Fillable FY 22 Johnson-O'Malley Application for Contract Part I

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FY 22 Johnson-O'Malley Application for Contract Part I

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Page 1
FY 22
Johnson-O'Malley
Application for Contract
Part I
Summary of Contents Contract Summary
Instructions: The purpose of Johnson-O'Malley funds are to provide programs to meet the special education needs of eligible JOM children
and to make available, program funding for allowable administrative and Indian Education Committee costs.
The application consist of four parts as summarized below:
PART I - CONTRACT SUMMARY
Page(s)
The Summary of Contents provides a preview of the application and the forms to be completed. 1
This page covers contractor identification, basic information, and signatures of the contractor's authorized representative, 2
the Indian Education Committee (IEC) chairperson and Muscogee (Creek) Nation JOM manager.
Privacy Act & Paper Reduction Act Statement and Service/School Locations, & enrollment information.
3
4
The Budget Summary / Justification page showing the consolidation of all projected program costs.
The contract
Administration,
IEC
and p
rogram
budgets
provided
the detailed breakdowns and justifications.
The total amounts are entered in the appropriate category of the Budget Summary.
PART II - CONTRACT ADMINISTRATION
"Assurances" outlines the contractor's responsibilities in the administration of the contract. 5
PART III - PROGRAMS
6
Needs Assessment Priority List: This describes how the special educational needs of Indian students were assessed, priority
needs identified and how these needs will be met.
7
Education Plan: This describes the program(s), based on the needs assessment, designed to meet the special educational
needs of JOM Indian students. Should describe in detail each program component, e.g. home-school counselor, pre-school
programs, and cultural enrichment. Use additional sheets as needed.
PART IV - INDIAN EDUCATION COMMITTEE (IEC)
8
The contractor must have an IEC that fully participates in program development and implementation.
The duties are outlined in 25 CFR 273.16 and allowable reasonable costs are contained in 273.18.
Should be used to explain the IEC's activities and projected budget needs in carrying out its responsibilities.
PART V - APPLICATION CHECK LIST
This section is a check list for all documents that should be attached to the Application.
9
Page 2
FY 22
Muscogee (Creek) Nation JOM Program
Education Contracts under Johnson-O`Malley Act
Application and Regulatory Reporting Requirement 25 CFR 273
1. Name of Public School District
Contact Person
_________________________________________
Address
_________________________________________
City State Zip
Code
_______________________________________________
Title
_______________________________________________
Address
Telephone ______________________________________
E
-mail ______________________________________
1. Eligible Student Count
Date submitted to Muscogee (Creek) Nation:
2. Proposed Budget $ Proposed Contract Period: ___________________________________
(Month/Year to Month/Year)
__________________________________________________________ Starting Date Ending
Sub-Contractor Certification: Name/Title of authorized School District Representative
The data in this application is true and correct, _____________________________________________
the document has been duly authorized by the
appropriate officials of the applicant and the _____________________________________________
applicant will comply with attached assurances.
Signature: ___________________________________
Date:
Indian Education Committee: Certification of Indian Education Committee Chairperson
Signature: __________________________________________
The Indian Education Committee has
participated fully in the planning and
development of this contract application.
FOR INTERNAL USE ONLY Date Received:
Date Forwarded:________________________________
Amount Approved:______________________________
Title: JOM Manager
To be completed by Muscogee (Creek) Nation
JOM Manager:
Certification:
I certify the application has been reviewed in
accordance with standards set forth in CFR,
Johnson-O`Malley regulations, and
is hereby recommended for approval.
Signature
:______
______________________________________
Date:
X
X
Page 3
Johnson-O'Malley
Application for Contract
Part I
SERVICE LOCATION, PRIVACY ACT AND PAPER REDUCTION ACT STATEMENT
a.
The authority to request this information is in Public Law 93-638, The Indian Self-Determination and Education Assistance Act of
1975.
b. This information is required in order to obtain supplemental educational assistance programs for eligible Indian children.
c. The information is collected and used to determine the amount of funding to be allotted to contractors serving eligible JOM Indian
students; to approve funding for supplemental programs to meet the special needs of Indian students that are in compliance with
appropriate statutes and regulations.
d. The routine use of this information is to ensure proper administration in the implementation of programs, for documentation, and
accountability purposes. The effect of not providing the information would mean that Indian children would not receive supplemental
education programs to meet their special needs.
I. Student Enrollment - Total Combined School Enrollment for Indian and Non-Indian (273.18 k)
Ages Elementary Jr. High
High
Name of School 3 yrs. 4 yrs. School
School School
Totals
Totals
II.
Eligible Indian Enrollment
Ages Elementary
Jr. High
High
Community/School 3 yrs. 4 yrs. School School School
Totals
Totals
Page 4
Johnson-O’Malley
Application for Contract
Part I
Contract Budget Summary
Instructions: In the spaces provided below summarize the total contract budget by category. The justification should
reflect the
items/services that will be
purchased in that category.
__________________________________
___________________________________
JOM Committee Chairperson Date
School Administrator Date
OCAS
Code
Category
Justification for budget amounts
Proposed
Budget
100
Personnel/Salaries
(payroll staff)
200
Fringe Benefits
(FICA, retirement)
300
Consultants/Contractual Services
(non-payroll staff, cultural instructors, presenters,
tutors)
400
Purchased Property
(repair and maintenance services)
500
Other Purchased Services
(student transportation, staff travel, contracted
food services, postage, telephone, printing,
advertising, mileage)
600
Supplies & Materials
(office, paper products, copier supplies, student
supplies, food & milk, books, periodicals,
magazines, workbooks)
700
Property
(eq
uipment, audio visual,
computers,
furniture)
800
Other Program Cost/IEC Cost
(dues, fees, conference registration fees, stipend,
training/conference fees, awards banquet, food
cost, incentives, IEC travel, etc.)
900
TOTAL
X
X
(description must be completed)
Page 5
Johnson-O`Malley
Application for
Contract
Part II
Required Assurances
Contract Administration
The contractor assures that they will comply with the statutes, regulations, and policies of the program under the Johnson-O`Malley Act
and contract provisions. (Regulations: 25 CFR 271, 273, and 276).
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
All reasonable steps were taken to obtain maximum Indian participation in the development, approval, and implementation of all
contracted programs herein proposed (273.4).
All students counted for services are eligible. A current list of eligible JOM Indian students showing degree of Indian blood,
grade, and tribal affiliation will be sent to the appropriate JOM staff during student count week.
The IEC (for this application) have participated fully in the planning and development of this application and are vested with all
powers and duties as outlined by regulation (273.16).
The application as approved by the IEC will not be changed or revised without the written approval of the IEC (273.17).
The education facilities where the programs are to be conducted shall be open to visits and consultations (273.18 g).
That the contract funds shall supplement, and not supplant, other funds and that use of these funds will not result in a decrease of
other funds. (273.34).
That other funds shall be used provide comparable services to non-Indian and Indian students, prior to the use of Johnson-
O`Malley funds for the provision of supplementary program services to Indian children (273.34, 273.41).
That Indian preference will be exercised in all hiring, training, and subcontracting in programs under this application (273.45).
That the required public liability insurance coverage will be in effect covering programs contracted and said insurance will be
applied for with this application (273.46).
The required record keeping system covering all required topics will be maintained for programs applied for with this application (273.47).
Access to contract records and documents will be allowed to authorized representatives of the Comptroller General and the
Secretary of the Interior (273.48).
Access to all-confidential records will be allowed to the Indian people which the contract affects and other interested parties (273.49).
A detailed annual report will be submitted to the MCN JOM office within 90 days following the ending date of each contract year (273.50).
All student records and confidential records/report will be maintained following the ending date of each contract year (273.54).
A current set of Indian Education Committee By-Laws which meet the criteria set forth in (273.15 c) has been given and reviewed
with IEC members.
Records of property purchased with contract funds will be maintained. Records of this MCN property will include description,
manufacturer’s serial number acquisition date and cost (276.11e).
An annually conducted inventory of government property assigned to the contract is on file for review.
Procedures established for hearing and responding to grievances from Indian students, parents, community members and tribal
representatives are attached (273.18 c).
Contract funds will not be used for capital outlay or debt retirement (273.35).
Attach copies of any subcontracts to be used in carrying out this contract.
Each IEC member will receive a copy of the completed application (273.16).
Local school districts will be responsible to insure against lost or damaged JOM property. The school shall maintain the property
in a reasonable state of repair consistent with the intended use and educational purposes (273.44).
Educational needs will be assessed and prioritized by the Indian Education Committee (273.16 b 2).
School will make available standardized test scores for needs assessments.
JOM staff employed with the school district will attend all training services sponsored by the Muscogee (Creek) Nation.
The school district and the Indian Education Committee will participate in monitoring processes.
In compliance as a minimum requirement of the Oklahoma Open Meeting Act, all scheduled meetings for the school year shall be
filed with the County Clerk. All regular and special-called JOM meeting shall be conducted on school or tribally owned property.
Basic parliamentary procedures utilizing Parliamentary Procedures will be observed.
All parents of eligible Indian students may serve and participate in all IEC activities and functions of the respective school district
in which their children are enrolled, regardless of residence.
In no instance shall there be discrimination against Indians or schools enrolling such Indians (273.38) (273.42).
IEC annual elections will comply with standardized voting policies and procedures as prescribed in the Muscogee (Creek)
Nation JOM Handbook and IEC approved governing By-Laws and is to be used by all Muscogee (Creek) Nation JOM contractors.
A JOM Handbook will be distributed to all JOM Schools and Indian Education Committees annually in advance of each School
Program Year. The Muscogee (Creek) Nation JOM Handbook will implement and set forth specific requirements for the
administration of the Johnson-O`Malley Program. Please refer to the handbook for specific information and blank program forms.
IEC Member initial:________
School Administration initial: ________
X X
Page 6
Johnson-O’Malley
Application for Contract
Part III
Needs Assessment Priority List
I. Describe the method by which the needs assessment and ranking process was carried out. Include the method of
assessment of other education program services available and the involvement of the Indian Education Committee,
parents, students and the Indian/Native community.
II. List the education needs of Indian students in priority order as determined by the required needs assessment.
A.
Priority needs of Indian students
demonstrating those needs.
B.
C.
D.
Supplementary funding
source and amount.
E.
F.
Are these
services
sufficient?
G.
Will JOM be used
to address these
needs?
H.
# of JOM
students
served?
1.
yes
no
yes
no
yes
no
2.
yes
no
yes no
yes
no
3.
yes
no
yes no
yes
no
4.
yes
no
yes
no
yes
no
5.
yes
no
yes
no
yes
no
6.
yes
no
yes no
yes
no
7.
yes
no
yes no
yes
no
Total # of
students
demonstrating
need.
Are services other
than JOM
provided to
address these
needs?
# of students
served by
column D.
Page 7
Johnson-O’Malley
Application for
Contract Part III
Education Plan
Instructions: Describe each program components, e.g. home school counselor, pre-school program, cultural enrichment,
below and on a separate sheet if needed. Enter cumulative totals on appropriate line in the Contract Budget Summary on page 5.
1.
2.
3.
4.
Name of school / pre-school/ project site:__________________________________________________
No.(#) of JOM eligible students counted:
Pre-K____ K-6____ 7-12_____
Length of programs: _____________ to ______________
(month/year to month/year)
1- Program and Staffing Needs
2 - Educational Goals
3 - Measurable Objectives
4 - Activities
Page 8
Johnson-O'Malley
Application for Contract
Part IV
IEC Activities and Budget Indian Education Committee Listing
NAME / OFFICE
ADDRESS
TELEPHONE
Instructions: The contractor must have an IEC that fully participates in program development and implementation.
The duties are as outlined in 273.17 (c). In carrying out its responsibilities, the IEC may have activities such as
regular meetings. workshops, travel cost, etc. Item number 5 will describe the activities and cost. The cost will
also be entered in the Contract Budget Summary, page 4 under the OCAS 800 code.
1. Describe the IEC’s activities regarding the planning and development of this application.
2 Describe the IEC’s activities regarding implementation and operation of the programs proposed in this application.
3 Describe the IEC’s activities regarding monitoring, evaluation, and staff effectiveness for the program components
in this application.
4 Does the contractor and IEC need training to increase the IEC effectiveness in carrying out their program
responsibilities? If so, describe the type of training needed and cost that may be incurred.
5 List travel, meetings, and other expenses with itemized cost. (stipend, travel, conference fees etc.)
Page 9
Johnson-O'Malley
Application for Contract
Part V
Application Check List
Please note that the following documents are attached to the Application or it will be considered incomplete and will not
be processed.
Items Required
Complete
Not complete
1. FY 22 Needs Assessment
a.
Minutes approving the discussion and prioritizing
b.
Needs Assessment Survey Form and Results
2. Minutes approving FY 22 Application
3.
Check Signatures on all documents
_______________________________________________ _______________________________________________
JOM Chairperson JOM Coordinator
X
X
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FY 22 Johnson-O'Malley Application for Contract Part I

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Completed 1 February 2022

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