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II. FRINGE <br />Position Title <br />Name * <br />Type and Rate <br />Amount <br />Paid by <br />Local <br />Agency <br />Amount <br />Paid by the <br />State <br />Contract <br />1. Nurse 1 <br />Name <br />❑ Retirement Rate: 10.51% <br />Cost per Total Cost <br />night <br />Number of <br />ni hts <br />In-state Lodging <br />❑ FICA Rate: 7.65% <br /># of dinners Total Cost (State rate) <br />❑Medical Rate/Amount: $ <br />State funded Meals, Instate <br />❑ Other: Rate: <br />Conference Registration <br />2. Nurse 2 <br />Name <br />❑ Retirement Rate: % <br />❑ FICA Rate: % <br />❑ Medical Rate/Amount: $ <br />❑ Other: Rate: <br />3. Nurse 3 <br />Name <br />❑ Retirement Rate: % <br />❑ FICA Rate: <br />❑ Medical Rate/Amount: $ <br />❑ Other: Rate: <br />TOTAL FRINGE PAID BY CONTRACT 1 $ <br />00012 <br />*Fringe benefit amounts may change due to longevity, etc. that the employee may be eligible for during the <br />school year. <br />Justification: Funds will be used to employ nationally certified school nurse(s) or registered nurse(s) working toward <br />national certification to work full time in schools and enhance the local school district's capacity to provide basic health services <br />to students. <br />111. Other <br />STAFF TRAVEL <br />In -State <br />Total miles <br />Cost per Total Cost <br />mile <br />In-state Mileage <br />Cost per Total Cost <br />night <br />Number of <br />ni hts <br />In-state Lodging <br /># of dinners Total Cost (State rate) <br /># of breakfasts # of lunches <br />State funded Meals, Instate <br />Conference Registration <br />0.00 <br />TRAINING PAID BY CONTRACT (If no funds available after covering salary and 0.00 <br />fringe for these positions, leave at 0.00. If funds available, amount is limited to a total <br />of $750 per position. See Scope of Work for Allowable Costs <br />CONTRACT TOTAL AMOUNT I $ <br />5 <br />