Master
Assessment
2016-2017
Community Impact Funding Application
Agency Name:
1110 Highway 26, Midhurst ON L0L 1X0
t 705.726.2301  f 705.726.4897
[email protected]
Agency Information
Agency Name:
Contact Person, Title:
Submitted with Partner?
Program/Project name:
2013/14 - $
Historic Funding (2013, 2014, 2015)
2014/15 - $
2015/16 - $
Funding requested in this application (2016
and 2017)
Community Impact Associate:
2016/17 - $
2017/18- $
Heather Owen
Date Completed:
Community Impact Specialist:
Carla Dermott
Date Completed:
Audited FS Assessment:
John Morrison, B.A., C.P.A., C.G.A.
Date Completed:
CI Council Member A:
Date Completed:
CI Council Member B:
Date Completed:
CI Council Member C:
Date Completed:
2
Expression of Interest - Agency/Program Assessment
To be completed by UWGSC CI Dept - For each question answered, rate the applicant’s response
according to “Red,” “Yellow” or “Green.”
Question
1.
Informative overview of agency that
discusses the human-care need they
address?
2.
Simcoe and/or Muskoka?
3.
Agency fits well within UWGSC priority
areas?
4.
Description of program that is relevant
to UWGSC’s mandate? Is agency
affecting the change we want to see in
the community?
Program fits within the priority area and
strategic call?
Program specifics demonstrate need
for program?
Program measurement concretely
described?
Program measurement reflects best
practices?
5.
Estimated costs clearly articulated?
Funding request (amount) is
appropriate relative to the services to
be provided.
The percentage of UWGSC funding for
the program is fiscally sound for the
overall stability of operations.
The percentage of increase (if any) in
funding is within reason and is a
justified increase for the projected
agency goals.
Red
Total:
Comments:
3
Yellow
Green
Expression of Interest - Organization Checklist
To be completed by UWGSC CI Specialist - For each section, list any concerns.
Registered Charitable Status:
Legal Requirements:
Policy and Procedure:
Governance:
Financial and Infrastructure:
Human Resources and Administration:
Mission, Vision and Planning:
United Way Support:
Comments:
Expression of Interest - Overall Comments from UWGSC CI
Department:
Comments from UWGSC CI:
Scoring: Red, Yellow or Green
Reasoning:
Recommend for Invitation to Apply? (Yes or No):
4
Part A
Part A – Agency Profile/Organization Assessment
To be completed by CI Specialist - For each question answered, rate the applicant’s response
according to “Red,” “Yellow” or “Green.”
Question
Red
1.
Authority of the local board?
2.
Substantial collaborative efforts with
other organizations?
Understands role and active in
community change?
Utilizing volunteers in appropriate
roles?
Effective recruitment, screening,
training, screening and evaluation
processes for volunteers?
Significant successes?
Agency addressing challenges?
Innovative ideas for use of TCS
services?
Staff is proud of accomplishments and
engaged in work?
4.
5.
Yellow
Green
Total:
Audited Financial Statements Analysis
UWGSC CI Specialist will insert financial ratios and comments from the UWGSC Director of
Finance & Operations here and note any areas of concern.
5
Part B
Part B - Program Information:
To be completed by Community Impact Specialist - For each question answered, rate the
applicant’s response. For each question answered, rate the applicant’s response according to
“Red,” “Yellow” or “Green.”
Question
Red
1&2. Well-chosen priority area?
3.
Good description of program that is
relevant to UWGSC’s mandate? Is agency
affecting the change we want to see in the
community?
Method of Measurement is sensitive to
client needs and program realities?
Method of Measurement is achievable and
based on research methods?
4.
Well-researched and documented need?
Current agency programs were determined
needed by thorough community needs
assessment?
5.
Solid understanding of the current needs
of their agency’s target group?
Target group well served by the agency?
Understanding of community solutions to
create change?
6.
Program specifics demonstrate need for
program?
7.
Plan in place to manage challenges?
8.
Well-defined terms of reference and
memorandum of understanding with
clearly defined roles within the proposed
partnership?
Total:
Comments:
6
Yellow
Green
Part B - Program Information:
To be completed by CI Council - For each question answered, rate the applicant’s response. For
each question answered, rate the applicant’s response according to “Red,” “Yellow” or “Green.”
Question
Red
1&2. Well-chosen priority area?
3.
Good description of program that is
relevant to UWGSC’s mandate? Is agency
affecting the change we want to see in the
community?
Method of Measurement is sensitive to
client needs and program realities?
Method of Measurement is achievable and
based on research methods?
4.
Well-researched and documented need?
Current agency programs were determined
needed by thorough community needs
assessment?
5.
Solid understanding of the current needs
of their agency’s target group?
Target group well served by the agency?
Understanding of community solutions to
create change?
6.
Program specifics demonstrate need for
program?
7.
Plan in place to manage challenges?
8.
Well-defined terms of reference and
memorandum of understanding with
clearly defined roles within the proposed
partnership?
Total:
Comments:
7
Yellow
Green
Part B – Performance Measures Model:
To be completed by Community Impact Specialist - For each question answered, rate the
applicant’s response. For each question answered, rate the applicant’s response according to
“Red,” “Yellow” or “Green.”
Question
9.
Model is complete and articulate?
How much did we do (outputs) - clear and
manageable given staff resources?
How much did we do (outputs) - could
reasonably lead to folks being better off
(bottom left/right boxes)?
How well did we do it – unit cost is
accurate and reasonable?
How well did we do it – effective and
efficient client/staff ratio?
How well did we do it – other measurable
ratios/statistics?
Is anyone better off - achievable and
measurable?
Is anyone better off - in line with UWGSC
priorities and common outcomes?
Is anyone better off – clear measurable
relationship between bottom left and
bottom right?
Able to articulate evidence of change as a
result of access to program?
Red
Total:
Comments:
8
Yellow
Green
Part B – Performance Measures Model:
To be completed by CI Council - For each question answered, rate the applicant’s response. For
each question answered, rate the applicant’s response according to “Red,” “Yellow” or “Green.”
Question
9.
Red
Model is complete and articulate?
How much did we do (outputs) - clear and
manageable given staff resources?
How much did we do (outputs) - could
reasonably lead to folks being better off
(bottom left/right boxes)?
How well did we do it – unit cost is
accurate and reasonable?
How well did we do it – effective and
efficient client/staff ratio?
How well did we do it – other measurable
ratios/statistics?
Is anyone better off - achievable and
measurable?
Is anyone better off - in line with UWGSC
priorities and common outcomes?
Is anyone better off – clear measurable
relationship between bottom left and
bottom right?
Able to articulate evidence of change as a
result of access to program?
Total:
Comments:
9
Yellow
Green
Part C
Part C – Budget and Finance:
To be completed by Community Impact Specialist - For each question answered, rate the
applicant’s response. For each question answered, rate the applicant’s response according to
“Red,” “Yellow” or “Green.”
Question
1. Attached completed budget that totals
correctly?
Funding request (amount) is appropriate
relative to the services to be provided.
The level of administrative overhead
(administration, fundraising, marketing and
communication costs) is a reasonable
percentage of the overall program
expenses.
There is a clearly defined allocation of
funds to local programs.
The percentage of UWGSC funding for the
program is fiscally sound for the overall
stability of operations.
The percentage of increase (if any) in
funding is within reason and is a justified
increase for the projected agency goals.
2. Well thought-out, detailed and organized
budget notes?
3. Detailed fundraising plan in place to secure
necessary funds?
4. Alternative plans in the event UWGSC
funding is not available or reduced?
Red
Total:
Comments:
10
Yellow
Green
Part C – Budget and Finance:
To be completed by CI Council - For each question answered, rate the applicant’s response. For
each question answered, rate the applicant’s response according to “Red,” “Yellow” or “Green.”
Question
1. Attached completed budget that totals
correctly?
Funding request (amount) is appropriate
relative to the services to be provided.
The level of administrative overhead
(administration, fundraising, marketing and
communication costs) is a reasonable
percentage of the overall program
expenses.
There is a clearly defined allocation of
funds to local programs.
The percentage of UWGSC funding for the
program is fiscally sound for the overall
stability of operations.
The percentage of increase (if any) in
funding is within reason and is a justified
increase for the projected agency goals.
2. Well thought-out, detailed and organized
budget notes?
3. Detailed fundraising plan in place to secure
necessary funds?
4. Alternative plans in the event UWGSC
funding is not available or reduced?
Red
Total:
Comments:
11
Yellow
Green
Part D
Overall Comments from Community Impact Specialist:
Comments from Community Impact Specialist:
Scoring: Red, Yellow or Green
Reasoning:
Recommend for Funding? (Yes or No):
Overall Comments from Community Impact Council:
Comments from Community Impact Council:
Scoring: Red, Yellow or Green
Reasoning:
Recommend for Funding? (Yes or No):
2016/17$
2017/18$
12