Describe your agency’s purpose, philosophy, goals, and objectives. Provide a description of the implementation plan for the completion of the DFD program. Will any of these services be provided by agency staff or consultants? If consultants, please provide information about the consultant’s experience? Describe the performance goals for the DFD program. How does the mission of DFD program align with your agency mission? How does the DFD program benefit/impact the community? Identify and describe any unique capabilities of your agency in delivering the service. Describe the agency’s outreach efforts and communication efforts for the DFD program. Identify past year program goals and summarize performance outcomes. Provide a summary of select agency accomplishments. Identify any changes, challenges, limitations, restrictions, and priorities on service delivery. If this is a renewal contract, describe at a minimum how has your program developed and made progress toward its goals in the past year? What barriers, if any, have impacted your agency’s ability to meet program goals? How are services evaluated? What are the results? Identify strengths and weaknesses noted in evaluations. If fees will be collected from recipients of any services outlined in the Contract Requirements, state the anticipated annual amount of revenue. Also state how those revenues will be used to offset the contract’s costs.
Contract Number: Program Name: PERFORMANCE OUTCOMES GOALS OBJECTIVES ACTIVITIES PERFORMANCE OUTCOMES 1. 1. 1. 2. 3. 4. 5. 2. 1. 2. 2. 3. 4. 5. 3. 1. 3. 2. 2 . 3 2
Contract Number: STATE OF JERSEY - DIVISION OF FAMILY DEVELOPMENT Annex A PROGRAM PERSONNEL INFORMATION - Section 2.4 Program Name: POSITION NAME/TITLE NAME OF EMPLOYEE DAILY HOURS % OF TIME TO (DEGREES, LICENSES, FUNCTIONAL DUTIES FROM TO FT PT % FT PT % FT PT % FT PT % FT PT % FT PT % FT PT % FT PT % FT PT %
NAME OF AGENCY: CONTRACT PERIOD: INDEX OF REQUIRED CONTRACT DOCUMENTS This index provides details of all required documents that must either be included with the contract package (see checklist) or must be available on site for inspections as noted in the Document Verification Sheet (DVS). Forms that are not included in the following pages, can be found by accessing the website at and clicking on the link for Standard Contract Documents. Document Required with first Contract and as Amended Required Annually and as Amended Checklist Required for on-site - DVS Form Check if submitted with package Contract Documents Standard Language Document (SLD) with original signatures (additional copies requested must also have original signature) 2 copies Annex A (including summary sheet and supporting schedules) 3 copies Annex B – Budget Form with all required forms, schedules, and signatures 3 copies Executive Order 129 (Public Law 2005, Chapter 92) Source Disclosure Certification Form ● Federal Funding Accountability and Transparency Act (FFATA) Worksheet (if applicable) ● Certification of Suspension and Debarment ● Agreements Copies of Subcontract/Consultant Agreement(s) ● Private/Public Donor Agreement (s) for Match Responsibilities ● HIPAA Business Associate Agreement (BAA) ● ● A copy of the Acknowledgement of Receipt of the New Jersey State Policy and Procedures for EEO/AA ● Insurances/Licenses/Certificates Liability Insurance Declaration Page and/or Malpractice Insurance ● Bonding Certificate ● Applicable Licenses (business and professional licenses) ● Current Affirmative Action Certificate or copy of renewal application sent to Treasury (AA302 – Affirmative Action Employee Information Report) ● Health/Fire Certificates ● Certificate of Occupancy or Continued Certificate of Occupancy ● Page Document Required with first Contract and as amended Required Annually and as Amended Checklist Required for on-site – DVS Form Check if submitted with package
STATE OF NEW JERSEY DIVISION OF FAMILY DEVELOPMENT List of Contracts/Grants Check here if this information already appears on the Annex B, Contract Information Form. If so, do not duplicate information here. Contracting Division/Office Program Name Type of Service Contract Number Contract Term Amount Division/Office Contact Person and Phone Number Provider Agency Contact Person and Phone Number