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Community Impact Program Outcome Report Form

Community Impact Program Outcome 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 program goals in each Impact Area are you striving to achieve?
 
 
 
   3) PROGRAM OUTCOME OBJECTIVES
 
  What were the three Program Outcome Objectives described in your funding application for the year 2010-2011 and your results?
 
  Year 1: 2010-2011 #1 #2 #3
 
  Targeted Objective (using number and percent of clients)
 
  Indicator of success and the tools used to measure this
 
  Actual Results for past 12 months
 
   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 PARTICIPATION
 
  What was the total number of people projected to be served?
 
 
 
  How many actually were served for the most recent time period?
 
 
 
   6) Partnerships
 
  Please describe partnerships that have been formed to better coordinate your services with other organizations:
 
 
 
   7) ROLE / IMPORTANCE OF UNITED WAY FUNDING
 
  How important was the United Way to you and your program?
 
 
 
   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) Community Impacts
 
  How has your program had an impact on the Community as a whole?
 
 
 
   10) PROGRAM STAFFING
 
  Any changes in staffing since your application for funding?
 
  Yes No
 
   11) 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 ***
   12) 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 No
 
  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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