Instructions for Completing Activities/Outcomes Form

INSTRUCTIONS FOR COMPLETING ACTIVITIES/OUTCOMES FORM

Performance Measurement is a system for measuring the resultsof public programs.

Why Performance Measurement?

No longer are legislators and funders satisfied with allocating dollars and getting back reports of numbers served and program activities. Performance measurement enables legislators, funding sources, and communities to know what impact the dollars have had i.e. what effect or change has resulted from dollars invested and how a person’s life or community has been changed.

Performance measurement starts with “the end in mind” e.g. what do you want to occur as a result of your service?

Performance measurement consists of:

High level outcomes: Desired results in social health or well-being. High level outcomes reflect the longer-term, global effects the program is intended to achieve. e.g. To reduce child abuse and neglect.

Activities: List the key activities/initiatives proposed to achieve the goal(s) and objective(s) of the grant program.

Staff Responsible: Indicate the staff or organizations responsible for carrying out each activity/initiative.

Output: An output is a process measure which describes the conditions under which measurements will be made. This may refer to the timeframe and/or implementation of an activity/initiative, frequency, number of participants, etc. Process measures are activity focused and contribute to interim outcomes. They do not reflect qualitative outcomes. E.g. the number of parents participating in parent education classes or the number of community presentations.

Outcomes: Interim improvements in participant’s or community progress towards a high level outcome. Interim outcomes reflect a more immediate or direct effects a program is intended to achieve. Outcomes typically address changes in participant performance/behavior that occur as a result of specific activities. They may include, but are not limited to a change or benefit in behavior, knowledge, skills, attitude, values, or condition.

Outcome Measures: Documents the condition of clients after a service has been provided e.g. increased skills, modified behavior, improved condition. Outcome measures address qualitative outcomes.

Outcome measures can include research based instruments with demonstrated reliability and validity, statistics, interviews, observations, rating scales, surveys, focus groups, records, goal attainment, etc.

Performance measurement enables program directors and communities to measure program effectiveness and demonstrate both quantitative andqualitative results that contribute to a higher level social outcome.

OVERVIEW OF ACTIVITIES/OUTCOMES Attachment A

FROM ____/____/____ TO ____/____/____ CONTRACTOR NAME ______CONTRACT

HIGH LEVEL OUTCOME:
ACTIVITIES
What the service/initiative does. / STAFF RESPONSIBLE / OUTPUT
What program produces.
Service frequency, participant numbers, begin/end dates. / INTERIM OUTCOMES FOR CHILD, FAMILY OR COMMUNITY
Qualitative results from activity. What difference will the service make? / EVALUATION
Qualitative & Quantitative Outcome Measures

* Outcomes may be measured using evaluation tools such as surveys, interviews, rating scales, records, case plan goal attainment, observations, statistics, etc.

BUDGET SUMMARY - DSS FUNDS AND MATCH FUNDSAttachment B, page 1

CONTRACT PERIOD: FROM_____/_____/_____ TO _____/_____/_____ CONTRACTOR NAME:______

BUDGET CATEGORY / JUSTIFICATION
(How costs were determined) / TOTAL DSS REQUEST / TOTAL MATCH AMOUNT
SALARIES
EMP. BENEFITS
POSTAGE
RENT & UTILITIES
EQUIPMENT
PRINTING
CONSUMABLE SUPPLIES
TRAVEL
OTHER
TOTAL REQUESTED FROM VDSS

AMOUNT PERCENT OF BUDGET

TOTAL REQUESTED FROM DSS
SUPPLIED FROM MATCH
TOTAL PROJECT BUDGET / 100%

ITEMIZED BUDGET - SALARIES AND EMPLOYEE BENEFITSAttachment B, page 2

FROM _____/_____/_____ TO _____/_____/_____ CONTRACTOR NAME: ______

SALARIES
STAFF POSITION / HOURS PER WEEK / % OF TIME ON PROJECT / ANNUAL SALARY / AOUNT REQUESTED FROM DSS
1.
2.
3.
4.
5.
6.
TOTAL SALARIES REQUESTED FROM DSS / ------/ ------/ ------

EMPLOYEE BENEFITS

NAME OF BENEFIT / STAFF POSITION (# ABOVE) / % OR RATE / ANNUAL COST / AMOUNT REQUESTED FROM VDSS
FICA
PENSION/RETIREMENT
HEALTH INSURANCE
WORKER'S COMPENSATION
UNEMPLOYMENT
OTHER (SPECIFY)
TOTAL EMPLOYEE BENEFITS REQUESTED FROM DSS / ------/ ------/ ------

Attachment B, page 3

PERSONNEL EXPENSE FORM

AGENCY/PROGRAM NAME______CONTRACT # ______FED ID #______

NAME AND TITLE / % OF TIME (spent on the funded project) / GROSS SALARY / SALARY EXPENSE (VDSS Funds Requested) / FICA / WORK. COMP. / LIFE INS. / HEALTH INS. / OTHER
(IDENTIFY) / TOTAL ANNUAL BENEFITS / BENEFITS MONTHLY EXPENSES
TOTALS:

ITEMIZED BUDGET - OTHER PROPOSED EXPENSESAttachment B, page 4

CONTRACT PERIOD: FROM _____/_____/_____ TO _____/_____/_____ CONTRACTORNAME______

LINE ITEM / JUSTIFICATION
(How costs were determined) / PROPOSED DSS FUNDS
POSTAGE TOTAL
Administrative
Program
RENT AND UTILITIES TOTAL
Rent
Utilities
Telephone
EQUIPMENT TOTAL
Equipment Purchase
Equipment Rental
PRINTING TOTAL
Administrative
Program
CONSUMABLE SUPPLIES TOTAL
Office
Program

(continued on Page 5)

ITEMIZED BUDGET - OTHER PROPOSED EXPENSESAttachment B, page 5

CONTRACT PERIOD: FROM _____/_____/_____ TO _____/_____/_____ CONTRACTOR NAME:______

LINE ITEM / JUSTIFICATION
(How costs were determined) / PROPOSED DSS FUNDS
TRAVEL TOTAL
Administrative
Program
OTHER TOTAL
Insurance
Professional Fees
Client Fund
Other (specify)
Other (specify)
Other (specify)
Other (specify)
Other (specify)
Other (specify)

TOTAL AMOUNT REQUESTED FROM DSS: $______

ITEMIZED BUDGET - MATCH DOCUMENTATIONAttachment B, page 6

CONTRACT PERIOD: FROM ___/___/___ to ___/___/___ CONTRACTOR NAME: ______

BUDGET CATEGORY / BRIEF DESCRIPTION / SOURCE / CASH / IN-KIND VALUE / TOTAL MATCH
Salaries
Employee Benefits
Postage
Rent and Utilities
Equipment
Printing
Consumable Supplies
Travel
Other (Specify)
Total Amounts Supplied by Match

Attachment C

EVIDENCE-BASED AND EVIDENCE INFORMED[1]

PROGRAMS AND PRACTICES CHECKLIST

This checklist may be used to assess whether a program or practice fits within a specific level of evidence-based or evidence-informed programs or practices.

Level I - Emerging Programs and Practices

PROGRAMMATIC CHARACTERISTICS

The program can articulate a theory of change which specifies clearly identified outcomes and describes the activities that are related to those outcomes. This is represented through a program logic model or conceptual framework that depicts the assumptions for the activities that will lead to the desired outcomes.

The program may have a book, manual, other available writings, training materials, OR may be working on documents that specifies the components of the practice protocol and describes how to administer it.

The practice is generally accepted in clinical practice as appropriate for use with children and their parents/caregivers receiving child abuse prevention or family support services.

RESEARCH & EVALUATION CHARACTERISTICS

There is no clinical or empirical evidence or theoretical basis indicating that the practice constitutes a substantial risk of harm to those receiving it, compared to its likely benefits.

Programs and practices have been evaluated using less rigorous evaluation designs that have with no comparison group, including “pre-post” designs that examine change in individuals from before the program or practice was implemented to afterward, without comparing to an “untreated” group

OR an evaluation is in process with the results not yet available.

The program is committed to and is actively working on building stronger evidence through ongoing evaluation and continuous quality improvement activities.

Level II - Promising Programs and Practices

PROGRAMMATIC CHARACTERISTICS

The program can articulate a theory of change which specifies clearly identified outcomes and describes the activities that are related to those outcomes. This is represented through presence of a program logic model or conceptual framework that depicts the assumptions for the activities that will lead to the desired outcomes.

The program may have a book, manual, other available writings, and training materials that specifies the components of the practice protocol and describes how to administer it. The program is able to provide formal or informal support and guidance regarding program model.

The practice is generally accepted in clinical practice as appropriate for use with children and their parents/caregivers receiving services child abuse prevention or family support services.

RESEARCH & EVALUATION CHARACTERISTICS

There is no clinical or empirical evidence or theoretical basis indicating that the practice constitutes a substantial risk of harm to those receiving it, compared to its likely benefits.

At least one study utilizing some form of control or comparison group (e.g., untreated group,placebo group, matched wait list) has established the practice’sefficacyover the placebo, or found it to be comparable to or better than an appropriate comparison practice, in reducing risk and increasing protective factors associated with the prevention of abuse or neglect.. The evaluation utilized a quasi-experimental study design, involving the comparison of two or more groups that differ based on their receipt of the program or practice. A formal, independent report has been produced which documents the program’s positive outcomes.

The local program is committed to and is actively working on building stronger evidence through ongoing evaluation and continuous quality improvement activities. Programs continually examine long-term outcomes and participate in research that would help solidify the outcome findings.

The local program can demonstrate adherence to model fidelity in program or practice implementation.

Level III - Supported Programs and Practices*

PROGRAMMATIC CHARACTERISTICS

The program articulates a theory of change which specifies clearly identified outcomes and describes the activities that are related to those outcomes. This is represented through the presence of a detailed logic model or conceptual framework that depicts the assumptions for the inputs and outputs that lead to the short, intermediate and long-term outcomes.

The practice has a book, manual, training, or other available writings that specifies the components of the practice protocol and describes how to administer it.

The practice is generally accepted in clinical practice as appropriate for use with children and their parents/caregivers receiving child abuse prevention or family support services.

RESEARCH & EVALUATION CHARACTERISTICS

There is no clinical or empirical evidence or theoretical basis indicating that the practice constitutes a substantial risk of harm to those receiving it, compared to its likely benefits.

The research supporting the efficacy of the program or practice in producing positive outcomes associated with reducing risk and increasing protective factors associated with the prevention of abuse or neglect meets at least one or more of the following criterion:

At least two rigorous randomized controlled trials (RCTs) in highly controlled settings (e.g., university laboratory) have found the practice to be superior to an appropriate comparison practice. The RCTs have been reported in published, peer-reviewed literature. OR
At least two between-group design studies using either a matched comparison or regression discontinuity have found the practice to be equivalent to another practice that would qualify as supported or well-supported; or superior to an appropriate comparison practice.

The practice has been shown to have a sustained effect at least one year beyond the end of treatment, with no evidence that the effect is lost after this time.

Outcome measures must be reliable and valid, and administered consistently and accurately across all subjects.

If multiple outcome studies have been conducted, the overall weight of evidence supports the efficacy of the practice. [If not applicable, you may skip this question.]

The program is committed and is actively working on building stronger evidence through ongoing evaluation and continuous quality improvement activities.

The local program can demonstrate adherence to model fidelity in program implementation.

Level IV - Well Supported Programs and Practices*

PROGRAMMATIC CHARACTERISTICS

The practice has a book, manual, training or other available writings that specify components of the service and describes how to administer it.

The practice is generally accepted in clinical practice as appropriate for use with children and their parents/caregivers receiving child abuse prevention or family support services.

RESEARCH & EVALUATION CHARACTERISTICS

Multiple Site Replication in Usual Practice Settings: At least two rigorous randomized controlled trials (RCT's) or comparable methodologyindifferent usual care or practice settings have found the practice to be superior to an appropriate comparison practice. The RCTs have been reported in published, peer-reviewed literature.

There is no clinical or empirical evidence or theoretical basis indicating that the practice constitutes a substantial risk of harm to those receiving it, compared to its likely benefits.

The practice has been shown to have a sustained effect at least one year beyond the end of treatment, with no evidence that the effect is lost after this time.

Outcome measures must be reliable and valid, and administered consistently and accurately across all subjects.

If multiple outcome studies have been conducted, the overall weight of the evidence supports the effectiveness of the practice.

The program is committed and is actively working on building stronger evidence through ongoing evaluation and continuous quality improvement activities.

The local program can demonstrate adherence to model fidelity in program implementation.

Programs and Practices Lacking Support or Positive Evidence

Programs or practices that do not meet the threshold for Level I Emerging and Evidence-informed fall within this category.

PROGRAMMATIC CHARACTERISTICS

⁯The program is not able to articulate a theory of change which specifies clearly identified outcomes and describes the activities that are related to those outcomes.

The program does not have a book, manual, other available writings, training materials that describe the components of the program.

RESEARCH & EVALUATION CHARACTERISTICS

Two or more randomized, controlled trials (RCTs) have found the practice has not resulted in improved outcomes, when compared to usual care.

If multiple outcome studies have been conducted, the overall weight of evidence does NOT support the efficacy of the practice.

No evaluation has been conducted. The program may or may not have plans to implement an evaluation.

Attachment D

Authorized Certifying Officials of each provider association applying for funding must sign the following forms listed below to be considered for this grant.

“SF 424B – Assurances – Non-Construction Programs”

“W-9 Request For Taxpayer Identification Number(s) and Certificate”

“SF 424B – Assurances – Non-Construction Programs”

1. Hold the “CTRL” key down while clicking on the link below to access form SF424B – Assurances – Non-Construction Programs, ORsimply click on the link below to access the form.

2. Once the form is accessed, click on “File,” then “Print.”

Read, sign and include form “SF424B – Assurances – Non-Construction Programs” in your completed application.

Attachment D.1

W-9 REQUEST FOR TAXPAYER IDENTIFICATION NUMBER(S) AND CERTIFICATE

Each person or organization doing business with the Commonwealth of Virginia must provide the follow information.

Please return this form in the enclosed envelope.

ORGANIZATION ENTITY: Original Submission

Please provide reportable name where applicable. Additional Addresses (See Back of Form)

Address correction

Check Only One:

_____ Individual_____ Sole Proprietor _____ Corporation

_____ Partnership _____ Government_____ Trust

_____ Estate _____ Other (Please Describe) ______

Social Security NumberEmployer Identification Number

______and/or ______

ENTER THE FOLLOWING:

Legal Name ______

(Must match the Social Security Number, if applicable)

Trade Name ______

(Must match the Employer Identification Number, if applicable)

Payment Address ______IRS 1099 Form ______

______Mailing Address ______

______

Dun’s # ______Dun’s # ______

Contact Person ______Telephone Number (______)______

______

Please respond to the following: (See back of form for definitions.)

Are you a United States Citizen?Yes ______No ______

Is your organization tax exempt?Yes ______No ______

Are you a Real Estate Agent?Yes ______No ______

Are you a Minority owned business?Yes ______No ______

Are you a Woman owned business?Yes ______No ______

Are you a Small business?Yes ______No ______

Are you a Faith Based Organization?Yes ______No ______(See Back)

______

If you are a Minority owned business, please indicate the type of Minority.

_____ African American _____Hispanic American _____Native American

_____ Asian-Pacific American _____ Subcontinent-Asian American _____ Other Minority

Are you registered with the Dept. of Minority Business Enterprise? If yes, enter your certificate No. ______.

______

Government Agencies, please respond to the following:

Are you Federal _____, State _____ or Local ______? (Please check one.)

If you are considered Local, what is your FIPS code ? ______

______

Certification: Under penalties of perjury, I certify that:

(1)The number (s) shown on this form is my correct taxpayer identification number (s) (or I am waiting for a number to be issued to me).

(2)The organization entity and all other information provided is accurate.

(3)I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding because of a failure to report all interest or dividends or the Internal Revenue Service has notified me that I am no longer subject to backup withholding.

(4) I am a U.S. person (including a U.S. resident alien).

(You must cross out item (3) above if you been notified by the IRS that you are currently subject to backup withholding because of under-reporting interest or dividends on your tax return.)

Signature Date

Attachment D.1, Page 2

Additional Address

If you have more that one shipping address and/or Purchase Order Address please list these addresses on a separate sheet of paper and attach it to your W-9 form. Identify each type of address as shipping or Purchase Order address. Please include your Dun’s number for each site. If you don’t have a Duns number you may obtain one by calling 1-888-814-1435

Definitions:

Small Business means a corporation, partnership, sole proprietorship or other legal entity formed for the purpose of making a profit, which is independently owned and operated, and has fewer than 100 employees or less than $1,000,000 in annual gross receipts.

Women-owned business means a business concern that is at least 51 percent owned by a non-ethnic woman or women (a minority woman is considered as a minority) who are U.S. citizens and who also control and operate it. "Control" in this context means exercising the power to make policy decisions. "Operate" in this context means being actively involved in the day-to-day management of the business. “Ownership” in this context includes stock ownership. (Please note that when reporting results, a business that is owned and operated by a minority woman will be reported as a minority-owned business and a business that is owned and operated by a non-minority woman will be reported as a woman-owned business.)

Minority-owned business means any business concern that is at least 51 percent owned by a minority individual or individuals (who are U.S. citizens) who also control and operate it. “Control,” “Operate,” and “Ownership” have the same meanings mentioned above. "Minority" includes African Americans, Hispanic Americans, Native Americans, Asian-Pacific Americans, Subcontinent-Asian Americans, and other minorities. "Native Americans" include American Indians, Eskimos, Aleuts and Native Hawaiians. "Asian-Pacific Americans" include U.S. citizens whose origins are in Japan, China, the Philippines, Vietnam, Korea, Samoa, Guam, U.S. Trust Territory of the Pacific Islands (Republic of Palau), Northern Marina Islands, Laos, Kampuchea (Cambodia), Taiwan, Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Republic of the Marshall Islands, or the Federated States of Micronesia. "Subcontinent- Asian Americans" include U.S. Citizens whose origins are in India, Pakistan, Bangladesh, Sri Lanka, Bhutan, or Nepal.

Faith Based Organizations: If you consider yourself a Faith Based Organization, please indicate on the front of the form in response to the question “Are you a Faith Based Organization”.

Department of Minority Business Enterprise: If you have not registered with the Virginia Department of Business Enterprise, please do so at your earliest convenience. Additional information may be obtained at their web site,

Attachment E

Instructions for Completing Activities/Outcomes Form

Signature ______Date ______

Additional Address

Definitions:

Signature Date