The United Way of Sarnia-Lambton -


			July 31, 2010

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Outcome Form

Agency Program Performance Report
To be used by both regularly Funded Agencies and Venture Grant Agencies to track the performance of each program that receives United Way funding. Please note that every field must be completed or it will not be accepted electronically.

	AGENCY:
	PROGRAM NAME:
	COMPLETED BY:
	E-MAIL ADDRESS:
	TELEPHONE:

	Instructions: Please use your Agency's United Way Program or Venture Grant Application for funding as a guide in completing this report. There is a Comment section at the bottom of this form to explain major variances in any of the components.

	NOTE: Repeat this sequence as needed for each funded Program that was stated in your Application for funding.

	1) STATEMENT OF SPECIFIC COMMUNITY NEED

	Using your United Way funding application, what did you state as the Specific Community Need that your program is trying to address?



	Is there any new information, for example, new Census data to support the Community Need, new study etc, that you can add?



	2) PROGRAM OUTCOME GOALS

	Using your United Way funding application, what did you state as the Program Outcome Goal(s) of the program?

3) PROGRAM OUTCOME OBJECTIVES

What were the Program Outcome Objectives described in your funding application?

What were the Actual results to date?

4) PROGRAM OUTCOME MEASURES

Please list the Measurement Tools agreed to (minimum of three) by the Agency and the United Way. Please note: Venture Grant Agencies require two.

5) PROGRAM SERVICES

What were the Services outlined in your funding application to the United Way?

Did you offer these Services throughout the year as you intended?

Yes

6) PROGRAM PARTICIPATION

What was the total number of people projected to be served?

How many actually were served for the most recent time period?

7) PROGRAM STAFFING

Any changes in staffing since your application for funding?

Yes

8) PROGRAM OUTCOME/IMPACTS

How have the clients benefited or been impacted from having this program in place? How do you know that you were successful?

9) ROLE / IMPORTANCE OF UNITED WAY FUNDING

How important was the United Way to you and your program?

10) PROGRAM IMPROVEMENTS AND COMMENTS

What changes has the Agency made to its program to improve the quality? Does the Agency feel any further changes need to be made to realize the full potential of the program?

*** THIS SECTION IS FOR VENTURE GRANT FINAL REPORTS ONLY ***

11) REVENUE AND EXPENDITURE SUMMARY

REVENUE

United Way Venture Grant funds

Other Sources:

TOTAL REVENUES

EXPENDITURES: please list

TOTAL EXPENDITURES

SURPLUS OR (DEFICIT)

Notes:

Do you have a client/customer who benefited from your programs and have experienced positive outcomes that would be willing to be highlighted in the United Way Campaign Video?

Yes

Reminder: As per the Business Contract, please forward your Agency's most recent audited financial statement and Foundation audit to the United Way office.

You will receive a copy of the completed form by email.
Please note that each field must be complete or your submission will not be accepted.

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Outcome Form

Agency Program Performance Report

To be used by both regularly Funded Agencies and Venture Grant Agencies to track the performance of each program that receives United Way funding. Please note that every field must be completed or it will not be accepted electronically.

To be used by both regularly Funded Agencies and Venture Grant Agencies to track the performance of each program that receives United Way funding.

Please note that every field must be completed or it will not be accepted electronically.