FY 2015/16 SICKLE CELL DISEASE FUNDING APPLICATION

FY 2015/16 SICKLE CELL DISEASE FUNDING APPLICATION

Application to Provide Sickle Cell Disease Services FY 2015/16 Directions and Information In I. Purpose & Overview The County of Volusia Community Assistance Division is soliciting funding applications from organizations incorporated in the State of Florida and registered with the Department of Agriculture and Consumer Services as a non-profit tax exempt organization and able to demonstrate a minimum of one year of successful service delivery to provide sickle cell disease services. The purpose of providing sickle cell services in Volusia County is to enhance the quality of life for all individuals with a sickle cell condition and to educate the community and encourage public awareness concerning the disease and its traits. Based on reports from the U.S. Census Bureau in 2013 there are an estimated 500,800 individuals residing in Volusia County. An estimated 63% which equates to 315,504 individuals are of child bearing age and could be potential carriers of the sickle cell gene. As a result, sickle cell education and awareness is a well needed service in our community. II. Services to be provided 1. Education and awareness of groups at risk for sickle cell disease. 2. Counseling, including but not limited to health management, financial management and family planning for children and adults. 3. Case management for persons with sickle cell disease to assist them access needed services, including but not limited to: A. Support groups B. Academic enhancement C. Nutrition/dietary supplement assistance D. Pharmaceutical assistance E. Transportation assistance 4. Electrophoresis screenings for children and adults to test for abnormal hemoglobin levels. III. Eligibility Requirements 1. The organization must be incorporated in the State of Florida and registered with the Department of Agriculture and Consumer Services as a non-profit corporation and be recognized by the Internal Revenue Service (IRS) as a non-profit tax exemption. 2. The organization must be able to demonstrate a minimum of one year of successful service delivery and financial management. (Verified by IRS 990)

3. The agency must not have any past or present monitoring or audit findings resulting in a suspension or loss of funding. 4. The organization must be in existence primarily to provide social services. IV. Use of funds County funds are to be provided only for sickle cell disease education, counseling, case management, electrophoresis and other supporting services. County funds may not be used for endowments, escrow accounts, contributions to other organizations, social activities or other related entertainment expenses, penalty fees for violations of Federal, State, or local law, interest payments or professional fees related to loans or refinancing, or for the purchase of capital equipment. V. Application process 1. Applications are available online at www.volusia.org/community_assistance/applications.htm or by emailing your request to bscott@volusia.org. 2. Contingency funding checklist, application (1 original and 12 copies), IRS 990 and audited financial statement or attestation with agency financial statements (balance sheet and profit and loss), must be submitted no later than February 19, 2016 by 4:00 p.m.to: County of Volusia Community Assistance Division 110 West Rich Avenue DeLand, FL 32720 Attention: Brittany Scott 3. All applications must be typed. Applications will be reviewed for completeness, and a determination of recommendation for funding will be made by the Children and Families Advisory Board through a scoring rubric. Incomplete applications may not be considered for funding. 4. All copies must be attached within the same packet and submitted at the same time. (The original application and 12 copies, the audited financial statement or attestation with agency financial statements, and the IRS 990) VI. Application Directions 1. Applications received after the due date will be accepted at the discretion of the Volusia County Council. Agencies will be required to provide a written explanation as to why the application could not be submitted on time.

2. When completing the budgets for both Section 1 and Section 2, you may add new lines with categories that further describe your agency s revenues and expenses. For example, if you receive substantial support from churches, you might add a line for Donations from local churches. 3. Section 2 Program Information must be completed for each program for which the agency is requesting funding. For example, if the agency requests funding for three programs, Section 2 must be completed three times, once for each program. In Section 2, please separate each program by using a sheet of colored paper as the first page of each program. 4. Do not submit the application in a binder, report cover, or folder. Simply make copies and place a staple in the upper left-hand corner. 5. To distinguish sections, please fill in your agency name and/or program name in the footer so that it will show up on each page. If you have more than one Section 2, change the A beside the Section 2 page numbers to B, for the second program, C, for the third program, etc. Subsequent pages for the first program would be 2A, 3A, 4A. 6. Complete all forms for total agency budget, total agency salaries, program budget, and program salaries. If Program Budgets are the same as Total Agency Budget, use the same information and complete forms. 7. Sign the original. Be sure both the Chief Executive Officer and the Chief Volunteer Officer has signed the original. VII. Program Description and Outcomes In Section 2 you are asked to provide outcomes for your programs. Outcomes demonstrate the difference the program makes in the lives of participants. Please number each program outcome and its associated components. The chart below summarizes the type of information to be submitted for program outcomes.

Activities (Services provided) What are you going to do? Activities are what a program does with its resourcesthe services it provides to fulfill its mission. Examples: shelter, training, education, counseling, mentoring Outputs (Units of service) How much are you going to do? Outputs are products of a program's activities indicated in numbers, or units of service. Examples: # of classes taught, # of hours of service delivered Outcome (How will you determine/measure whether you achieved the outcome?) How are you going to measure the success of what you are going to do? Outcome indicators are the specific items of information that track a program's success on outcomes. They describe observable, measurable characteristics Expected Outcomes (What are the benefits to program participants?) What difference does this program make? Outcomes are benefits for participants during or after their involvement with a program. Examples: increased skills, modified behavior, improved condition Example: 85% will earn better grades following completion of the program. Expectation for proposed year (MMYY/MMYY) How many clients are you proposing to serve? Provide the proposed number and percent of participants that are expected to achieve the outcome in the proposal year. Example: 85 of 100 participants, 85% are expected to earn better grades following the program, than in the grading period immediately preceding the program. VIII. Questions/Contact Person Brittany Scott, Children and Families Program Coordinator Volusia County Community Assistance Division 110 West Rich Avenue Deland, FL 32720 (386)736-5955 Ext. 12959 bscott@volusia.org

County of Volusia Application to Provide Sickle Cell Disease Services FY 2015/16 Agency Name: Address: City, State, Zip Code: Mailing Address: City, State, Zip Code: Telephone/Fax: Email: Agency s Fiscal Year: Federal ID#: DUNS#: Executive Director: Board Volunteer Chair: We hereby certify that all programs receiving funding from the County of Volusia will: 1. Provide services regardless of race, religion, color, sex, or national origin 2. Not require attendance at religious services as a condition of assistance (if agency is affiliated with any religious entity) nor will the program attempt any religious conversion of service recipients 3. Comply with ADA standards as it relates to persons with disabilities We hereby certify there is a written code of conduct that governs performance of the officers, employees, and agents engaged in procurement which states they will avoid any conflict or interest. We hereby certify that all employees of any agency working directly with children have been screened through the Florida Department of Law Enforcement (FDLE) abuse registry and are records of this action are on file at the agency. Our signatures acknowledge that the information contained in this funding application may be shared with other funders. In addition, this certifies that this request is consistent with our organization's mission, Articles of Incorporation and Bylaws, and has been approved by a majority of the agency s Board of Directors or Advisory Board. Volunteer Board Chair Agency Executive Director Date Date NOTE: Original application should contain the original signatures on this page. Please mark the original on the cover page 1

Checklist Completed Section 1 in its entirety, pages 1 to 10. Completed and attached Section 1 s Agency Budget and Agency Salaries, pages 11 to 15 and In-Kind Summary Page 16. Completed Section 2 for each program for which agency is requesting funding. Completed and attached Section 2 s Cost Effectiveness/Cost Efficiency, Program Budget, Program Salaries and In-kind Summary portions for each program. Both the Agency Executive Director and the Board s Volunteer Chair have signed the application. Submitted 1 original application and 12 copies Submitted one copy of the most recent IRS 990 Submitted one copy of the most recent audit and management letter (if applicable) or attestation with internally generated financial statements for most recent fiscal year to include a balance sheet and profit and loss statement. 2

Section 1 Financial Overview: Explain the steps your agency has taken to reduce overhead costs in the current year and how the agency plans to reduce costs in the proposed year. Include the reasons for the reduction in costs i.e. cuts in funding, increased efficiency, collaboration. In addition, explain how, or if, the reduction of costs affects the amount of service provided. Has the agency given any raises in the last year? If so, explain and include the percentage of the increase by position and program budget. 3

I. Agency funding summary List amounts requested from all funding sources for this application period. County of Volusia Funding Type Children and Families Advisory Board $ $ Other County of Volusia Sources CDBG, JAG, ETC. $ County of Flagler Funding Type Source: $ United Way of Volusia Flagler Counties Funding Funding Type Citizens' Review Process $ Amount Requested Amount Requested Amount Requested Status: (denied, pending, approved) Status: (denied, pending, approved) Status: (denied, pending, approved) State of Florida Funding Source Children's Medical Services $ Department of Children and $ Families Adult Services $ Alcohol Drug Abuse, and $ Mental Health Developmental Disabilities $ Economic Self-Sufficiency $ Family Safety and Preservation $ Department of Health $ Department of Juvenile Justice $ Department of Vocational $ Rehabilitation $ $ Amount Requested Status: (denied, pending, approved) Anticipated Date of Notification 4

Other Include additional efforts to obtain revenues from other grantors and private foundations not listed above*. Status: Funding Amount Anticipated Date of (denied, pending, Source: Requested: Notification approved) 1. 2. 3. 4. 5. *Add lines for additional grants Fundraising Using the table below, please list your organization's current and planned fundraising efforts. This would include, but is not limited to, special events, sales to the public, and direct mail. Activity/Event Current Revenue from this Activity/Event Proposed Revenue from this Activity/Event Anticipated Date of Activity/ Event 1. 2. 3. 4. *Add lines for additional fundraising activities. Programs for which the agency is requesting funding with this application: Program Amount Requested 1. 2. 3. 4. *Add rows as needed until all programs are listed Total Amount Requested: 5

II. Purpose of Agency: Describe what the agency does, (services provided), how it is done (service delivery). Describe the need being met. How does the agency differ from other agencies in avoiding duplication of services? What is the agency s mission? III. Agency challenges and/or successes (i.e. accreditation): Explain the challenges experienced in the last year including significant loss of revenue and the impact to the program(s) for the current year or upcoming year. Also discuss agency successes. 6

IV. Agency organizational and administrative assessment: 1. Administrative Date of Articles of Incorporation: Date of Agency By-Laws: Do you have a governing Board of Directors in Volusia/Flagler Counties? *If no, please describe your system of governance (i.e., chapter of national Organization with local advisory board, local advisory board has representation on larger regional Board of Directors, program is part of public entity, etc.). Do you have an advisory board composed of clients and community members? Are the organization s meeting minutes retained and current? Is training or orientation provided for new board members? Are there term limits established for the board members? How often did the governing body meet during the last calendar year? What do your bylaws state regarding board participation? Describe the average attendance and level of participation. Do any board members receive any payment from the agency? If yes, please explain: 7

Board Roster: Using the table below, provide requested information regarding the Board of Directors or other governing body Name Residence City and Zip code Gender/Race Ethnicity Board Position Business Affiliation Date Appointed 8

2. Regulatory Florida Corporate Registration Number: Florida Department of Agriculture and Consumer Affairs Solicitation of Contribution Number: Is the Agency current on payment of withholding taxes? If not, is there an IRS approved payment plan? Explain: Does the Agency have the IRS Determination letter identifying classification? Does the Agency have the federal employer ID statement/letter? Does the Agency have current fire inspection certificates for all program sites? Does the Agency have proof of current general liability insurance? Does the Agency have proof of current worker s compensation insurance? Does the Agency have proof of current vehicle insurance, if applicable? N/A Does the Agency have proof of current volunteer insurance, if applicable? N/A Does the Agency have current health inspection certificates if applicable? N/A 3. Internal Control/Financial Management Does the agency have any past and/or present monitoring or audit findings resulting in a suspension or loss of funding? If yes, please explain the finding(s), the status or resolution of the finding, the funder, and the amount of funding. 9

Does your organization owe any repayment of funds to any funding sources? Has your organization declared bankruptcy or had any assets attached by any court within the last three years? If you answered "yes" to any of the above fiscal condition questions, please attach a written explanation directly behind this page. Does the Agency have written financial policies and procedures? Does the Agency have established accounting procedures verifying all income and expenses? Does the Agency have an independent audit on an annual basis? If Agency does not have an independent audit, are the agency financials reviewed and approved by the Board? Does the Agency have policy/procedure defining personnel authorized to purchase materials and services on behalf of the Agency? Does the Agency have policy/procedure for reimbursement of employee job-related expenses (e.g. travel)? Does the Agency maintain petty cash funds? Is the Agency current in all payables? (Ex: rent, taxes, salaries, etc.) Are property records which describe the location and condition of equipment maintained? Are individual payroll records maintained on each employee? 10

Is there adequate segregation of duties among personnel to preclude misappropriation of funds? If not, explain. Are checks issued in pre-numbered sequential order, and all applicable check numbers accounted for? When not in use, are checks kept in a secure location? 4. Monitoring: Does an independent, national monitoring group such as CARF or NAEYC accredit the agency? If answered yes, please attach copy of certification. Identify any funder that monitors the agency, indicating date of last monitoring Agency 5. Service Delivery: Date The agency has adopted a target area for service delivery with a defined and recognizable boundary. The target area is: Note: Please indicate a specific city or cities, or all of Volusia and/or Flagler Counties 6. Fees: Are there guidelines for assessing fees? Does the bookkeeper and cashier know these guidelines? Is every effort extended to collect fees? Does an official of the agency approve uncollectible write-offs? 11

7. Personnel: Are personnel policies in writing and approved by the Board of Directors? Are up to date job descriptions provided to all employees at the time of initial employment? Are job descriptions on file for all positions? Is the performance of each staff member evaluated at least annually? Are staff members asked to review and comment on their evaluation? Is there a mechanism in place for review of contracted services? Are individual payroll records maintained on each employee? 8. Client records: Are all client records kept confidential? Are client records kept in a locked and secured place? Are there procedures for standardization of client records? Are there client release forms signed before fulfilling requests for client records? 12

TOTAL AGENCY BUDGET AGENCY NAME: A. B C. Prior Year D. Prior E. Current Year F. Current G. Proposed H. % Increase Proposal Year Actuals Proposal Year Year Between (Copy from 2013-2014 application.) (Copy from 2013-2014 application.) Projections F. AND G. (MMYY-MMYY)* (MMYY-MMYY)* (MMYY-MMYY)* (MMYY- MMYY)* (MMYY- MMYY)* REVENUES: 1 GOVERNMENTAL FUNDING City-- Volusia County (CFAB) #VALUE! Volusia County (ADM match) Volusia County (Special Contracts) Volusia County (JAG) Volusia County (Other) Flagler County State (list agency) Medicaid Federal (list agency) Medicare -- 2 GOVERNMENT SUBTOTAL 0 0 0 0 0 3 UNITED WAY United Way of Volusia-Flagler Other United Ways 4 UNITED WAY SUBTOTAL 0 0 0 0 0 5 AGENCY GENERATED INCOME 13

Contributions/Fundraising Trusts/Bequests Foundation Funding Membership Dues/Client Fees Product/Service Sales Investment Income Other Income (Itemize) 6 AGENCY GENERATED INCOME 0 0 0 0 0 TOTAL REVENUE: 0 0 0 0 0 EXPENSES: 6 Administration Expenses 7 Program Expenses 8 TOTAL EXPENSES: 0 0 0 0 0 9 TOTAL REVENUE: #REF! #REF! #REF! #REF! #REF! #REF! 10 TOTAL EXPENSES: 0 0 0 0 0 11 EXCESS/(DEFICIT): #REF! #REF! #REF! #REF! #REF! #REF! Column C. Provide prior year proposal from 2013-2014 application. Column G. Provide your budget for the proposed year. Column D. Provide prior year actual, for your fiscal year that is complete. Again, indicate your agency's fiscal year using MM/YY-MM/YY format. Use your agency's fiscal year, indicated in MM/YY-MM/YY format. Column H. Indicates the % increase (or decrease) from current year to Column E. Provide the current year proposal from the 2014-2015 application. proposed year. Column F. Provide the projections for the current fiscal year. The formula is (Proposed Year - Current Year Projections) Indicate your agency's fiscal year using MM/YY-MM/YY format. Current Year Projections 14

AGENCY NAME: A. B. C. D. E. Basis F. Current G. Proposed Hrs. donated Hourly of Year Year IN-KIND REVENUE: Description Rate calculation (MMYY-MMYY)* (MMYY-MMYY)* 1 IN-KIND Volunteers 2 IN-KIND Rent 3 IN-KIND 4 IN-KIND 5 IN-KIND 6 IN-KIND 7 TOTAL REVENUE: 0 0 In-Kind is defined as anything given to the agency to support the programs that the agency would otherwise have to pay for. Indicate all sources of in-kind. For volunteer in-kind indicate basis of calculation. For example, if there are 20 hours per week of volunteer time donated, multiply by hourly rate times 52 weeks. 20 x $10.00=200.00x52=$10,400.00 15

Section 2 I. Program Information: Complete this section, Program Information, for each program for which you are requesting funding. Print this cover sheet on colored paper. Agency Name: Program Name: Amount Requested: Select only one of the following categories that best describe if: Children are the primary recipients of the service Adults are the primary recipients of the service In this section include the following in this order: Program Information (this Word document) Program Cost Effectiveness/Cost Efficiency Summary (Excel) Program Budget (Excel) Program Salaries (Excel) In-Kind (Excel) 16

Agency Collaboration 1. List below all agency collaborations for which there are written memorandum of understandings and indicate the specific provision of services. 2. Describe the need for service. 3. How are you addressing the problem differently than other agencies which provide the same or similar services? 4. Does this program receive state or federal matching funds? 5. Does the program use these requested funds to match state or federal funds? 6. List the funding source, ratio and maximum amounts of all matching funds. 7. Describe the goal of the program. 8. Number of units of service provided (Duplicated services) 2015-2016 projection 9. Number of clients to be served: (Unduplicated services) 2015-2016 projection 10. Benefit per client: (Number of clients served, unduplicated, divided by total program cost) 11. Are there any significant changes to the program as previously funded, or, any changes to the demographics? If so, explain. 12. Did you request a grant from this particular funding source for this program last year? 17

13. If yes, and an increase in funding has been requested, please explain the reasons for applying for additional money. 14. Does this program have a change in the number of staff or staff hours dedicated to it? 15. If yes, please explain the reason(s) for the increase or decrease in staff. 16. If you did not previously request a grant for this program, is it a new program for your agency? 17. If this is not a new program, how long has it been in existence? 18. Are client fees charged for this program? 19. If yes, what is the range of fees and how are they determined? 20. If fees are not charged, why? 21. How is client eligibility determined for this program? 22. Describe the waiting list for program services (include the length of the list and how it is managed) 18

Program location(s) and schedule: Location Time Day(s) Program staff: Number of paid staff involved in operating the program: Number of staff Number of volunteers List staff positions and schedule for program described: Staff Schedule 19

II. Program description and outcomes: Program Name: Program Goal(s): Program description: 1. Provide a narrative description of this program including target population. What are your efforts to reach the at-risk population? 20

Program Description and Outcomes 1. Activities (What services are provided?) Outputs (What amount of services will be provided? (Units of service) Outcome Indicators/Measures/Tools (How will you measure whether you achieved the outcome?) Expected Outcomes/goals (What are the benefits to program participants?) Expectation Proposed Year (MMYY/MMYY) 2. 3. 21

4. Activities (What services are provided?) Outputs (What amount of services will be provided? (Units of service) Program Description and outcomes (continued) Outcome Indicators/Measures/Tools (How will you measure whether you achieved the outcome?) Expected Outcomes/goals (What are the benefits to program participants?) Expectation Proposed Year (MMYY/MMYY) 5. 6. 22

2. How do you use outcomes to evaluate your programs and make changes going forward? 23

III. Program Demographics Summary DO NOT LEAVE BLANK: Please complete the following table summarizing the demographic characteristics of clients served by this program. If there are no prior year clients put N/A. Do not use percentage, put actual numbers of clients. Please note that these figures are number of clients served unduplicated, not number of services provided. Demographic Characteristics by program A. Prior year clients (Actual) mm/yy-mm/yy* B. Current year clients (Projected) mm/yy-mm/yy* C. Proposed year clients (Projected) mm/yy-mm/yy* AGE GROUP 0-5 6-10 11-17 18-29 30-54 55-64 Over 65 Undocumented TOTAL Male Female Undocumented GENDER TOTAL ETHNIC BACKGROUND Caucasian African-American Hispanic Asian-American Native American Other Undocumented TOTAL 24

Demographic Characteristics by program LEGAL RESIDENCE Northwest Barberville 32105 Cassadaga 32706 DeLand 32720, 32721, 32722, 32723 DeLeon Springs 32130 Glenwood 32722 Lake Helen 32744 Pierson 32180 Seville 32190 Northeast Daytona Beach 32114, 32115,32116, 32117, 32118, 32119, 32120, 32121, 32122, 32123, 32124, 32125, 32126, 32198 Daytona Beach Shores 32116 Holly Hill 32117, 32125 Ormond Beach 32173, 32174, 32175, 32176 Ponce Inlet/Wilbur-by-the-Sea 32127 Port Orange 32127, 32128, 32129 South Daytona 32121 Southwest DeBary 32713, 32753 Deltona 32725, 32738, 32738, 32739 Enterprise 32725 Orange City 32763, 32774 Osteen 32764 Southeast Edgewater 32132, 32141 New Smryna Beach 32168, 32169, 32170 Oak Hill 32759 Flagler Bunnell 32110 Flagler Beach 32136, Marineland 32086 Palm Coast 32135, 32137, 32142, 32164 TOTAL A. Prior year clients (Actual) mm/yymm/yy* B. Current year clients (Projected) mm/yymm/yy* C. Proposed year clients (Projected) mm/yymm/yy* *Column Description A. Actual clients served during agency s last fiscal year. Indicate year in MMYY/MMYY format. B. Estimated number of clients to be served in agency s current fiscal year. Indicate year in MMYY/MMYY format. C. Number of clients your agency proposes to serve in the upcoming fiscal year. Indicate year in MMYY/MMYY format. 25