Attachment 8 – Checklist for ADAMH SFY 2017 Application Materials

Note: All applicants should attend a brief informational session regarding the funding guidelines and requirements for SFY 2017. These will be offered on Wednesday, November 30, 2016, at 9:30 a.m. and offered again on Friday, December 2, 2015 at 1:30 p.m. These will be held at the ADAMH Board office.

You should also read Attachment 6, “Programs and Services” and Attachment 7, “Preliminary Program Planning Budget.” If you are a new applicant, it is recommended that you call and meet with ADAMH staff before submitting an application.

Applications should be submitted electronically and one (1)hard copy should also be submitted. You should send the electronic copies to:

and hard copy should be given to:

Patricia Waits, Program Coordinator

Fairfield ADAMH Board

108 W. Main Street, Suite A

Lancaster, Ohio 43130

Applications are due no later than January 13, 2017. Late or incomplete applications will not be accepted.

Please complete the following sections of the Service Provider Contract Application:

Section I (begins on page 4):

_____ Completion of page with signatures of Executive Director/CEO and Agency Board President/Chair at the bottom of the page

Section II (begins on page 5):

_____ Description of mission and purpose of your organization

_____ Current Organizational chart

_____ Provide Special Areas of Expertise

_____ Financial Overview of organization including:

_____ Revenue Budget

_____ Expense Budget

_____ Operating Reserves

_____ Provide Management Information

_____ Provide Marketing and Outreach Information

_____ Provide Project Descriptions (describe need, define goals, specify objectives, outline program activities, identify people responsible for project success & who in community will help support your project, and process and outcome measures)

_____ Logic Model for each project

Grant in Aid Agencies:

_____ Narrative

_____ Attachment 3 – Budget Information

_____ Eligibility requirements & cost for participation in the programs

All Agencies:

_____ Attachment 2 - Population Appendices (AOD, MH, or one for Non-UFMS) including Modifier 3 codes if applicable

Section III (begins on page 9):

_____ Signatures of Executive Director/CEO and Agency Board President/Chair at the bottom of page13

_____Copy of Verification of Registration if applicant is new or there are changes in current provider information

_____ Agency brochure or summary of services

_____Copy of most recent 501 (c)(3) including authorization of name change if applicant is new or there are changes in current provider information

_____ List of current board members with email addresses and term dates and acknowledgement that the majority of board members serve without compensation

_____ List of agency board meeting dates, times and places

_____Most recent Form 990 and Audit that includes June 30, 2015 with Officer’s Signature on page 6 of Form 990

_____ Copy of policy/procedure for Civil Rights and Equal Opportunity if applicant is new or there are changes in current provider information

_____ Copy of agency’s client rights and grievances policy/procedure if applicant is new or there are changes in current provider information

_____ Copy of agency’s major unusual incident policy/procedure if applicant is new or there are changes in current provider information

_____ Copy of agency’s continuous quality improvement plan if applicant is new or there are changes in current provider information

_____ Certificate of insurance with required coverage and with ADAMH Board listed as a name insured

_____ Copy of most recent annual report to include a full description of activities

_____ Copy of agency’s “All Hazards Contingency Plan”

_____ Copy of brochures, articles, letterhead, etc. indicating acknowledgement of funder

_____ Copy of the agency’s Health and Safety policy/procedure if applicant is new or there are changes in current provider information

_____ Signatures of Executive Director/CEO and Agency Board President/Chair at the top of page14 acknowledging having read and agreed to the assurances on pages 13

_____Attachment 3 & 4 Logic Model (All)

Section IV (begins on page 14):

_____ Outcome Success Story

Please list any other documents included in this application:

______