REQUEST TO APPLY FOR GRANT
TO BE COMPLETED BY DEPARTMENT/AGENCY FOR COMPETITIVE
GRANT APPLICATIONS UP TO S250.000

Instructions: Fill oui and sign this sheet and submit to the Office of Budget and .Ajialysis,
Oepartments must attach the draft application, or the pertinent portions ofthe application that describe
the general grant requirements and how the department would utilize the grant funding. If the grant
application is too cumbersome to include, the depanment shall attach a short memo that includes this
infonnation.

Depanment Submitting Grant: Public Health Department
Contact Name: Dolores Alvarado Phone Number: ("408) 423-0706

Title of Grant: Expansion of HIV Rapid Testing

Amount of Grant and Length of Term: $20,000 July 1,2006 - October 3E 2007
Is there a County Match? Cash Percentage:^ (%)Amount:
In-Kind Percentage: None (%)Amount:
.Aiiencv Issuinii Grant: KAISER PERMANENTE

Short Description of Grant, including .ALL departments that would be affected by grant award:
This funding will be utilized to support the establishment of the new HIV Rapid Testing sites in the
community-based settings. The Department will divide the funds equally amongst the community-based
agencies that will be selected to perform the HIV Testing services.

■Agency or Depanment Head Signature, or Designee;
Date Needed: September 12,2006
TO BE COMPLETED BY OBA .ANALYST AND THE DEPUTY COUNTY EXECUTIVE

Recommended for .Approval by OBA:

Yes

□

KoO

.Appro\ed by Deputy County Executive;

Yes

□

No

□
Lasr updaied: 6/S’2005