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CCF Evaluation – Follow-up Survey

Question

Previous Version

Proposed change

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Address:______________

Street: _______________________________________________________

City/State:________________________ Zipcode:____________

6 and 6a.

6. During the past 15 months, did your organization receive services/assistance from [The Intermediary]?

 Yes  No

6a. If yes, please indicate the type of assistance/service (Check all that apply)

• Financial Assistance  If financial assistance, what was the total amount of funding you received during the past 15 months from this source? $______________________

• One-on-one, customized technical assistance (TA)

• Training through workshops or conferences

• Other (Specify:) _______________________________

6. During the past 12 months, did your organization receive any of the following services/assistance from [The Intermediary]? (Check all that apply.)

Financial Assistance [ ] 01

If financial assistance, what was the total amount of funding you received during the
Past 12 months from this source?	$

Technical Assistance (TA) (one-on-one consultation tailored to your organization’s needs) [ ] 02

If yes, please characterize the TA received as either:

On-going [ ] 03

One-time episode [ ] 04

Training through workshops or conferences [ ] 05

If yes, please characterize the Training received as either:

On-going [ ] 06

One-time episode [ ] 07

Other (Specify:) [ ] 94

None [ ] 00

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7a.

No previous 7b

7b. In the last two years, has your organization filed a 990 tax form?

Yes[ ] 01

No[ ] 02

No previous 7c

7c. What is your organization’s EIN number?___________________________

8

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

9

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

No previous 10b

10b. If yes, was this external assessment conducted/guided by:

[the intermediary] [ ] 01

Other [ ] 02

Both [ ] 03

11a.

Has your organization added/expanded or reduced programmatic areas in the past 15 months?

• Yes  Please describe __________________________________________________________

• No

11a. Eliminate “or reduced”

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Add:  NA – we do not provide or have not yet provided services to individuals/families

14

Add:  NA – we do not provide or have not yet provided services to individuals/families

16

Add (under “type of assistance”):  Did not receive this type of assistance

19

Add: (Check all that apply):

19

 Another staff person

 Another staff person: explain______________________________

20

Add: (Check all that apply):

22

Add: Yes, have financial management procedures that provide checks and balances, but they are not written [ ] 02

22

No previous 22a

22a. Has your accounting system changed in the past year?

Yes (Briefly explain:) [ ] 01

No [ ] 02

24

No previous 24a

24a. What was your organization’s total revenue over the past 12 months?

$

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Reformat the question into multiple parts for clarity (see 24b, c, and d below)

24b.

No previous 24b

24b.Please indicate the amount of revenue from these sources over the past 12 months.

Revenue Source	Total amount of funds from this source in the past 12 months
Direct mail fundraising
Special fundraising events
Fundraising appeals made in church or community
Door-to-door fundraising appeals
Grants/contracts
Allocation from another organization (such as your church)
Fees for service (Specify):­­­­­­­­­­­­­­­_______________________________________
Other (Specify):­­­­­­­­­­­­­­­_______________________________________

24c. In the past 12 months, did your organization apply for or receive a grant/contract?
 Yes  No (If no, skip to Q33)

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:)

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Renumbered as 24d.

Please list the source and amount of each cash grant that your organization has received in the past 12 months. Then check the box(es) for each that describes what your organization intended to accomplish with this money. In the first row, if applicable, please describe the grant your organization received from [the intermediary]. If you need more space to record information about grants, please complete the list using the formatted chart at the end of this survey (page 34). Copy this chart as many times as needed to complete this list.

Source of Grant	Amount of Grant	Goal of Grant (Check all that apply)
#1 [The intermediary] NA – did not receive a grant from [the intermediary] #2 Federal gov agencies State gov agencies Local gov agencies Foundations Other federated giving groups (ex United Way) Other (specify)	$______	Start up new program Implement programmatic Best Practices Expand type of services Increase number of service recipients Develop Board of Directors Train administrative staff (Specify area of training:) Train program staff (Specify;) _________________ Increase/diversify income and resourcees Improve image/public relations Improve general management, financial management or administrative systems Develop system for tracking outcomes Other (Specify:) Start up new program Implement programmatic Best Practices Expand type of services Increase number of service recipients Develop Board of Directors Train administrative staff (Specify area of training:) Train program staff (Specify;) _________________ Increase/diversify income and resourcees Improve image/public relations Improve general management, financial management or administrative systems Develop system for tracking outcomes Other (Specify:)

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31

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32

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

• Yes

• No

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

ADD: Yes, we have a written fund raising/fund-development plan [ ] 01

Yes, we have a fund raising/fund-development plan but it is not written [ ] 02

No [ ] 03

33

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34

Renumber 32: Add percent time to help define positions. Reorder columns in chart so that (a) + (b) = (c):

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 provid-ing 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)	#		+	#			=	#

35

What is the estimated total number of volunteer hours contributed by all unpaid staff/volunteers in an average week?

__________

Renumber 33: ADD: “If you have unpaid staff/volunteers,” before the question.

ADD: 33a. If you do not have volunteers, is recruiting volunteers

A current goal of your organization [ ] 01

Not a goal because of the nature of organization’s work [ ] 02

Not a current goal, but a likely future goal [ ] 03

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38

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ADD: “NA – we do not have paid staff” and “NA – we do not have volunteer staff”

39

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ADD: “NA – we do not have paid staff” and “NA – we do not have volunteer staff”

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Change format and separate into two questions:

ADD: 38a. 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) [ ] 01

Training related to fundraising (e.g. grant writing, developing a funding plan) [ ] 02

Training related to service delivery (e.g. training in order to start a new service, training to increase skills needed for direct service role) [ ] 03

None of these activities [ ] 04

38b. 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 [ ] 02

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ADD Focus Area: Hiring additional staff

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Add Focus Area: Researching/finding resources to determine how best to form a board

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ADD: Exclude computers that are personal or public property.

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

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