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1/30/24, 5 00 PM HSOA 24 57 <br />https //chapelhillnc workflow opengov com/#/explore/records/63447/react form details/63447 11/13 <br />What methods/tools will your organization use to evaluate the proposed program’s effectiveness? Please <br />include specific examples, such as a logic model. <br />Please briefly describe how your proposed programs aligns with evidence-based approaches to addressing <br />human service need(s). <br />Please describe one to three key partnerships/collaborations that add the most value to the success of the <br />proposed programs. <br />If you are not awarded a Community Impact Award, what would your agency’s funding request be? <br />Applicant Statement <br />Disclosure of Conflicts of Interest <br />Are any board members or agency employees, <br />including their immediate relatives and business <br />associates, current beneficiaries of the proposed <br />program for which funds are being requested? <br />No <br />Are any board members or agency employees, <br />including their immediate relatives and business <br />associates, members of or related to members of <br />the governing bodies of Chapel Hill, Carrboro, or <br />Orange County? <br />No <br />Are any board members or agency employees, <br />including their immediate relatives and business <br />associates, paid providers of goods or services to or <br />have other financial interest in the proposed <br />program? <br />Yes <br />Are any board members or employees,including <br />their immediate relatives and business associates, <br />related to employees of that Town of Chapel Hill, <br />Town of Carrboro, or Orange County? <br />No <br />Docusign Envelope ID: 3F291284-28EA-4C38-99B9-60DFE2A69BE8