If agency is a non-profit corporation with fewer than five board members, explain the rationale for the number of board members, and indicate what, if any, compensatory controls are in place to mitigate self-dealing and other potential abuses by the Board. Board Committees/ Advisory Committees Committee Name Committee Purpose The Board of Directors’ 2014 meetings for the agency will be held on the following dates: January May September February June October July November April August December Contractor agrees to retain Board of Directors’ meeting minutes for a period of at least four (4) years following contract termination and agrees to provide Milwaukee DHHS access to the meeting minutes upon request. Authorized Signature: _______________________ Date: _________________ Printed Name: ____________________________________Title: __________________________ Agency: _________________________________________________________ YEAR 2014 AGENCY OWNERS/STOCKHOLDERS/OFFICERS ITEM # 7 (applicable to all organizations) Please list each agency owner, stockholder, officer, LLC manager, Partner, and/or LLC member, and indicate the office title and total compensation. For Non-profits this will include names of officers appointed by the Board (such as COO or CEO). In addition, for For-profit organizations also provide the percentage of ownership interest, amount of prior year’s distributions or dividends from the agency
PROGRAM LOGIC MODEL and ANNUAL EVALUATION REPORT (Sample) ITEM # 29a A B C C1 D E F G H Inputs Processes/Program Activities Outputs For evaluation report Expected Outcomes Indicators Projected level of achievement For evaluation report Actual level of achievement Actual of achievement Description of changes example Staff Clients sites (list major ones) living curriculum (vans) Staff establish sites for community activities. Staff and clients identify community interests. Staff arrange/coordinate transportation to/from community activities. Staff facilitate community activities. Staff conduct pre and post activity workshops to teach and support clients’ involvement in community life 32 clients will participate in 500 community living Outcome 1:Clientsincrease awareness of community resources. Number and percent of clients who demonstrate an increase in awareness of community resources, as measured by pre and post test scores 24 (75%) of clients will achieve the outcome Outcome 2: Clients increase utilization of public and private services in their community. Number and percent of clients who demonstrate an increase in utilization of public and private services in their community 24 (75%) of clients will achieve the outcome Outcome 3: Clients generalize acquired skills to other home and community living situations Number and percent of clients who generalize acquired skills to other home and community living situations 24 (75%) of clients will achieve the outcome
29a and b partially comprise the points scored under Service Plan and Delivery PROGRAM LOGIC ANNUAL EVALUATION REPORT ITEM # 29a A B C C1 D E F G H Inputs Processes/Program Activities Outputs For evaluation report Expected Outcomes Indicators Projected level of achievement For evaluation report Actual level of achievement Actual of achievement Description of changes