Form 0 a

OMB No. 0970-0293

Expiration Date: 12/31/2008

Compassion Capital Fund Evaluation

Baseline Survey

This survey is a part of the application for assistance (financial and technical assistance) from [name]. Completing an application for assistance is voluntary. However, completion of this form is a requirement for organizations that choose to apply for assistance. Completed surveys should be submitted with all the other materials required as part of your request for financial assistance or technical assistance.

Information obtained through this survey will also be used for research purposes in a study sponsored by the U.S. Department of Health and Human Services to learn about the effects of capacity building services supported through the Compassion Capital Fund (CCF) program.

The survey responses will be accessed by the intermediary organization to which you are applying for assistance and by staff at the research firms conducting the evaluation of the Compassion Capital Fund. The research firms are: Abt Associates and Branch Associates. The evaluation includes collecting information from faith-based and community organizations at the time of an initial request for assistance and again approximately 15 months later to obtain updated information.

Notice: The Paperwork Reduction Act of 1995 requires the agency to inform all potential persons who respond to this collection of information that such persons are not required to respond unless it displays a currently valid OMB control number. (See 5 C.F.R. 1320.5(b)(2)(i)). The time required to complete this collection of information is estimated to average 30 minutes per response, including the time to review instructions and complete the information collection.

Responses to this data collection will be used only for statistical purposes. The reports prepared for this study will summarize findings across organizations and will not associate responses with a specific organization or individual. We will not provide information that identifies you or your organization to anyone outside the study team, except as required by law.

Please answer the questions in this survey about the organization (or project) that will be the primary recipient/beneficiary of the assistance requested, should your application be accepted. Throughout this questionnaire, the unit that is slated to be the primary recipient/beneficiary of the assistance is referred to as “your organization.” Please answer all questions about the current state of your organization.

1. Name of your organization that will be the primary recipient/beneficiary of assistance requested:

2. Street: ____________________________________________________________________________________________

City/State:________________________ Zipcode:____________

3a. Name of individual primarily responsible for completing this application:

3b. Date of completion:_______________________

4. Title:

5. Phone number: ______ - ______ - ____________ Email address:

6. Is your organization requesting:  Financial assistance  Technical assistance  Both

7. For what purpose(s) are you applying for assistance? (Check all that apply)

• Start up new program

• Implement programmatic Best Practices

• Expand type of services

• Increase number of people served

• Develop Board of Directors

• Train administrative staff

• Train program staff

• Increase/diversify funding and resources

• Improve image/public relations

• Improve general management, financial management or administrative systems

• Develop system for tracking outcomes

• Recruit, develop, or manage volunteers

• Expand/strengthen community partnerships/networking

• Strengthen long-term sustainability of the organization

• Other (Specify:)

8. Prior to this application, did your organization receive any assistance from [name]?

• Yes   Received financial assistance
   Received one-on-one, customized technical assistance
   Received training

• No

9. How did your organization learn about the availability of [name]’s CCF financial assistance (sub-award) program or technical assistance (TA) services? (Check all that apply)

• Announcement in local newsletter or other publication

• Announcement on intermediary’s website or other website (Specify site):
  

• Notice from intermediary’s mailing list (or email list)

• Conference or other gathering of faith-based and community organizations (name of conference/group:)
  

• Personal/professional network

• Other (Specify:)

Organization Profile

10a Please check the boxes that describe the organization that is the intended recipient/beneficiary of the requested assistance. The organization is… (Check all that apply)

• Unincorporated

• Incorporated, but hosted by a 501(c)(3) organization that serves as a fiscal agent

• In process of obtaining 501(c)(3) status

• 501(c)(3) organization

• Other (Specify:)

10b. What is your organization’s EIN number?___________________________

11. In what year was your organization formed? ___________

12. In what year did your organization begin providing services? ___________

• NA – our organization has not yet begun providing services

• NA - our organization does not provide direct services

13. Please check the box that best describes your organization:

• Faith-based/religious organization

• Non-religious community-based organization

14. Which describes the geographic area(s) where your organization provides services? (Check all that apply)

Urban (continuously built-up area of 50,000 residents or more) Large town (population between 10,000 and 50,000)

Rural (population under 2,500, not within a greater metropolitan area) Suburban (area with a commuting relationship with an urban center)

15. Does your organization have a mission statement?

 Yes, we have a written mission statement  Yes, we have a mission statement but it is not written  No

16. Does your organization have a strategic plan?

 Yes, we have a written strategic plan  Yes, we have a strategic plan but it is not written  No

17. In the past 12 months, has your organization conducted or participated in an assessment of organizational strengths/needs?

 Yes  No

17a. If yes, was the assessment conducted/guided by an external individual/entity?  Yes  No

Program Services

18. What are your organization’s primary programmatic areas? (Check all that apply)

At risk youth/children and youth services Economic/community development Elderly/disabled services Health Services Homelessness/housing assistance Hunger Job training/welfare-to-work Marriage/relationships Abstinence/pregnancy prevention

Prison ministry or prisoner reentry services Drug and alcohol rehabilitation Education Services to immigrants (including ESL) Other (Specify:) Other (Specify:)

19. Has your organization added/expanded programmatic areas within the past 12 months?  Yes  No

We would like to know about the number of people your organization serves. If you serve families, please count each family as one service recipient, otherwise please count individuals served as one service recipient.

19. Please give your best estimate of the total number of service recipients (individuals/families) your organization served in the most recent month of full service delivery: _________

• We do not provide services to individuals or families (skip to Q 21)

20a. Compared to about the same period a year ago, has the number of individuals or families served

• Increased

• Decreased

• Stayed about the same

21. Does your organization conduct formal measurement/assessments of the results and benefits of the services provided to individuals or families?  Yes  No

21a. If yes, who conducts the assessment:  In-house staff  External individual/organization  Both

22. Does your organization seek and obtain regular feedback from individuals/families on their satisfaction with services?

 Yes  No  NA – we do not provide or have not yet provided services to individuals/families

23. Below is a table listing possible focus areas for an organization. Please check one box for each focus area. See the key below.

A = Not a focus because we are satisfied with our achievement in this area

B = Have implemented steps to address focus area

C = Have developed plans or ideas to work on this, but haven’t implemented them yet

D = Know we should work on this but we lack the time or resources

E = Not an area of focus at this time

Focus Area	A	B	C	D	E
Increasing the number of clients served by the organization					
Increasing the number or scope of services offered to clients					
Incorporating a new approach to services to improve quality/ effectiveness					
Expanding services to include new group of service recipients or geographic area					
Developing a way to collect more information about our clients, including number and characteristics of clients as well as how they are helped by our programs					
Strengthening the organization’s ability to evaluate its overall effectiveness					

Financial Management

24. In the last completed fiscal year, what were your organization’s total expenditures? If you have been in operation less than one year, please tell us your organization’s total expenditures to date. $____________________

25. Does your organization have a designated person who is responsible for financial management (paying bills, making deposits, keeping records)?  Yes  No

26. Is the Executive Director/head of your organization the person responsible for financial management or is there another person responsible for this activity?

 Executive Director/head  Another staff person: explain______________________________

 Other: explain______________________________

27. Your organization prepares its budget (Check all that apply):

• Annually

• Quarterly

• Monthly

• Other (Specify:)

• The organization does not develop a budget on a regular basis.

28. Has your organization had an audit of its finances/financial records by an external auditor?  Yes  No

28a. If yes, was an audit conducted in any of the following years: 2002, 2003, or 2004?  Yes  No

29. Does your organization have financial management procedures that provide checks and balances for ensuring expenditures are properly authorized?

• Yes, have written financial management procedures that provide checks and balances

• Yes, have financial management procedures that provide checks and balances, but they are not written

• No

30. Please indicate the extent to which each of the following is considered a focus area for your organization. Please check one box for each focus area. See the key below.

A = Not a focus because we are satisfied with our achievement in this area

B = Have implemented steps to address focus area

C = Have developed plans or ideas to work on this, but haven’t implemented them yet

D = Know we should work on this but we lack the time or resources

E = Not an area of focus at this time

Focus Area	A	B	C	D	E
Developing systems that will help manage the organization’s finances more effectively.					
Putting in place a budgeting process that ensures effective allocation of resources.					

Funding

31. Has your organization ever applied for a federal grant or contract?  Yes  No  Don’t know

32a. What was your organization’s total revenue over the past 12 months? $______________

32b. In the past 12 months, did your organization apply for or receive a grant/contract?  Yes  No (If no, skip to

Q32c) If yes,please complete the following:

	Number of applications for funding submitted in the past 12 months	Number of applications approved in the past 12 months	Number of applications for funding submitted in the past 12 months that are pending	Total amount of funds from this source in the past 12 months
Grants/contracts from federal government agencies
Grants/contracts from state/local government agencies
Grants/contracts from Foundations
Grants from other federated giving groups (ex. United Way)
Other (specify:________________)

32c. Please answer the following questions as they apply to your other revenue sources over the past 12 months.

Revenue Source	Total revenue from this source in the past 12 months
Direct mail fundraising
Special fundraising events
Fundraising appeals made in house of worship or community
Door-to-door fundraising appeals
Allocation from another organization (ex: from parent/host organization)
Fees for service (Specify):­­­­­­­­­­­­­­­______________________________________
Interest earned from endowments and other investments
Unsolicited donations
Other (Specify):­­­­­­­­­­­­­­­______________________________________

33. Has your organization sought funding from any new sources (never before accessed) over the past 12 months?

 Yes  No

33a. Has your organization obtained funding from any new sources (never before accessed) over the past 12 months?

 Yes  No

34. Has your organization ever hired a grant/contract writer to prepare applications for funding?

 Yes  No

35. Has your organization ever hired a grant/contract writer to train staff to prepare applications for funding?

 Yes  No

36. Has your organization ever sent key staff to grant/contract writing workshops or similar learning opportunities?

 Yes  No

37. Does your organization have a fund raising/fund-development plan?

• Yes, we have a written fund raising/fund-development plan

• Yes, we have a fund raising/fund-development plan but it is not written

 No

38. Below is a table listing possible focus areas for an organization. Please check one box for each focus area. See the key below.

A = Not a focus because we are satisfied with our achievement in this area

B = Have implemented steps to address focus area

C = Have developed plans or ideas to work on this, but haven’t implemented them yet

D = Know we should work on this but we lack the time or resources

E = Not an area of focus at this time

Focus Area	A	B	C	D	E
Identifying and pursuing new sources of government funding.					
Identifying and pursuing new sources of non-government funding.					
Identifying and pursuing new sources of in-kind donations.					
Developing a fund-development plan (including setting fundraising goals).					

Human Resources

The following set of questions is about the staff at your organization. Please report only on staff who work for your organization on a regular basis at least two hours per week, either as paid staff or as unpaid staff/volunteers.

39. Please indicate the number of staff of each type and count each person as either primarily an administrative staff person (column a) or primarily a direct service staff person (column b). Column (c) should be equal to (a)+(b).

	(a) Number of staff spending more than 50% of their time working in an administrative capacity	(b) Number of staff spending more than 50% of their time providing direct services	(c) Total number of staff currently working at organization
Paid Staff
full-time (30 or more hrs/wk)	#_________________ +	#_________________ =	#_____________________
part-time (between 2 and 30 hrs/wk)	#_________________ +	#_________________ =	#_____________________
Unpaid Staff/Volunteers
full-time (30 or more hrs/wk)	#________________ +	#_________________ =	#_____________________
part-time (between 2 and 30 hrs/wk)	#________________ +	#_________________ =	#_____________________

40. If you have unpaid staff/volunteers, what is the estimated total number of volunteer hours contributed by all unpaid staff/volunteers in an average week?

__________

• NA – no unpaid staff/volunteers

41. Compared to about the same period a year ago, has the number of paid staff

 Increased  Decreased  Stayed about the same  NA – Organization was not in existence a year ago

42. Compared to about the same period a year ago, has the number of volunteer staff

 Increased  Decreased  Stayed about the same  NA – Organization was not in existence a year ago

43. Is the head of your organization (e.g., the executive director) a paid position?

 Yes, paid full-time salary  Yes, paid part-time salary  No, not a paid position

44. Over the past 5 years (or, if your organization is less than 5 years old, over the life of
the organization), how many individuals have served as head of your organization? __________

45. Is there a written job description for each staff position or job category?

Paid staff:  Yes  No  NA – we do not have paid staff

Volunteer staff:  Yes  No  NA – we do not have volunteer staff

46. Does your organization conduct annual performance reviews for

Paid staff?  Yes  No  NA – we do not have paid staff

Volunteer staff?  Yes  No  NA – we do not have volunteer staff

Leadership and Staff Development

47a. Which of the following did the head of the organization participate in the past 12 months?

 Training related to management and administration (e.g. financial management, personnel management,

outcomes measurement)

 Training related to fundraising (e.g. grant writing, developing a funding plan)

 Training related to service delivery (e.g. training in order to start a new service, training to increase

skills needed for direct service role)

 None of these activities

47b. Please specify the number of other paid and volunteer staff that participated in the following in the past 12 months:

_____# Training related to management and administration (e.g. financial management, personnel management, outcomes measurement)

_____# Training related to fundraising (e.g. grant writing, developing a funding plan)

_____# Training related to service delivery (e.g. training in order to start a new service, training to increase skills needed for direct service role)

 No paid or volunteer staff participated in these kinds of activities

48. In the past 12 months, has the head of your organization met regularly with a mentor who shares expertise and provides coaching and guidance regarding the duties and responsibilities of an executive director/organizational leader?

 Yes  No

49. In the past 12 months, has any staff met regularly with a mentor who shares expertise and provides instruction and guidance on performing the roles assigned to the staff?

 Yes  No

50. Below is a table listing possible focus areas for an organization. Please check one box for each focus area. See the key below.

A = Not a focus because we are satisfied with our achievement in this area

B = Have implemented steps to address focus area

C = Have developed plans or ideas to work on this, but haven’t implemented them yet

D = Know we should work on this but we lack the time or resources

E = Not an area of focus at this time

Focus Area	A	B	C	D	E
Creating a plan or locating resources to help our executive director and other staff improve their leadership abilities.					
Providing staff with professional development and training to enhance skills in service delivery or skills in administration and management.					
Recruiting, developing, and managing volunteers more effectively.					

Governance

51. Is there a Board of Directors focused solely on your organization? (Recall that “your organization” refers to the unit that is slated to be the primary beneficiary of this assistance.)

 Yes  We do not have a Board of Directors, but we have an advisory panel  No

51a. If no Board of Directors, does your organization have plans for establishing a Board of Directors?  Yes  No

(If no, go to question 58)

52. How many individuals are currently on your organization’s Board? ________

53. How many vacant positions are there on the Board? _________

54. Does the Board provide a formal orientation for new Board members?  Yes  No

55. At Board meetings, does someone regularly take minutes and keep record of attendance?

 Yes  No

56. What are the primary activities of the Board (Check all that apply)

Outreach to community and key stakeholders Develop organization’s budget Recruit new board members Set goals and strategies for the organization Review performance of programs & program outcomes

Review organization’s financial records to ensure funds were properly spent in support of the organization’s mission Conduct performance reviews of executive director Conduct performance reviews of other staff Other (specify):___________________

57. In the past 12 months, did any members of the Board participate in any training or similar learning opportunities to learn more about governance or roles and responsibilities of Board members?

 Yes  No

58. Below is a table listing possible focus areas for an organization. Please check one box for each focus area. See the key below.

A = Not a focus because we are satisfied with our achievement in this area

B = Have implemented steps to address focus area

C = Have developed plans or ideas to work on this, but haven’t implemented them yet

D = Know we should work on this but we lack the time or resources

E = Not an area of focus at this time

Focus Area	A	B	C	D	E
Researching/finding resources to determine how best to form a board					
Recruiting Board members with diverse expertise					
Developing a Board that represents a cross-section of our community					
Developing a Board with ties to different constituencies					
Providing information to the Board so they can better understand their responsibilities and create plans for improving their performance.					

Technology

59. How many functioning computers does your organization have? Exclude computers that are personal or public property. ________

60. Is this number sufficient for organization/staff needs?  Yes  No

61. Are staff sufficiently proficient in the use of computers/software as needed by your organization?  Yes  No

62. What kind of access does your organization have to the Internet?

• High Speed access

• Dial Up access

• No Internet access

63. Is the Internet used in support of organizational activities?  Yes  No

63a. If yes, in what ways (check all that apply)

• Supports the organizational website

• Staff uses internet to learn about funding opportunities

• Staff uses internet to gather information (data/statistics) needed to write grant applications

• Other (Specify:)

Recordkeeping

64. Does your organization regularly use computer software to keep financial records?  Yes  No

65. Organizations keep different types of records about program participants and services. Please indicate whether you keep records in the areas below and whether they are kept as paper or electronic records.

A = We do not keep records on this

B = We keep records on paper

C = We keep records electronically

D= NA – we do not have or do not yet have program participants and/or services

Types of Records	A	B	C	D
Number of individuals or families enrolled in/served through programs				
Referral sources of service recipients (referred by another agency, heard about program from friend)				
Needs of individuals/families upon first contact with program				
Types of services provided to individuals/families				
Information about individual service recipients’ outcomes				
Other (Specify:)			

Community Engagement

66. Which of the following has your organization done in the past 12 months to expand awareness about the organization to individuals or families in the community/service area? (Check all that apply)

Created or updated a website Developed or distributed written materials (such as a brochure or newsletter) Made presentations to faith-based or other community groups

Utilized public service announcements or paid advertising Other (Specify:) None

66a. Which of the following has your organization done in the past 12 months to expand awareness about the organization to potential partners or funders? (Check all that apply)

Created or updated a website Developed or distributed written materials (such as a brochure or newsletter) Made presentations to faith-based or other community groups

Utilized public service announcements or paid advertising Other (Specify:) None

67. Within the past 12 months, has your organization undertaken a specific activity (e.g., meeting with constituents, community mapping, needs assessment survey) to gain an understanding of the needs in your service area/community?

 Yes  No

68. Is your organization engaged in partnership arrangements with other organization in the community/service area?

 Yes  No

68a. If yes, what are the primary purposes of the partnership(s) (check all that apply)

• To receive and make service recipient referrals

• To develop & operate joint programming

• To access new funding sources (funding alliance)

• To recruit volunteers

• To participate in advocacy, awareness and education

• To obtain in-kind donations

• To assess community/service recipient needs

• Peer learning (learning circle, study group)

• To access complementary skills/knowledge (Specify:) _____________________________________________

• Other reasons for partnership (Specify:)

68b. If yes, what sector is/are project partners (Check all that apply)

• Government

• Business

• Educational institution

• Secular non-profit

• Faith-based sector

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November 21, 2005