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NC Department of Health and Human Services
NC Division of Public Health
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Policies and Procedures

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 Administration - Updated 10/02/18

Document Format, Size (if DPH file) Last Modified* (if DPH file)
Adverse Weather Policy N/A N/A
External Inquiries Policy (Public Records Requests, Media Requests, Legislative Inquiries) PDF, 50 KB 10/02/18
Gift Card Policy PDF, 25 KB 04/27/18
Management of DPH Policies and Procedures PDF, 22 KB 04/20/18
Performance Management PDF, 44 KB 04/20/18
Email Signature Policy PDF, 152 KB 09/24/14


Document Format, Size (if DPH file) Last Reviewed and / or Modified* (if DPH file)
Gift Card Policy PDF, 25 KB 04/27/18
Grant Budget Review Policy and Procedure PDF, 26 KB 04/01/17
ITS E-Billing Procedures PDF, 121 KB 06/17/11
ITS E-Billing Procedure Example PNG, 216 KB 06/17/11
Key NCAS Budget Reports Found Through XTND PDF, 18 KB 04/14/10
Purchasing Program PDF, 310 KB 12/19/17


Document Format, Size (if DPH file) Last Modified* (if DPH file)
2017 DHHS Equal Employment Opportunity (EEO) Plan PDF, 693 KB N/A

 Grants Management - Updated 10/18/18

A. Policies

Document Format, Size (if DPH file) Last Reviewed and / or Modified* (if DPH file)
Grant Budget Review Policy and Procedure PDF, 26 KB 04/01/17
Grants Management Policy DOC, 44 KB 04/20/18
Procedure for Applying for a Grant DOC, 58 KB 04/01/17
Procedure for Preparing to Receive the Grant DOC, 37 KB 04/01/17
Procedure for Implementing the Grant DOC, 34 KB 04/22/17
Procedure for Managing the Grant DOC, 35 KB 04/01/17
Procedure for Closing out the Grant DOC, 31 KB 04/01/17

B. Forms

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Form 606A: Notification of Application for Grant Funds/Awards N/A N/A State agencies are required by statute (G.S. 143C-7-1) to notify the Office of State Budget and Management (OSBM) of all applications made for grant funds and/or other funds that require an application.
606A Instructions: Instructions for Reporting Grant Applications/Awards N/A N/A Line-by-line instructions for Form 606A
SF 424: Application for Federal Assistance PDF N/A From website
SF 424 Example and Instructions DOC, 390 KB 08/26/08 SF 424 example provided by DPH
SF 424A: Budget Information - Non-Construction Programs PDF N/A From website
SF 424A Example and Instructions DOC, 390 KB 01/22/09 SF 424A example provided by DPH
Cost Allocation Plan (CAP) Update Request DOCX, 56 KB 05/15/13 Form used by the Cost Accounting Branch in establishing and maintaining the Cost Accounting Plan; documents the initiation of cost centers (RCCs) as well as changes to existing centers.
Draft Prior Approval for Grant Action PDF, 98 KB 10/22/15 Current guidance on level of approval required for grant actions.

C. Grant Proposal Worksheet Resources

D. Grant Application Checklists

  1. Personnel Checklist (DOC, 31 KB)
  2. Purchasing/Facility Checklist (DOC, 31 KB)
  3. Contracts Checklist (DOC, 42 KB)
  4. OW Audit Determination Form (XLS, 13 KB)
  5. IT Checklist (DOC, 37 KB)
  6. Budget Checklist (DOC, 23 KB)

E. Related Information - Updated 10/18/18

 Health and Safety - Updated 09/17/18

Document Format, Size (if DPH file) Last Reviewed and / or Modified* (if DPH file)
Accident/Injury Reporting and Investigation Procedure PDF, 125 KB 06/15/17
Adverse Weather Policy N/A N/A
Automated External Defibrillator Procedure PDF, 65 KB 04/01/17
DPH Tobacco-Free Campus Policy PDF, 24 KB 04/01/17
DPH Tobacco-Free Campus Policy: Frequently Asked Questions PDF, 114 KB 01/20/16
Emergency Action Plan PDF, 445 KB 09/04/18
Emergency Evacuation PDF, 118 KB 04/01/17
Hazard Communications Policy and Procedure PDF, 48 KB 04/01/17
Workplace Smoking and E-Cigarette Policy (DHHS) N/A 08/10/15


 Human Resources

 Monitoring and Compliance

A. Overview

The Subrecipient Monitoring Plan Tools are provided to help DPH programs develop a Subrecipient Monitoring Plan (if required by federal, state, and departmental policy), and to provide information to help monitor contracts effectively.

  • Who? According to the DHHS Monitoring of Programs policy, each division that has financial assistance arrangements with subrecipients shall develop and maintain a subrecipient monitoring plan - DPH programs are responsible for developing and maintaining their own plan(s).
  • What is a Subrecipient Monitoring Plan? The Division of Public Health Subrecipient Monitoring Plan (provided below at Item C) is the basis for monitoring program and fiscal compliance with state and federal requirements. The primary objective of the monitoring plan(s) developed by programs is to ensure that subrecipients are complying with applicable rules and regulations and that the program(s) are accomplishing their intended purpose(s).
  • How? The Division's Subrecipient Monitoring Plan (Item C) details how DPH plans to monitor its programs.
  • When? How often should monitoring and reporting occur? The frequency and intensity of monitoring techniques applied to a given subrecipient will be directly proportional to the level of risk assigned. The amount of financial and programmatic monitoring, and the techniques used, will vary based upon the DPH risk-based system outlined in Section "VI. Risk Assessment" of the Division's Subrecipient Monitoring Plan.
  • Why? To comply on federal, state, and departmental levels - further regulatory background information is available in the Division's Subrecipient Monitoring Plan. Links to specific regulations are available under "Resources" (Item F).

B. Definitions

Definitions of key Subrecipient Monitoring Plan terms:

  1. Grant: A giving of funds for a specific purpose.
  2. Pass-through Entities: State agencies in receipt of federal or state funds that are sub-awarded to private or other state agencies for provision of services in support of a specific program or project. Pass-through entities are responsible for monitoring grants to provide reasonable assurance that:
    1. Federal and state grant funds are expended in ways that meet provisions of pertinent statutes, regulations, agency administrative requirements, relevant OMB circulars, and the terms of the award notice.
    2. Adequate progress is being made toward achieving the sub-award project’s goals and objectives (as defined in award application packets).
  3. Subrecipient Agency: An agency or organization that receives federal or state awards from the Division of Public Health. These agencies are usually non-profit or governmental agencies or organizations, but in some instances may be for-profit entities. (State agencies routinely monitored by the Office of the State Auditor are not necessarily included in this definition, but consideration should be based on prior experience with the state agency in question.
  4. Federal or State Awards: Financial assistance and cost-reimbursement contracts that non-federal and non-state entities receive directly from federal or state awarding agencies or indirectly from pass-through entities. (The payments received for goods or services provided as a vendor are not considered federal or state awards.)
  5. Monitoring: Activities that are part of a continuous improvement strategy designed to assure that public funds are allocated and spent in a manner that maximizes the level of program benefits to the public and to other stakeholders (e.g. granting agency, DPH, and the subrecipient). Monitoring is incorporated into all aspects of the post-award process.
  6. Cost Disallowance: A charge to a grant that the division determines to be unallowable, according to the applicable cost principles (OMB Circular A-122 for non-profit organizations, A-21 for educational institutions, and A-87 for state, local, and Indian tribal governments) or other award terms and conditions. The general rule of thumb for any costs to be considered proper is that they must be allowable, allocable, necessary, reasonable, and treated consistently.
  7. Temporarily Withholding Funds: Action taken by the division, after appropriate administrative procedures have been followed, which delays a subrecipient’s ability to access its grant funds until it takes corrective action required by the pass-through entity.
  8. Suspension: Action by the division that temporarily suspends financial assistance under the award, pending corrective action by the subrecipient or a pass-through entity’s decision to terminate the award.
  9. Termination: Permanent cancellation of the subrecipient’s authority to obligate all or part of the funds awarded to it. Awards may be terminated under the following conditions as outlined in OMB Circular A-110:
    1. By the division, if the subrecipient materially fails to comply with the terms and conditions of the award;
    2. By the division, with the consent of the subrecipient; or
    3. By the subrecipient, upon sending written notification to the agency stating the reasons for the termination.
  10. Voiding of a Grant: Determining that the award was obtained fraudulently, or was otherwise illegal or invalid from inception. Voiding, in effect, is a decision that the grant never legally existed. Such determinations are rare, but possible.
  11. Debarment and Suspension: Government-wide actions based on Executive Order 12549 which exclude a person or organization from participating in grants or other assistance awards. Suspensions are temporary actions, not to exceed 18 months, generally leading to debarment, implemented only when immediate action is needed to protect the government’s interest. Debarment generally lasts three years.

C. DPH Subrecipient Monitoring Plan

This is the current DPH Subrecipient Monitoring Plan.

Document Format, Size (if DPH file) Last Modified* (if DPH file)
DPH Subrecipient Monitoring Plan PDF, 282 KB 10/10/16
Appendix A: Internal Control Questionnaire Form 1 Word, 72 KB 10/10/16
Appendix A: Internal Control Questionnaire Form 2 Word, 110 KB 10/10/16
Appendix B: Risk Assessment Form Word, 60 KB 06/13/17
Appendix C: Subrecipient Monitoring Log Word, 24 KB 08/23/06
Appendix D: Monitoring Tool / Instrument Word, 58 KB 08/23/06
Appendix E: Monitoring Documentation Form Word, 22 KB 08/23/06
Appendix F: Example Risk Notification Letter Word, 21 KB 08/23/06

Appendix G: DPH Subrecipient Report

Please contact Curt Martin.

Appendix H: Financial Checklist Word, 41 KB 10/10/16

D. Monitoring Plan Template

The following template was provided by the Office of the State Auditor. You may use this or modify as necessary to develop your program's plan.

Document Format, Size (if DPH file) Last Modified* (if DPH file)
Monitoring Plan Template Word, 59 KB 08/23/06

E. Monitoring Plan Tools

The following tools may be used and/or modified to suit the purpose of your program's specific plan. Some of these tools were provided by the Office of the State Auditor. The tools refer to grants monitoring since the purpose is to monitor grant funds that are passed on to subrecipients who may be contractors or local health departments.

Document Format, Size (if DPH file) Last Modified* (if DPH file)
Grants Monitoring Assistance Worksheet Word, 21 KB 08/23/06
Grants Monitoring Periodic Reports Desk Review Worksheet Word, 39 KB 08/23/06
Grants Monitoring Phone Call Worksheet Word, 23 KB 08/23/06
Grants Monitoring Site Visit Worksheet Word, 23 KB 08/23/06
Grants Monitoring Pre-Award Risk Assessment Checklist Word, 30 KB 08/23/06
Program Activities and Accomplishments Report Word, 32 KB 08/23/06
Grants Monitoring and Performance Evaluation Worksheet Word, 25 KB 08/23/06
Grants Monitoring Individual Grant Monitoring Plan Worksheet Word, 39 KB 08/23/06
Grants Monitoring Corrective Action Worksheet Word, 23 KB 08/23/06
Example of Conflict of Interest Policy Word, 42 KB 08/23/06
Notification Letter for Site Visit Monitoring Word, 277 KB 01/14/09
Pre-Assessment Survey Word, 31 KB 08/23/06
Monitoring Procedures Word, 50 KB 08/23/06
Monitoring Visit Agenda Word, 64 KB 08/23/06
On-Site Program Review Word, 81 KB 08/23/06
Monitoring Process Evaluation Word, 32 KB 08/23/06
Monitoring Visit Exit Conference Word, 62 KB 08/23/06
Quality Improvement Recommendations Excel, 22 KB 08/23/06

F. Resources/Links

Links to pertinent grants monitoring information, including policy and statutes.

G. Training

Grants monitoring training information.

Recent Program Monitoring Training Format, Size (if DPH file) Last Modified* (if DPH file)
Allocation of Shared Costs and Allocation Plan Development PDF, 393 KB 08/25/16
The DOs and DON'Ts of Financial Review PDF, 1.75 MB 08/25/16
Introduction to Monitoring PPT; 1 MB 06/30/16
Introduction to Monitoring Webinar N/A 06/30/16
Office of Management and Budget Omni-Circular Summary of Changes PDF, 1.1 MB 08/25/16

1. Review of NC CARES Provider Compliance Review; 2. DHHS Office of Internal Audit (OIA) Fiscal Monitoring Training (starts at 50:10)

N/A 11/28/17
Draft DPH Subrecipient Monitoring (SRM) Plan
Note, 10/10/16: If you are looking for the final version of the SRM Plan, it is available above, under "C. DPH Subrecipient Monitoring Plan".
Review of Draft SRM Plan and Related Assessment Documents Webinar 09/16/16
SRM Plan Revision Approach and Summary PDF, 110 KB 09/16/16
Draft SRM Plan DOC, 76 KB 09/16/16
Internal Control Questionnaire Form 1 DOC, 72 KB 09/16/16
Internal Control Questionnaire Form 2 DOC, 110 KB 09/16/16
Risk Assessment DOC, 60 KB 09/16/16
Financial Checklist DOC, 41 KB 09/16/16
Tracking and Reporting Format, Size (if DPH file) Last Modified* (if DPH file)
Monitoring Tracking Spreadsheet Webinar MP4* 03/15/16
Monitoring Tracking Spreadsheet Q and A Webinar MP4* 03/15/16
Document Format, Size (if DPH file) Last Modified* (if DPH file)
Public Health Monitoring Summit PowerPoint, 473 KB 10/24/08
Summary of Meeting with Monitors and Administrative Consultants Format, Size (if DPH file) Last Modified* (if DPH file)
LTAT Nurse/Admin Consultants Map PDF, 39 KB 03/08/18
Meeting Summary Word, 38 KB 12/18/08
Monitoring Schedule and Tools PDF, 290 KB 12/18/08
Internal Fiscal Monitoring Training Format, Size (if DPH file) Last Modified* (if DPH file)
Internal Fiscal Monitoring Training Summary Word, 29 KB 03/11/09
Fiscal Monitoring Presentation PPT, 4.66 MB 03/11/09
ACU Subrecipient Monitoring Plan Site Visit Checklist Word, 27 KB 03/11/09
Site Visit Verification Checklist Word, 26 KB 03/11/09
Procedure for AIDS Care Unit Subrecipient Monitoring Review Word, 46 KB 03/11/09
Financial Programmatic Checklist Word, 67 KB 03/11/09
Communicable Disease Branch Site Visit Report (Format) Word, 26 KB 03/11/09
Site Visit Worksheet Word, 98 KB 03/11/09

*If you do not have a media player for MP4 files, VLC media player is a free and open source multimedia player we recommend if you can download and install software on your machine.


Document Format, Size (if DPH file) Last Modified* (if DPH file)
Procurement Card Manual PDF, 118 KB 09/26/16
Purchasing Program PDF, 310 KB 12/19/17

 Records Management

A. Overview

In December 2017 DHHS adopted a Functional Records Schedule. This replaces all Division and program-level records retention schedules, as well as the statewide General Schedule. The Functional Schedule is designed to simplify records retention by designating large categories of records based upon their functions rather than types of records based upon particular office processes and filing systems. According to G.S. 121-5 and G.S. 132-3, we may only destroy public records with the consent of the Department of Natural and Cultural Resources. The Functional Records Schedule provides this consent.

In addition to the Functional Schedule, records related to grant funded processes must be retained according to the DHHS Controller’s Office Retention Schedule. This includes Medicaid funded processes.

B. Retention and Disposition Schedules

C. Training Presentations

D. Forms

Document Format, Size (if DPH file) Notes
Records Management Documents from the NC Department of Natural and Cultural Resources N/A Forms and templates from NCDNCR
Records Retrieval Form PDF Use to request records stored at the State Records Center or other storage facilities.

E. Resources

 Risk Management

Document Format, Size (if DPH file) Last Modified* (if DPH file)
Medicaid False Claims Act Policy and Procedure DOC, 82 KB 05/20/14
Public Health Code of Ethics PDF, 36 KB 04/09/18
Risk Management Program PDF, 73 KB 08/01/17


Document Format, Size (if DPH file) Last Modified* (if DPH file)
Cleaning Permanently Assigned Motor Fleet Vehicles PDF, 25 KB 04/12/11
DHHS Enterprise Reservation Booking Guide PDF, 307 KB 03/08/16
DHHS Travel Policies and Regulations (requires Intranet login) N/A N/A
Enterprise Reservation Directory (NC) XLS, 98 KB 03/08/16
Travel Procedures PDF, 53 KB 08/12/14
Use of Motor Fleet Management (MFM), Rental or Personal Vehicles PDF, 42 KB 01/04/13











Updated: November 28, 2018