Smart Start Format for Activities

NORTH CAROLINA PARTNERSHIP FOR CHILDREN Smart Start Format for Activities

Partnership Name:Burke County Partnership for Children, Inc. Submission Date:______

____ Revised/scope change: Activity begun in ______year ______New Activity

______NCPC request I. Activity Title:

II. Activity Codes: a) PSC - b) PBIS ID - a) List the purpose service code (PSC) that best describes this activity. Please refer to the NCPC Fiscal Department’s “Chart of Accounts” located on SmartNet. b) List the PBIS ID number that best reflects your partnership’s strategy for implementing this activity. Please refer to the most recent “PBIS ID Numbers Chart” located on SmartNet.

III. Full Activity Description (FAD): After reading this section, the reader should have knowledge of the activity and how it will operate. Assume the reader has little familiarity with the partnership or the county and answer as completely and in as much detail as possible. Please be sure to address the following using either narrative style or specifically answering the questions:

A. Grants: Yes No Does this activity contain grants of any kind or   incentives to participants? What is being given to participants? If you have checked yes, describe in detail.

B. Medicaid Reimbursement: Is any portion of this activity Medicaid reimbursable?   If you have checked yes, describe in detail.

C. What specific service will be offered? If it is similar to other services in the county please explain how this service will enhance, expand or work with the service currently offered.

D. Describe the population to be served. Eligibility criteria for participation must be included.

F. What specific services/tasks will be done and by whom? Include staff that will be paid for with Smart Start funds and describe what they will be doing.

G. Describe in full how the service will operate.

H. Describe when and where this service will operate.

I. Collaborations: What collaborations were necessary to implement this activity? List organizations and agencies that have collaborated in the development or delivery of this Service.

Specific Conditions Document Program and Planning Department Rev. 10/24/05, 11/08/05 NORTH CAROLINA PARTNERSHIP FOR CHILDREN Smart Start Format for Activities

Partnership Name:Burke County Partnership for Children, Inc. Submission Date:______

IV. Projected Outputs (Numbers/Counts): Outputs are counts. Some of the things to consider tracking are:  number of children served  number of families served  number of child care teachers/family child care providers/directors served  number of child care centers/family child care homes served  number of information packets distributed  number of referrals; number of workshops/sessions offered  number of service units (e.g. home visits, units of therapy, counseling sessions)  There may be others. Please include those that apply to the activity and any others the partnership has decided to track. Make sure the quarterly reporting system categories are addressed.

List one output on each line of the following chart (insert lines as needed). Complete each column on the chart with the required information.

List one output per line How will this be measured? Who will track it? Example: 100 centers will receive Technical Assistants’ logs Technical Assistants will report to program (x service) coordinator

V. NEED and OUTCOMES

Describe the need(s) to be addressed by this activity:

Actual and projected outcomes identified for this activity. Enter one outcome in a row with no more than 3 outcomes for each activity. For assistance in writing outcomes, refer to the Word document titled Smart Start Activity Outcome Checklist. (The outcomes should be linked to the above need.)

Outcomes – Previous FY (list year) How did the actual outcome compare with the projected What factors explain why the actual outcome? outcomes exceeded or did not meet Projected Outcome Actual Outcome Exceeded Met Did Not the projected outcomes? Meet

Specific Conditions Document Program and Planning Department Rev. 10/24/05, 11/08/05 NORTH CAROLINA PARTNERSHIP FOR CHILDREN Smart Start Format for Activities

Partnership Name:Burke County Partnership for Children, Inc. Submission Date:______Outcomes – Current FY (list year) How do you anticipate the actual outcomes will compare to the What factors explain why the actual projected outcomes at the end of outcomes may exceed or may not Projected Outcome this FY? meet the projected outcomes? Exceed Meet Will Not Meet

Projected Outcomes – Upcoming FY (list year)

VII. Projected Line Item Budget and Narrative: Include a budget and narrative that details projected expenses in a line item budget format. Be sure to include specifics for each projected expense, i.e. Personnel: 2 FT CCHCs at $35,000/year including benefits. If this activity has multiple funding sources, discuss within the narrative in- kind or matching funds that are being leveraged.

VIII. Contract Activity Description (CAD), 200 words maximum: This section will be used in developing service contracts. Write the CAD after you complete the full activity description (FAD). Refer to the Smart Start Cost Principles for additional items to be included. The following information must be addressed when writing the CAD:

 What service will be provided  For whom will the service will be done  Who will provide the service  How will the service be delivered

Optional with Planning Consultant input:  Where will the service be delivered  When will the service be delivered

In addition, the contract activity description (CAD) must:  Be written in the future tense  Be limited to 200 words or less in length  Spell out all acronyms and abbreviations when first used  Be written in paragraph form (no bullet or numbered lists)  Be free of spelling, grammatical and spacing errors

Specific Conditions Document Program and Planning Department Rev. 10/24/05, 11/08/05