ODP

“Provider Transformation”

Leadership Boot Camp

Application

ODP

“Provider Transformation”

Leadership Boot Camp

Application

Please submit your application by email to y close of business Wednesday, April 12, 2017. If you have any questions, please contact

Diane Cashman | Director of Employment

Department of Human Services| Bureau of Policy and Quality Management

Phone: 717.783.5755 | Fax: 717.783.6583

Agency Name:______

What Counties do you provide services in:______

Name and Title of person submitting application:______

Phone Number: ______Email Address:______

Boot Camp Location _____Pittsburgh

_____Mechanicsburg

_____Malvern

  1. Do you operate non-residential programs that serve people with disabilities that are considered congregate, non-integrated, and/or utilize a U.S. Dept. of Labor 14-c certificate? YES____ NO_____

IF YES,

  1. Is it a licensed facility, and, if so, what license does it hold? ______
  2. Do public funds support the recipients’ participation in the program, and if so, which funding/program (List all)? ______

______

  1. If the services are funded by a Medicaid HCBS waiver which waiver service definitions are used to support the recipients’ participation in the program?

______

  1. How many people attend those programs? ______
  2. In your opinion, how many of these people couldwork in competitive integrated employmentif supported with appropriate services? ______
  1. Do you currently provide supported employment services? YES____ NO_____
  1. Do you currently provide non-employment services that enable individuals to engage with their communities in a meaningful way? YES____ NO_____
  1. How many staff do you have working on developing individual jobs in the community engaging employers?______
  1. How many people with disabilities do you help to attain community integrated employment during an average year?______
  1. What funding sources do you currently use to support these efforts (for example, OVR, ODP Medicaid dollars, state dollars, Bureau of Autism services, Ticket to Work, local high schools, SSA Work Incentives, grants, agency foundation funds, fund raising, other)? ______
  1. What percentage of total revenuedoes your organization generate from its prevocational services, transitional work services, day habilitation services, supported employment services, and other community services? ______
  1. Using between 300 and 500 words, please describe why your agency is seeking the “provider transformation” assistance offered through EFSMLP. Describe where your organization is in the process of considering future service model changes, or the extent to which your agency has made a commitment to making necessary changes to support Employment First within your organization and sustaining the changes beyond this project? (Please attach answer to this application).
  1. If selected for the Leadership Boot Camp, will your organization commit to sending a team consisting of at least 3 officials who hold leadership positions in your agency, such as: Executive Director or CEO, Finance Director or CFO, Program Director or COO, and/or Board President or other board officer. If you cannot commit to this, please describe and justify an alternative team member(s). ______

______

  1. Please attach to this application your organization’s most recently filed IRS form 990. (In addition to the 990 you may include your organization’s most recent annual report, but it is not mandatory.)

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