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Maternal, Child, & Adolescent Health Program:

FY 2011-12 Agreement Funding Application (AFA)

For Local Health Jurisdictions (LHJs) & Community Based Organizations (CBOs)

MO-10-0047 MCAHFI

The MCAH Fiscal function is to establish the legal agreements between the CDPH and agencies that conduct the MCAH-funded programs; perform administrative and fiscal oversight of MCAH legal agreements; provide administrative support to the CDPH MCAH Program and its agencies, and manage the program budgets.

It is important to use the forms, documents, and procedures specific to the fiscal year that you are budgeting or invoicing. Below are forms and documents specific to 2011-12.

Agreement Funding Application (AFA) Components

  • AFA Letter (MCAH, AFLP, BIH) (PDF)Opens a nerw browser window.
  • AFA Letter (CHVP-NFP) (PDF)Opens a nerw browser window.
  • AFA Letter (CHVP-HFA) (PDF)Opens a nerw browser window.
  • AFA Checklist (Word)Opens a nerw browser window.
  • AFA Update Form (Word)Opens a nerw browser window.
  • Allocation Tables

  • MCAH / BIH / FIMR / SIDS (PDF)Opens a nerw browser window.
  • AFLP (PDF)Opens a nerw browser window.
  • CHVP (PDF)Opens a nerw browser window.
  • Budget/Invoice Templates

  • Multi Program Budget Invoice Template (BIT)  (MCAH, BIH, AFLP, CHVP) (Excel)
    AlertThis file is temporarily unavailable.  Please contact your Contract Manager to access this file.
  • AFLP - CBO Monthly Invoicing, Updated June 2010 (Excel, 9.5MB)Opens a nerw browser window.
  • Medi-Cal Factor Tables

  • MCAH Medi-Cal Factor Table (PDF)Opens a nerw browser window.
  • BIH Medi-Cal Factor Table (PDF)Opens a nerw browser window.
  • Scope(s) of Work, SOW

  • SOW AFLP (Word)Opens a nerw browser window.
  • SOW BIH (Word)Opens a nerw browser window.
  • SOW CHVP (PDF)Opens a nerw browser window.Revised 2-7-12
  • CHVP Attachment A Program Operational Requirements (PDF)Opens a nerw browser window.Revised 2-7-12
  • SOW FIMR  (Word)Opens a nerw browser window.
  • SOW MCAH / SIDS (Word)Opens a nerw browser window.
  • Instructions for Completing MCAH SOW (Word)Opens a nerw browser window.
  • Forms

  • Attestation of Compliance with the Sexual Health Education Accountability Act of 2007 (Word)Opens a nerw browser window.
  • CHVP Attachment B Staffing Report (Word)Opens a nerw browser window.
  • CHVP Attachment C Transmittal Form (Word)Opens a nerw browser window.
  • CDPH 1203 - Contractor Equipment Purchased with CDPH Funds (Word)Opens a nerw browser window.
  • CDPH 1204 - Inventory/Disposition of CDPH Funded Equipment (Word)Opens a nerw browser window.
  • STD 152 - Property Survey Report (Word)Opens a nerw browser window.
  • SPMP Questionnaire (Word)Opens a nerw browser window.
  • Subcontract Agreement Transmittal Form (Word)Opens a nerw browser window.
  • Travel Reimbursement Information, 07-11 (Word)Opens a nerw browser window.
  • Sample Invoice Cover Letter (Word)Opens a nerw browser window.
  • Federal Financial Participation Calculation File, Version 2.04 (Excel)Opens a nerw browser window.
  • Weekly Time Study Form (Excel)Opens a nerw browser window.
  • HIPAA Business Associate Exhibit (Word)Opens a nerw browser window.
  • MCAH Local Health Jurisdiction Profile Narrative (Word)Opens a nerw browser window.
  • CHVP Local Health Jurisdiction Profile Narrative (Word)Opens a nerw browser window.
  • Certification Statement for the use of Certified Public Funds (PDF)Opens a nerw browser window.
  • Prior Year AFA's/RFA's

  • FY 2010-2011 (AFA)
  • FY 2009-2010 (AFA)
  • FY 2008-2009 (AFA)
  • Archive List
  • Reference

  • Fiscal Policy and Procedures Manual
  • Federal Financial Participation (FFP)
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    Last modified on: 7/19/2012 3:24 PM