Consultation Form 2017-2018 / 1

National Direct Consultation Instructions

CNCS expects State Commissions and National Direct applicants to consult and coordinate activities at the local level, as specified in Section 131 of the NCSA (42 U.S.C. § 12583). This consultation is designed to ensure the most effective use of national service resources and lead to enhanced coordination.

To ensure coordination:

National Direct applicants, except federally-recognized Indian Tribes, must:

Before application submission:

  • Consult with the State/Territory Commission of each state and/or Territory in which the organization knows it will operate and describe this consultation in their applications.
  • Contact the State/Territory Commissions for details about the consultation process.
  • Provide information that connects the proposed activities to the current State/Territory Service plan and/or State logic model.

After grant award:

  • Provide the State/Territory Commission with contact information for National Direct programs in the state and/or Territory and update these lists on an annual basis.
  • Participate in the State/Territory Commission’s annual needs assessment and training plan development activities, and in the development of its state/territory service plan, as well as appropriate training and other events.
  • Include the State/Territory Commission on the National Direct’s mailing list and invite it to appropriate training and other events.

State Commission Contacts:

Initial consultation and questions may be directed to Don Stamper, Executive Director – Missouri Community Service Commission, at (573) 751-5012 or .

Submission & Deadline:

Completed National Direct Consultation Forms should be submitted via email to Jerron M. Johnson, Chief Field Program Officer – Missouri Community Service Commission, at by 5:00 pm (CST) on Wednesday, January 18, 2017.

Missouri Community Service Commission

301 W. High St., Room 770

P.O. Box 118

Jefferson City, MO 65101-1517

Main Phone: (573) 751-7488

Toll Free: (877) 210-7611

Missouri Community Service Commission | 301 West High Street, Ste 770 | Jefferson City, Missouri 65101
State Service CommissionContact Person / Jerron M. Johnson, Chief Field Program Officer

LEGAL APPLICANT INFORMATION
Organization
Contact Person (Name & Title)
Street Address
City, State, and Zip
Email Address
Phone
APPLICATION INFORMATION
Application Type / New (First-time or Previous Grantee)
Re-compete
Continuation (Year of 3 Year Cycle)
Grant Type / National Direct
Education Award
Professional Corps
Indian Tribe
AmeriCorps Program Model
(check one) / National (Members at local organizations directly controlled by parent)
Affiliates(Members at affiliates of parent – limited direct control)
Consortium(Members at independent organizations that interact on activities beyond AmeriCorps)
Intermediary(Members at unrelated organizations)
Proposed AmeriCorps National Program Name
Program/Grant Period (Start and End Date)
MEMBER SLOT INFORMATION
MT
(300 hrs) / QT
(450 hrs) / RHT
(675 hrs) / 2-YR HT
(900 hrs) / 1-YR HT
(900 hrs) / FT
(1700 hrs)
Total Number of
Member Slots
Total Member Slots Proposed for Missouri
BUDGET INFORMATION
Total Proposed Operating Budget / $
Total CNCS Share of Proposed Budget / $
Total CNCS Share Proposed for Missouri / $
Total Number of MSYs
Cost per MSY / $ / MSY
Proposed Source of Match
PROGRAM OVERVIEW
AmeriCorps Program Focus
(Brief narrative of the community
problem and need being addressed.)
Description of Proposed Activities
(Brief succinct description of how Members will achieve results. Explainexactly what Members will be doing. Give a clear picture of Member activities.)
Target Beneficiaries within the State
Target Outputs and Outcomes within the State
PREVIOUS YEAR PERFORMANCE (if applicable)
Prior Years Data on Primary
Performance Measures
Prior Year Member Enrollment Rate
Prior Year Member Retention Rate
ORGANIZATIONAL CAPABILITY
Date of Most Recent A-133 or Financial Audit (If there were findings, how were they resolved?)
Role of Parent in Administration of Program at State Level(i.e. site monitoring; background checks; training and development)
AmeriCorps Program Staff (How many staff in the State will oversee the program? If none in the State, what staff will oversee the program?)
Overview of Proposed Site(s)
(For each proposed site, provide the following information
Operating or service site:
Location of site
Number of Members:
Does this site oversee Members from any other AmeriCorps program? If so, please name. / Site 1:
Site 2:
Site 3:
NATIONAL SERVICE COLLABORATION
Skills and Resources to Share w/ Other Streams of National Service within the State