Program Information
Program Information Instructions
Please fill out the boxes below
Site Name
Site Phone Number
Address
 City
 County
 State
 Zip
Primary Contact
Name
 First
 Last
Title
Email
Phone (extension)
If the site supervisor is unknown at this time, please check the box below
Site Supervisor is unknown
Site Supervisor Name
 First
 Last
Title
Email
Phone (extension)
Address
 City
 County
 State
 Zip
5202 Eastpark Boulevard, Suite 109, Madison, WI 53718 • Phone 608-277-7477 • Fax 608-277-7474
E-Mail: [email protected] • Website: www.wphca.org
 How many members is your organization requesting? (Please check
only one.)
☐1
☐2
☐3
☐4
☐ Other ______________
 Does your organization anticipate requesting at least one AmeriCorps
Member each year, over our 3 year grant period?
☐ Yes
☐ No
 Which Performance Measure will your Member(s) primarily address?
☐ Access to Care (Insurance enrollment, recruiting new patients,
decreasing no-show rates, etc.)
☐ Volunteer Recruitment Management
5202 Eastpark Boulevard, Suite 109, Madison, WI 53718 • Phone 608-277-7477 • Fax 608-277-7474
E-Mail: [email protected] • Website: www.wphca.org
NARRATIVE
Narrative Instructions
a) Need - Provide persuasive evidence that identified needs exist in the targeted community(ies). Describe
the community problem(s) your Member(s) will be working on. Provide documentation of the
extent/severity of the need in the target community. Describe the target community including whether it is
economically disadvantaged. Explain why you selected this population to be served.
b) AmeriCorps Members as Highly Effective Means to Solve Community Problems - What will Members
do? Describe the key roles Members will complete. What will the organization accomplish that it would
not otherwise accomplish through existing staff and/or volunteers?
c) Evidence-Based/Evidence-Informed and Measurable Community Impact - Describe how the
interventions the AmeriCorps Members are engaged in are either evidence-based or evidence-informed
and will have a measurable community impact. Explain the impact of the AmeriCorps investment.
Evidence-based approaches are those that have been shown, through research or statistically significant
evaluation findings, to have an impact. Evidence-informed approaches are those that have been shown,
through internal performance data or theory of change research, to have an impact. What is the overall
change you hope to see by the end of the program year? What demonstrable impact will your program
have? In other words, what are your outputs and outcomes and how will these be measured? *Note: Your
Member’s activities should be planned with these end outcomes in mind; however, sites will not be
penalized if outcomes are not met.
Narrative
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5202 Eastpark Boulevard, Suite 109, Madison, WI 53718 • Phone 608-277-7477 • Fax 608-277-7474
E-Mail: [email protected] • Website: www.wphca.org
POSITION DESCRIPTION
Position Description Instructions
Please use the format below to write your position description.
Remember that while the majority of your member’s activities need to focus on at least one of the
Performance Measures outlined in the application instructions, not every duty and responsibility
outlined in the position description is required to align with the selected Performance Measure(s).
Position Title: Title of AmeriCorps position on site
Department: HR, Communications, Outreach, Dental, Operations, etc.
Reports To: Title of Site Supervisor
Summary
Short paragraph(s) describing the main responsibilities and focus of this position. Narrative
Duties & Responsibilities
 Bullet pointed list of duties, responsibilities, tasks
Qualifications/Skills
Short paragraph(s) with the skills and expertise necessary/desired for this position
Education and/or Experience
Short description of the desired experience/education for this position
5202 Eastpark Boulevard, Suite 109, Madison, WI 53718 • Phone 608-277-7477 • Fax 608-277-7474
E-Mail: [email protected] • Website: www.wphca.org
PLAN FOR VOLUNTEER RECRUITMENT
Plan for Volunteer Recruitment Instructions
A cornerstone of the AmeriCorps Program has been the generation of non-AmeriCorps volunteers.
Volunteers expand the reach of your organization by, for example, reaching more patients in an outreach
campaign or handing out information to community members during a health fair. By creating volunteer
opportunities and helping organizations engage volunteers, AmeriCorps programs expand their impact
on the community. Volunteer involvement should enhance or build upon the direct service goals of the
HealthCorps program. Your plan should detail how volunteers will be recruited and/or managed, the
activities volunteers will be engaged in, and how this will help meet the identified community needs
detailed in the previous section. Additionally, the plan should address how volunteers will be trained to
carry out these activities
Plan for Volunteer Recruitment
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5202 Eastpark Boulevard, Suite 109, Madison, WI 53718 • Phone 608-277-7477 • Fax 608-277-7474
E-Mail: [email protected] • Website: www.wphca.org
MEMBER TRAINING AND DEVELOPMENT
Member Training and Development Instructions
Describe your plan for orienting Members to AmeriCorps, the community they are serving, their
placement site, and the service they will perform. Training is an important part of a Member’s service
experience and Host Sites should provide training both for Members’ current service assignments and for
their overall professional development. Members will participate in regular professional development
trainings through the HealthCorps Program, but it is expected that Host Sites will provide in-service
trainings and outside training as needed
Member Training and Development
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5202 Eastpark Boulevard, Suite 109, Madison, WI 53718 • Phone 608-277-7477 • Fax 608-277-7474
E-Mail: [email protected] • Website: www.wphca.org
MEMBER RECRUITMENT AND RETENTION
Member Recruitment and Retention Instructions
Describe your plans for recruiting and retaining Members. Describe how an attempt will be made to
include Members from the local communities to be served by your program. Describe how your
organization will attempt to recruit, engage, and retain traditionally underrepresented populations as
well as your history working with those populations or how you will ensure success if this is a new
population being recruited. Underrepresented populations may include new Americans, low-income
individuals, or youth from disadvantaged backgrounds, rural residents, older Americans, veterans or
family members of veterans, people of color, Native Americans, and/or individuals with disabilities. How
will you ensure that Members are retained for the entirety of the service year?
Member Recruitment and Retention
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5202 Eastpark Boulevard, Suite 109, Madison, WI 53718 • Phone 608-277-7477 • Fax 608-277-7474
E-Mail: [email protected] • Website: www.wphca.org
HOST SITE FIT
Host Site Fit Instructions
Describe who the lead supervisor will be for the AmeriCorps Member(s). What is your succession plan in
the event that the current supervisor leaves or is out for an extended period of time? Why is this staff
person the optimal choice to serve as the site supervisor? Describe the work space available for the
Member(s). Is there a dedicated desk/cubicle? Are there any standard technological deficiencies (no
phone, computer, or keyboard)?
Host Site Fit
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5202 Eastpark Boulevard, Suite 109, Madison, WI 53718 • Phone 608-277-7477 • Fax 608-277-7474
E-Mail: [email protected] • Website: www.wphca.org