Safecare Siteapplication

SAFECARE SITEAPPLICATION

Instructions: Applicants should type responses to application questions directly underneath each question within this Word document. Please refer to the SafeCare Application Guidebook for further instructions on responding to each question of this application.Completed applications, including Letters of Support and organizational charts or graphics should be emailed to Erin McFry, , by 5:00 pm EST, December 19, 2014. Applications should be saved in the following format, SafeCare Application_Agency Name.doc.

Applicant Contact information:

Organization/Agency name:

Organization/Agency address:

Organization/Agency phone:

Name of Application Primary Contact:

Title:

Phone:

Email Address:

Name of Application Alternate Contact:

Title:

Phone:

Email Address:

1.0 Organization(s)/System(s) Profile and Experience

1.1 Provide a general description of the organization(s) in this application.

1.2 If the applicant includes more than one organization, describe the collaborative partnership that is applying and the specific roles each organization will play in the implementation of SafeCare. Include a graphic if useful.

1.3Briefly describe any prior successful collaborations by the organizations in the partnership.

2.0 Service system in which SafeCare will be implemented

2.1 Describe the service system in which you will implement SafeCare.

2.2 Describe the population that will receive SafeCare from your organization. What eligibility and exclusion criteria will your organization use to determine whether a family will receive SafeCare services?

2.3 Is your organization already providing services within the system to the SafeCare population you described in 2.2? If so, list the number of referrals you receive monthly or annually for cases appropriate to the proposed client base.

2.4 If you are currently providing services to the targeted SafeCare population, briefly describe what services clients receive, how many sessions they receive, and atwhat frequency do you visit this population of clients? If you are adding SafeCare sessions to your current services, you must justify this in 2.9.

2.5 Describe other services, if any, that clients will receive in the home by your providers in addition to SafeCare.

2.6 Describe the sourcesof your referrals for SafeCare. Who sends you referrals and how will you educate them on SafeCare?

2.7 Describe how you will ensure that your SafeCare providers will have referrals when they complete workshop training and the intended caseload (i.e., number of clients receiving SafeCare at one time) once they are fully implementing SafeCare.

2.8 If new referral sources will be employed, describe any marketing strategies that will be implemented to access new referral sources or to ensure those new sources supply adequate volumes of appropriate referrals.

2.8 Describe how home visiting and related SafeCare services will be funded. Please provide a letter of support indicating that your funding source will reimburse for SafeCare services.

3.0 Staffing plan for SafeCare implementation

3.1Describe the staffing plan to carry out the SafeCare implementation.When describing your staffing plan, include the following information:

• Identify administrators, supervisors/managers, and/or leadership at each organization involved in your application whowill oversee the implementation.
• Identify the individuals to be trained as home visitors and coaches/trainers and the local coordinator (if known).Where will they sit within each organization?
• For each home visitor and coach/trainer, briefly describe theirbackground and experience in providing services, supervising, or related experiences. If you have not yet identified the individuals to be trained as home visitors and coaches/trainers, describe what qualifications you will seek for each position.
• Indicate whether each home visitor and coach/trainer is a full time staff (or part time) and describe their other job responsibilities aside from providing SafeCare-based services once they are trained.

3.2Describe any experiences your staff or agency has in implementing and/or delivering Evidence-Based Practices?

3.3 Describe any communications about SafeCare implementation you have had with the organizations applying for training. Who has been informed of a possible SafeCare implementation?Describe any concerns/challenges that have been raised from providers, supervisors, or administrators?

3.4Do you anticipate having staff provide SafeCare services in Spanish?Approximately how many referrals do you receive annually for Spanish-only speaking clients?How many of your staff will be implementing SafeCare in Spanish.

4.0 Sustainment and Spread of SC:

4.1 Describe how you will expand SafeCare by training additional staff in the second year of this implementation project. Who will be trained and where will they sit? If new trainees sit in a different organization, be sure to provide letters of support from leadership in that organization.

4.2 How will time be allotted in coach/trainer’s schedule to allow for training and supporting new staff? Please describe the other job duties of your coach/trainers.

4.3 Describe funding for coach and trainer activities.

5.0 Supplies you will need

• Implementing SafeCare requires that $20 worth of supplies are provided for each family (e.g. photocopies of SafeCare documents, health supplies, and safety supplies).
• Each home visitor will require access to a smart phone or tablet that can be used for real time data recording/reporting.
• All staff will require access to computers and internet connections for using the SafeCare Training Portal.

5.1 Please indicate that you acknowledge the requirements for materials needed for implementing SafeCarelisted in the three bullets above and the SafeCare Site Guide Book.

☐The applying organization acknowledges and takes responsibility for supplying the necessary resources to implement SafeCare as bulleted above.