2021 New York State AmeriCorps Competitive Application Review Process REVIEWER WORKSHEET (The individual reviewer worksheet does not determine final consensus scoring) Proposal Name: Reviewer Name (Print): Section Totals Section A Executive Summary: (Required) SUBTOTAL: YES / NO Section B Program Design: Theory of Change and Logic Model (0-24) ______ + EVIDENCE BASE + Notice Priority (0) + Member Experience (0-6) ______ Note: Evidence Base (20 points) will be reviewed separately by OCFS Strategic Planning and Policy Development staff on 2021 Evidence Review Tool = SUBTOTAL: ________ (0-30) Section C Organizational Capability: Organization Background and Staffing (0-9) ______ + Compliance and Accountability (0-8) ______ + Culture that Values Learning (0-4) ______ + Member Supervision (0-4) ______ = SUBTOTAL: ________(0-25) Section D Cost Effectiveness & Budget Adequacy: Cost Effectiveness and Budget Adequacy (0-25) = SUBTOTAL: ________ (0-25) Section E Evaluation Plan: (Required for recompeting grantees only) YES / NO APPLICATION SCORE: ________(0-80) 1 Section A: Executive Summary Executive Summary (No points) Comments: • Did the applicant provide an Executive Summary? Yes No Section B: Program Design (8 subsections) 1.Theory of Change and Logic Model (0-24 points) Comments: The Theory of Change Shall address: • Did the applicant clearly describe that the proposed intervention is responsive to the Yes No identified community problem? • Did the applicant clearly describe the proposed intervention is clearly articulated including the design, dosage, target population, and roles of AmeriCorps Yes No members and (if applicable) leveraged volunteers? • Did the applicant clearly describe how the intervention is likely to lead to the outcomes identified in the applicant’s theory of Yes No change? 2 Section B: Program Design (CONTINUED) • Did the applicant clearly describe how the expected outcomes articulated in the application narrative and logic model represent meaningful progress in Yes No addressing the community problem identified by the applicant? • Did the applicant clearly describe the rationale for utilizing AmeriCorps members Yes No to deliver the intervention(s) is reasonable? • Did the applicant clearly describe the service role of AmeriCorps members will produce significant contributions to existing Yes No efforts to address the stated problem? Note: The logic model is a visual representation of the applicant’s theory of change. Programs may include short, medium or long-term outcomes in the logic model. Applicants are not required to measure all components of their theory of change. The applicant’s performance measures should be consistent with the program’s theory of change and should represent significant program activities. In the application narrative, applicants should discuss their rationale for setting output and outcome targets for their performance measures. Rationales and justifications should be informed by the organization’s performance data (e.g., program data observed over time that suggests targets are reasonable), relevant research (e.g., targets documented by organizations running similar programs with similar populations), or prior program evaluation findings. Applicants with multiple interventions should complete one Logic Model chart which incorporates each intervention. Logic model content that exceeds three pages will not be reviewed. 3 Section B: Program Design (CONTINUED) The Logic Model shall depict: • Did the applicant provide a summary of the community problem. Yes No • The inputs or resources that are necessary to deliver the intervention, including but not limited to: Locations or sites in which members o Yes No will provide services o Number of AmeriCorps members that will deliver the intervention • The core activities that define the intervention or program model that members will implement or deliver, including: o The duration of the intervention (e.g., the total number of weeks, sessions or months of the intervention). o The dosage of the intervention (e.g., Yes No the number of hours per session or sessions per week.) o The target population for the intervention (e.g., disconnected youth, third graders at a certain reading proficiency level). • The measurable outputs that result from delivering the intervention (i.e. number of beneficiaries served types and number of activities conducted.) If applicable, identify Yes No which National Performance Measures will be used as output indicators. 4 • Outcomes that demonstrate changes in knowledge/skill, attitude, behavior, or condition that occur as a result of the intervention. If applicable, identify which Yes No National Performance Measures will be used as outcome indicators. Theory of Change and Logic Model (0-24 points) Total Points Awarded: _________ Section B: Program Design (CONTINUED) 2. Evidence Base Note: Evidence Base (20 points) will be reviewed separately by OCFS Strategic Planning and Policy Development staff on 2021 Evidence Review Tool 3. Notice Priority (0 points) Comments: • Did the applicant clearly describe how its proposed program is within one or more of the 2021 AmeriCorps Funding Priorities section of the 2021 Notice of Funding Availability and more fully described in the 2021 Mandatory Yes No Supplemental Guidance and the proposed program meets all of the requirements detailed in the Funding Priorities section and in the 2021 Mandatory Supplemental Guidance. Notice Priority (0 points allowable) 4. Member Experience (0-6 points) Comments: • Did the applicant clearly describe how the AmeriCorps members will gain skills as a result of their training and service that can be utilized and will be valued by future Yes No employers after their service term is completed? 5 • Did the applicant clearly describe how the program will recruit AmeriCorps members from the geographic or demographic Yes No communities in which the program operates? • Did the applicant clearly describe how the applicant will foster and inclusive service culture where different backgrounds, talents, and capabilities are welcomed and Yes No leveraged for learning and effective service delivery? Member Experience (0-6 points) Total Points Awarded: _________ Section B Program Design (0-30 points allowable for all 5 subsections) TOTAL POINTS AWARD: ________ Section C: Organizational Capacity (4 subsections) 1. Organizational Background and Staffing (0-9) Comments: • Did the applicant clearly describe the roles, responsibilities, and structure of the staff that will be implementing the AmeriCorps program Yes No as well as providing oversight and monitoring for the program? Organizational Background and Staffing (0-9 allowable) Total Points Awarded: _________ 2. Compliance and Accountability (0-8) Comments: • Did the applicant clearly describe a monitoring and oversight plan to prevent and detect non- compliance and enforce compliance with AmeriCorps rules and regulations including those related to prohibited and unallowable Yes No activities and criminal history checks at grantee, subgrantee (if applicable), and service site locations? 6 • Did the applicant provided CNCS-required evaluation report that meets CNCS Yes No requirements (if applicable)? • Did the applicant provided CNCS-required evaluation report is of satisfactory quality (if Yes No applicable)? Note: Commission of National and Community Service will provide the reviewers with the CNCS-required evaluation report requirement for each application because the it various based on how many years has program been operational. OCFS subject matter expert will also provide feedback and comment whether if the evaluation reports meet CNCS requirement and/or they are of satisfactory quality. The reviewers the final determination on score based on the information provided above. Compliance and Accountability (0-8 allowable) Total Points Awarded: _________ Section C: Organizational Capacity (CONTINUED) 3. Culture that Values Learning (0-4) Comments: • Did the applicant clearly describe how the applicant’s board, management, and staff collects and uses information for learning Yes No and decision making? Culture that Values Learning (0-4 allowable) Total Points Awarded: _________ 4. Member Supervision (0-4) Comments: • Did the applicant clearly describe how the AmeriCorps members will receive sufficient guidance and support from their supervisor Yes No to provide effective service? 7 • Did the applicant clearly describe how the AmeriCorps supervisors will be adequately trained/prepared to follow AmeriCorps and Yes No program regulations, priorities, and expectations? Member Supervision (0-4 allowable) Total Points Awarded: _________ Section C Organizational Capability (0-25 points allowable for 4 subsections) TOTAL POINTS AWARD: ________ Section D: Cost Effectiveness and Budget Adequacy (1 subsection) Note: Reviewers will assess the quality of the application’s budget to the following criteria below. Do not assume all sub-criteria are of equal value. This criterion will be assessed based on the budget submitted. No narrative should be entered in the narrative box except for “See budget.” 1. Cost Effectiveness and Budget Adequacy (0-25 points) Comments: • Is the budget submitted without mathematical errors and proposed costs are allowable, reasonable, and allocable to the Yes No award? • Is the budget submitted with adequate information to assess how each line item is Yes No calculated? • Is the budget submitted in compliance with the budget instructions? Yes No • Is the match information submitted with