United Way of Broward County - Request for Applications
Request for Applications (RFA)
For Fiscal Year 2018/19 Services
For
Universal and Selective
Behavioral Health Prevention Programs
Available February 5, 2018
Closes March 9, 2018
United Way Commission on Substance Abuse
Application for Behavioral Health Universal and Selective Prevention Programs
Available February 5, 2018
Closing March 9, 2018
United Way of Broward County - Request for Applications
UNITED WAY OF BROWARD COUNTY
REQUEST FOR APPLICATIONS: Behavioral Health Prevention
Part I: APPLICANT AGENCY INFORMATION (Maximum Score is 15 Points)
- General Agency Information
Applicant Agency Legal Name:
Main Administrative Address:
City & State: / Zip Code:
Telephone Number:
Website:
CEO/Executive Director:
Office Phone Number: / E-mail Address:
Federal Identification Number:
Applicant Agency Fiscal Year: Beginning (mm/dd): Ending (mm/dd):
- Certification of Accuracy and Compliance
I do hereby certify that all facts, figures, and representations made in the application are true and correct. Furthermore, all applicable statutes, terms, conditions, regulations and procedures for program compliance and fiscal control will be implemented to ensure proper accountability. I certify that the funds requested in this application will not supplant funds that would otherwise be used for the purposes set forth in this program and are a true estimate of the amount needed to operate the proposed program. The filing of this applicationhas been authorized by the contracting entity and I have been duly authorized to act as the representative of the agency in connection with this application. I also agree to follow all Terms, Conditions, and applicable federal and state statutes.
______
Print Authorized Official’s NameAuthorized Official’s Title
______
Authorized Official’s Signature(Blue Ink)Date
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United Way Commission on Substance Abuse
Application for Behavioral Health Universal and Selective Prevention Programs
Available February 5, 2018
Closing March 9, 2018
United Way of Broward County - Request for Applications
- Organization Background (Up to 15 points)
- Provide a concise description of the Applicant Agency, including its history, years of operation, general mission statement and primary services provided.
250 words, approx. ½ page
- How does the Applicant Agency support the United Way of Broward County?
☐ Workplace fundraising campaign
☐ Facility tours
☐ Speakers’ bureau members
☐ Event Support
☐ Other (Please describe) ______
- Has the Applicant Agency been a defendant in any litigation or regulatory action in the last three (3) years? If yes, provide a brief explanation of each instance.
- Accreditation and Accreditation Process: All funded agencies must be accredited by 2020.
250 words, approx.. ½ page
Is the Applicant Agency currently accredited? If yes, please include the name of the accrediting body, the level of accreditation, and the time period.
If not currently accredited, please describe your plans to prepare for accreditation during the coming year and which accrediting body you plan to pursue and why.
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Part II: PROGRAM INFORMATION (Maximum Score is 60 Points)
- Program Information:
Program Name:
Funding Category:
Applicants may propose Universal and/or Selective programs to serve either Children/Youth or adults in a single application. If proposing to serve both Children/Youth and Adults, separate applications are required for each target population.
☐ Behavioral Health Universal Prevention
☐ Behavioral Health Selective Prevention
Population Category: / ☐ Children/Youth
☐Adults
Funding Request: / $
Is this program currently funded by UWBC? / Yes ☐ / No ☐
- Application/Program Contact Information:
Name:
Title:
Phone Number:
E-mail Address:
- Program Location(s):
(Attach additional addresses as needed)
Name of Service LocationAddress:
City & State: / Zip Code:
Name of Service Location
Address:
City & State: / Zip Code:
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- Program Summary
500 words, approx. 1 page (Up to 10 points)
Please summarize the proposed program including in the project title and requested funding amount. Provide an overview of the evidence-based model to be provided, the program’s key components, target population including individuals with unique needs such as military veterans, LGBT and gender diverse individuals and individuals with limited English proficiency, numbers to be served and geographic area.
If proposing a replication of a successful local program, clearly describe the program components, how long the program has been fully operational, current funding source(s) and present verifiable information as to program validity and history of positive impact. Describe the population that has been previously served and provide support for the proposed target population to be served with the requested funding.
- Statement of Need
500 words, approx. 1 page (Up to 15 points)
Describe the geographic area and target population to be served, including vulnerable populations with unique service needs such as military veterans, LGBT and gender diverse individuals and those with limited English proficiency and all service location(s). Provide a detailed overview of the conditions/problems/issues that demonstrates a clear need for the proposed services and why United Way funding is needed. The response should include demographics about the city, school, and/or neighborhood statistics for the proposed service area and other data that clearly supports program need.
- Evidence Based Prevention Model
1,000 words, approx. 2 pages (Up to 15 points)
Please provide a detailed description of the proposed evidence-based model with supporting evidence of its effectiveness with the proposed population. Discuss your experience with the proposed model and/or why it is an appropriate fit for your organization’s services. Describe client eligibility and how the population will be recruited and retained. Describe the proposed service schedule (days, hours, etc.) and dosage (frequency and duration).
Applicants proposing a replication of a local behavioral health program must explain why it is an appropriate expansion of your current organization’s services and provide sufficient information regarding program design, program components, frequency and duration of interventions including the following:
a.How the content and structure of the proposed program is similar to programs that have been deemed best or promising practices in peer-reviewed literature (SAMHSA's National Registry of Evidence-based Programs and Practices (NREPP):
b.How the interventions are based on sound scientific principles of community prevention;
c.The # of times the program has been implemented;
d.The fidelity of its implementation; and
e.The results of outcome performance and/or outcomes evaluations.
- Location(s) Where Services Will Be Provided
250 words, approx. ½ page (Up to 5 Points)
Demonstrate that your organization has access to, and control over, the physical space where services are to be provided.
If services will be provided in a physical space, or more than one location, that is outside of your organization’s immediate control, provide documentation that the property owner has given permission for use of the space for your proposed program.
- Evaluation Plan
500 words, approx. 1 page (Up to 5 points)
Describe your proposed evaluation processes. Please provide an overview of your proposed outcomes using a “Results Based Accountability” framework and your target goals for each. Describe the measurement tools you intend to employ. Describe the proposed data collection methodology and data collection points.
- Organizational Capacity
500 words, approx. 1 page (Up to 5 points)
Describe the agency’s experience with providing the proposed service. Describe the agency’s experience in working with the targeted population. Please provide an overview of key staffs’ experience with providing the proposed service to the target population. Address how and why the agency is uniquely qualified to provide services in the geographic area proposed. Please provide a detailed overview of the agency’s cultural and linguistic competencies. Please address whether the program or age.
- Collaboration and Coordination
250 words, approx. ½ page (Up to 5 points)
Describe the agency’s existing programmatic and any other relevant collaborations, partnerships, or coordination of services. Explain the agency’s capacity to leverage other services, funding, and/or resources.
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PART III:ORGANIZATIONAL ATTACHMENT(S) CHECKLIST
(Required/No Point Value)
Attachment A:
Audited Financial Statement(s): Must be included with Application as Organizational Attachment “A”. Applicant Agencies are required to submit their audited financial statements for the most recently completed fiscal year or the previous fiscal year if the most recent one ended within 180 days of the due date of this Application. Smaller agencies (those agencies with annual revenues less than $300,000) must submit unaudited compiled financial statements prepared by a CPA.
Attachment B:
Applicant Agency Verification: Complete and attach the two (2) page form provided as Organizational Attachment “B” to the Application. Requires original signature duly verifying the authority of the signatory to act on behalf of the Applicant Agency for this Application and certifies that all representations made in the Application are true and correct.
Attachment C:
Certificate of Corporation: Must be submitted as Organizational Attachment “C”. The Applicant Agency is required to attach a printout of the Public Inquiry page from Corporations Online, ( dated within twelve (12) months of the due date of this RFA, stating that Applicant Agency is active. In the alternative the Applicant Agency may submit a copy of its Certificate of Corporation from the Secretary of State, State of Florida certified and dated by the Secretary of State within twelve (12) months of the due date of this RFA. This Certificate must state on its face that the Applicant Agency is active. Please note that a copy of the Articles of Incorporation, acknowledgement of Annual Reports, or any similar document does not meet the requirements of this section.
Attachment D:
Current Drug Free Work Place Certification: Complete and attach the two (2) page form provided as Organizational Attachment “D”. This certifies that the Applicant Agency will provide a drug-free workplace. Notarized original signature required.
Attachment E:
IRS determination of 501 (c) (3) nonprofit status, if applicable. Include as Organizational Attachment “E”.
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Attachment F:
Client Non-Discrimination Policy: A sample policy is provided. Include the Applicant Agency’s current policy as Organizational Attachment “F”. The Applicant Agencywill not engage in or commit any discriminatory practice in violation of the BrowardCounty Human Rights Act. Original signature required.
Attachment G:
Current Equal Employment Opportunity Policy: A sample policy is provided. Include the Applicant Agency’s current policy as Organizational Attachment “G”.
Attachment H:
Current Americans with Disabilities Act Policy: A sample policy is provided. Include the Applicant Agency’s current policy as Organizational Attachment “H”.
Attachment I:
Include a direct line Organizational Chart showing where this program would function within the Applicant Agency if the requested funds are awarded. The Organizational Chart should be attached to this Application as Organizational Attachment “I”.
Attachment J:
Not-for-Profit organizations must include a list of the Applicant Agency’sBoard of Directors, and/or Advisory Board, including their addresses and offices held within the Board as Organizational Attachment “J”.
Attachment K:
The second page of the Organizational Profile for Providers, which has been submitted to 211-Broward First Call for Help, must be attached to this Application as OrganizationalAttachment “K”. Directions for obtaining the appropriate form can be accessed by calling the Information Manager at 211-Broward First Call for Help at (954) 390-0493 or by emailing at
Attachment L:
Cultural Linguistic Policy and Plan: Include the Applicant Agency’s current policy as Organizational Attachment “L”.
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Organizational Attachment “A”
AUDITED FINANCIAL STATEMENTS
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United Way Commission on Substance Abuse
Application for Behavioral Health Universal and Selective Prevention Programs
Available February 5, 2018
Closing March 9, 2018
United Way of Broward County - Request for Applications
Organizational Attachment “B”
AGENCY VERIFICATION
NAME OF Applicant Agency: ______
I hereby certify that:
1.I am duly authorized to sign this Application.
2.I have participated in and/or read the information provided in this Application and agree to the terms and conditions in the Application.
3.Quotations and all other responses in this Application are, to the best of my knowledge, accurate and true.
4.I recognize that failure to be truthful in this Application may result in the canceling of a contract award.
5.I understand that United Way of Broward County will award the contract that is most advantageous to Broward County, taking all other factors into consideration.
6.I certify that all persons, companies or parties interested in the Application, made it without collusion with any other person, persons, company or parties submitting an Application and that it is in all respects made in good faith.
7.I certify that NO litigation is threatened or pending which could impair this Applicant Agency’s ability to fulfill the provisions of this Application.
8.I certify that NO adverse action is pending or threatening by any regulatory, licensing, or oversight Applicant Agency which could impair the Applicant Agency’s ability to fulfill the provisions of this Application.
9.All Applicant Agency decisions regarding recruitment, hiring, promotions, releases, and conditions of employment will be made without regard to consideration of race, creed, religion, gender, country of national origin, age, physical or mental handicap, marital status or any other factor which cannot lawfullybe used as a basis for an employment decision.
10.The budget included in this Application is a reasonable estimate of the anticipated revenues and expenditures for the activities proposed.
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Organizational Attachment “B”, Agency Verification, page 2
11.Any of the following documents are available upon request by the United Way of Broward County and will be produced by the Applicant Agency within five (5) work days and may not need to be submitted with this Application:
a.Agency By-laws
b.Personnel Policies and Procedures
c.Job Descriptions
d.Licenses to Operate Agency/Program
If any of these statements cannot be made, please explain on a separate 8 ½ x 11 sheet of paper and attach to this form.
OFFICIAL AUTHORIZED TO SIGN AND BIND Applicant Agency TO APPLICATION: / WITNESS SIGNATURES:Signature / Signature
Name (Print or Type) / Name (Print or Type)
Title (Print or Type) / Date
Date
Signature
Name (Print or Type)
Date
10
United Way Commission on Substance Abuse
Application for Behavioral Health Universal and Selective Prevention Programs
Available February 5, 2018
Closing March 9, 2018
United Way of Broward County - Request for Applications
OrganizationalAttachment “C”
CERTIFICATE OF CORPORATION
11
United Way Commission on Substance Abuse
Application for Behavioral Health Universal and Selective Prevention Programs
Available February 5, 2018
Closing March 9, 2018
United Way of Broward County - Request for Applications
Organizational Attachment “D”
DRUG FREE WORKPLACE CERTIFICATION
The undersigned Applicant Agency hereby certifies that it will provide a drug-free workplace program by:
(1)Publishing a statement notifying its employees that unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace, and specifying the actions that will be taken against employees for violations of such prohibition;
(2)Establish a continuing drug-free awareness program to inform its employees about:
(I)The danger of drug abuse in the workplace;
(ii)The policy of maintaining a drug-free workplace;
(iii)Any available drug counseling, rehabilitation, and employee assistance programs; and
(iv)The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
(3)Giving all employees engaged in performance of a contract a copy of a statement required by subparagraph (1);
(4)Notifying all employees, in writing, of the statement required by subparagraph (1), that as a condition of employment on a covered contract, the employee shall;
(I)Abide by the terms of the statement; and
(ii)Notify the employer in writing of the employee’s conviction under criminal drug statute for a violation occurring in the workplace no later than 5 calendar days after such conviction;
(5)Notifying United Way of Broward County in writing within 10 calendar days after receiving under subdivision (4) (ii) above, from an employee or otherwise receiving actual notice of such conviction. The notice shall include the position title of the employee;
(6)Within 30 calendar days after receiving notice under subparagraph (4) of a conviction, taking one of the following actions with respect to an employee who is convicted of a drug abuse violation occurring in the workplace:
(I)Taking appropriate personnel action against such employee, up to and including termination;
(ii)Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purpose by federal, state, or local health, law enforcement, or other appropriate agency; and
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Organizational Attachment “D”, Drug Free Workplace Certification, page 2
(7)Making a good faith effort to maintain a drug-free workplace program through implementation of subparagraphs (1) through (6).
______
(Applicant Agency Signature)
______
(Print Applicant Agency Name)
STATE OF
COUNTY OF
The foregoing instrument was acknowledged before me this day of ,
20 , by ______
(Name of individual signing)
As of
(Title) (Name of Applicant Agency/entity)
Known to me to be the person described herein, or who produced as identification, and who did/did not take an oath.
NOTARY PUBLIC
My commission expires:
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United Way Commission on Substance Abuse
Application for Behavioral Health Universal and Selective Prevention Programs
Available February 5, 2018
Closing March 9, 2018
United Way of Broward County - Request for Applications
OrganizationalAttachment “E”
IRS Form 501(c) (3)
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Organizational Attachment “F”
CLIENT NON-DISCRIMINATION POLICY
In accordance with Title VII of the Civil Rights Act of 1964, the Americans with Disabilities Act of 1990, and the Broward County Human Rights Act (Broward County Code, Chapter 16½), the Applicant Agency’s decisions regarding the delivery of services under any Agreement with Broward County will be made without regard to, or consideration of race, age, religion, color, gender, sexual orientation, national origin, marital status, physical or mental disability, political affiliation, or any other factor which cannot be lawfully used as a basis for service delivery.