IDesILaytags=,61 05180b032003ASDDSHS05_180bfukp`5%eP`4jcs Ҏ=,n*T;Fn4D h~} U; &,28>DJPV\bhntz6`Submit 6 ˬXY[6s6$64*35140800190180187jH4workpage-#####;#####-####() -(###) ###-####@@X  9 @@@@@@ @@@@@. .T8T Tݲ90/_T09/5M 8T.M lT/|LN M N TM "T/'T0/TLA./T..\AM   A.  A.@@@  @@N68/@@3 1&@XXjdVXXdʜ(?d fp 7l  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~lۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥ ContractNumber ProgramArea DateStamp AgencyNameAgencyTelephone AgencyFAXAgencyAddress_StreetAgencyAddress_CityAgencyAddress_StateAgencyAddress_ZipAgencyMailingAddress_StreetAgencyMailingAddress_CityAgencyMailingAddress_StateAgencyMailingAddress_ZipImplementingNameImplementingAddress_StreetImplementingAddress_CityImplementingAddress_StateImplementingAddress_ZipImplementingTelephoneSSN ProjectTitleLegalAuthorityNameAgencySignatureDateAcceptance_Yes Acceptance_NoOJJSignatureDateProjectDirectorNameProjectDirectorAddress_StreetProjectDirectorAddress_CityProjectDirectorAddress_StateProjectDirectorAddress_ZipProjectDirectorTelephoneProjectDirectorFAXProjectDirectorEmailFinancialOfficerNameFinancialOfficerAddress_StreetFinancialOfficerAddress_CityFinancialOfficerAddress_StateFinancialOfficerAddress_ZipFinancialOfficerTelephoneFinancialOfficerFAXFinancialOfficerEmail AgencyName1Date ProjectTitle1A_PositionTitles A_StateFunds A_CashMatchA_ProjectTotalA_StateFunds_TotalCashMatch_TotalA_ProjectTotal_TotalA_Justification AgencyName2Date1 ProjectTitle2 B_Listing B_StateFunds B_CashMatchB_ProjectTotalB_Total C_Listing C_StateFunds C_CashMatchC_ProjectTotalC_TotalB_StateFunds_TotalB_CashMatch_TotalC_StateFunds_TotalC_CashMatch_Total AgencyName3Date2 ProjectTitle3 D_Listing D_StateFunds D_CashMatchD_ProjectTotalD_Total E_Listing E_StateFunds E_CashMatchE_ProjectTotalE_TotalD_StateFunds_TotalD_CashMatch_TotalE_StateFunds_TotalE_CashMatch_Total AgencyName4Date3 ProjectTitle4 F_Listing F_StateFunds F_CashMatchF_ProjectTotalF_Total G_Listing G_StateFunds G_CashMatchG_ProjectTotalG_TotalF_StateFunds_TotalF_CashMatch_TotalG_StateFunds_TotalG_CashMatch_Total AgencyName5Date4 ProjectTitle5ProposedTime_FromDateProposedTime_ToDateA_Personnel_TotalB_Supplies_Total C_Other_TotalD_CapitalOutlay_TotalE_Travel_TotalF_Contractual_TotalTotalDirectChargesG_IndirectCharges_TotalTotalProjectCost Federal_TotalMatch OtherSourceOtherSourceAmountSourceOfFunds_TotalProjectSummary OtherSource1OtherSourceAmount1 OtherSource2OtherSourceAmount2 OtherSource3OtherSourceAmount3 OtherSource4OtherSourceAmount4FederalPercentMatchPercentageOtherSourcePercentSourceOfFunds_PercentOtherSourcePercent1OtherSourcePercent2OtherSourcePercent3OtherSourcePercent4A_Personnel_StateFundsB_Supplies_StateFundsC_Other_StateFundsD_CapitalOutlay_StateFundsE_Travel_StateFundsF_Contractual_StateFundsTotalDirectCharges_StateFundsG_IndirectCharges_StateFundsTotalProjectCost_StateFunds AgencyName6Date5 ProjectTitle6 AgencyName7Date6 ProjectTitle7 ProjectPlan AgencyName8Date7 ProjectTitle8ProjectOutcomes1ProjectObjectives1Month1_1Month2_1Month3_1Month4_1Month5_1Month6_1Month7_1Month8_1Month9_1 Month10_1 Month11_1 Month12_1 AgencyName9Date8 ProjectTitle9ProjectOutcomes2ProjectObjectives2Month1_2Month2_2Month3_2Month4_2Month5_2Month6_2Month7_2Month8_2Month9_2 Month10_2 Month11_2 Month12_2 AgencyName10Date9ProjectTitle10 AgencyName11Date10ProjectTitle11ProjectEvaluatorSupervisor ProjectPlan1 AgencyName12Date11ProjectTitle12LogicModel_OutcomesLogicModel_Indicators LogicModel_DataCollectionMethods"LogicModel_DataCollectionFrequencyLogicModel_SamplingStrategyXYZ[\]^_`abcdefghijklmneP qrstuvwxyz{|}~~~~~~~}}}}}}||||||{{{{{{zzzzzzyyyyyyxxxxxxwwwwwwvvvvvvuuuuuuttttttssssssrrrrrrqqqqqqppppppoooooonnnnnnmmmmmmllllllkkkkkkjjjjjjiiiiiihhhhhhggggggffffffeeeeeeddddddccccccbbbbbbaaaaaa``````______^^^^^^]]]]]]\\\\\\[[[[[[ZZZZZZYYYYYYXXXXXXWWWWWWVVVVVVUUUUUUTTTTTTSSSSSSRRRRRRQQQQQQPPPPPPOOOOOONNNNNNMMMMMMLLLLLLKKKKKKJJJJJJIIIIIIHHHHHHGGGGGGFFFFFFEEEEEEDDDDDDCCCCCCBBBBBBAAAAAA@@@@@@??????>>>>>>======<<<<<<;;;;;;::::::999999888888777777666666555555444444333333222222111111000000//////......------,,,,,,++++++******))))))((((((''''''&&&&&&%%%%%%$$$$$$######""""""!!!!!!   ,S`,B~=YQ<!:VoD 1h3w,:VG4~*k6:Wi su] c=:SC>?S=>: GD;::BU2fE43݀Iyо"82A'!? 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f(#X"Oމ!;%2<m)] L+ XI an*! 9CB@ qBB=ތfGX"@RcQgyBe *q(,p15Ҟ"{ C^?, @9l9H8)Or͌3qWQrܼW ,, ,HH  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~~~~~~~}}}}}}||||||{{{{{{zzzzzzyyyyyyxxxxxxwwwwwwvvvvvvuuuuuuttttttssssssrrrrrrqqqqqqppppppoooooonnnnnnmmmmmmllllllkkkkkkjjjjjjiiiiiihhhhhhggggggffffffeeeeeeddddddccccccbbbbbbaaaaaa``````______^^^^^^]]]]]]\\\\\\[[[[[[ZZZZZZYYYYYYXXXXXXWWWWWWVVVVVVUUUUUUTTTTTTSSSSSSRRRRRRQQQQQQPPPPPPOOOOOONNNNNNMMMMMMLLLLLLKKKKKKJJJJJJIIIIIIHHHHHHGGGGGGFFFFFFEEEEEEDDDDDDCCCCCCBBBBBBAAAAAA@@@@@@??????>>>>>>======<<<<<<;;;;;;::::::999999888888777777666666555555444444333333222222111111000000//////......------,,,,,,++++++******))))))((((((''''''&&&&&&%%%%%%$$$$$$######""""""!!!!!!   ,,&KP1()NE'!CqkfU)/6#\XV(dD6I\XW'0ityP( d</+ {>v 1b )Myum k3S&M ,, ,HH  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~~~~~~~}}}}}}||||||{{{{{{zzzzzzyyyyyyxxxxxxwwwwwwvvvvvvuuuuuuttttttssssssrrrrrrqqqqqqppppppoooooonnnnnnmmmmmmllllllkkkkkkjjjjjjiiiiiihhhhhhggggggffffffeeeeeeddddddccccccbbbbbbaaaaaa``````______^^^^^^]]]]]]\\\\\\[[[[[[ZZZZZZYYYYYYXXXXXXWWWWWWVVVVVVUUUUUUTTTTTTSSSSSSRRRRRRQQQQQQPPPPPPOOOOOONNNNNNMMMMMMLLLLLLKKKKKKJJJJJJIIIIIIHHHHHHGGGGGGFFFFFFEEEEEEDDDDDDCCCCCCBBBBBBAAAAAA@@@@@@??????>>>>>>======<<<<<<;;;;;;::::::999999888888777777666666555555444444333333222222111111000000//////......------,,,,,,++++++******))))))((((((''''''&&&&&&%%%%%%$$$$$$######""""""!!!!!!   ,, {%* >M & ; 1om4ޒA$#* @# D#*m|p7!O;%-_* w>+3Z ) rG' ~k) !L(uBU}|(\ ,,,HH  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~~~~~~~}}}}}}||||||{{{{{{zzzzzzyyyyyyxxxxxxwwwwwwvvvvvvuuuuuuttttttssssssrrrrrrqqqqqqppppppoooooonnnnnnmmmmmmllllllkkkkkkjjjjjjiiiiiihhhhhhggggggffffffeeeeeeddddddccccccbbbbbbaaaaaa``````______^^^^^^]]]]]]\\\\\\[[[[[[ZZZZZZYYYYYYXXXXXXWWWWWWVVVVVVUUUUUUTTTTTTSSSSSSRRRRRRQQQQQQPPPPPPOOOOOONNNNNNMMMMMMLLLLLLKKKKKKJJJJJJIIIIIIHHHHHHGGGGGGFFFFFFEEEEEEDDDDDDCCCCCCBBBBBBAAAAAA@@@@@@??????>>>>>>======<<<<<<;;;;;;::::::999999888888777777666666555555444444333333222222111111000000//////......------,,,,,,++++++******))))))((((((''''''&&&&&&%%%%%%$$$$$$######""""""!!!!!!  ,, DqүR NN *! `%e @ @  5P  AGENCY NAME&,@$ @  6P$ DATE$&@ STATE GRANT APPLICATION p@$ @@  #7A$  PROJECT TITLE$>.@ $Q  411. DESCRIPTION OF THE PROJECT (START ON THIS PAGE)     /p"0$ PAGE 8  /@$D@0  801$ :Project's Plan to hire a qualified, independent evaluator:    P008ified, independent evaluator:   ` DRAFTN=HH^=M  DN/P/ 0 DSHS 05-180B (REV. 05/2012)  s masterpage masterpagez ( " (vEvEvEvEvEvE] A=}\ 08Q #{z }  DFF)#7C;oM "" z h  ContractNumber ProgramArea DateStamp AgencyNameAgencyTelephone AgencyFAXAgencyAddress_StreetAgencyAddress_CityAgencyAddress_StateAgencyAddress_ZipAgencyMailingAddress_StreetAgencyMailingAddress_CityAgencyMailingAddress_StateAgencyMailingAddress_ZipImplementingNameImplementingAddress_StreetImplementingAddress_CityImplementingAddress_StateImplementingAddress_ZipImplementingTelephoneSSN ProjectTitleLegalAuthorityNameAgencySignatureDateAcceptance_Yes Acceptance_NoOJJSignatureDateProjectDirectorNameProjectDirectorAddress_StreetProjectDirectorAddress_CityProjectDirectorAddress_StateProjectDirectorAddress_ZipProjectDirectorTelephoneProjectDirectorFAXProjectDirectorEmailFinancialOfficerNameFinancialOfficerAddress_StreetFinancialOfficerAddress_CityFinancialOfficerAddress_StateFinancialOfficerAddress_ZipFinancialOfficerTelephoneFinancialOfficerFAXFinancialOfficerEmail AgencyName1Date ProjectTitle1A_PositionTitlesA_AnnualSalaryA_TimePercentToProject A_ItemTotalA_AnnualSalary_TotalA_Percent_TotalA_ItemTotal_TotalA_Justification AgencyName2Date1 ProjectTitle2 B_ListingB_Unit B_UnitCost B_ItemTotalB_Total C_ListingC_Unit C_UnitCost C_ItemTotalC_Total AgencyName3Date2 ProjectTitle3 D_ListingD_Unit D_UnitCost D_ItemTotalD_Total E_ListingE_Unit E_UnitCost E_ItemTotalE_Total AgencyName4Date3 ProjectTitle4 F_ListingF_Unit F_UnitCost F_ItemTotalF_Total G_ListingG_Unit G_UnitCost G_ItemTotalG_Total AgencyName5Date4 ProjectTitle5ProposedTime_FromDateProposedTime_ToDateA_Personnel_TotalB_Supplies_Total C_Other_TotalD_CapitalOutlay_TotalE_Travel_TotalF_Contractual_TotalTotalDirectChargesG_IndirectCharges_TotalTotalProjectCost Federal_TotalMatch OtherSourceOtherSourceAmountSourceOfFunds_TotalProjectSummary OtherSource1OtherSourceAmount1 OtherSource2OtherSourceAmount2 OtherSource3OtherSourceAmount3 OtherSource4OtherSourceAmount4FederalPercentMatchPercentageOtherSourcePercentSourceOfFunds_PercentOtherSourcePercent1OtherSourcePercent2OtherSourcePercent3OtherSourcePercent4 AgencyName6Date5 ProjectTitle6 AgencyName7Date6 ProjectTitle7 ProjectPlan AgencyName8Date7 ProjectTitle8ProjectOutcomes1ProjectObjectives1Month1_1Month2_1Month3_1Month4_1Month5_1Month6_1Month7_1Month8_1Month9_1 Month10_1 Month11_1 Month12_1 AgencyName9Date8 ProjectTitle9ProjectOutcomes2ProjectObjectives2Month1_2Month2_2Month3_2Month4_2Month5_2Month6_2Month7_2Month8_2Month9_2 Month10_2 Month11_2 Month12_2 AgencyName10Date9ProjectTitle10 AgencyName11Date10ProjectTitle11ProjectEvaluatorSupervisor ProjectPlan1 AgencyName12Date11ProjectTitle12LogicModel_OutcomesLogicModel_Indicators LogicModel_DataCollectionMethods"LogicModel_DataCollectionFrequencyLogicModel_SamplingStrategy;\<:!}%;\& &}&szXNNZ3Submit nf 05180b032003T8T 1TR<`ASD_T`R<DSHSXJI05_180b\T/l<l3'3'&3'd'`=@ʴo5S od6r* SignatureVersion Data Vers\$ Blue Keys*Graphics0Header6 FieldList\< Form Infof LayoutPropsl'x DesPathInfol'~CellDisplayNameu`psilaZ porpsila`<E porpsilal porpsilar6f~this SignatureVersion Data Vers\$ Blue Keys*Graphics0Header6 FieldList\< Form Infof LayoutPropsl'x DesPathInfol'~R]TKm  `ROFFICE OF JUVENILE JUSTICE (OJJ) State Grant Application Please read all instructions carefully.   ! 9   For assistance, contact the Department of Social and Health Services (DSHS) Office of Juvenile Justice at (360) 902-7526 or FAX (360) 902-7527. @@Age Aeg >x Age,Arial (Q0MFor assistance, contact the Department of Social and Health Services (DSHS) (ZCCOffice of Juvenile Justice at (360) 902-7526 or FAX (360) 902-7527.@  dp CONTRACT NUMBER=@   e!p  PROGRAM AREA10$Q0$  FOR OJJ USE ONLY-U U- Age -U,Arial (!FOR OJJ USE ONLY0$@  g@$  DATE STAMP&p$Qp  (1. APPLICANT: DO NOT USE PERSON'S NAMEp@  h  AGENCY NAME,p@  ip TELEPHONE NUMBER@p$@  j$  FAX NUMBER' p@p  kq STREET ADDRESS6 p$ p@p  lqp CITY p@ p  mq STATE p$@ p  nq$ ZIP CODE p @    o   MAILING ADDRESS7 p $ p @    p  p CITY p @    q   STATE p $@   r  $ ZIP CODE  $Q 0 " |2. IMPLEMENTING AGENCY: ENTER AGENCY, DEPARTMENT OR CONTRACTOR DIRECTLY IMPLEMENTING THE PROJECT (DO NOT USE PERSON'S NAME   @   s  ! NAME @   t 0  STREET ADDRESS6  p@   u! ` CITY p @   v ! STATE @   w! ZIP CODE  $@   y  !$ TELEPHONE NUMBER@  $@  z 0$ eFEDERAL EMPLOYER IDENTIFICATION NUMBER OR SOCIAL SECURITY NUMBER (MANDATORY FOR FEDERAL TAX PURPOSES)`T `T -U `T,Arial (k:FEDERAL EMPLOYER IDENTIFICATION NUMBER OR SOCIAL SECURITY (k+NUMBER (MANDATORY FOR FEDERAL TAX PURPOSES) $Q`0 ;3. PROJECT TITLE: ENTER BRIEF, DESCRIPTIVE PROJECT TITLE P$@  #{`$ NAMEP$Q 4. APPLICANT'S AGREEMENTf+ /0$  Omission of any required information or certification may be cause for denial of the application. The Department shall take a final approval/disapproval action on all applications within 90 days of receipt by the Department of a conforming application, together with all required certifications. The Department shall not consider an application conforming unless the applicant has completed all items in accordance with instructions and has submitted the necessary certifications. The applicant must submit two signed completed applications to: OFFICE OF JUVENILE JUSTICE, DEPARTMENT OF SOCIAL AND HEALTH SERVICES, PO BOX 45828, OLYMPIA WA 98504-5828. llJ J `T J,Arial ("Omission of any required information or certification may be cause for denial of the application. The Department shall take a final approval/disapproval ("action on all applications within 90 days of receipt by the Department of a conforming application, together with all required certifications. The ("Department shall not consider an application conforming unless the applicant has completed all items in accordance with instructions and has submitted ("the necessary certifications. The applicant must submit two signed completed applications to: OFFICE OF JUVENILE JUSTICE, DEPARTMENT OF ("ASOCIAL AND HEALTH SERVICES, PO BOX 45828, OLYMPIA WA 98504-5828.0$@0  1$ NAME AND TITLE OF AUTHORIZED OFFICER (PERSON WITH LEGAL AUTHORITY: COUNTY COMMISSIONERS' CHAIRMAN OF THE BOARD, MAYOR, CITY/TOWN MANAGER, AGENCY DIRECTOR)+0$@  @$ DATEP APPLICANT'S SIGNATURE M0 0 *ACCEPTANCE OF OFFER COUNTEROFFER FOR DSHS !0  ` ! 0@  p!   Acceptance - `0! @  p! Non-acceptance > 0P $OJJ CONTRACTING OFFICER'S SIGNATURE  !0!0$@ 0   1$ DATE!0!$Q!p!# ~5. PROJECT DIRECTOR: PERSON IN DIRECT CHARGE OF PROJECT (DAY-TO-DAY OPERATIONS AND PREPARATION OF REQUIRED PROGRESS REPORTS)!#`@"`  !"a NAME AND TITLE2#`$@#  #p# STREET ADDRESS6$&`$&` p@%`  $%a ` CITY$ p&`@%`  $ %a STATE$&`@ %`  $%a ZIP CODE!#`$@!"`  !"a$ TELEPHONE NUMBER@#`$$@"#  #p#$  FAX NUMBER'$&`$@#%`  $%a$ E-MAIL ADDRESS2&`'$Q&'$ 6. FINANCIAL OFFICER: PERSON IN CHARGE OF FISCAL MATTERS (ACCOUNTING, FUNDS MANAGEMENT, EXPENDITURE, VERIFICATIONS, FINANCIAL REPORTS)''(@$'  ' ' NAME AND TITLE2(*@%)  () STREET ADDRESS6*+*+ p@&*  * * ` CITY* p+@'*  * * STATE*+@(*  * * ZIP CODE'($@)'  ' '$ TELEPHONE NUMBER@(*$@*)  ()$  FAX NUMBER'*+$@+*  * *$ E-MAIL ADDRESS2`  $  The applicant is applying for a grant award in the amount shown in the proposed BUDGET SUMMARY (Section 8 of this application) for the purposes identified in this application. By signing and submitting this application, the applicant agrees that this document, together with the STANDARD CONDITIONS AND CERTIFICATIONS (Attachment A of this application), becomes an offer to contract with Washington State Department of Social and Health Services (DSHS or the Department) which, if accepted, binds the applicant to the following: ,lJ ,Jl >x ,lJ,Arial (>"The applicant is applying for a grant award in the amount shown in the proposed BUDGET SUMMARY (Section 8 of this application) for the purposes (I"identified in this application. By signing and submitting this application, the applicant agrees that this document, together with the STANDARD (T"CONDITIONS AND CERTIFICATIONS (Attachment A of this application), becomes an offer to contract with Washington State Department of Social and (_"bHealth Services (DSHS or the Department) which, if accepted, binds the applicant to the following:p $  The applicant agrees that this offer becomes a binding contract when a copy of this page is signed by the OJJ Office Chief and returned to the applicant together with an Approved Budget and Special Conditions form provided, however: ]J ]J ,lJ ]J,Arial (o"The applicant agrees that this offer becomes a binding contract when a copy of this page is signed by the OJJ Office Chief and returned to the applicant (z"Otogether with an Approved Budget and Special Conditions form provided, however:   a. w6 w6 ]J w6,Arial ("a.$  In the event any budget category amount differs from the amount shown in Section 8 of this application, as modified by the Approved budget and Special Conditions, that amount shall be considered to be a counteroffer. The Department shall consider the counteroffer accepted by the applicant unless rejected in writing within 30 days after the date of mailing of such counteroffer by the Office of Juvenile Justice (hereinafter referred to as OJJ) to the applicant. w"J "wJ w6 w"J,Arial (,In the event any budget category amount differs from the amount shown in Section 8 of this application, as modified by the Approved budget and (,Special Conditions, that amount shall be considered to be a counteroffer. The Department shall consider the counteroffer accepted by the applicant (,unless rejected in writing within 30 days after the date of mailing of such counteroffer by the Office of Juvenile Justice (hereinafter referred to as OJJ) (,to the applicant.   b. 6 6 w"J 6,Arial ("b.`$  Upon acceptance of this offer/counteroffer, the applicant shall be referred to as the "Contractor" and the Contractor agrees to accept and abide by the special terms and conditions. VV"J "J 6 "J,Arial (,Upon acceptance of this offer/counteroffer, the applicant shall be referred to as the "Contractor" and the Contractor agrees to accept and abide by the (,special terms and conditions.$+/@$/p"0$ PAGE 1 HBGrant ApplicationP001P001@`I?HoBGrant Application ``@$ DRAFTN=HH=MGrant ApplicationE/p"0$ PAGE 1 : 1@ @,  P  AGENCY NAME,@$@-  P$ DATE@ STATE GRANT APPLICATION p@$ @.@  #A$  PROJECT TITLE.@ $Q  p ,10. BUDGET DETAILS: CATEGORY A. PERSONNEL    /p"0$ PAGE 3  $p 4 This category is for services rendered by all personnel employed by the project. Costs incurred include salaries, benefits, uniforms, and special clothing. SALARIES AND WAGES: Payment for personal services rendered in accordance with rates, hours, terms and conditions as authorized by law or stated in employment contracts. OVERTIME, HAZARDOUS DUTY, ETC. PERSONAL BENEFITS: FICA, retirements, insurance, etc. UNIFORMS AND CLOTHING: Only uniforms for special clothing required by the nature of the employment and paid for by the employer may be listed. NOTE: Project funds may not be used to pay a percentage of the compensation of any person who was employed by the implementing agency before the project starting date without prior specific authorization from the Department separate from the grant approval. Specific authorization is not required if a person currently employed by the applicant or the implementing agency is transferred from his/her prior position to the project if the transfer creates a personnel vacancy to be filled by hiring a new employee.   K }   ^Q ^Q "J ^Q,Arial (p"This category is for services rendered by all personnel employed by the project. Costs incurred include salaries, benefits, uniforms, and special clothing. ("SALARIES AND WAGES(~: Payment for personal services rendered in accordance with rates, hours, terms and conditions as authorized by law or stated ("in employment contracts. ("OVERTIME, HAZARDOUS DUTY, ETC. ("PERSONAL BENEFITS: (}$ FICA, retirements, insurance, etc. ("UNIFORMS AND CLOTHING:(z Only uniforms for special clothing required by the nature of the employment and paid for by the employer may be listed. ("NOTE: Project funds may not be used to pay a percentage of the compensation of any person who was employed by the implementing agency before the ("project starting date without prior specific authorization from the Department separate from the grant approval. Specific authorization is not required if a ("person currently employed by the applicant or the implementing agency is transferred from his/her prior position to the project if the transfer creates a ("8personnel vacancy to be filled by hiring a new employee.p$@/  Title  p @/    LIST POSITION TITLES W p@/   0 ANNUAL SALARY  y y ^Q y,Arial ( ANNUAL SALARYp 0@/    PERCENT OF TIME TO PROJECT     y  ,Arial ( PERCENT OF (TIME TO ( PROJECT 0p$ @/   @$  ITEM TOTAL / $p p  H0 p!Pq  2. Match  % p 0 H1 p!Pq  2. Match  % p 0$ H2 p!Pq  2. Match  %  CATEGORY TOTAL Ip p 0p 0$/@$D@3!  !!$  JUSTIFICATION AND EXPLANATION: Justify all positions in terms of days and/or hours required to perform the GOALS, OBJECTIVES, AND TASKS set forth. Calculate fringe benefits for each position or class of positions. xxT T   T,Arial (JUSTIFICATION AND EXPLANATION: Justify all positions in terms of days and/or hours required to perform the GOALS, OBJECTIVES, AND TASKS set (Jforth. Calculate fringe benefits for each position or class of positions.PP 0 %     pP 0 %     P@ 0 %     P` 0 %     P 0 %     P 0 %     P 0 %     0P 0 %     PP 0 %     pP 0 %     P@ 0 %     P` 0 %     @ %     Budget 1P002B=MBudget 1 2. Match   %  $$ %    `$ `$H= p!Pq  2. Match  "% @$$ %    `$ H> p!Pq  2. Match  "%  `H? p!Pq  2. Match  "%  ` $H@ p!Pq  2. Match  "% `$ $ %    ` $ ` HM  TOTAL PROJECT FUNDS   l  `$HN p!Pq  2. Match   % $$ %    `$p$Cpp D9. PROJECT SUMMARY: GIVE A BRIEF NARRATIVE SUMMARY OF THE PROJECT.p/@$HO p!Pq  2. Match  "% /`/ BDSHS 05-180 (REV. 09/2002) PROPOSED REVISION - DO NOT PRINT MILLIE/p"0$ PAGE 2  @HA p!Pq  2. Match  "%  @ `HB p!Pq  2. Match  "%  `@$HC p!Pq  2. Match  "% $@$ %    `@$@`HD p!Pq  2. Match  "% @` `HE p!Pq  2. Match  "% @ ``$HF p!Pq  2. Match  "% $`$ %   @ ``$`HG p!Pq  2. Match  "% ` `HH p!Pq  2. Match  "% ` `$HI p!Pq  2. Match  "% $$ %   ` `$HJ p!Pq  2. Match  "%  `HK p!Pq  2. Match  "%  `$HL p!Pq  2. Match  "% $$ %    `$(-T$@ @4  P  AGENCY NAME,@$ @5  P$ DATE@ STATE GRANT APPLICATION p@$ @6@  #A$  PROJECT TITLE.@ $Q @  +10. BUDGET DETAILS: CATEGORY B. SUPPLIES    /p"0$ PAGE 4  `$p  This category is for articles and commodities which are consumed or materially altered when used. The following are types of supplies. OFFICE SUPPLIES: For example, office stationery, forms, small items of equipment, and maps, films, books, periodicals, and tapes. OPERATING SUPPLIES: For example, chemicals, drugs, medicines, laboratory supplies, cleaning and sanitation supplies, food for human consumption, fuel, household and institutional supplies, and clothing. REPAIR AND MAINTENANCE SUPPLIES: For example, building materials and supplies, paints and painting supplies, plumbing supplies, electrical supplies, motor vehicle repair materials and supplies, other repair and maintenance supplies, and small tools.       _Q _Q T _Q,Arial (q"This category is for articles and commodities which are consumed or materially altered when used. The following are types of supplies. ("OFFICE SUPPLIES:(ms For example, office stationery, forms, small items of equipment, and maps, films, books, periodicals, and tapes. ("OPERATING SUPPLIES:(~ For example, chemicals, drugs, medicines, laboratory supplies, cleaning and sanitation supplies, food for human consumption, (":fuel, household and institutional supplies, and clothing. (" REPAIR AND MAINTENANCE SUPPLIES:(l For example, building materials and supplies, paints and painting supplies, plumbing supplies, electrical ("nsupplies, motor vehicle repair materials and supplies, other repair and maintenance supplies, and small tools. $@7  Title   0@8      *ITEMIZED LISTING (DESCRIPTION OF THE ITEM)  0@9    @  UNIT   0@:      UNIT COST + 0$ @;    @ $  ITEM TOTAL /  $ 0 0$ H: p!Pq  2. Match  % @ CATEGORY TOTAL I 0$$Q P =10. BUDGET DETAILS: CATEGORY C. OTHER SERVICES AND CHARGES   @ ". $@;  Title  ". 0@8"  "" HITEMIZED LISTING (WORD OR WORDS DESCRIBING THE COST ITEM, I.E., POSTAGE) I"0. @9"  "@" UNIT ". 0@:"  ""  UNIT COST +" 0. $ @;"  " @"$  ITEM TOTAL /. /@ 0. 0/@$ H> p!Pq  2. Match  % ./@ CATEGORY TOTAL I. 0/@$P !#  This category is for services other than PERSONNEL which are required in the administration of the project. Such services may be provided by some agency of the government unit or by private business organizations. The following are types of services and charges classified under this category. COMMUNICATION: For example, telephone, telegraph, and postage. TRANSPORTATION: For example, freight and express charges, and messenger service. ADVERTISING PUBLIC UTILITY SERVICE PRINTING AND BINDING REPAIRS AND MAINTENANCE INSURANCE RENTALS: For example, buildings, and equipment and machinery. MISCELLANEOUS: For example, tuition and other training fees, dues, subscriptions and memberships, and taxes. ) 8 i y   T c RR#F F# _Q #F,Arial ("This category is for services other than PERSONNEL which are required in the administration of the project. Such services may be provided by some ("agency of the government unit or by private business organizations. The following are types of services and charges classified under this category. ("COMMUNICATION: (m1 For example, telephone, telegraph, and postage. ("TRANSPORTATION: (qB For example, freight and express charges, and messenger service. (" ADVERTISING ("PUBLIC UTILITY SERVICE ("PRINTING AND BINDING ("REPAIRS AND MAINTENANCE (" INSURANCE ( " RENTALS: ( L6 For example, buildings, and equipment and machinery. ("MISCELLANEOUS: (m^ For example, tuition and other training fees, dues, subscriptions and memberships, and taxes."$0 @8 p!Pq  2. Match  %  0 @9 p!Pq  2. Match  % . 0/@ @< p!Pq  2. Match  % . /@ 0 @= p!Pq  2. Match  % Budget 2P003P003 2. Match  `% Budget 2by private business organizations. The following are types of services and charges classified under this category. ("COMMUNICATION: (m1 For example, telephone, telegraph, and postage. ("TRANSPORTATION: (qB For example, freight and express charges, and messenger service. (" ADVERTISING ("PUBLIC UTILITY SERVICE ("PRINTING AND BINDING ("REPAIRS AND MAINTENANCE (" INSURANCE ( " RENTALS: ( L6 For example, buildings, and equipment and machinery. ("MISCELLANEOUS: (m^ For example, tuition and other training fees, dues, subscriptions and memberships, and taxes.t;F0(###) ###-#########;#####-#### // r###000#,##0.002###0#,##0@@X  R9 @@@@@@ @@@@@A`G|.G. 5. G. G. 5<. A<5 pt.l aA`<`A` A@A A>ƣ Aݢ> M R9ݢ*]Q9P<R9QK<@@@ @@X  " @@@  @@X   @@@   @@X   @@ 9<.@@X 2 HNT     @@X   @@@  cs@@X  ~ @@@   @@X  j @@ƙ"#8@@X  HNT    Nk@ @?  P  AGENCY NAME,@$ @@  P$ DATE@ STATE GRANT APPLICATION p@$ @A@  #A$  PROJECT TITLE.@ $Q ! ;10. BUDGET DETAILS: CATEGORY D. CAPITAL OUTLAY/EQUIPMENT   2 /p"0$ PAGE 5  $p > This category is for nonexpendable outlays which result in the acquisition of, rights to, or additions to fixed assets, other than structures. The following are some of the types of charges under this category. NOTE: Exclude small tools. MACHINERY AND EQUIPMENT: For example, communications equipment (typewriter, microcomputer), janitorial; laboratory, office furniture and equipment, heavy duty work equipment, and other machinery and equipment.   _Q _Q #F _Q,Arial (q"This category is for nonexpendable outlays which result in the acquisition of, rights to, or additions to fixed assets, other than structures. The following are (|"Osome of the types of charges under this category. NOTE: Exclude small tools. ("MACHINERY AND EQUIPMENT(s: For example, communications equipment (typewriter, microcomputer), janitorial; laboratory, office furniture and ("Hequipment, heavy duty work equipment, and other machinery and equipment. p$@B  Title   p0@? P    Q )ITEMIZED LISTING (DESCRIBE THE COST ITEM)  p0@@ P   @ Q UNIT  p 0@A P    Q  UNIT COST + p 0$ @B P   @ Q$  ITEM TOTAL /  p$ 0 0$ HE p!Pq  2. Match  % ` CATEGORY TOTAL I 0$$Q0 P )10. BUDGET DETAILS: CATEGORY E. TRAVEL    . $@F  Title  . 0@A   ITEMIZED LISTING G0. @B  @ UNIT . 0@C    UNIT COST + 0. $ @D   @$  ITEM TOTAL /. /@ 0. 0/@$ HI p!Pq  2. Match  % ./@ CATEGORY TOTAL I. 0/@$p 0#  Travel costs are for domestic travel. Contractors may follow their own established rate for staff travel as long as the rate does not exceed the allowable state rate. The allowable state rate for mileage will be used. Air fare should be the lowest coach fare. F F _Q F,Arial ("Travel costs are for domestic travel. Contractors may follow their own established rate for staff travel as long as the rate does not exceed the allowable (" state rate. ("]The allowable state rate for mileage will be used. Air fare should be the lowest coach fare.$0 @C p!Pq  2. Match  %  0 @D p!Pq  2. Match  % . 0/@ @G p!Pq  2. Match  % . /@ 0 @H p!Pq  2. Match  % Budget 3P004P004 2. Match  `% Budget 3TE@ FEDERAL GRANT APPLICATION T|@$ @z@  #n:@ @J  P  AGENCY NAME,@$ @K  P$ DATE@ STATE GRANT APPLICATION p@$ @L@  #A$  PROJECT TITLE.@ $Q 710. BUDGET DETAILS: CATEGORY F. CONTRACTUAL SERVICES    /p"0$ PAGE 6  $p  The following types of personal services may be contracted: EVALUATION/RESEARCH LEGAL ACCOUNTING MEDICAL AND HEALTH SERVICES AUDITING SOCIAL SERVICES  _Q _Q F _Q,Arial (q"?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~lPGMDU@ @U  P  AGENCY NAME,@$ @V  P$ DATE@ STATE GRANT APPLICATION p@$ @W@  #A$  PROJECT TITLE.@$Q 7. PROJECT PERIODGp@0 gA project period is one year and may not exceed one year except by prior agreement with the Department. y0@HX  @P Proposed project period is form p0HY @ to  $  $Q @  8. BUDGET SUMMARYM @ @$P The proposed project budget is shown below. If the proposal is accepted for contracting, the budget on the Approved budget and Special conditions form supersedes the proposed budget shown below. ffO O F O,Arial ($The proposed project budget is shown below. If the proposal is accepted for contracting, the budget on the Approved budget and Special conditions ($0form supersedes the proposed budget shown below.  $  @ P BUDGET CATEGORIES Y @ V Enter the category totals from Section 10. BUDGET DETAILS. The sum of categories A - F is entered as TOTAL DIRECT CHARGES. If indirect costs are claimed, enter the amount in G. These may not exceed ten (10) percent of the TOTAL DIRECT CHARGES. Add TOTAL DIRECT CHARGES and INDIRECT CHARGES, and enter the sum on TOTAL PROJECT COSTS line. ll* * O *,Arial ($3Enter the category totals from Section 10. BUDGET ($4DETAILS. The sum of categories A - F is entered as ($-TOTAL DIRECT CHARGES. If indirect costs are ($6claimed, enter the amount in G. These may not exceed ($/ten (10) percent of the TOTAL DIRECT CHARGES. ( $&Add TOTAL DIRECT CHARGES and INDIRECT ($,CHARGES, and enter the sum on TOTAL PROJECT ($ COSTS line.  ` HZ     A. Personnel  6   ` H\     B. Supplies  0   ` H^   C. Other services and charges  }  ` H`   D. Capital outlay/equipment  r  @ ` Hb 0@  E. Travel  ' @` ` Hd P` F. Contractual services  _ ` ` Hf p TOTAL DIRECT CHARGES   q  ` Hh  G. Indirect charges  O  ` Hj  TOTAL PROJECT COST   f @pp SOURCE OF FUNDS N @  1. h: h: * h:,Arial (y$1. ` U May not exceed amount approved by the Governor's Juvenile Justice Advisory Committee. h" "h h: h",Arial (y,1May not exceed amount approved by the Governor's (,$Juvenile Justice Advisory Committee.@  2. : : h" :,Arial ($2.  J Must be funds specifically appropriated for project in applicant's budget. " " : ",Arial (,7Must be funds specifically appropriated for project in (,applicant's budget.@@  Project income must be applied to project operational costs or deducted from the grant award. It is important that all anticipated project income be included in the budget. hh  " ,Arial ($*Project income must be applied to project ($-operational costs or deducted from the grant ($5award. It is important that all anticipated project ($!income be included in the budget. ` Hl   1. State  "  ` Hn    2. Match  %  #$p %      `$@#$p %      `$ Hp  p!Pq  2. Match  %  `Hq  p!Pq  2. Match  % `#$p %      ` $ ` H  TOTAL PROJECT FUNDS   l #$p %      `$p$Qpp D9. PROJECT SUMMARY: GIVE A BRIEF NARRATIVE SUMMARY OF THE PROJECT.p/@$H p!Pq  2. Match  % /p"0$ PAGE 2  @Hs p!Pq  2. Match  %  @ `Ht p!Pq  2. Match  % #0$p %      `@$@`Hv p!Pq  2. Match  % @` `Hw p!Pq  2. Match  % #P$p %     @ ``$`Hy p!Pq  2. Match  % ` `Hz p!Pq  2. Match  % #p$p %     ` `$H| p!Pq  2. Match  %  `H} p!Pq  2. Match  % #$p %      `$    $    $  $  $ @ @$@`@`$``$$$$$  $ @ @$@`@`$``$$$ `#Hm p!Pq  2. Match  %  `#Ho  p!Pq  2. Match  %  ` #Hr !p!Pq  2. Match  %  `#H "p!Pq  2. Match  %  `@#Hu #p!Pq  2. Match  % @ ``#Hx $p!Pq  2. Match  % ` `#H{ %p!Pq  2. Match  %  `#H~ &p!Pq  2. Match  %  0 P  TOTAL BUDGET > ` $ @[  A_Personnel_StateFunds   ` $ @]  B_Supplies_StateFunds   `$ @_  C_Other_StateFunds   ` $ @a  D_CapitalOutlay_StateFunds   `@$ @c  E_Travel_StateFunds  @ ``$ @e  F_Contractual_StateFunds  ` `$ @g  TotalDirectCharges_StateFunds   `$ @i  G_IndirectCharges_StateFunds   `$ @k  TotalProjectCost_StateFunds   0 $  STATE FUNDS 8Budget SummaryP006STATE FUNDS 7Budget Summary` #p!Pq  2. Match  "% @ ``#Hc $p!Pq  2. Match  "% ` `#Hf %p!Pq  2. Match %  `#Hi &p!Pq  2. Match  % Budget SummaryDRAFTN=HHs=MBudget Summary @ @  {P  AGENCY NAME&,@$ @  |P$ DATE$&@ STATE GRANT APPLICATION p@$ @@  #}A$  PROJECT TITLE$>.@ $Q  +13. EVALUATION DESIGN (START ON THIS PAGE)    /p"0% PAGE 12 " @@ &Plan for Contracting with an Evaluator     p$ On this page, within the box below, state how you plan to hire a qualified, independent evaluator, or give the name and qualifications of the evaluator you have already selected. A qualified evaluator is someone with a graduate degree in a relevant discipline (and course work in statistics), or a person who has conducted successful project evaluations. You may be able to find a qualified evaluator at your local college or university. You may also be able to find a qualified evaluator by asking other agencies in your community. If you need help finding an evaluator, please call the Office of Juvenile Justices, at (360) 725-3600.       &  (  W  b   $-.$ >If your project is funded, the GJJAC expects you to identify your independent evaluator and send a coy of your contract with the evaluator within 45 days of your contact start date.    +p,$@+  ~++$  EVALUATOR WILL BE SUPERVISED BY:$q +p$H@   $ :Project's Plan to hire a qualified, independent evaluator:   $ P012ified, independent evaluator:   `  qualified, independent evaluator:   & DRAFTN=HH=MH=M EVALUATOR WILL BE SUPERVISED BY:?0gq($H@  $ :Project's Plan to hire a qualified, independent evaluator:   0?g ;\;\,;\@T ;\h  %;\| & R2%,VlP@ @  xP  AGENCY NAME&,@$ @  yP$ DATE$&@ STATE GRANT APPLICATION p@$ @@  #zA$  PROJECT TITLE$>.@ $Q   )13. EVALUATION DESIGN (START ON PAGE 12)    /p"0% PAGE 11 " # eThe goal of the evaluation is to assess the effectiveness of the project. The evaluation must be conducted by an objective outside party. A written evaluation report, including an executive summary, is required. The Contractor shall allocate at least seven percent (7%) of the budget for evaluation. List the budget under CONTRACTUAL SERVICES on page 6.  _H _H Y} _H,Arial (q"|The goal of the evaluation is to assess the effectiveness of the project. The evaluation must be conducted by an objective (}"|outside party. A written evaluation report, including an executive summary, is required. The Contractor shall allocate at ("mleast seven percent (7%) of the budget for evaluation. List the budget under CONTRACTUAL SERVICES on page 6. /@$  $ Submit a description of the overall evaluation design using the Logic Model format (see page 14). Attach as many pages as required to properly address the topics.  DDR R _H R,Arial ("{Submit a description of the overall evaluation design using the Logic Model format (see page 14). Attach as many pages as ("(required to properly address the topics.  $ All new grant applicants those funding regional program development units, and technical assistance grant applications, must answer this section. Where applicable, continuation funding grant applicants should discuss the status of their evaluation efforts to date using this format.   U U R U,Arial ("}All new grant applicants those funding regional program development units, and technical assistance grant applications, must ("|answer this section. Where applicable, continuation funding grant applicants should discuss the status of their evaluation ("#efforts to date using this format.   $ The Department shall not issue the payment for the final Financial Report until the Office of Juvenile Justice has approved a copy of the evaluation report.  >>U U U U,Arial ("~The Department shall not issue the payment for the final Financial Report until the Office of Juvenile Justice has approved a ("copy of the evaluation report.P ` oRI. PLANS TO CONTRACT WITH AN EVALUATOR ON THE NEXT PAGE. Describe your plan to contact with an evaluator.  :  ;  ?   @$ RII. LOGIC MODEL Use the Logic Model below to describe the Outcomes, Indications, Data Collection Methods/Tools, Data Collection Frequency/ Schedule, and Sampling Strategy.        $QQQQQ 0P ~Short, intermediate or longer term changes anticipated in participants' lives, and/or in organization or community conditions.  ~~N N U N,Arial (_Short, intermediate or (jlonger term changes (uanticipated in (participants' lives, (and/or in organization ( or community ( conditions. 0 [Detailed examples that can be seen, heard, or read that demonstrate outcomes are being met.  66N N N N,Arial (_Detailed examples that (jcan be seen, heard, or (uread that demonstrate (outcomes are being (met. 0 Method for gathering statistics for the assessment of the project. They need to be valid and reliable, culturally appropriate, and are within the agency's resources to implement.  Ni Ni N Ni,Arial (_Method for gathering (jstatistics for the (uassessment of the (project. They need to (be valid and reliable, (culturally appropriate, (and are within the (agency's resources to ( implement. 0 3Describe when and how often data will be collected.  Ne eN Ni Ne,Arial (_oDescribe when and how (jooften data will be (uo collected. 4How frequently you are in contact with participants.  q q Ne q,Arial ({How frequently you are ({in contact with ({ participants. ` 7When data will be available to you and confidentiality.  q q q q,Arial ({When data will be ({available to you and ({confidentiality.  ` ?Whether you are accountable for short-term or long-term change.  q q q q,Arial ({Whether you are ({accountable for ({short-term or long-term ({change. P` 0$@# [State whether the entire participant population will be included or a sample will be taken.  ""NI NI q NI,Arial (_State whether the entire (jparticipant population (uwill be included or a (sample will be taken.@ Outcomes   , @  Indicators   +  Data Collection Methods/Tools  2Zu 2uZ NI 2Zu,Arial (CData Collection (M Methods/Tools "Data Collection Frequency/Schedule  2aZ a2Z 2Zu 2aZ,Arial (CData Collection (MwFrequency/Schedule$ Sampling Strategy and Size  2ZU 2UZ 2aZ 2ZU,Arial (CSampling Strategy (Mand Size` _(These are appropriate for the project and are something for which it can be held accountable.)  ::  2ZU ,Arial ((These are appropriate (for the project and are (something for which it ( can be held ( accountable.)0 p(These are directly related to the outcome and help to define it, and are measurable during the project period.)  NN   ,Arial ((These are directly related (to the outcome and help (to define it, and are (measurable during the (project period.)  (You may use "off the shelf" data collection tools or develop your own. These may be case records, assessments, interviews, survey, etc.)  zz r r    r,Arial ((You may use "off the (shelf" data collection tools (or develop your own. (These may be case (records, assessments, (interviews, survey, etc.)  Consider:   ' @$ UIf the project has less than 100 participants, all participants should be included.   ~J ~J  r ~J,Arial (If the project has less (than 100 participants, (all participants should (be included. @$ CIf you need to sample, describe which sampling method you will use.    K K ~J K,Arial (If you need to sample, (describe which (sampling method you ( will use. 0- !0  For example:   8 !p#` /Increase in grades (GPA) at end of school year.   !B ! B K  !B,Arial (+Increase in grades ()+(GPA) at end of (4+ school year.! !`#%` !Increase in pro-social behaviors.  0!Z !0Z  !B 0!Z,Arial (A+Increase in pro-social (L+ behaviors.# $`% &` !Decrease in aggressive behaviors.  H!r !Hr 0!Z H!r,Arial (Y+ Decrease in (d+aggressive behaviors.%@ %`&(` Decrease in recidivism.  a! !a >x a!,Arial (r+ Decrease in (}+ recidivism.& '` 0- !0  For example:   8 !p %` eAt least 30 of the 40 youth will have an increase in grades (GPA) at the mid-semester marking period.  RR c  c a!  c,Arial (At least 30 of the 40 ()youth will have an (4increase in grades (? (GPA) at the (Jmid-semester marking (Uperiod.! ! `% (p` NAt least 30 of the 40 youth will show an increase in pro-social verbal skills.  Q Q  c Q,Arial (bAt least 30 of the 40 (myouth will show an (xincrease in pro-social (verbal skills.% & `( *` 4No project youth will be in a fight during the week.    Q ,Arial (No project youth will (be in a fight during the (week.( ( `* ,` 3No project youth will be arrested during the month.     ,Arial (No project youth will (be arrested during the (month.* +0 ` 0- !0  For example:   8 !p#` 9Attendance taken at every after-school mentoring session.   Bp  pB   Bp,Arial ( Attendance taken at () every after-school (4 mentoring session.! !`#$p` Student grades.   @ # $ `$&` 2Teacher's daily log that records student behavior.  Bwp Bpw  Bp Bwp,Arial (S Teacher's daily log (^ that records student (i behavior.$ % `' (` (Referrals to the principal for fighting.  hp hp Bwp hp,Arial (y Referrals to the ( principal for fighting.'@ '`()` Survey of parents.   I ( )0`)*`` Police arrest records.   V ) *` 0- !0  For example:   8 !p#` 0At entry into project and at end of school year.   qB q B hp  qB,Arial ({At entry into project (){and at end of school (4{year.! !`#%@` Weekly, during the project.  4q^ q4^  qB 4q^,Arial (E{Weekly, during the (P{project.$ $@`%p& ` At one-year follow-up.   X % %`&P)` [Confidentiality forms will be signed with Administrator of the Courts to use JUVIS records.  88[q q[ 4q^ [q,Arial (l{Confidentiality forms (w{will be signed with ({Administrator of the ({Courts to use JUVIS ({records.&p &` 0-$ !0#  For example:   8 !p"$` All students in the project.   7P  P7 [q  7P,Arial (All students in the ()project.! !`# $$` (All teachers of students in the project.  (RP (PR  7P (RP,Arial (9All teachers of (Dstudents in the project.#0 #p`$&@$` )Every third student entering the project.  DnP DPn (RP DnP,Arial (UEvery third student (`entering the project.$ %0`-p .0 *    -p.# This was adapted from page 52, Outcomes for Success 2000 Edition, by the Evaluation Forum, Organization Research Services, Inc. and Clegg and Associates.  ::!G !G DnP !G,Arial (+qThis was adapted from page 52, Outcomes for Success 2000 Edition, by the Evaluation Forum, Organization Research (+(Services, Inc. and Clegg and Associates.P011  Activities   ,  Outputs  #  Outcomes  . $ Goal(s)  ! Pp *   P$ This was adapted from page 31, Outcomes for Success 2000 Edition, by the Evaluation Forum, Organization Research Services, Inc. and Clegg and Associates.  88&L 8&L 6fP &L,Arial (0qThis was adapted from page 31, Outcomes for Success 2000 Edition, by the Evaluation Forum, Organization Research (0(Services, Inc. and Clegg and Associates./`/ BDSHS 05-180 (REV. 09/2002) PROPOSED REVISION - DO NOT PRINT MILLIE/p"0$ PAGE 9 @`  Logic Model *   A `p Process   '  Ul  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~lրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրր ``? @ @  9P  AGENCY NAME&,@$ @  :P$ DATE$&@ STATE GRANT APPLICATION p@$ @@  #;A$  PROJECT TITLE$>.@ $Q  0 12. TIME PHASING   S /p"0$ PAGE 9  /@$@  0$ The timetable should identify each of the outcomes and outputs the project must complete. It should also include the ongoing tasks necessary to keep the project operating.  NNYT YT ! YT,Arial (nThe timetable should identify each of the outcomes and outputs the project must complete. It should also include the ongoing tasks (y(necessary to keep the project operating. /@ @w   = PROJECT OUTCOMES V /@@@w   > 0 *PHASING OF OUTPUTS AND ACTIVITIES (TASKS) w} w} YT w},Arial (PHASING OF OUTPUTS AND ( ACTIVITIES (TASKS)@/@`@w   ?P P 1 `/@@w   @p p 2 /@@w   A  3 /@@w   B  4 /@@w   C  5 /@@w   D  6 /@ @w   E  7  /@ @@w   F0 0 8  @/@!`@w   G P !P 9 !`/@"p@w   H!p "` 10  "p/@#@w   I" # 11  #/@$@w   J# $ 12  @$@0 MONTHS #P009MONTHS #TN=HHqT=M4h~L @ @  KP  AGENCY NAME&,@$ @  LP$ DATE$&@ STATE GRANT APPLICATION p@$ @@  #MA$  PROJECT TITLE$>.@ $Q @  12. TIME PHASING (CONTINUED)    /p"0% PAGE 10 " /@$@ + 0$ The timetable should identify each of the outcomes and outputs the project must complete. It should also include the ongoing tasks necessary to keep the project operating.  NNYT YT w} YT,Arial (nThe timetable should identify each of the outcomes and outputs the project must complete. It should also include the ongoing tasks (y(necessary to keep the project operating.  /@ @|  \0 PROJECT OUTCOMES V /@@@}  ]0 0 *PHASING OF OUTPUTS AND ACTIVITIES (TASKS) Y} Y} YT Y},Arial (mPHASING OF OUTPUTS AND (v ACTIVITIES (TASKS) @/@`@~  ^0PP 1  `/@@  _0pp 2  /@@  `0 3  /@@  a0 4  /@@  b0 5  /@@  c0 6  /@ @  d0 7   /@ @@  e00 0 8  @/@!`@  f0 P!P 9  !`/@"p@  g0!p"` 10   "p/@#@  h0"# 11   #/@$@  i0#$ 12   @$`0 MONTHS #P010MONTHS #TN=HHqT=M}@ @|  xP  AGENCY NAMEw,@$ @}  yP$ DATEw@ FEDERAL GRANT APP}x_ | "   '()5679:;KLMxyz{|}|ۥۥۥۥۥۥ±''ۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥۥ_ porpsilaZ porpsila`<E porpsilal porpsilarData{zywvutsrqponmlkjihged     &%$#"!    )('8765=>?@ABCDEFGHIJ;:9\]^_`abcdefghiMLKzyx~}|{& h& {>:%;\:(;\:%;\& h& & {>:%>;\:%;\:%;\:%;\:%;\:%;\& h& & {>;\:%;\>;\:%:%;\:%:%;\:%;\& h& & {>:%>;\:%:%;\:%;\:%;\:%;\& h& & {& & & & & &  ;\;\,;\@T ;\h  %;\|  & R2%,,;\@;\T ;\h ;\| %`1$,;\@;\T ;\h ;\| %`1$ ;\,@;\T ;\h ;\| %;\  & & & & & &  ;\;\,;\@T ;\h  %|  & R2;\%,& h& & {& h& & {& h& & {& h& & {& h& & {& h& & {& h& & {ArialTimes New RomanRomane\;$e\e\;%;\& h& & {& & & & & &  ;\;\,;\@T ;\h  %;\|  & R2%,& ;\,@;\T ;\h ;\| %;\  & h& & {& h& & {& h& & {& h& & {& h& & {& h& & {& h& &Sp@ @  P  AGENCY NAME,@$ @  P$ DATE@ STATE GRANT APPLICATION p@$ @@  #A$  PROJECT TITLE.@ $Q@  14. LOGIC MODEL   Q /p"0% PAGE 13 " P$H@  0P > Outcomes: Short, intermediate or longer term changes anticipated in participants' lives, and/or in the organization or community conditions.     Y Y !G Y,Arial (mOutcomes(mI:(yShort, intermediate or (longer term changes (anticipated in (participants' lives, (and/or in the (organization or (community conditions.P$H@  ` g> Indicators: Detailed examples that can be seen, heard, or read that demonstrate outcomes are being met.    ppr r Y r,Arial ( Indicators(H:(Detailed examples that (can be seen, heard, or (read that demonstrate ( outcomes are being (,met.$H@   R Data Collection Methods/Tools: Methods for gathering statistics for the assessment of the project. Measures need to be valid and reliable, culturally appropriate, and within the agency's resources to implement.        ,,_ _ r _,Arial (sData Collection ( Methods/Tools(]:(Methods for gathering (statistics for the (assessment of the (project. Measures need (to be valid and reliable, (culturally appropriate, (and within the agency's (resources to implement.&$H@  & R Data Collection Frequency/Schedule: Describe when and how often data will be collected, and if you need confidentiality agreements.    "  #  x x _ x,Arial (Data Collection (Frequency/Schedule(u:(Describe when and how (often data will be (&collected, and if you (2need confidentiality (> agreements.&/@$H@  &/@ > Sampling Strategy: State whether the entire participant population will be included, or you will use a sample. If the project has less than 100 participants, all participants should be included.      e e x e,Arial (ySampling Strategy(yl:(State whether the entire (participant population (will be included, or you (will use a sample. If the (project has less than (100 participants, all (participants should be ( included.P013participants should be ( included.TN=HH=M  44N 4N N N,Arial (_Detailed examples that (jcan be seen, heard, or (uread that demonstrate (outcomes are being (met. 0;<Sxl_mrkJnj@pqorh%x {  c+S'D5d9K Ci0  1     b K n U  ' C }d  ' = T    7| % p_(P6p:L Oy g P b  L   9  0 q < # ^ K k x  +uaG    s  }        u.vGtwasyy       H %g I /h J 9i ?^ @_ A` Ba Cb D c E d F e G f  ,Ll  9 Y y !#$%&0e'C `{~ ;>] t=\ c8 V{z } , w=e)V7v;M U"  z    ContractNumber ProgramArea DateStamp AgencyNameAgencyTelephone AgencyFAXAgencyAddress_StreetAgencyAddress_CityAgencyAddress_StateAgencyAddress_ZipAgencyMailingAddress_StreetAgencyMailingAddress_CityAgencyMailingAddress_StateAgencyMailingAddress_ZipImplementingNameImplementingAddress_StreetImplementingAddress_CityImplementingAddress_StateImplementingAddress_ZipImplementingTelephoneSSN ProjectTitleLegalAuthorityNameAgencySignatureDateAcceptance_Yes Acceptance_NoOJJSignatureDateProjectDirectorNameProjectDirectorAddress_StreetProjectDirectorAddress_CityProjectDirectorAddress_StateProjectDirectorAddress_ZipProjectDirectorTelephoneProjectDirectorFAXProjectDirectorEmailFinancialOfficerNameFinancialOfficerAddress_StreetFinancialOfficerAddress_CityFinancialOfficerAddress_StateFinancialOfficerAddress_ZipFinancialOfficerTelephoneFinancialOfficerFAXFinancialOfficerEmail AgencyName1Date ProjectTitle1A_PositionTitles A_StateFunds A_CashMatchA_ProjectTotalA_StateFunds_TotalCashMatch_TotalA_ProjectTotal_TotalA_Justification AgencyName2Date1 ProjectTitle2 B_Listing B_StateFunds B_CashMatchB_ProjectTotalB_Total C_Listing C_StateFunds C_CashMatchC_ProjectTotalC_Total AgencyName3Date2 ProjectTitle3 D_Listing D_StateFunds D_CashMatchD_ProjectTotalD_Total E_Listing E_StateFunds E_CashMatchE_ProjectTotalE_Total AgencyName4Date3 ProjectTitle4 F_Listing F_StateFunds F_CashMatchF_ProjectTotalF_Total G_Listing G_StateFunds G_CashMatchG_ProjectTotalG_Total AgencyName5Date4 ProjectTitle5ProposedTime_FromDateProposedTime_ToDateA_Personnel_TotalB_Supplies_Total C_Other_TotalD_CapitalOutlay_TotalE_Travel_TotalF_Contractual_TotalTotalDirectChargesG_IndirectCharges_TotalTotalProjectCost Federal_TotalMatch OtherSourceOtherSourceAmountSourceOfFunds_TotalProjectSummary OtherSource1OtherSourceAmount1 OtherSource2OtherSourceAmount2 OtherSource3OtherSourceAmount3 OtherSource4OtherSourceAmount4FederalPercentMatchPercentageOtherSourcePercentSourceOfFunds_PercentOtherSourcePercent1OtherSourcePercent2OtherSourcePercent3OtherSourcePercent4 AgencyName6Date5 ProjectTitle6 AgencyName7Date6 ProjectTitle7 ProjectPlan AgencyName8Date7 ProjectTitle8ProjectOutcomes1ProjectObjectives1Month1_1Month2_1Month3_1Month4_1Month5_1Month6_1Month7_1Month8_1Month9_1 Month10_1 Month11_1 Month12_1 AgencyName9Date8 ProjectTitle9ProjectOutcomes2ProjectObjectives2Month1_2Month2_2Month3_2Month4_2Month5_2Month6_2Month7_2Month8_2Month9_2 Month10_2 Month11_2 Month12_2 AgencyName10Date9ProjectTitle10 AgencyName11Date10ProjectTitle11ProjectEvaluatorSupervisor ProjectPlan1 AgencyName12Date11ProjectTitle12LogicModel_OutcomesLogicModel_Indicators LogicModel_DataCollectionMethods"LogicModel_DataCollectionFrequencyLogicModel_SamplingStrategyA_Personnel_StateFundsB_Supplies_StateFundsC_Other_StateFundsD_CapitalOutlay_StateFundsE_Travel_StateFundsF_Contractual_StateFundsTotalDirectCharges_StateFundsG_IndirectCharges_StateFundsTotalProjectCost_StateFundsB_StateFunds_TotalB_CashMatch_TotalC_StateFunds_TotalC_CashMatch_TotalD_StateFunds_TotalD_CashMatch_TotalE_StateFunds_TotalE_CashMatch_TotalF_StateFunds_TotalF_CashMatch_TotalG_StateFunds_TotalG_CashMatch_Totalevelop your own. These may be case records, assessments, inteҎl  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~lրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրրր ContractNumber ProgramArea DateStamp AgencyNameAgencyTelephone AgencyFAXAgencyAddress_StreetAgencyAddress_CityAgencyAddress_StateAgencyAddress_ZipAgencyMailingAddress_StreetAgencyMailingAddress_CityAgencyMailingAddress_StateAgencyMailingAddress_ZipImplementingNameImplementingAddress_StreetImplementingAddress_CityImplementingAddress_StateImplementingAddress_ZipImplementingTelephoneSSN ProjectTitleLegalAuthorityNameAgencySignatureDateAcceptance_Yes Acceptance_NoOJJSignatureDateProjectDirectorNameProjectDirectorAddress_StreetProjectDirectorAddress_CityProjectDirectorAddress_StateProjectDirectorAddress_ZipProjectDirectorTelephoneProjectDirectorFAXProjectDirectorEmailFinancialOfficerNameFinancialOfficerAddress_StreetFinancialOfficerAddress_CityFinancialOfficerAddress_StateFinancialOfficerAddress_ZipFinancialOfficerTelephoneFinancialOfficerFAXFinancialOfficerEmail AgencyName1Date ProjectTitle1A_PositionTitles A_StateFunds A_CashMatchA_ProjectTotalA_StateFunds_TotalCashMatch_TotalA_ProjectTotal_TotalA_Justification AgencyName2Date1 ProjectTitle2 B_Listing B_StateFunds B_CashMatchB_ProjectTotalB_Total C_Listing C_StateFunds C_CashMatchC_ProjectTotalC_TotalB_StateFunds_TotalB_CashMatch_TotalC_StateFunds_TotalC_CashMatch_Total AgencyName3Date2 ProjectTitle3 D_Listing D_StateFunds D_CashMatchD_ProjectTotalD_Total E_Listing E_StateFunds E_CashMatchE_ProjectTotalE_TotalD_StateFunds_TotalD_CashMatch_TotalE_StateFunds_TotalE_CashMatch_Total AgencyName4Date3 ProjectTitle4 F_Listing F_StateFunds F_CashMatchF_ProjectTotalF_Total G_Listing G_StateFunds G_CashMatchG_ProjectTotalG_TotalF_StateFunds_TotalF_CashMatch_TotalG_StateFunds_TotalG_CashMatch_Total AgencyName5Date4 ProjectTitle5ProposedTime_FromDateProposedTime_ToDateA_Personnel_TotalB_Supplies_Total C_Other_TotalD_CapitalOutlay_TotalE_Travel_TotalF_Contractual_TotalTotalDirectChargesG_IndirectCharges_TotalTotalProjectCost Federal_TotalMatch OtherSourceOtherSourceAmountSourceOfFunds_TotalProjectSummary OtherSource1OtherSourceAmount1 OtherSource2OtherSourceAmount2 OtherSource3OtherSourceAmount3 OtherSource4OtherSourceAmount4FederalPercentMatchPercentageOtherSourcePercentSourceOfFunds_PercentOtherSourcePercent1OtherSourcePercent2OtherSourcePercent3OtherSourcePercent4A_Personnel_StateFundsB_Supplies_StateFundsC_Other_StateFundsD_CapitalOutlay_StateFundsE_Travel_StateFundsF_Contractual_StateFundsTotalDirectCharges_StateFundsG_IndirectCharges_StateFundsTotalProjectCost_StateFunds AgencyName6Date5 ProjectTitle6 AgencyName7Date6 ProjectTitle7 ProjectPlan AgencyName8Date7 ProjectTitle8ProjectOutcomes1ProjectObjectives1Month1_1Month2_1Month3_1Month4_1Month5_1Month6_1Month7_1Month8_1Month9_1 Month10_1 Month11_1 Month12_1 AgencyName9Date8 ProjectTitle9ProjectOutcomes2ProjectObjectives2Month1_2Month2_2Month3_2Month4_2Month5_2Month6_2Month7_2Month8_2Month9_2 Month10_2 Month11_2 Month12_2 AgencyName10Date9ProjectTitle10 AgencyName11Date10ProjectTitle11ProjectEvaluatorSupervisor ProjectPlan1 AgencyName12Date11ProjectTitle12LogicModel_OutcomesLogicModel_Indicators LogicModel_DataCollectionMethods"LogicModel_DataCollectionFrequencyLogicModel_SamplingStrategy$5;?5: @ @  'P  AGENCY NAME&,@$ @  (P$ DATE$&@ STATE GRANT APPLICATION p@$ @@  #)A$  PROJECT TITLE$>.@ $Q`  111. DESCRIPTION OF THE PROJECT (START ON PAGE 8)    /p"0$ PAGE 7  # nSubmit a description of the project using the outline format shown below. Address all topics listed. Attach as many pages as required to properly address the topics. I. GENERAL NEEDS STATEMENT A. State the need this project is designed to alleviate. B. Support the need by statistical (local based) data/information. C. Clearly define target population as to number and characteristics. D. List other possible community resources. E. Indicate why other community resources are not adequate to meet the need. F. State how the project will address the need. II. IMPLEMENTATION AND METHODS A. Describe the research-based methods and techniques to be used to meet the outputs and identify the research approach. Program must be based on sound theory supported by positive or promising research results. B. Identify the sources, expected number of referrals, and the manner in which those referrals are likely to occur. C. As applicable, outline the involvement of any other community organization/agency (human services, juvenile court, schools, law enforcement, support groups, service clubs, etc.). D. Identify agencies from which letters of agreement will be obtained. E. Describe staffing and staff qualifications. III. LOGIC MODEL Use the Logic Model below to describe the resources, activities, outputs, outcome, and goal(s) of the project.    >  ]      vv_H _H >x _H,Arial (s"|Submit a description of the project using the outline format shown below. Address all topics listed. Attach as many pages (",as required to properly address the topics. ("I. GENERAL NEEDS STATEMENT(,:A. State the need this project is designed to alleviate. (,DB. Support the need by statistical (local based) data/information. (,GC. Clearly define target population as to number and characteristics. (,-D. List other possible community resources. (,OE. Indicate why other community resources are not adequate to meet the need. (,1F. State how the project will address the need. ( "II. IMPLEMENTATION AND METHODS(,qA. Describe the research-based methods and techniques to be used to meet the outputs and identify the research (),k approach. Program must be based on sound theory supported by positive or promising research results. (7,uB. Identify the sources, expected number of referrals, and the manner in which those referrals are likely to occur. (E,xC. As applicable, outline the involvement of any other community organization/agency (human services, juvenile court, (S,F schools, law enforcement, support groups, service clubs, etc.). (a,HD. Identify agencies from which letters of agreement will be obtained. (o,0E. Describe staffing and staff qualifications. ("III. LOGIC MODEL(,nUse the Logic Model below to describe the resources, activities, outputs, outcome, and goal(s) of the project. /@$$QQQQQ#p  EProgram inputs. Elements or ingredients that constitute the program.    _H ,Arial (Program inputs. (Elements or ingredients (that constitute the (program.#p  LMethods for providing the program. Specific processes or events undertaken.     ,Arial (Methods for providing (the program. Specific (processes or events ( undertaken.#p  LUnits of service or product units. How many, how often, over what duration?  i i  i,Arial (Units of service or (product units. How (many, how often, over (what duration?#p#0 |Short intermediate or longer-term changes anticipated in participants' lives and/or in organization or community conditions.  ~~e= e= i e=,Arial (oShort intermediate or (olonger-term changes (oanticipated in (oparticipants' lives (oand/or in organization (!o or community (/o conditions.#p$!p# XUltimate impact(s) expected to occur, usually beyond what one program alone can achieve.  44!I I! e= !I,Arial (Ultimate impact(s) (expected to occur, (usually beyond what (one program alone can (achieve.#p- $$  For example:   8 %P&`  Three FTEs.   2 %` %`&@'` %After school facility and playground.  Z! !Z !I Z!,Arial (k+After school facility (v+and playground.&` &`()p` College student volunteers.  w! !w Z! w!,Arial (+College student (+ volunteers.(0 (p`)*p` Foundation funding.   P ) * `#p- $$  For example:   8 %P &` After school mentoring.  Ku Ku w! Ku,Arial (\ After school (g mentoring.%` % `' '` Homework assistance.   [ ' 'P `( )`  Health snack.   7 ( )0 `) +` 3Positive reinforcement for non-aggressive behavior.    Ku ,Arial (Positive reinforcement (for non-aggressive ( behavior.) * `#p- $$  For example:   8 %P'`` BThree-hour program every day after school for 40 at-risk students.  Kp Kp  Kp,Arial (\ Three-hour program (g every day after school (r for 40 at-risk students.%` %`')` One hour homework assistance.  qp qp Kp qp,Arial ( One hour homework ( assistance.' (`)p*` One hour sports and exercise.  p p qp p,Arial ( One hour sports and ( exercise.) )`+,p` One hour snack and reading.  p p p p,Arial ( One hour snack and ( reading.+  +``#p- $$  For example:   8 %P'`` /Increase in grades (GPA) at end of school year.  Kq qK >x Kq,Arial (\{Increase in grades (g{(GPA) at end of (r{ school year.%` %`')` !Increase in pro-social behaviors.  qq qq Kq qq,Arial ({Increase in pro-social ({ behaviors.' 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