Orange County NC Website
Browse       Search
DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 t A- continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Prooram/Proiect Description,(Label your responses as outlined below; not to exceed 3 pages.) <br /> Please provide the following information about the proposed program/project: <br /> See attached <br /> b) Summarize the program services proposed and how the program will address the chosen <br /> Town/County priority? <br /> c) Describe the local need or problem to be addressed in relation to the Consolidated Plan or <br /> other community priorities (i.e. Council/Board Goals). Cite local data to support the need <br /> for this program and the population being served. <br /> d) Describe the population to be served or the area to benefit and indicate how you will <br /> identify beneficiaries. <br /> e) Who specifically will carry out the activities and in what location will they be carried out? <br /> f) Describe specifically the period over which the activities will be carried out, the frequency <br /> with which the activities will be carried out, and the frequency with which services will be <br /> delivered. Include an implementation timeline. <br /> g) Provide a bulleted list of other agencies, if any, with which your agency <br /> coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) <br /> to be funded. For each, give specific examples of the coordinated/collaborative efforts. <br /> h) Describe what would happen if requested funding is not awarded at all or if a reduced <br /> allocation is recommended. <br /> i) Include any other pertinent information. <br /> Program/Project Information <br /> j) Complete the Target Population and Program Beneficiary Demographics Chart <br /> k) Complete the Schedule of Positions Chart for Program Staff <br /> I) Disclosure of Potential Conflicts of Interested must be signed <br /> m) Complete the Work Statement Chart to describe the work to be performed, and be sure to <br /> attach copies of all data collection tools that will be used to verify achievement of program <br /> goals and objectives. Describe who will be responsible for monitoring progress. <br /> Information to Complete <br /> j.) Target Population <br /> Complete the following tables to the best of your ability. Show numbers of participants and <br /> percentages, as applicable, in each category. <br /> Please indicate whether this project/program will serve: ri Persons E Households LI Units <br /> Program: <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender <br /> Male 50 60 65 <br /> Female 63 96 103 <br /> Total 113 156 168 <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) <br /> Main Application 1/25/2016 11:36:35 AM Page 6 of 16 <br />