0 a

Change Table

CCF Evaluation – Baseline Survey

Question

Previous Version

Proposed Change

1

Name of your organization

Name of the organization that will be the primary recipient/beneficiary of assistance requested

2

Address:___________________________________________________________

Street: ____________________________________________________ City/State:________________________ Zipcode:____________

3

ADD: 3b. Date of completion:_______________________

9

ADD: (Check all that apply)

ADD:

• Personal/professional network

10a

Renumbering from 10 to 10a

10b

No previous 10b

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

11

In what year was your organization established? ___________

In what year was your organization formed? ___________

12

ADD:

 NA – our organization has not yet begun providing services

 NA - our organization does not provide direct services

15

Does your organization have a written mission statement?  Yes  No

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 written strategic plan?  Yes  No

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

20

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

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

 Increased  Decreased  Stayed about the same

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.

20. Please give your best estimate of the total number of people (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

22

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

 Yes  No

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

24

ADD: If you have been in operation less than one year, please tell us your organization’s total expenditures to date.

26

 Another staff person

 Another staff person: explain______________________________

27

ADD: (Check all that apply):

29

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

 Yes  No

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

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

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

• No

32

Delete the following from this question; Address these sources of revenue in new 32b &32 c (see below)

Please answer the following questions as they apply to fundraising activities over the past 12 months.

	Number of applications for funding submitted in the past 12 months	Number of applications approved in the past 12 months	Total amount of funds from this source in past 12 months	% of total revenue obtained 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 (e.g., United Way)
Direct mail fundraising
Special fundraising events
Fundraising appeals made in church or community
Door-to-door fundraising appeals
Other (Specify:) _______ ____________

32a

No previous 32a

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

32b

No previous 32 b

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 n 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

No previous 32c

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 worshp 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):­­­­­­­­­­­­­­­_______________________________________

37

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

 Yes  No

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

39

Rearrange columns a, b & c so that a + b = c.

Define “primarily administrative” as “spending more than 50% of their time working in an administrative capacity”

Define “primarily a direct service staff person” as “spending more than 50% of their time providing direct services”

40

ADD: “If you have unpaid staff/volunteers” before the question

ADD:  NA – no unpaid staff/volunteers

41

ADD  NA – Organization was not in existence a year ago

42

ADD  NA – Organization was not in existence a year ago

45

ADD  NA – we do not have paid staff

 NA – we do not have volunteer staff

46

ADD  NA – we do not have paid staff

 NA – we do not have volunteer staff

Delete the following from this question; Address training activities in new 47a and 47b (see below)

Use the chart below to indicate the extent to which the head of your organization or staff (paid or volunteer) participated in training (or similar learning opportunities) related to:

management and administration (such as financial management, personnel management, outcomes measurement), fundraising (grant writing, developing a funding plan), or

service delivery (training in order to start a new service, training to increase skills needed for direct service role)

	(a) Did the head of the organization participate in the past 12 months	(b) Number of other paid and volunteer staff that participated in the past 12 months
Training related to management and administration	 Yes  No	#
Training related to fundraising	 Yes  No	#
Training related to service delivery	 Yes  No	#

47a

No previous 47a

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

No previous 47b

47b. Please specify the number of paid and volunteer staff (excluding the head of the organization) 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

51

ADD:  We do not have a Board of Directors, but we have an advisory panel

51a

51a. If no, does your organization have plans for establishing a Board of directors?  Yes  No (Go to question 59)

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)

58

ADD to chart:

Researching/finding resources to determine how best to form a board

59

ADD: Exclude computers that are personal or public property

65

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