23). This may not be the same individual as noted in the Annex A summary sheet. In the event of emergency notification, please include e-mail and fax number. Contract Signatory Title Mailing Address Telephone Number - - Fax Number - - E-Mail Address
Explain your referral process with the CWA and other community resources and collaboration efforts. Accessing supportive social services is paramount due to the urgent need to obtain basic services. Provide details of your staffing composition – experience and language, percentage of time allocated under this contract, and projected staff to client ratio. Cultural and linguistically competent staff is essential due to the language and social barriers many of the populations face. Describe how your internal process and monitoring procedures ensure that refugees do not receive duplicated services if they are eligible for services under more than one grant. Describe how your agency plans to evaluate the program. Explain how your agency plans to collect data. Identify any strengths and weaknesses from prior evaluations. Explain the monitoring and quality assurance of the program including: Submit a copy of the Agency’s Quality Assurance and Monitoring Policies and Procedures. Provide information on refugee’s satisfaction survey for program services. How often is this survey done? If your agency does not have a customer survey, please describe your plan to implement one. Does the agency have a wait list for any services? If yes, how does the agency determine which refugees receive services and when? What systems are in place to ensure that accurate records are maintained for completing all required program and fiscal reports? How does your agency provide linguistically and culturally appropriate services to clients? Provide information on your program staff’s multi-lingual capacity (languages, cultural and translation services). How does your program ensure compliance with Title VI (LEP policy)? Are program forms, flyers and other written materials translated into client’s native language? Do clients sign forms indicating their understanding of the program requirements and services? How is this issue addressed with illiterate clients? Describe your agency’s English language and literacy services. What barriers or challenges do you anticipate in the implementation of the program goals, objectives, activities and achieving its outcomes? Identify any challenges, limitations, or restrictions on services and coordination. What will be your agency’s strategy for addressing the challenges? Describe how your agency will meet the objectives, goals, and deliverables of the contract as detailed in the scope of work. What systems are in place to ensure that accurate records are maintained for completing all required program and fiscal reports?
Executive Order 129 Source Disclosure 1 Certification of Suspension or Debarment 1 Standardized Board Resolution indicating who is authorized to sign: Contracts and Checks 1 Annex A (including summary sheet and supporting schedules) 3 Annex B –Budget Form (Expense Summary, Details and Schedules 1-6) 3 List of Contracts 1 Equipment Inventory 1 Liability Insurance 1 Bonding Certificate 1 Names, Titles, Addresses and Terms of Board of Directors 1 Copy of Audit Report 1 Current Affirmative Action Certificate or copy of renewal application sent to Treasury (AA302) 1 Chapter 51, Public Law 2005—For-Profit agencies only 1 Federal Funding Accountability and Transparency Act (FFATA) Worksheet (if applicable) 1 Copies of Subcontracts 1 Document Number of Copies to be submitted Notification of Licensed Public Accountant (NLPA) (include copy of Accountant’s Certification) 1 Private/Public Donor Agreement for Match Responsibilities 1 Organization Chart 1 W-9 Form (for new provider only) 1 Conflict of Interest Policy 1 1 As Applicable: ACH – Credit authorization for automatic deposits (for new requests only) 1 W-9 Form (for new providers) 1 Other: Purchase and Property Disclosure Form (Iran Form) 1