Daily Rules, Proposed Rules, and Notices of the Federal Government


Indian Health Service

Office of Urban Indian Health Programs; Title V HIV/AIDS Competing Continuation Grants

Announcement Type:Title V HIV/AIDS Competing Continuation Grants.

Funding Opportunity Number:HHS-2010-IHS-UIHP-0001.

Catalog of Federal Domestic Assistance Number:93.193.

Key Dates:

Application Deadline Date:March 1, 2010.

Review Date:April 1, 2010.

Earliest Anticipated Start Date:July 1, 2010.

I. Funding Opportunity DescriptionStatuary Authority

The Indian Health Service (IHS), Office of Urban Indian Health Programs (OUIHP) announces competing continuations for the 4-in-1 Title V grants responding to an Office of HIV/AIDS Policy (OHAP), Minority AIDS (Acquired Immunodeficiency Syndrome) Initiative (MAI). This program is authorized under the authority of the Snyder Act, Public Law 67-85 and 25 U.S.C. 1652, 1653 of the Indian Health Care Improvement Act, Public Law 94-437, as amended. This program is described at 93.193 in the Catalog of Federal Domestic Assistance (CFDA).


This competitive continuation seeks to expand OUIHP's existing Title V grants to increase the number of American Indian/Alaska Natives (AI/AN) with awareness of his/her HIV status. This will provide routine and/or rapid HIV screening, prevention, and pre- and post-test counseling (when appropriate). Enhancement of urban Indian health program HIV/AIDS activities is necessary to reduce the incidence of HIV/AIDS in the urban Indian health communities by increasing access to HIV related services, reducing stigma, and making testing routine.


These competing continuation grants will be used to enhance HIV testing, including rapid testing and/or standard HIV antibody testing and to provide a more focused effort to address HIV/AIDS prevention, targeting some of the largest urban Indian populations in the United States. The grantees will attempt to provide routine HIV screening foradults as per 2006 Centers for Disease Control and Prevention (CDC) guidelines and pre- and post-test counseling (when appropriate). These grants will be used to identify best practices to enhance HIV testing, including rapid testing and/or conventional HIV antibody testing, and to provide a more focused effort to address HIV/AIDS prevention in AI/AN populations in the United States.

The nature of these projects will require collaboration with the OUIHP to: (1) Coordinate activities with the IHS National HIV Program; (2) participate in projects in other operating divisions of the Department of Health and Human Services (HHS) such as the CDC, Substance Abuse and Mental Health Services Administration, Health Resource and Services Administration and the Office of HIV/AIDS Policy; and (3) submit and share anonymous, non-identifiable data on HIV/AIDS testing, treatment, and education.

These grants are also intended to encourage development of sustainable, routine HIV screening programs in urban facilities that are aligned with 2006 CDC HIV Screening guidelines ( Key features include streamlined consent and counseling procedures (verbal consent, opt-out), a clear HIV screening policy, identifying and implementing any necessary staff training, community awareness, and a clear followup protocol for HIV positive results including linkages to care. Grantees may choose to bundle HIV tests with sexually transmitted disease (STD) screening.

II. Award Information

Type of Award:Title V Competitive Continuation Grants.

Estimated Funds Available:The total amount identified for Fiscal Year (FY) 2010 is five awards totaling $75,000. Individual awards must include one project evaluation and provide administrative support of the project. All future awards under this announcement are subject to the availability of funds. Hence, the agency has no obligation to award additional funding beyond the first year.

Anticipated Number of Awards:Five grant awards will be made under the program.

Project Period:July 1, 2010-June 30, 2012.

Award Amount: $75,000.

A. Requirements of Recipient Activities

In FY 2010, each grantee's attempted goal shall include screening as many individuals as possible; however, each funded program'sattemptedgoal will be to increase screening to a minimum of 300 AI/AN tested per program funded, for a total of 1,500 AI/AN tested. This reflects an MAI requirement to maintain the actual cost per MAI fund HIV testing client below the medical care inflation rate. This does not include counts of re-testing individuals in the same year. Each program shall also collect evidence, as part of the testing process, to document lessons learned, best practices, and barriers to increased routine HIV screening within this population.

III. Eligibility Information1. Eligibility

This funding announcement is limited to Urban Indian organizations, as defined by 25 U.S.C. 1603(h), and is limited to urban Indian organizations which meet the following criteria:

* Received State certification to conduct HIV rapid testing (where needed);

* Health professionals and staff have been trained in the HIV/AIDS screening tools, education, prevention, counseling, and other interventions for AI/ANs;

* Developed programs to address community and group support to sustain risk-reduction skills;

* Implemented HIV/AIDS quality assurance and improvement programs; and

* Must provide proof of non-profit status with the application.

Urban Indian organization means a non-profit corporate body of any Indian tribe or any legally established organization of Indians which is controlled by one or more such bodies or by a board of directors elected or selected by one or more such bodies (or elected by the Indian population to be served by such organization) and which includes the maximum participation of Indians in all phases of its activities. 25 U.S.C. 1603(h).

2. Cost Sharing or Matching

The OUIHP does not require matching funds or cost sharing.

3. Other Requirements

If application budget exceeds the stated dollar amount that is outlined within this announcement, it will not be considered for funding.

IV. Application and Submission Information1. Obtaining Application Materials

Applicant package may be found on ( or at:

2. Content and Form Application Submission

The applicant must include the project narrative as an attachment to the application package.

Mandatory documents for all applicants include:

* Application forms:

* SF-424.

* SF-424A.

* SF-424B.

* Budget Narrative (must be single spaced).

* Project Narrative (must not exceed 10 pages).

* Tribal Resolution or Tribal Letter of Support (Tribal Organizations only).

* Letter of Support from organization's Board of Directors (Title V Urban Indian Health Programs only).

* 501(c) (3) Certificate (Title V Urban Indian Health Programs only).

* Biographical sketches for all key personnel.

* Disclosure of Lobbying Activities (SF-LLL) (if applicable).

* Documentation of current OMB A-133 required Financial Audit, if applicable. Acceptable forms of documentation include:

* E-mail confirmation from Federal Audit Clearinghouse (FAC) that audits were submitted; or

* Face sheets from audit reports. These can be found on the FAC Web site:

Public Policy Requirements:

All Federal-wide public policies apply to IHS grants with exception of the Discrimination policy.

Requirements for Project and Budget Narratives:

A.Project Narrative:This narrative should be a separate Word document that is no longer than 10 pages (see page limitations for each Part noted below) with consecutively numbered pages. Be sure to place all responses and required information in the correct section or they will not be considered or scored. If the narrative exceeds the page limit, only the first 10 pages will be reviewed. There are three parts to the narrative: Part A--Program Information; Part B--Program Planning and Evaluation; and Part C--Program Report. See below for additional details about what must be included in the narrative.

Part A:Program Information (page limitation)

Section 1: Needs

Part B:Program Planning and Evaluation (page limitation)

Section 1: Program Plans

Section 2: Program Evaluation

Part C:Program Report (page limitation)

Section 1: Describe major Accomplishments over the last 24 months.

Section 2: Describe major Activities over the last 24 months.

B.Budget Narrative:This narrative must describe the budget requested and match the scope of work described in the project narrative. The page limitation should not exceed three pages.

3. Submission Dates and Times

The application from each urban Indian organization must be submitted electronically through by 12 midnight Eastern Standard Time (EST) on March 1, 2010. Any application received after the application deadline will not be accepted for processing, and it will be returned to the applicant(s) without further consideration for funding.

If technical challenges arise and assistance is required with the electronic application process, contact Customer Support via e-mail tosupport@grants.govor at (800) 518-4726. Customer Support is available to address questions 24 hours a day, 7 days a week (except on Federal holidays). If problems persist, contact Tammy Bagley, Division of Grants Policy (DGP) ( at (301) 443-5204. Please be sure to contact Ms. Bagley at least ten days prior to the application deadline. Please do not contact the DGP until you have received a tracking number. In the event you are not able to obtain a tracking number, call the DGP as soon as possible.

If an applicant needs to submit a paper application instead of submitting electronically via, prior approval must be requested and obtained (seepage 16 for additional information). The waiver must be documented in writing (e-mails are acceptable)beforesubmitting a paper application. A copy of the written approval must be submitted along with the hardcopy that is mailed to the DGO (Refer to Section IV to obtain the mailing address). Paper applications that are submitted without a waiver will be returned to the applicant without review or further consideration. Late applications will not be accepted for processing, will be returned to the applicant and will not be considered for funding.

4. Intergovernmental Review

Executive Order 12372 requiring intergovernmental review is not applicable to this program.

5. Funding Restrictions

* Pre-award costs are allowable pending prior approval from the awarding agency. However, in accordance with 45 CFR part 74, all pre-award costs are incurred at the recipient's risk. The awarding office is under no obligation to reimburse such costs if for any reason any of the urban Indian organizations do not receive an award or if the award to the recipient is less than anticipated.

* The available funds are inclusive of direct and appropriate indirect costs.

* Only one competing continuation award will be issued to each organization.

* IHS will not acknowledge receipt of the application.

6. Electronic Submission Requirements

Use thehttp://www.Grants.govWeb site to submit an application electronically and select the "Apply for Grants" link on the homepage. Download a copy of the application package, complete it offline, and then upload and submit the application via the Web site. Electronic copies of the application may not be submitted as attachments to e-mail messages addressed to IHS employees or offices.

Applicants that receive a waiver to submit paper application documents must follow the rules and timelines that are noted below. The applicant must seek assistance at least ten days prior to the application deadline.

Applicants that do not adhere to the timelines for Central Contractor Registry (CCR) and/or registration and/or request timely assistance with technical issues will not be considered for a waiver to submit a paper application.

Please be aware of the following:

* Please search for the application package in by entering the CFDA number or the Funding Opportunity Number. Both numbers are located in the header of this announcement.

* Paper applications are not the preferred method for submitting applications. However, if you experience technical challenges while submitting your application electronically, please contact Support directly at: (800) 518-4726. Customer Support is available to address questions 24 hours a day, 7 days a week (except on Federal holidays).

* Upon contacting, obtain a tracking number as proof of contact. The tracking number is helpful if there are technical issues that cannot be resolved and a waiver from the agency must be obtained.

* If it is determined that a waiver is needed, you must submit a request in writing (e-mails are acceptable) toGrantsPolicy@ihs.govwith a copy include a clear justification for the need to deviate from the standard electronic submission process.

* If the waiver is approved, the application should be sent directly to the DGO by the deadline date of March 1, 2010.

* Applicants are strongly encouraged not to wait until the deadline date to begin the application process through as the registration process for CCR and could take up to fifteen working days.

* Please use the optional attachment feature in to attach additional documentation that may be requested by the DGO.

* All applicants must comply with any page limitation requirements described in this Funding Announcement.

* After electronically submitting the application, applicants will receive an automatic acknowledgment from that contains a tracking number. The DGO will download the application from and provide necessary copies to the appropriate agency officials. Neither the DGO nor the OUIHP will notify applicants that the application has been received.

E-mail applications will not be accepted under this announcement.

Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS)

Applicants are required to have a DUNS number to apply for a grant or cooperative agreement from the Federal Government. The DUNS number is a unique nine-digit identification number provided by D&B, which uniquely identifies an entity. The DUNS number is site specific; therefore each distinct performance site may be assigned a DUNS number. Obtaining a DUNS number is easy and there is no charge. To obtain a DUNS number, access is through the following Web site to expedite the process call (866) 705-5711.

Another important fact is that applicants must also be registered with the CCR and a DUNS number is required before an applicant can complete their CCR registration. Registration with the CCR is free of charge. Applicants may register online at information regarding the DUNS, CCR,and processes can be found at:

Applicants may register by calling 1 (866) 606-8220. Please review and complete the CCR Registration worksheet located at

V. Application Review Information

Points will be assigned to each evaluation criteria adding up to a total of 100 points.

1. Evaluation Criteria

The instructions for preparing the application narrative also constitute the evaluation criteria for reviewing and scoring the application. Weights assigned to each section are noted in parentheses. The narrative should include all prior years of activity; information for multi-year projects should be included as an appendix (seeE. "Categorical Budget and Budget Justification" at the end of this section for more information). The narrative should be written in a manner that is clear to outside reviewers unfamiliar with prior related activities of the urban Indian organization. It should be well organized, succinct, and contain all information necessary for reviewers to understand the project fully.

A. Understanding of the Need and Necessary Capacity (15 Points)1. Understanding of the Problem

a. Define the project target population, identify their unique characteristics, and describe the impact of HIV on the population.

b. Describe the gaps/barriers in HIV testing for the population.

c. Describe the unique cultural or sociological barriers of the target population to adequate access for the described services.

2. Facility Capability

a. Briefly describe your clinic programs and services and how this initiative will assist to commence, compliment and/or expand existing efforts.

b. Describe your clinic's ability to conduct this initiative through:

* Your clinic's present resources.

* Collaboration with other providers.

* Partnerships established to accept referrals for counseling, testing, and referral and confirmatory blood tests and/or social services for individuals who test HIV positive.

* Linkages to treatment and care: partnerships established to refer out of your clinic for specialized treatment, care, confirmatory testing (if applicable) and counseling services.

B. Work Plan (40 Points)1. Project Goal and Objectives

Address all of the following program goals and objectives of the project. The objectives must be specific as well as quantitatively and qualitatively measurable to ensure achievement of goal(s).

* Implementation Plan

a. Identify the proposed program activities and explain how these activities will increase and sustain HIV screening.

b. Describe policy and procedure changes anticipated for implementation that include:

(1) Support of the 2006 CDC Revised HIV Testing Recommendations.

(2) Community awareness.

(3) Age ranges of persons to be screened.

(4) Bundling of HIV testing with STD tests.

(5) Type of HIV Screen/Test (Rapid, Conventional, Western Blot) and who will perform test (in-house, send-out).

c. Provide a clear timeline with quarterly milestones for project implementation.

d. Certify that the program identified and agreed to follow the state regulations for HIV testing in their state and how the clinic will follow their state reporting guidelines for seropositive results.

e. Describe how individuals will be selected for testing to identify selection criteria and which group(s)--if any--will you be able, via state regulations, to offer testing in an opt-out format.

f. Describe how the program will ensure that clients receive their test results, particularly clients who test positive.

g. Describe how the program will ensure that individuals with initial HIV-positive test results will receive confirmatory tests. If you do not provide confirmatory HIV testing, you must provide a letter of intent or Memorandum of Understanding with an external laboratory documenting the process through which initial HIV-positive test results will be confirmed.

h. Describe the program strategies to linking potential seropositive patients to care.

i. Describe the program quality assurance strategies.

j. Describe how the program will train, support and retain staff providing counseling and testing.

k. Describe how the program will ensure client confidentiality.

l. Describe how the program will ensure that its services are culturally fluent and relevant.

m. Describe how the program will attempt to streamline procedures so as to reduce the overall cost per test administered.

C. Project Evaluation (20 Points)1. Evaluation Plan

The grantee shall provide a plan for monitoring and evaluating the HIV rapid test and/or standard HIV antibody test.

2. Reporting Requirements

The following quantitative and qualitative measures shall be addressed:

* Required Quantitative Indicators (Quantitative)

a. Number of tests performed and number of test refusals.

b. Number of clients learning of their serostatus for the first time via this testing initiative (unique patients, non-repeated tests).

c. Number of reactive tests and confirmed seropositive (actual and proportion).

d. Number of clients linked to care/treatment or referrals for prevention counseling.

e. Number of individuals receiving their confirmatory test results.

* Required Qualitative Information

a. Measures in place to protect confidentiality.

b. Identify barriers of implementation as well as lessons learned for best practices to share with other IHS/Urban or Tribal entities.

c. Sustainability plan and measures of ongoing testing in future years, after grant money has been spent.

* Other quantitative indicators may be collected to improve clinic processes and add to information reported; however, they are not required.

a. Number of clients who refused due to prior knowledge of status.

b. Number of rapid versus standard antibody test.

c. Number of false negatives and/or positives after confirmatory testing.

* Develop a plan for obtaining knowledge, attitudes, and behavior data pending official approval of patient survey.

D. Organizational Capabilities and Qualifications (10 Points)

This section outlines the broader capacity of the organization to complete the project outlined in the work plan. It includes the identification of personnel responsible for completing tasks and the chain of responsibility for successful completion of the project outlined in the work plan.

1. Describe the organizational structure.

2. Describe the ability of the organization to manage the proposed project. Include information regarding similarly sized projects in scope and financial assistance as well as other grants and projects successfully completed.

3. Describe what equipment (i.e.,phone, Web sites,etc.) and facility space (i.e.,office space) will be available for use during the proposed project. Include information about any equipment not currently available that will be purchased throughout the agreement.

4. List key personnel who will work on the project.

* Identify existing personnel and new program staff to be hired.

* In the appendix, include position descriptions and resumes for all key personnel. Position descriptions should clearly describe each position and duties indicating desired qualifications, experience, and requirements related to the proposed project and how they will be supervised. Resumes must indicate that the proposed staff member is qualified to carry out the proposed project activities and who will determine if the work of a contractor is acceptable.

* Note who will be writing the progress reports.

* If a position is to be filled, indicate that information on the proposed position description.

* If the project requires additional personnel beyond those covered by the supplemental grant (i.e.,Information Technology support, volunteers, interviewers,etc.), note these and address how these positions will be filled and, if funds are required, the source of these funds.

* If personnel are to be only partially funded by this supplemental grant, indicate the percentage of time to be allocated to this project and identify the resources used to fund the remainder of the individual's salary.

E. Categorical Budget and Budget Justification (15 Points)

This section should provide a clear estimate of the project program costs and justification for expenses for the entire grant period. The budget and budget justification should be consistent with the tasks identified in the work plan. The budget focus should be on routinizing and sustaining HIV testing services as well as reducing the cost per person tested.

1. Categorical budget (Form SF 424A, Budget Information Non-Construction Programs) completing each of the budget periods requested.

2. Narrative justification for all costs, explaining why each line item is necessary or relevant to the proposed project. Include sufficient details to facilitate the determination of cost allowability.

3. Budget justification should include a brief program narrative for the second and third years.

4. If indirect costs are claimed, indicate and apply the current negotiated rate to the budget. Include a copy of the rate agreement in the appendix.

2. Review and Selection Process

Each application will be prescreened by the DGO staff for eligibility and completeness as outlined in the funding announcement. Incomplete applications and applications that are non-responsive to the eligibility criteria will not be referred to the Objective Review Committee. Applicants will be notified by DGO, via letter, to outline the missing components of the application.

To obtain a minimum score for funding, applicants must address all program requirements and provide all required documentation. Applicants that receive less than a minimum score will be informed via e-mail of their application's deficiencies. A summary statement outlining the strengths and weaknesses of the application will be provided to these applicants. The summary statement will be sent to the Authorized Organizational Representative that is identified on the face page of the application.

In addition to the above criteria/requirements, the application will be considered according to the following:

A.The submission deadline:March 1, 2010. The application submitted in advance of or by the deadline and verified by the postmark will undergo a preliminary review to determine that:

* The applicant is eligible in accordance with this grant announcement.

* The application is not a duplication of a previously funded project.

* The application narrative, forms, and materials submitted meet the requirements of the announcement allowing the review panel to undertake an in-depth evaluation; otherwise, it may be returned.

B. The Competitive Continuation Review date is April 1, 2010. Competitive Continuation applications that are complete, responsive, and conform to this program announcement will be reviewed for merit. Prior to review, the application will be screened by the DGO to determine eligibility. Programs proposed should be those in which the IHS has the authority to provide either directly or through funding agreements. These programs should be designed for the benefit of IHS beneficiaries. If an urban Indian organization does not meet these requirements, the application will not be reviewed. The application will be evaluated and rated on the basis of the evaluation criteria listed in Section V. 1. The criteria are used to evaluate the quality of a proposed project and determine the likelihood of success.

C. Anticipated Announcement and Award Dates

Anticipated announcement date is June 1, 2010 with an Award Date of July 1, 2010.

VI. Award Administration Information1. Award Notices

The Notice of Award (NoA) will be initiated by the DGO and will be mailed via postal mail to the urban Indian organization. The NoA will be signed by the Grants Management Officer, and this is the authorizing document under which funds are dispersed to the approved entities. The NoA will serve as the official notification of the grant award and will reflect the amount of Federal funds awarded for the purpose of the grant, the terms and conditions of the award, the effective date of the award, and the budget/project period. The NoA is the legally binding document and is signed by an authorized grants official within the IHS.

2. Administrative Requirements

Grants are administered in accordance with the following regulations, policies and OMB cost principles:

A. The criteria as outlined in this Program Announcement.

B.Administrative Regulations for Grants:

* 45 CFR part 92, Uniform Administrative Requirements for Grants and Cooperative Agreements to State, Local and Tribal Governments.

* 45 CFR part 74, Uniform Administrative Requirements for Grants and Agreements with Institutions of Higher Education, Hospitals, and other Non-profit Organizations.

C.Grants Policy:

* HHS Grants Policy Statement, Revised 01/07.

D.Cost Principles:

*Title 2:Grant and Agreements, Part 225--Cost Principles for State, Local, and Indian Tribal Governments (OMB A-87). Title 2: Grant and Agreements, Part 230--Cost Principles for Non-Profit Organizations (OMB Circular A-122).

E.Audit Requirements:

* OMB Circular A-133, Audits of States, Local Governments, and Non-profit Organizations.

3. Indirect Costs

This section applies to all grant recipients that request reimbursement of indirect costs in their grant application. In accordance with HHS Grants Policy Statement, Part II-27, IHS requires applicants to obtain a current indirect cost rate agreement prior to award. The rate agreement must be prepared in accordance with the applicable cost principles and guidance as provided by the cognizant agency or office. A current rate covers the applicable grant activities under the current award's budget period. If the current rate is not on file with the DGO at the time of award, the indirect cost portion of the budget will be restricted. The restrictions remain in place until the current rate is provided to the DGO.

Generally, indirect costs rates for IHS grantees are negotiated with the Division of Cost Allocation the Department of Interior (National Business Center) your organization has questions regarding the indirect cost policy, please call (301) 443-5204 to request assistance.

4. Reporting Requirements

The reporting requirements for this program are noted below.

A. Progress Reports

Program progress reports on number of tests performed and milestones are required semi-annually by the OUIHP in order to satisfy quarterly reports due to funding source at MAI. These reports will include a brief comparison of actual accomplishments to the goals established for the period, or if applicable, provide sound justification for lack of progress, reasons for unmet milestones (if applicable), and other pertinent information as required.

B. A Final Assessment and Evaluation report must be submitted within 90 days of expiration of the budget/project period.

C. Semi-annual Financial Status Reports (FSR) must be submitted within 30 days after the six months period ends. Refer to the terms and conditions of the grant award for details on submission times. Final FSRs are due within 90 days after the end of the project period. Standard Form 269 (long form for those reporting on program income; short form for all others) will be used for financial reporting.

D. Participation in a minimum of two teleconferences. Teleconferences will be required semi-annually (unless further followup is needed) for technical assistance and information to be provided and progress to be shared among grantees with the OUIHP and National HIV Program Consultant.

E. Federal Cash Transaction Reports are due every calendar quarter to the Division Payment Management, Payment Management Branch. Failure to submit timely reports may cause a disruption in timely payments to the grantee.

Grantees are responsible and accountable for accurate reporting of the Progress Reports and Financial Status Reports which are generally due [semi-annually/annually]. Financial Status Reports (SF-269) are due 90 days after each budget period and the final SF-269 must be verified from the grantee records on how the value was derived.

Failure to submit required reports within the time allowed may result in suspension or termination of an active agreement, withholding of additional awards for the project, or other enforcement actions such as withholding of payments or converting to the reimbursement method of payment. Continued failure to submit required reports may result in one or both of the following: (1) The imposition of special award provisions; and (2) the non-funding or non-award of other eligible projects or activities. This requirement applies whether the delinquency is attributable to the failure of the grantee organization or the individual responsible for preparation of the reports.

Telecommunication for the hearing impaired is available at: TTY (301) 443-6394.

VII. Agency Contacts Grants (Business):Kimberly Pendleton, Grants Management Officer, 801 Thompson Avenue, TMP Suite 360, Rockville, MD 20852, (301) 443-5204 Program (Programmatic/Technical):Danielle Steward, Health Systems Specialist, Office of Urban Indian Health Programs, 801 Thompson Avenue, Suite 200, Rockville, MD 20852, (301) 443-4680

The Public Health Service (PHS) strongly encourages all grant and contract recipients to provide a smoke-free workplace and promote the non-use of all tobacco products. In addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some cases, any portion of the facility) in which regular or routine education, library, day care, health care or early childhood development services are provided to children. This is consistent with the HHS mission to protect and advance the physical and mental health of the American people.

Dated: February 2, 2010. Yvette Roubideaux, Director, Indian Health Service.