Community Clinics Initiative Grantee Progress Report Form

Tides Foundation

Building Capacities Program Major Capital Campaign Gifts

Grantee reports are important because they serve at least four purposes.

 Provide Community Clinic Initiative staff with an update on your progress.  Encourage grantees to reflect on what they’ve learned about their organizational capacities and needs.  Share lessons that may benefit other clinics.  Provide Tides Foundation with feedback on ways to strengthen our grant program.

Please submit your grant report using the following eight-part format. If you have any questions or would like to discuss what to include in the report, call Jane Stafford at 415-561-6356 or email her at [email protected].

Send your completed grant report to: Or email to:

Olivia Nava [email protected] CCI Program Associate Tides P.O. Box 29907 San Francisco, CA 94129

Please ensure that your complete report includes: _____ 1. Contact and Grant Information _____ 2. Campaign Activities Update _____ 3. Project Update Narrative addressing the questions provided _____ 4. Consultants _____ 5. Foundations List _____ 6. Challenge Grant Donation Details. If you received a Challenge Grant, please report your donations using the format provided. _____ 7. Sources and Uses (budget to actual) using the format provided _____ 8. Increase to Access to Care chart

1. Contact and Grant Information

Grantee Name:______

Grant Number:______Grant Amount:______

Contact Person: ______

Phone:______Email:______2. Campaign Activities Update a. Please fill in the following tables indicating your clinic’s fund development resources and activities for your Major Capital Campaign and your CCI MCCG (Major Capital Campaign Gift) grant.

Campaign and Fund Development Staff and Resources Which of the following Is this resource in place as a Is this resource supported all, resources does your clinic result of your major capital or in part, by your CCI grant or currently have in place? campaign? other types of CCI support? (Check all that apply and complete the corresponding questions) Campaign Director (for capital N/A Yes No campaign only)

Fund Development Consultant Yes No Yes No (as part of capital campaign efforts)

Development Director (with Yes No Yes No intention of retaining after capital campaign)

FT Fund Development Staff Yes No Yes No Number of FTE: ______If yes, number of FTE: ______If yes, number of FTE: ______Titles of FTE: ______Titles of FTE: ______Titles of FTE: ______

PT Fund Development Staff Yes No Yes No Number of PTE: ______If yes, number of PTE: ______If yes, number of PTE: ______Titles of FTE: ______Titles of PTE: ______Titles of PTE: ______

Campaign Committee N/A Yes No

Campaign Feasibility Study N/A Yes No Date of completion: ______

Fund Development Software: Yes No Yes No Purchased Installed Generating reports

Donate Now button on Yes No Yes No website for online fundraising Fund Development Activities Which of the following activities Is this activity part of your Is this activity supported all, or has your clinic engaged in major capital campaign? in part, by your CCI grant or within the last year? other types of CCI-related (Check all that apply and support? complete the corresponding questions) Board development around Yes No Yes No fundraising (participation in fund development and/or contributions) Staff development around Yes No Yes No fundraising (participation in fund development and/or contributions) Local fund development Yes No Yes No Produced fund raising event Yes No Yes No (i.e. gala event, major donor dinner) If so, did you have corporate sponsors? Yes No First time holding this event?  Yes No Solicited community groups Yes No Yes No through speaking engagements If so, first time doing this? Yes No Sent direct mail appeal Yes No Yes No If so, first time doing this? Yes No Sold marketing products (i.e. Yes No Yes No books, sweatshirts, coffee mugs) If so, first time doing this? Yes No Engaged in other fund Yes No Yes No development activities If so, please describe:______First time doing this? Yes No Engaged in online fundraising Yes No Yes No If so, how frequently do you receive online donations? Often Sometimes Rarely Never Board involved in solicitations Staff involved in solicitations Before campaign Now Before campaign Now None None None None Some Some Some Some Active Active Active Active b. Please indicate your organization’s progress towards its capital campaign goals by filling out the table below: Fund Development Progress Board Staff Individuals Foundations Corporations Government Other Number of prospects Number of prospects committed Number of new donors (of those prospects committed) Number of returning donors (of those prospects committed) Target $ amount Actual $ amount raised c. Which of the following describes your capital project and capital campaign? (Check all that apply) Proposed facility Same location Expansion Renovation New location Relocation (replacement facility) Additional facility New construction Pre-existing building Flagship or headquarters location Have site control of the property Own the property Under purchase contract: When will you own the property? ______Lease: Number of years on your lease: ______Own other sites: Number:______Have you completed your facilities project (construction/purchase)?. Yes No If not, when is it projected to be complete? ______Have you completed your capital campaign? Yes No If not, when is it projected to be complete? ______3. Project Update Narrative Please limit your narrative to four pages.

This section is designed to provide Tides CCI staff with a succinct progress report on your grant. BTW Consultants, the CCI evaluator, also will analyze answers across grantees to identify trends. You may answer the questions individually or write one narrative, as long as your update addresses all of the questions below.

Q1: Update Your Building Project: Please provide a general update on your facilities project. How far along is the project? Explain any changes or updates made to the design or implementation of your facilities project and why. Have there been any outstanding problems or issues that have stalled work on the project? Please explain. Address the following areas as applicable: a. Site control (signed long-term lease and term, ownership status, etc.) b. Application or approval for any debt financing c. Architectural and engineering designs d. Permits and construction e. Furnishings and equipment plans or purchase orders

Q2: Capital Campaign--Activities, Challenges and Changes: Please describe briefly your fund raising activities for your major capital campaign. Please describe any key challenges that arose during the project, how you addressed them and any lessons you’ve drawn from this experience.

Q3: Accomplishments: What did you accomplish towards building your fund development capacity? In addition to the grid on the previous page, please provide examples that demonstrate ways in which your organization’s fund development capacity has increased and the ways in which this additional capacity has impacted your organization. Were there any surprises? How do you expect to utilize the fund development infrastructure you have built as you move past your capital project and into the future?

Q4: Challenge Grant: If you received a challenge grant, how did it help you raise contributions from new funders? Has it improved your outlook for engaging in future fund development in any way? If so, how?

Q5: Assistance from CCI: Aside from CCI’s major capital gift, what kind of assistance have you received from CCI on your capital campaign? How has CCI helped you achieve your capital campaign goals? Please address the following areas as applicable: a. Assistance provided by CCI in developing funding partners and/or favorable lending relationships b. Technical assistance provided by CCI staff c. Technical assistance provided by Capital Link or Capital Incubator d. CCI conferences, trainings and workshops e. Other types of CCI resources and/or assistance from CCI staff

Q6: Relationship With Local Community: Did your capital campaign project in any way strengthen your standing in or relationship with your local community? Did any of your campaign’s activities raise awareness among local community members of your work? If so, how?

Q7: Improving or Expanding Access to Care: Please detail the impact of your campaign on access to care. The last page of this report asks for specific numbers detailing your service expansion and increased access for patients. Please use your narrative to better explain how you plan to use the additional space that is available and what new services you will be able to provide.

Q8: Top Lessons Learned. In a complex capital facilities project, there are many lessons learned. We are trying to collect these lessons to share with your colleagues as they embark upon their own projects. What are the top lessons (3-10) that you and your organization have learned about capital development projects. These can be brief statements and explanations of the top things you want to quickly share with your colleagues.

Q9: Favorite Story. Every project has a favorite story. Tell us yours. The surprise that came from nowhere that saved the project budget or timeline. The volunteer or donor who gave it their all. The disaster that had a silver lining. One that touches the heart.

4. Consultants Please provide the name(s) and contact information of the consultant(s) that you hired with funds from your Major Capital Campaign Gift. If you have the resume(s) of the consultant(s), please include them as attachment(s).

If you used consultants that you did not hire with CCI funds but would like to recommend to your peers, please also list their names on this chart. Consultant Contact Info What Services How Useful Were Those Would You Why or Why Was this (Please Were Provided? Services? Recommend Not? consultant include firms, (Circle One: This hired with such as 1= Not at all Useful, 5= Very Consultant to your Major Useful) Capital Link, Your Peers? Capital as well as Campaign individuals) Gift? 1 2 3 4  Yes   Yes  5 No No Not at all useful Very Useful 1 2 3 4  Yes   Yes  5 No No Not at all useful Very Useful 1 2 3 4  Yes   Yes  5 No No Not at all useful Very Useful 1 2 3 4  Yes   Yes  5 No No Not at all useful Very Useful 1 2 3 4  Yes   Yes  5 No No Not at all useful Very Useful 1 2 3 4  Yes   Yes  5 No No Not at all useful Very Useful 1 2 3 4  Yes   Yes  5 No No Not at all useful Very Useful 1 2 3 4  Yes   Yes  5 No No Not at all useful Very Useful 1 2 3 4  Yes   Yes  5 No No Not at all useful Very Useful 1 2 3 4  Yes   Yes  5 No No Not at all useful Very Useful 5. Capital-funding Foundation List Please list all the Foundations that have supported your facilities project. *If CCI provided assistance in helping you access resources from other Foundations, please indicate this on the following table and explain how CCI assisted your organization in the box provided below.

Foundation Name Type of Foundation Received Amount Did you receive (Community, Private, etc.) assistance funding from from CCI in this foundation securing this previously? funding? (Yes/No)* (Yes/No) *Use this box to explain how CCI has helped your organization access funds from other Foundations. 6. Challenge Grant Donation Details Did you receive a challenge grant from CCI?  Yes  No. If yes, please attach an accounting of your challenge grant donations using the following format.

Commitment Donor Name Affiliation Date Amount

Total: 7. Sources and Use s (budge t-to-actual) We are not asking for a detailed report on expenditures of CCI’s funds. We would like to see a comparison of your entire campaign’s budgeted to actual sources and uses.

These figures accurate as of: (Date)

ACTUAL BUDGET (TO DATE) Sources 1 L oan am ount 2 C linic equity (down paym ent) 3 C apital C am paign (total projected) Individuals C orporations F oundations G overnm ent Grants Other (s pecify) S ubtotal: Capital Campaign $ - $ - 4 Other s ources (s pecify)

S ubtotal: Other S ources $ - $ - Total Sources $ - $ -

Uses 1 Acquis ition

E nvironm ental As s es s m ents , S urvey, Title 2 R eports and Ins urance, Apprais als 3 C ons truction 4 P ercent cons truction contingency 5 Architecture and E ngineering 6 P erm its and F ees 7 L egal and other cons ultants 8 F inancing 9 F undrais ing 10 E quipm ent and F urnis hings 11 Technology backbone 12 Occupancy and licens ure 13 Total project contingency 14 Other (s pecify) 8. Expected Services or Access to Care Increases Please fill in the following table reflecting the rise in volume that you expect from your facilities expansion project.

Measures Year before expansion First year after expansion Second year after expansion Number of Unduplicated Patients

Number of Patient Visits

Number of Medical FTE: ______FTE: ______FTE: ______Providers/Clinicians PTE: ______PTE: ______PTE: ______

Number of Medical Exam Rooms

Number of Dental FTE: ______FTE: ______FTE: ______Hygienists/Dental Assistants PTE: ______PTE: ______PTE: ______Number of Dental Operatories

Number of Mental FTE: ______FTE: ______FTE: ______Health Providers PTE: ______PTE: ______PTE: ______

Number of Offices for Mental Health Services

Square Feet

Number of Health FTE: ______FTE: ______FTE: ______Education/Outreach Staff PTE: ______PTE: ______PTE: ______Additional services/staff/areas of increase (please describe): ______