by applicants as described in 45 CFR 75.205. As required by 45 CFR part 75 Appendix XII of the Uniform Guidance, NFEs are required to disclose in FAPIIS any information about criminal, civil, and administrative proceedings, and/or affirm that there is no new information to provide.

This applies to NFEs that receive Federal awards (currently active grants, cooperative agreements, and procurement contracts) greater than $10,000,000 for any period of time during the period of performance of an award/project. Mandatory Disclosure Requirements As required by 2 CFR part 200 of the Uniform Guidance, and the HHS implementing regulations at 45 CFR part 75, the IHS must require an NFE or an applicant for a Federal award to disclose, in a timely manner, in writing to the IHS or pass-through entity all violations of Federal criminal law involving fraud, bribery, or gratuity violations potentially affecting the Federal award. All applicants and recipients must disclose in writing, in a timely manner, to the IHS and to the HHS Office of Inspector General all information related to violations of Federal criminal law involving fraud, bribery, or gratuity violations potentially affecting the Federal award. 45 CFR 75.113.

Disclosures must be sent in writing to. U.S. Department of Health and Human Services, Indian Health Service, Division of Grants Management, ATTN. Paul Gettys, Acting Director, 5600 Fishers Lane, Mail Stop.

09E70, Rockville, MD 20857. (Include “Mandatory Grant Disclosures” in subject line), Office. (301) 443-5204, Fax. (301) 594-0899, Email.

Paul.Gettys@ihs.gov. AND U.S. Department of Health and Human Services, Office of Inspector General, ATTN. Mandatory Grant Disclosures, Intake Coordinator, 330 Independence Avenue SW, Cohen Building, Room 5527, Washington, DC 20201, URL.

Https://oig.hhs.gov/​fraud/​report-fraud/​. (Include “Mandatory Grant Disclosures” in subject line), Fax. (202) 205-0604 (Include “Mandatory Grant Disclosures” in subject line) or, Email. MandatoryGranteeDisclosures@oig.hhs.gov.

Failure to make required disclosures can result in any of the remedies described in 45 CFR 75.371 Remedies for noncompliance, including suspension or debarment (see 2 CFR part 180 and 2 CFR part 376). VII. Agency Contacts 1. Questions on the programmatic issues may be directed to.

LCDR Monique Richards, MSW, LICSW, Start Printed Page 60893 Public Health Advisor, Indian Health Service, Division of Behavioral Health, 5600 Fishers Lane, Mail Stop. 08N70C, Rockville, MD 20857, Telephone. (240) 252-9625, Fax. (301) 443-5610, Email.

Monique.Richards@ihs.gov. 2. Questions on grants management and fiscal matters may be directed to. Sheila Miller, Grants Management Specialist, Indian Health Service, Division of Grants Management, 5600 Fishers Lane, Mail Stop.

09E70, Rockville, MD 20857, Phone. (240) 535-9308, Fax. (301) 594-0899, Email. Sheila.Miller@ihs.gov.

3. Questions on systems matters may be directed to. Paul Gettys, Acting Director, Division of Grants Management, Indian Health Service, Division of Grants Management, 5600 Fishers Lane, Mail Stop. 09E70, Rockville, MD 20857, Phone.

(301) 443-2114. Or the DGM main line (301) 443-5204, Fax. (301) 594-0899, email. Paul.Gettys@ihs.gov.

VIII. Other Information The Public Health Service strongly encourages all grant, cooperative agreement, and contract recipients to provide a smoke-free workplace and promote the non-use of all tobacco products. In addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some cases, any portion of the facility) in which regular or routine education, library, day care, health care, or early childhood development services are provided to children. This is consistent with the HHS mission to protect and advance the physical and mental health of the American people.

Start Signature Elizabeth A. Fowler, Acting Director, Indian Health Service. End Signature End Preamble [FR Doc. 2021-24039 Filed 11-3-21.

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A continuum of socioeconomic status ranging from the least to the most privileged persons is evidenced in population studies, with profound implications for health and care.1 Individuals in the diflucan dosage for yeast female most disadvantaged social group suffer from extreme poverty and face several specific challenges to their health and healthcare.2 They frequently cannot meet their most basic needs (including their physiological needs, most acutely exemplified by homelessness) and are at a higher risk of health problems and accelerated ageing due to unhealthy habits (eg, unhealthy diet and drug consumption), harmful environmental and biological factors and social isolation.1–4 As a result, the most socially disadvantaged persons have higher rates of premature mortality, especially caused by suicide and violence, and higher prevalence of all types of diseases, particularly infectious diseases and mental disorders.2 5 Besides, care for chronic conditions is compromised for this population group, which relies to a substantial degree in emergency care, particularly in health systems that do not guarantee universal health coverage.5Even considering the relative size of the most deprived extreme of the social continuum (eg, about 0.5% of the UK adult population in 2018 was considered homeless),6 the scale of …Anyone who has been tracking the public health literature on the greater risks experienced by minority ethnic groups in the antifungals diflucan will have been struck by the almost ubiquitous use of the acronym ‘BAME’. Government public health agencies use BAME as a modifying adjective for ‘… communities’, ‘… groups’, ‘… households’, ‘… people’, ‘… diflucan dosage for yeast female populations’, ‘… staff’ and as a noun. A 2020 report by Public Health England1 on the impact of antifungal medication on minority ethnic groups mentioned BAME 217 times without defining the term other than spelling out the acronym. Such usage is redolent of Ian Hacking’s ‘kinds of person’,2 a social group brought into being by the creation of labels for them and whose life narratives are dependent on social practices associated with such labelling.While ‘BME’ (black and minority ethnic) entered the lexicon in the early 1980s and was first used in Parliamentary proceedings in 1987,3 BAME made a later debut in this source in 2004 diflucan dosage for yeast female but had exceeded BME in frequency by 2020.4 A search of the GOV.UK portal—the website for the UK Government launched in 2012—reveals that results for the use of BAME substantially outpace BME (428 vs 242), a progressively widening gap that now makes it the government’s collective term of choice for minority ethnic groups.

Astonishingly, all five petitions submitted in June 2020 to the UK Government and Parliament5 requesting the banning or review of BAME were rejected on the grounds that ‘the Government’s guidance on writing about ethnicity already states that it does not use BAME or BME for a number of reasons’. The disingenuousness and obvious falsity diflucan dosage for yeast female of the statement derives from the fact that this guidance relates only to the work of the Race Disparity Audit, a small unit in the Cabinet Office, and not to Government as a whole. The growing usage of these acronyms has also been apparent in the work of the media and the third and private sectors. Indeed, BAME was added to the Oxford English Dictionary’s ‘new words list’ in 2014, diflucan dosage for yeast female confirming its arrival in the authoritative lexicon of contemporary English and further sustaining its use.The use of BAME is problematic for a number of reasons.

A survey diflucan dosage for yeast female by the Race Disparity Audit, the best available evidence, found that among nearly 300 people across the UK, <1% either recognised the acronym or knew what it stood for,6 against a required government standard of 80% of the UK population. The term is generally used to refer to all minority ethnic groups except those that are white, thus excluding such groups as Gypsies, Roma and Travellers, some of the most disadvantaged and marginalised in Britain. It is illogically constructed, the use of ‘minority ethnic’ following ‘black’ and ‘Asian’ suggesting that diflucan dosage for yeast female these pan-ethnicities are not minority ethnic groups. Moreover, the acronym implies that the individuals captured by it are a homogeneous group and it singles out and highlights specific pan-ethnicities (‘black’ and ‘Asian’), raising issues of exclusion and divisiveness.

Black British Academics argue that BME and BAME ‘reproduce unequal power relations where white is not a visible marker of identity and is therefore a privileged identity’.7 Both the Office for National diflucan dosage for yeast female Statistics and Cabinet Office advise against the use of these acronyms.In policy work on racial/ethnic disparities and inequities and structural or systematic racism, the language of BME and BAME offers a convenient shorthand for those who are discriminated against by virtue of their physical appearance, but at the cost of confusion, ambiguity and a lack of understanding. Unfortunately, these acronyms are gaining in reality with respect to usage by government and the media. A wider public debate is invited on appropriate diflucan dosage for yeast female collective terminology for minority ethnic groups. There is evidence that terms like ‘minority ethnic’ and ‘ethnic minority’ are widely accepted and understood and a case for the use of accurate description to delineate the population groups encompassed by collective terms..

A continuum of socioeconomic status ranging from the least to the most privileged persons is evidenced in population studies, with profound implications for health and care.1 Individuals in the most disadvantaged social group suffer from extreme poverty and face several specific challenges to their health and healthcare.2 They frequently cannot meet their most basic needs (including their physiological needs, most acutely exemplified cheap diflucan online by homelessness) and are at a higher risk of health problems and accelerated ageing due to unhealthy habits (eg, unhealthy diet and drug consumption), harmful environmental and biological factors and social isolation.1–4 As a result, the most socially disadvantaged persons have higher rates of premature mortality, especially caused by suicide and violence, and higher prevalence of all types of diseases, particularly infectious diseases and mental disorders.2 5 Besides, care for chronic conditions is compromised for this population group, which relies to a substantial degree in emergency care, particularly in health systems that do not guarantee universal health coverage.5Even considering the relative size of the most deprived extreme of the social continuum (eg, about 0.5% of the UK adult population in 2018 was considered homeless),6 the scale of …Anyone who has been tracking the public health literature on the greater risks experienced by minority ethnic groups in the antifungals diflucan will have been struck by the almost ubiquitous use of the acronym ‘BAME’. Government public health agencies use BAME as a modifying adjective for ‘… communities’, ‘… groups’, ‘… households’, ‘… people’, ‘… populations’, ‘… staff’ and as a noun cheap diflucan online. A 2020 report by Public Health England1 on the impact of antifungal medication on minority ethnic groups mentioned BAME 217 times without defining the term other than spelling out the acronym. Such usage is redolent of Ian Hacking’s ‘kinds of person’,2 a social group brought into being by the creation of labels for them and whose life narratives are dependent on social practices associated with such labelling.While ‘BME’ (black and minority ethnic) entered the lexicon in the early 1980s and was first used in Parliamentary proceedings in 1987,3 BAME made a later debut in this source in 2004 but had exceeded BME in frequency by 2020.4 A search of the GOV.UK portal—the website for the UK Government launched in 2012—reveals that results for the use of BAME substantially outpace BME (428 vs 242), a progressively widening gap that now makes it the government’s collective term of choice for minority ethnic groups cheap diflucan online.

Astonishingly, all five petitions submitted in June 2020 to the UK Government and Parliament5 requesting the banning or review of BAME were rejected on the grounds that ‘the Government’s guidance on writing about ethnicity already states that it does not use BAME or BME for a number of reasons’. The disingenuousness and obvious falsity of the statement derives from the fact that this guidance relates only to the work of the Race Disparity Audit, a small unit in the Cabinet Office, and not to Government as a whole cheap diflucan online. The growing usage of these acronyms has also been apparent in the work of the media and the third and private sectors. Indeed, BAME was added to the Oxford English Dictionary’s ‘new words list’ in 2014, confirming its arrival in the cheap diflucan online authoritative lexicon of contemporary English and further sustaining its use.The use of BAME is problematic for a number of reasons.

A survey by the Race Disparity Audit, the best available evidence, found that among nearly 300 people across the UK, <1% either recognised the acronym or knew what it stood for,6 against a required government standard cheap diflucan online of 80% of the UK population. The term is generally used to refer to all minority ethnic groups except those that are white, thus excluding such groups as Gypsies, Roma and Travellers, some of the most disadvantaged and marginalised in Britain. It is illogically cheap diflucan online constructed, the use of ‘minority ethnic’ following ‘black’ and ‘Asian’ suggesting that these pan-ethnicities are not minority ethnic groups. Moreover, the acronym implies that the individuals captured by it are a homogeneous group and it singles out and highlights specific pan-ethnicities (‘black’ and ‘Asian’), raising issues of exclusion and divisiveness.

Black British Academics argue that BME and BAME ‘reproduce unequal power relations where white is not cheap diflucan online a visible marker of identity and is therefore a privileged identity’.7 Both the Office for National Statistics and Cabinet Office advise against the use of these acronyms.In policy work on racial/ethnic disparities and inequities and structural or systematic racism, the language of BME and BAME offers a convenient shorthand for those who are discriminated against by virtue of their physical appearance, but at the cost of confusion, ambiguity and a lack of understanding. Unfortunately, these acronyms are gaining in reality with respect to usage by government and the media. A wider public debate is invited on appropriate collective terminology for minority cheap diflucan online ethnic groups. There is evidence that terms like ‘minority ethnic’ and ‘ethnic minority’ are widely accepted and understood and a case for the use of accurate description to delineate the population groups encompassed by collective terms..

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Elizabeth Holmes, CEO of Theranos, attends a panel discussion during the Clinton Global Initiative's annual meeting in New York, September 29, 2015.Brendan McDermid | ReutersSAN diflucan para que serve JOSE, CALIF. €“ A former Theranos scientist testified Friday that Elizabeth Holmes pressured her to validate blood test results from the company's Edison machine to speed up a rollout in Walgreens despite problems with the device's accuracy.Surekha Gangakhedkar, a senior scientist at Theranos for eight years who reported directly to Holmes, testified that she returned from a vacation in August 2013 and discovered that Theranos was about to launch its Edison blood-testing devices in Walgreens stores."I was very stressed and unhappy and concerned with the way the launch was going" diflucan para que serve Gangakhedkar said. "I was not comfortable with the plans that they had in place so I made a decision to resign and not continue working there."Gangakhedkar diflucan para que serve recalled meeting with Holmes in September 2013 about the issues that prompted her resignation."At that time she mentioned that she has promised to deliver to the customers and didn't have much of a choice then to go ahead with the launch," Gangakhedkar said becoming emotional on the stand."Ms. Holmes said diflucan para que serve she didn't have much of a choice?. " asked Robert Leach, an assistant U.S.

Attorney."Yes," she replied.Despite signing a non-disclosure agreement, Gangakhedkar said she printed some documents and took them home when she quit because she was "worried about the launch, I was actually scared that if things do not go well I would be blamed."Gangakhedkar was granted immunity from criminal charges in exchange for her testimony.She testified that in August 2013 she didn't think the Edison 3.0 and 3.5 were ready to be used for diflucan para que serve patient testing, adding "there were problems with getting consistent results." However, Gangakhedkar recalled that Holmes was pressuring the team to validate the tests even though "in my opinion she was aware," of the accuracy issues.Holmes is fighting 12 charges of wire fraud and conspiracy to commit wire fraud, and has pleaded not guilty. In opening statements, her defense attorney told jurors that Holmes was an ambitious young woman who made mistakes but didn't diflucan para que serve commit a crime.Earlier in the day, Erika Cheung, a former lab associated turned whistleblower, concluded her testimony after three days on the stand. Cheung recalled that frequent quality control failures in the lab created substantial delays in test results for patients."We had diflucan para que serve people sleeping in their cars because it was just taking too long," Cheung testified. "Every few days we were having to run samples over and over again."Cheung, who quit Theranos six months after joining as a college graduate, said she "became concerned probably a month in with the Vitamin D samples."Gangakhedkar's testimony continues diflucan para que serve on Tuesday. Among the insiders the government plans to call to testify next is Daniel Edlin, a project manager who reported directly to Holmes and worked on the Walgreens partnership.

Edlin was also friends with Holmes' brother, Christian.An influential Food and Drug Administration advisory committee on Friday rejected a proposal to distribute booster shots of Pfizer and BioNTech's antifungal medication treatment to the general public, paring back those plans to unanimously recommend the third shots diflucan para que serve to people age 65 and older and other vulnerable Americans."It's likely beneficial, in my opinion, for the elderly, and may eventually be indicated for the general population. I just diflucan para que serve don't think we're there yet in terms of the data," said Dr. Ofer Levy, a treatment and infectious disease specialist at Boston Children's Hospital.The panel voted 16-2 against distributing the treatments to Americans 16 and older, before unanimously embracing an alternate plan to give boosters to older Americans and those at a high risk of suffering from severe illness if they diflucan para que serve get the diflucan. That's previously included people with diabetes, heart disease, obesity and other so-called comorbidities.Pfizer's stock closed down 1.3%, while shares of BioNTech fell 3.6%.The nonbinding decision by the FDA's treatments and Related Biological Products diflucan para que serve Advisory Committee comes as the Biden administration has said it wants to begin offering booster shots to the general public as early as next week, pending authorization from U.S. Health regulators.

While the agency hasn't always followed diflucan para que serve the advice of its committee, it often does. A final FDA decision diflucan para que serve could come in a matter of hours. The Centers of Disease Control and Prevention has scheduled a two-day meeting next week diflucan para que serve to discuss plans to distribute the third shots in the U.S."We are not bound at FDA by your vote, just so you understand that. We can tweak diflucan para que serve this as need be," Dr. Peter Marks, the agency's top treatment regulator, reminded the panel after the votes.

He asked the group for suggestions on what diflucan para que serve other populations the FDA should consider for boosters, like front-line health workers and other occupations that face more exposure to antifungal medication.The committee vote was expected to be a controversial one as some scientists, including two senior FDA officials who were involved in the meeting Friday, have said they aren't entirely convinced every American who has received the Pfizer treatment needs extra doses right now.White House chief medical advisor Dr. Anthony Fauci said he diflucan para que serve wasn't surprised they didn't recommend the shots for people 16 and older. Fauci, who has publicly backed boosters, hesitated in an interview Friday on "Closing Bell" to guess what the committee would ultimately decide."I don't want to get ahead of the advisory committee at the time that they're deliberating," he said.Liesl Eibschutz, a medical diflucan para que serve student from Dartmouth University, loads a syringe with Pfizer antifungal medication treatment before giving it to people on the first day that people ages 16 and up can receive the treatment at Kedren Health on Thursday, April 15, 2021 in Los Angeles, CA.Allen J. Schaben | Los Angeles Times | Getty ImagesIn a paper published days before the advisory committee meeting, a leading group diflucan para que serve of scientists said available data showed treatment protection against severe disease persists, even as the effectiveness against mild disease wanes over time. The authors, including two high-ranking FDA officials and multiple scientists from the World Health Organization, argued Monday in the medical journal The Lancet that widely distributing booster shots to the general public is not appropriate at this time.In outlining plans last month to start distributing boosters as early as next week, Biden administration officials cited three CDC studies that showed the treatments' protection against antifungal medication diminished over several months.

Senior health officials said at the time they worried protection against severe disease, hospitalization and death "could" diminish in the months ahead, especially diflucan para que serve among those who are at higher risk or were inoculated during the earlier phases of the vaccination rollout.Before the vote, some committee members said they were concerned there wasn't enough data to make a recommendation, while others argued third shots should be limited to certain groups, such as people over age 60 who are known to be at higher risk of severe disease. Some members diflucan para que serve raised concerns about the risk of myocarditis in younger people, saying more research is needed.Dr. Hayley Gans, a voting member, said she was "struck" that the FDA was diflucan para que serve asking the committee to look at the totality of the evidence presented Friday because some data, including on safety, was still insufficient.Another member, Dr. Paul Offit, said he would support boosters for people over 60, but had trouble backing third shots for younger groups due to a higher risk of myocarditis.Before the vote diflucan para que serve Friday, the committee listened to several presentations on data to support the wide distribution of booster shots, including from health authorities from Israel, where officials began inoculating the nation's population ahead of many other countries and began offering third shots to their citizens in late July.Phil Krause, an FDA treatment regulator and a co-author of The Lancet paper, was critical of the findings presented Friday, saying much of the data had not been reviewed by the federal agency or had not been peer-reviewed. He said the models used were complex and scientists have to ensure it "is giving you the correct results.""That's part of the difficulty at looking at this kind of data without having the chance for FDA to review it," he said.In documents made public by the FDA on Wednesday, Pfizer said an observational study in Israel showed a third dose of the antifungal medication treatment six months after a second shot restores protection from to 95%.

The data was collected diflucan para que serve from July 1 through Aug. 30 when the fast-spreading diflucan para que serve delta variant was surging throughout the country.In a presentation Friday, Dr. Sharon Elroy-Preiss of Israel's Health Ministry argued that if officials there had not begun distributing boosters at the end of diflucan para que serve July, the nation likely would have exceeded its hospital capacity. Health officials began to see a trend, she said, of individuals in their 40s and 50s who diflucan para que serve were fully vaccinated become critically ill with antifungal medication."We didn't want to wait to see those results and we knew that we needed to vaccinate a larger portion of the population in order to get the numbers down quickly," she told the committee. Israeli health authorities expected severe cases to average 2,000 by late August, she said.

"We were able to dampen that effect and our severe cases are roughly 700 or less and have stayed stable, even diflucan para que serve though we still have days at 10,000 confirmed cases."She also said the booster shots were well tolerated by many people, citing data that showed there was only one case of myocarditis, a rare heart inflammation condition that's been linked to mRNA treatments, out of roughly 2.9 million people who received the extra doses.Pfizer's booster side effects are also comparable with those that emerge after receiving the second treatment dose, Dr. Joohee Lee, an officer at the FDA's Office of treatments Research and Review, said during the meeting.Of the 289 booster recipients ages 18 to 55 monitored in Pfizer's phase three trial, 63.8% developed fatigue, 48.4% had headaches and 39.1% experienced muscle diflucan para que serve pain. The FDA studied side effects in 2,682 recipients of Pfizer's second antifungal medication dose, ranging from 16 to 55 years diflucan para que serve old, reporting fatigue among 61.5% of patients, headaches among 54% and muscle pain among 39.3%. One adverse event — swelling of the lymph nodes — occurred in 5.2% of booster recipients but just 0.4% of those who received their diflucan para que serve first two doses."The majority were mild to moderate and they did resolve," Lee said of the lymphadenopathy cases. "Although one is reported to be ongoing at this time.".

Elizabeth Holmes, CEO of Theranos, attends cheap diflucan online a panel discussion during the Clinton Global Initiative's annual site link meeting in New York, September 29, 2015.Brendan McDermid | ReutersSAN JOSE, CALIF. €“ A cheap diflucan online former Theranos scientist testified Friday that Elizabeth Holmes pressured her to validate blood test results from the company's Edison machine to speed up a rollout in Walgreens despite problems with the device's accuracy.Surekha Gangakhedkar, a senior scientist at Theranos for eight years who reported directly to Holmes, testified that she returned from a vacation in August 2013 and discovered that Theranos was about to launch its Edison blood-testing devices in Walgreens stores."I was very stressed and unhappy and concerned with the way the launch was going" Gangakhedkar said. "I was not comfortable with the plans that they had in place so I made a decision to resign and not continue working there."Gangakhedkar recalled meeting with Holmes in September 2013 about the issues that prompted her resignation."At that time she mentioned that she has promised to deliver to the customers and didn't have much of cheap diflucan online a choice then to go ahead with the launch," Gangakhedkar said becoming emotional on the stand."Ms.

Holmes said cheap diflucan online she didn't have much of a choice?. " asked Robert Leach, an assistant U.S. Attorney."Yes," she replied.Despite signing a non-disclosure agreement, Gangakhedkar said she printed some documents and took them home when she quit because she was "worried about the launch, I was actually scared that if things do not go well I would be blamed."Gangakhedkar was granted immunity from criminal charges in exchange cheap diflucan online for her testimony.She testified that in August 2013 she didn't think the Edison 3.0 and 3.5 were ready to be used for patient testing, adding "there were problems with getting consistent results." However, Gangakhedkar recalled that Holmes was pressuring the team to validate the tests even though "in my opinion she was aware," of the accuracy issues.Holmes is fighting 12 charges of wire fraud and conspiracy to commit wire fraud, and has pleaded not guilty.

In opening statements, her defense attorney told jurors that cheap diflucan online Holmes was an ambitious young woman who made mistakes but didn't commit a crime.Earlier in the day, Erika Cheung, a former lab associated turned whistleblower, concluded her testimony after three days on the stand. Cheung recalled that frequent quality control failures in the lab created substantial delays in test results for cheap diflucan online patients."We had people sleeping in their cars because it was just taking too long," Cheung testified. "Every few days we were having to run samples over and over again."Cheung, who quit Theranos six months after joining as a college graduate, said she "became concerned probably a month in with the Vitamin D cheap diflucan online samples."Gangakhedkar's testimony continues on Tuesday.

Among the insiders the government plans to call to testify next is Daniel Edlin, a project manager who reported directly to Holmes and worked on the Walgreens partnership. Edlin was also friends with Holmes' brother, Christian.An influential Food and Drug Administration advisory committee on Friday rejected a proposal to distribute booster shots of Pfizer and BioNTech's antifungal medication treatment to the general public, paring back those plans to unanimously recommend the third shots to people age 65 and older and other vulnerable Americans."It's likely beneficial, in my cheap diflucan online opinion, for the elderly, and may eventually be indicated for the general population. I just don't think we're there cheap diflucan online yet in terms of the data," said Dr.

Ofer Levy, a treatment and infectious disease specialist at Boston Children's Hospital.The panel voted 16-2 against distributing the treatments to Americans 16 and older, before unanimously embracing an alternate plan to give boosters to older Americans and those at a high risk of suffering from severe illness if they get cheap diflucan online the diflucan. That's previously included people with diabetes, heart disease, obesity and other so-called comorbidities.Pfizer's stock closed down 1.3%, while shares of BioNTech fell 3.6%.The nonbinding decision by the FDA's treatments and Related Biological cheap diflucan online Products Advisory Committee comes as the Biden administration has said it wants to begin offering booster shots to the general public as early as next week, pending authorization from U.S. Health regulators.

While the agency hasn't always followed the advice of its cheap diflucan online committee, it often does. A final FDA cheap diflucan online decision could come in a matter of hours. The Centers of Disease Control and Prevention cheap diflucan online has scheduled a two-day meeting next week to discuss plans to distribute the third shots in the U.S."We are not bound at FDA by your vote, just so you understand that.

We can tweak this cheap diflucan online as need be," Dr. Peter Marks, the agency's top treatment regulator, reminded the panel after the votes. He asked the group for suggestions on what other populations the FDA should consider for boosters, like front-line health workers and other occupations that face more exposure to antifungal medication.The committee vote was expected cheap diflucan online to be a controversial one as some scientists, including two senior FDA officials who were involved in the meeting Friday, have said they aren't entirely convinced every American who has received the Pfizer treatment needs extra doses right now.White House chief medical advisor Dr.

Anthony Fauci said he wasn't surprised they didn't recommend the shots for people 16 and older cheap diflucan online. Fauci, who has publicly backed boosters, hesitated in an interview Friday on "Closing Bell" to guess what the committee would ultimately decide."I don't want to get ahead of the advisory committee at the time that they're deliberating," cheap diflucan online he said.Liesl Eibschutz, a medical student from Dartmouth University, loads a syringe with Pfizer antifungal medication treatment before giving it to people on the first day that people ages 16 and up can receive the treatment at Kedren Health on Thursday, April 15, 2021 in Los Angeles, CA.Allen J. Schaben | Los Angeles Times | Getty ImagesIn a cheap diflucan online paper published days before the advisory committee meeting, a leading group of scientists said available data showed treatment protection against severe disease persists, even as the effectiveness against mild disease wanes over time.

The authors, including two high-ranking FDA officials and multiple scientists from the World Health Organization, argued Monday in the medical journal The Lancet that widely distributing booster shots to the general public is not appropriate at this time.In outlining plans last month to start distributing boosters as early as next week, Biden administration officials cited three CDC studies that showed the treatments' protection against antifungal medication diminished over several months. Senior health officials said at cheap diflucan online the time they worried protection against severe disease, hospitalization and death "could" diminish in the months ahead, especially among those who are at higher risk or were inoculated during the earlier phases of the vaccination rollout.Before the vote, some committee members said they were concerned there wasn't enough data to make a recommendation, while others argued third shots should be limited to certain groups, such as people over age 60 who are known to be at higher risk of severe disease. Some members raised concerns about the risk of myocarditis in cheap diflucan online younger people, saying more research is needed.Dr.

Hayley Gans, a voting member, said she was "struck" that the FDA was cheap diflucan online asking the committee to look at the totality of the evidence presented Friday because some data, including on safety, was still insufficient.Another member, Dr. Paul Offit, said he would support boosters for people over 60, but had trouble backing third shots for younger groups due to a higher risk of myocarditis.Before the vote Friday, the committee listened to several presentations on data to support the wide distribution of booster shots, including from health authorities from cheap diflucan online Israel, where officials began inoculating the nation's population ahead of many other countries and began offering third shots to their citizens in late July.Phil Krause, an FDA treatment regulator and a co-author of The Lancet paper, was critical of the findings presented Friday, saying much of the data had not been reviewed by the federal agency or had not been peer-reviewed. He said the models used were complex and scientists have to ensure it "is giving you the correct results.""That's part of the difficulty at looking at this kind of data without having the chance for FDA to review it," he said.In documents made public by the FDA on Wednesday, Pfizer said an observational study in Israel showed a third dose of the antifungal medication treatment six months after a second shot restores protection from to 95%.

The data was collected from July 1 through Aug cheap diflucan online. 30 when the fast-spreading delta variant was surging throughout the country.In a presentation Friday, cheap diflucan online Dr. Sharon Elroy-Preiss of Israel's Health Ministry argued that if officials there had not begun distributing boosters at the end of cheap diflucan online July, the nation likely would have exceeded its hospital capacity.

Health officials began to see a trend, she said, of individuals in their 40s and 50s who were fully vaccinated become critically ill with cheap diflucan online antifungal medication."We didn't want to wait to see those results and we knew that we needed to vaccinate a larger portion of the population in order to get the numbers down quickly," she told the committee. Israeli health authorities expected severe cases to average 2,000 by late August, she said. "We were able to dampen that effect and our severe cases are roughly 700 or less and have stayed stable, even though we still have days at 10,000 confirmed cases."She also said the booster shots were well tolerated by many people, citing data that showed there was only one case of myocarditis, a rare heart cheap diflucan online inflammation condition that's been linked to mRNA treatments, out of roughly 2.9 million people who received the extra doses.Pfizer's booster side effects are also comparable with those that emerge after receiving the second treatment dose, Dr.

Joohee Lee, an officer at the FDA's Office of treatments Research and Review, said during the meeting.Of the 289 booster recipients ages 18 to 55 monitored cheap diflucan online in Pfizer's phase three trial, 63.8% developed fatigue, 48.4% had headaches and 39.1% experienced muscle pain. The FDA studied side effects in 2,682 recipients of Pfizer's cheap diflucan online second antifungal medication dose, ranging from 16 to 55 years old, reporting fatigue among 61.5% of patients, headaches among 54% and muscle pain among 39.3%. One adverse event — swelling of the lymph nodes — occurred in 5.2% of booster recipients but just 0.4% of those who received their first two doses."The majority were mild to moderate and they did resolve," cheap diflucan online Lee said of the lymphadenopathy cases.

"Although one is reported to be ongoing at this time.".

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