FY18/19 Funding Application
INSTRUCTIONS FOR THE FUNDING APPLICATION
· The Final Funding Application Deadline is Friday, March 2, 2018 at 12:00 p.m. (noon). [NO EXCEPTIONS]
· Applications must be submitted to: St. Louis Office for Developmental Disability Resources
2334 Olive Street
St. Louis, MO 63103
314-421-0090
· Staff of DD Resources will prepare a funding recommendation to the Board Committee. A copy of the recommendation will be sent to the Agency’s Executive Director. To expedite this process, no additional contact will be made with Agencies once the application has been received by DD Resources.
· To ensure accountability, all applicants must comply with the guidelines set forth in the DD Resources Funding Manual (Revised September 2010) and the Board Approved Funding Cycle Guidelines (Revised November 2014).
· The applicant must submit one (1) three-hole punched single-sided application with original signatures and one (1) three-hole punched single-sided copy. The copy must be legible.
· The application must be written in a minimum of eleven (11) point font. Narrative portions must be single-spaced.
· Agencies may contact the St. Louis Office for Developmental Disability Resources (DD Resources) Agency Relations and/or Fiscal Departments with questions regarding the application and/or to receive application training. However, no questions, training sessions, or meetings will be addressed or provided after Friday, February 23, 2018 at 4:30 p.m.
· All applicants must submit a Public Disclosure Copy of Form 990 with this application. Applicants receiving $25,000.00 or more will be required to submit an audit at the close of the agency’s fiscal year as outlined in the Funding Manual (Revised September 2010).
· Please be certain all applicable questions are addressed. The Funding Application represents the Agency’s request. Applications that are incomplete, missing attachments, or not in the sequence and/or format as shown in this application will not be considered for funding. Listed below is the sequencing format for all completed applications. Please mark “NA” on the checklist below if the indicated form does not apply to the agency’s request.
CHECKLIST
All items below are required to be submitted with the application unless noted otherwise.
_____ CHECKLIST (this page)
_____ AGENCY CONTACT INFORMATION
_____ REQUEST SUMMARY
_____ ASSURANCE STATEMENT AND INDEMNIFICATION CLAUSE
_____ PROGRAM ANALYSIS
_____ RATE AND UNIT COMPARISON
_____ RESERVE POLICY
_____ STAFFING PATTERN
_____ PROGRAM BUDGET
_____ PROGRAM REVENUE
_____ CONTRACTED TRANSPORTATION BUDGET
_____ IN-HOUSE TRANSPORTATION BUDGET
APPLICATION SUPPORT DOCUMENTS – (Submit only one copy of the following items regardless of the number of programs being submitted for consideration.)
/ Annual Renewal Items(Check with DD Resources Fiscal Department to determine if any of the items below are required with the application)
/
Certificate of Corporate Good Standing (less than 12 months since issue date)
/Certificate of Insurance (must list DD Resources as an ‘Additional Insured’)
/Most recent audit including POS unit rate calculation (If program funded $25,000 or more or the cumulative amount for multiple programs is $25,000 or more)
/Management Letter (if applicable)
/Public Disclosure Copy of Form 990 (for all agencies)
/Current List of Board of Directors
(Include board position and work affiliation for each member)
/ Submit Updates OnlyBylaw Revisions
Articles of Incorporation
501(c)(3) Tax Exempt Status
AGENCY CONTACT INFORMATION
For Funding Period July 1, 2018 through June 30, 2019
Submitted by:
Name of Agency/Corporation Applying for Funds
Mailing Address City State Zip Code
______
Name and Title of Person Completing Form Email Address of Person Completing Form
______
Name of Program Director Email Address of Program Director
______
Name of Financial Contact Person Name of Agency Director
______
Agency Phone Number Agency Website Address
______
Agency Fax Number General Agency Email Address
Request Summary
This application is to request funding for: (Check appropriate categories)
Program Services Transportation Services
Name of Program: ______
*PLEASE NOTE: Agencies wishing to make changes to existing programs (i.e. number of individuals served, program implementation, program format, etc.) must meet with the DD Resources Executive Director, or designee, prior to submitting a funding application. ONE WEEK prior to the meeting, agencies MUST submit a brief proposal which includes a summary of the program, the target population, number of consumers to be served, projected unit request, unit rate, and other costs associated with the program. Unit rate information should include all activities covered by the unit rate. Requests for salary grants must also include a budget (cost breakdown).
*Date of Meeting with Executive Director OR DESIGNEE: ______
Amount Requested 07/01/18 through 06/30/19
The amount requested must not exceed the program’s approved allocation for FY17/18. There is no guarantee of continued funding. All application dollar amounts should be rounded down to the nearest whole number.
Program Services ______
**Transportation Services ______
Total amount requested ______
**Please complete In-House Transportation (page 13) if your agency has a separate unit rate for transportation.
ASSURANCE STATEMENT
We, the undersigned, hereby certify that the statements made in this application are correct to the best of our knowledge and belief, that we are authorized to sign this application on behalf of the applicant, and that we have read, understand, and shall comply with the Funding Manual and the Funding Agreement, if funding is approved for the program.
Indemnification clause
We, the undersigned, hereby certify that the Agency agrees to hold harmless, defend and indemnify DD Resources for any and all loss and liability for bodily injury, personal injury and/or property damage stemming from any acts, negligence, misfeasance or omissions arising out of the Agency's performance of this Agreement. The Agency further agrees to hold harmless, defend and indemnify DD Resources for any and all liability that may be incurred by DD Resources if DD Resources or the Agency is found to be in violation of the Americans with Disabilities Act as a result of acts or omissions on the part of the Agency or its employees or agents or those acting on its behalf. The Agency agrees it has or shall obtain, prior to the commencement of this Agreement, and maintain liability insurance, naming DD Resources as an Additional Insured, in form and amount sufficient to indemnify DD Resources for any loss or liability and it shall, provide DD Resources with documentation evidencing this insurance within six (6) weeks after the date of this Agreement.
In addition the undersigned certify that the agency has no outstanding tax or other liens and/or pending legal actions against any agency property or assets. Finally, the agency’s Board of Directors is aware of and agrees to pursue funding from DD Resources.
______
Signature, Agency Director Date Signature, Board Chairperson Date
(or designated Board Member)
______
Printed Name, Agency Director Date Printed Name, Board Chairperson Date
(or designated Board Member)
SERVICE CATEGORIES
Residential Services:
Definition: Residential Services support eligible individuals with acquiring, developing and maintaining skills needed to live in the community. Residential Services promote healthy and safe independent living for eligible individuals.
Supported Living services include teaching independent living skills such as: cooking, cleaning, grooming/hygiene, laundry, comparison shopping, housing, budgeting, bill paying, emergency procedures, and providing support with medical needs which include but are not limited to assisting with doctor appointments and medication management. All service recipients for Supported Living must be 18 or over; services cannot be provided to individuals enrolled in high school.
Expectations:
Program administrators will:
· Assess the consumers’ need for the service.
· Assist the consumer with establishing an individual support plan, with outcomes (based on the assessment and consumer input), which will guide the delivery of service.
· Ensure services are structured and provided to assist consumers in achieving individual service outcomes.
· Document outcome related activities, showing progress toward achieving individual service outcomes.
· Adjust strategies when a consumer is not making progress toward achieving individual service outcomes.
· Fade, or end, supports when services are requested to maintain skills or provided on an as needed basis.
Outcome: Individuals with developmental disabilities develop and maintain the skills and abilities to live safely and independently in the City of St. Louis.
Employment Services:
Definition: Employment Services support eligible individuals with acquiring, developing and maintaining the skills needed for employment. Employment services should assist the eligible individuals with reaching their maximum potential in job duties and responsibilities, earned wages/income, and overall satisfaction with the chosen career.
Job Retention services are accessed once an individual’s Vocational Rehabilitation supported employment benefits have been exhausted or denied and the individual’s employment support needs are at a frequency of 25% or less of his/her total hours worked.
Expectations:
Program administrators will:
· Assess the consumers’ need for the service.
· Assist the consumer with establishing an individual support plan, with outcomes (based on the assessment and consumer input), which will guide the delivery of service.
· Ensure services are structured and provided to assist consumers in achieving individual service outcomes.
· Document outcome related activities, showing progress toward achieving individual service outcomes.
· Adjust strategies when a consumer is not making progress toward achieving individual service outcomes.
· Fade, or end, supports when services are requested to maintain skills or provided on an as needed basis.
Outcome: Individuals with developmental disabilities reach their maximum potential as indicated by job duties and responsibilities, earned wages/income, and overall satisfaction with the chosen career.
Related Services:
Definition: Related Services support eligible individuals with acquiring, developing and maintaining skills that are not entirely Residential or Employment by definition but are necessary for healthy, safe and full inclusion in the community. Related Services can include socialization programs and training services for the purpose of promoting empathy, awareness, education and advocacy for developmental disabilities as well as reducing social stigma commonly associated with developmental disabilities.
Expectations:
Program administrators will:
· Assist the consumer with establishing an individual support plan, with outcomes (from consumer input), which will guide the delivery of service
· Ensure services promote accessibility, inclusion, and reduce stigma commonly associated with developmental disabilities.
Outcome: Individuals with developmental disabilities develop and maintain the skills and abilities to locate and participate in meaningful activities within their community and home environments.
PROGRAM ANALYSIS
Provide a response to each statement/question regarding the services for which funding is being requested.
1. Provide an impact statement for the program including details related to how the program helps DD Resources meet its mission.
2. Provide a response to each of the questions below, describing the program in detail:
a) What specific services and supports are provided?
b) What is the target population (age of consumers to be served, eligibility criteria, etc.)?
c) What is the program’s setting (school, agency, community, home, etc.)?
d) What is the proposed frequency and duration of the program (i.e. how often the service takes place on average, whether it is ongoing or time-limited, and if time-limited, the length of time a consumer may participate)?
e) Is the program offered in an individual setting, group setting, or both? If offered in a group, please include the staff to client ratio and identify the group size, including any restrictions to group size.
f) Provide any additional information regarding how the agency plans to implement this program.
3. Measurable Outcomes:
a) List the measurable outcomes for this program.
b) What data is collected to measure progress toward the outcomes?
c) At what frequency is data reviewed?
d) How is the data used in the agency/program’s quality improvement process?
4. Does this program follow an established model of best practices or a form of evidence-based research to guide service implementation? Please cite any published works or the model to be followed during program implementation. If not, explain why the program does not follow a specific model or evidence-based research.
5. Discuss the agency’s qualifications and specialized experience related to this program (e.g. program coordinator backgrounds, staff training, program certification/accreditation, etc.). Provide support for why the agency is uniquely qualified to implement this program.
6. If applicable, please explain client fees, program fees, co-pays and/or out-of-pocket expenses participants might expect (including lodging and food during trips). Include the specific fee amounts, what is covered by the fees, how the fees are determined, and the available financial assistance for those who are unable to afford the fees.
7. What is the agency/program’s fundraising plan?
8. If the agency is requesting to make changes to the structure of its program, please ensure any requested changes are in line with discussions from the program’s Funding Cycle Meeting, and provide the following information:
a) Specify any changes related to the unit request, unit rate amount or other budgetary changes (including changes to transportation costs or participant fees).
b) If this is a grant program, summarize any changes to the staffing pattern/key implementers.
c) Summarize all proposed changes to the structure of the program or program implementation.
9. Provide a brief, general description of the agency’s program to be utilized in DD Resources’ Program Directory and/or on DD Resources’ website if funding is approved.
10. Prior to submitting the funding application, please visit DD Resources’ website (stldd.org), “Funded Services’ tab, to verify that DD Resources is using the agency’s most current logo. Updated logos can be sent to the Agency Relations Representative; logos must be in either JPEG or PNG format.
RATE AND UNIT COMPARISON
Compare the rates, units, and number of consumers served with the program’s other funding sources.
Funding sources for FY17/18 / Rate / Number of Units / Number of Consumers Served / Funding sources for FY18/19 / Proposed Rate / Proposed Units / Number of Consumers to be ServedDD Resources / DD Resources
Productive Living Board / Productive Living Board
Jefferson County DDRB / Jefferson County DDRB
DDRB of St. Charles / DDRB of St. Charles
DMH / DMH
OTHER: (write in) / OTHER: (write in)
OTHER: (write in) / OTHER: (write in)
1. What is the definition of the proposed unit (i.e. hour, day, or event)? ______