DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF ________________________
RFA APPROVAL FORM
RFA # ___________________
RFA TITLE: _________________________________________________________________________________
BRIEF PURPOSE:
____________________________________________________________________________________________
____________________________________________________________________________________________
RFA submitted to:
PUBLIC _____ PRIVATE NON-PROFIT _____ PRIVATE FOR-PROFIT
_____
FUNDING SOURCE:
FEDERAL _______ STATE _______ BOTH FEDERAL & STATE _______
FUND TYPE: ______ CO # ________ ACCT # ___________ CENTER # ____________ AMOUNT __________
FUND TYPE: ______ CO # ________ ACCT # ___________ CENTER # ____________ AMOUNT __________
DIRECT SERVICES: ____________
INDIRECT SERVICES: __________
BOTH: __________
1.
INITIATOR: ______________________ DATE SUBMITTED: ____________________
2.
__________________________________ _______ APPROVAL
DATE: __________
SECTION/PROGRAM CHIEF
_______ DISAPPROVAL
COMMENTS: _________________________________________________________________________
_____________________________________________________________________________________
3.
__________________________________ _______ APPROVAL
DATE: __________
CONTRACT OFFICE
_______ DISAPPROVAL
COMMENTS: _________________________________________________________________________
_____________________________________________________________________________________
4.
__________________________________ _______ APPROVAL
DATE: __________
BUDGET OFFICE
_______ DISAPPROVAL
COMMENTS: _________________________________________________________________________
_____________________________________________________________________________________
5.
__________________________________ _______ APPROVAL
DATE: __________
DIRECTOR/DESIGNEE
_______ DISAPPROVAL
COMMENTS: _________________________________________________________________________
_____________________________________________________________________________________
RFA Check List:
_______________ RFA and Attachments
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