Application Instructions

Virginia Department of Health Emergency Preparedness and Response Programs (EP&R) Offer of Financial Assistance for Private H1N1 Vaccination Providers

The Centers for Disease Control and Prevention has awarded the Virginia Department of Health (VDH) grant funds to support public health preparedness and response to the Novel H1N1 influenza. VDH is pleased to use this funding to offer special assistance to providers and centralized distribution organizations to offset eligible expenses related to reporting H1N1 vaccination data into the Virginia Immunization Information System (VIIS). For sites that have a central distribution organization, such as retail pharmacies and hospital chains, only the parent entity is an eligible applicant.

This is a reimbursement based grant up to $1000. Conditions of eligibility will be confirmed by VDH, and providers must submit an application to be considered for the funding. An application may be submitted online by clicking on the Submit the Form link to the right or via hard copy to the address or fax number shown below.

Application Instructions

Eligibility and Requirements

1. Applicant must be a private provider or corporate centralized distribution organization (retail pharmacy or hospital chain) with a prescribing official (e.g. M.D., D.O.) and be able to provide adequate (as described in the H1N1 Vaccine Provide Agreement) vaccine storage capacity.
2. Applicant must submit verification of its Federal Identification Number (FIN). Verification can be provided in the following formats:
   • Copy of the original letter from IRS issuing FIN
   • Copy of the latest tax return (1st page only)
3. Applicant must have signed an H1N1 Vaccine Provider Agreement.
4. Applicant must agree to report vaccine doses administered via the Virginia Immunization Information System (VIIS) and have made entries of doses administered into VIIS.
5. Applicant must submit the Virginia EPR H1N1 Financial Assistance Application including the signatures of the Authorized Provider Representative and the Point of Contact for Grant Management of the organization.
6. Each applicant can submit only one (1) application. Each application may have multiple items that are eligible for funding but cannot exceed $1000.
7. Funding is limited to purchases and/or obligations made from October 1- February 28, 2010.

Items Eligible for Funding:

Staff and administrative costs associated with vaccine tracking administration in VIIS.

Programming or development costs for electronic tracking and reporting of vaccine doses administered in VIIS

Submission Requirements:

A completed EPR H1N1 Financial Assistance Application with all required information must be submitted by November 30, 2009 by 5:00 pm.

Application may be submitted on-line at /epidemiology/DiseasePrevention/H1N1/ProviderResources.htm, via fax to 804-864-7029 or by mail to EPR - Provider Vaccination Assistance, 109 Governor Street, 13th Floor, Richmond, VA 23219.

Review Process
Only applications that have met the above eligibility and submission guidelines will be accepted. Accepted applications will be forwarded to a grant review committee within five business days of submission.

This committee will review each application to determine if all eligibility and application requirements have been met. Each applicant meeting full eligibility will be awarded a reimbursement grant. Applicants will be notified in writing within 30 days of final review. Approved applicants will be requested to sign an agreement to the following terms and conditions for reimbursement.

1. Awards shall not be transferable. Any funds disbursed pursuant to an award shall be properly used and accounted for at all times. Grantee is to be responsible for the preparation and maintenance of proper accounting records which shall be maintained for a period of not less than five (5) years and which shall be subject to and available for inspection by the Commissioner or his agent and for state audit inspections.
2. Funds shall be reimbursed solely to grantee for items, services or purposes for which they were awarded. Grantee must comply with all conditions as noted on Award Notice. Should any audit reveal that funds were disbursed for Item(s) not awarded funding, the grantee shall be held responsible for repayment.
3. Reimbursement shall not be made for expenditures or commitments made prior to or after the conclusion of the grant period dates. Grant period concludes on March 30, 2010. Documentation must be submitted to the EPR for reimbursement of awarded Item(s) by the grant deadline. No extension will be granted.
4. Grant funds are for purchased items only. Leased equipment is not eligible for reimbursement.
5. Requests for reimbursement that have not been submitted to EPR by March 30, 2010 shall be considered expired and become ineligible for reimbursement.
6. The grantee shall not discriminate in the provision of its services or in the conduct of its business or affairs on the basis of race, color, creed, religion, sec, disability or national origin.
7. To obtain reimbursement of grant awards, grantee shall submit a copy of an itemized, dated, numbered invoice, along with appropriate receipts to EPR, certified and signed by the organization's authorized representative. A single invoice is to be submitted to EPR by grant deadline, March 30, 2010.