Request for Proposal Document
Application Package
West Virginia 21st Century Community Learning Center (21stCCLC) Program
Thirteenth Annual Grant Competition
Anticipated funding: July, 2016
provided by
The West Virginia Department of Education
http://21stcclc.k12.wv.us/
with funding from
The U.S. Department of Education
http://www.ed.gov/21stcclc
http://www.afterschool.gov
Minimum Funding of $50,000
Maximum Funding of $220,000
APPLICATION DUE DATE
The original application and an electronic copy on a USB flash drive must be
received by 12:00 p.m., Friday, May 13, 2016,
at the Office of Federal Programs, care of Brittney Bostic,
West Virginia Department of Education
Building 6, Room 330
1900 Kanawha Blvd., East
Charleston, WV 25305
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Request for Proposal Document 2
TABLE OF CONTENTS
TABLE OF CONTENTS…………………………………………………………...2
2016 OVERVIEW…………………………………………………………………..3
GENERAL APPLICATION GUIDELINES……………………………………...4
CONTENT OF APPLICATION…………………………………………………..8
COVER PAGES…………………………………………………………………...19
APPLICATION CHECKLIST FORM…………………………………………..21
WV 21ST CCLC PROJECT SUMMARY AND ABSTRACT FORM………….22
WVDE – 21st CCLC GRANT BUDGET FORM………………………………...26
BUDGET NARRATIVE ITEMS…………………………………………………28
ASSURANCE FORMS……………………………………………………………30
PRINCIPLES OF EFFECTIVENESS…………………………………………...38
APPENDICES FORMS B, D, E, F……………………………………………….39
LOGIC MODEL ………………………………………………………………….46
INTENT TO APPLY FORM …………………………………………………….54
Request for Proposal Document 3
2016 OVERVIEW
West Virginia Department of Education’s
21 Century Community Learning Center Grant Program
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WHAT IS IT?
The West Virginia Department of Education (WVDE) is pleased to announce the thirteenth state
21st Century Community Learning Center (21stCCLC) competition for grants. The intent of this
federal grant program is to provide opportunities for communities to establish activities in
community learning centers that:
(1) provide opportunities for academic enrichment, including providing tutorial
services to help students, particularly students who attend low-performing
schools, to meet State and local student academic achievement standards in core
academic subjects, such as reading and mathematics;
(2) offer students a broad array of additional services, programs, and activities, such
as youth development activities, drug and violence prevention programs,
counseling programs, art, music, and recreation programs, technology education
programs, and character education programs, that are designed to reinforce and
complement the regular academic program of participating students; and
(3) offer families of students served by community learning centers opportunities
for literacy and related educational development.
This program is authorized under Title IV, Part B of the federal Elementary and Secondary
Education Act, H.R.-1. Allocations for each state are based upon a portion of a state’s Title I
population ages 5-17, as well as census information. West Virginia expects to award
approximately 1 million dollars in new 21st CCLC grants. By federal statute, a 21st CCLC grant
may not be less than $50,000 per year. This year each eligible program may receive up to
$220,000. If you are applying for only one site, the maximum grant award is $120,000. Awarded
grants cannot exceed five years with descending funds in years four and five for successful
programs.
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GENERAL APPLICATION GUIDELINES
WHO CAN APPLY?
Public and private organizations may apply for funding. Examples of public and private
organizations include, but are not limited to: local education agencies, non-profit agencies, city and
county government agencies, faith-based organizations, institutions of higher education and forprofit agencies.
Federal criteria require that states make awards to applicants that will primarily serve students that
attend schools with a high concentration of low-income students.
Applicants may have a partner agency and submit a joint application from a Local Education
Agency (LEA) and at least one public or private organization, city or county governmental agency,
faith-based organization, higher education institution or for-profit corporation. The lead agency
may be the LEA, the community-based organization, the faith-based organization or other public
or private agency/institution, but the lead must always partner with at least one eligible school. To
be eligible to apply for this grant award an applicant must serve students who primarily attend:
(i) schools eligible for schoolwide programs under Title I, Section 1114 of the
No Child Left Behind Act, and the families of these students; or
(ii) schools with at least 40 percent of its students eligible for free or reduced
priced lunch, and the families of these students.
The applicant must provide evidence in Appendix F of planning with the partner agency during
the creation of the application, such as meeting agendas, sign-in sheets, etc. The partner must also
be described in the grant narrative as having significant, ongoing involvement in the program (as
defined in the Competitive Priorities section of this application).
HOW DO WE APPLY?
Participation in this Bidders’ Conference is strongly recommended, but not required, for
submission of an application. To prepare an application, use the WV 21st CCLC Application
Package information available for download from the WVDE 21st CCLC web site at
http://21stcclc.k12.wv.us/. (For general 21st CCLC information, go to: www.ed.gov/21stcclc.)
Applicants are REQUIRED to notify WVDE of the intent to apply for 21st CCLC funding by
April 1, 2016. Please email the Intent to Apply form to Benitez Jackson at bljackso@k12.wv.us.
A list of all 2016 applicants will be sent to each applying organization.
Completed applications must arrive at the West Virginia Department of Education’s 21st CCLC
office by 12:00 p.m. Friday, May 13, 2016. Applications will not be accepted if the current RFP
has not been used, and an original signed copy along with an electronic version via USB flash
drive are submitted after the 12:00 p.m. May 13 deadline.
WVDE will utilize a review process using individuals with diverse background and expertise to
evaluate the applications. Grant-award announcements will be made in July, 2016 with funding
also expected to begin that month. WVDE reserves the right to not award all grant monies and/or
to negotiate specific grant amounts. All awards are subject to the availability of federal funds, and
grants are not final until a WVDE grant award is fully executed.
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To comply with ESEA Title IV Part B Section 4204 (b)(2)(L), each applicant must sign an
assurance that the community was given notice of its intent to submit an application and that the
application and any waiver request be available for public review after submission of the
application. This form will comprise Appendix E.
Due Process for Unsuccessful Applications
Applicants that wish to appeal a grant award decision must submit a letter of appeal to the WVDE.
Appeals are limited to the grounds that the WVDE failed to correctly apply the standards for
reviewing the application as specified in this RFP. Appeals based on a disagreement with the
professional judgment of the grant reviewers will not be considered.
The appellant must file a full and complete written appeal, including the issue(s) in dispute, the
legal authority or other basis for the appeal position, and the remedy sought. The letter must have
an original signature of the authorized agent who signed the application. An original and two
copies of the appeal should be delivered or mailed to:
Melanie B. Purkey
Executive Director of the Office of Federal Programs
West Virginia Department of Education
Building 6, Room 330
1900 Kanawha Boulevard East
Charleston, WV 25305-0330
The Department must receive the letter of appeal within 30 calendar days of the Notification of
Grant Award announcement. Upon review of the appeal, a response will be provided to the
complainant within 30 days.
If the WVDE does not rescind its ruling, the applicant may apply to the Secretary of the U.S.
Department of Education within 20 days of the applicant receiving a written notification of the
results of the appeal.
Upon request, the WVDE will make available records, pertaining to the review or appeal,
including the records of other applicants.
FOR WHAT ACTIVITIES MAY A GRANTEE USE 21ST CCLC FUNDS?
Each eligible organization that receives an award may use the funds to carry out a broad array of
before- and after-school activities (including weekends and summer recess periods) that advance
student achievement. In the view of the U.S. Department of Education and WVDE, local grantees
are limited to providing activities within the following list:
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remedial education activities, including tutoring
homework help
academic enrichment learning programs, including providing additional assistance to
students to allow the students to improve their academic achievement
mathematics and science education activities
arts and music education activities
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entrepreneurial education programs
mentoring programs
programs that provide after-school activities for limited English proficient students that
emphasize language skills and academic achievement
recreational activities
telecommunications and technology education programs
expanded library service hours
programs that promote parental engagement, family literacy, and adult skill
development
programs that provide assistance to students who have been truant, suspended, or
expelled to allow the students to improve their academic achievement
drug and violence prevention programs, counseling programs, and character education
programs
health and nutrition
Applicants are reminded of their obligation under section 504 of the Rehabilitation Act to
ensure that their proposed community learning centers program activities are accessible to
persons with disabilities.
WHAT ARE THE COMPETITIVE PRIORITIES?
Priority will be given to the following:
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Schools identified as a Priority or Focus School
A Priority school is one that has been identified as among the persistently lowestperforming schools in the State, irrespective of Title I eligibility, based on the most recent
assessment data available. A Focus School is one that has a large gap between a particular
subgroup and the non-subgroup. For high schools, the gap targeted is graduation rate. At
the elementary and middle school levels the gap targeted is achievement.
Two priority points will be added to the base score for service to one listed school, 4 points
for more than one listed school.
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Programs that provide opportunities for participants in science, technology, engineering,
arts and mathematics (STEAM) will be awarded two priority points.
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Programs that provide services limited to middle school and/or high school students only
will be awarded two priority points.
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Services to students attending schools designated as in need of improvement under section
1116 of ESEA and that are submitted jointly by school districts receiving Title I funds and
community-based organizations or other public or private organizations will be awarded
four priority points. If you have received priority points under the first bullet in this
section, you will only receive two additional points for the partnership.
The following clarification comes from the USDOE Nonregulatory Guidance for 21st CCLC
programs.
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In determining whether an application has been “submitted jointly,” States should look for
evidence in the application that the LEA and at least one other organization collaborated in the
planning and design of the program, each have substantial roles to play in the delivery of
services, share grant resources to carry out those roles, and have significant ongoing
involvement in the management and oversight of the program. States may want to consider
what organization(s) wrote the application, what organization will be the fiscal agent, whether
there is a history of these organizations working together, and whether there is evidence in the
application of integration of the after-school program activities with the regular school day
program. Letters of endorsement are not by themselves sufficient evidence that
organizations or school districts have substantially been involved in the design of a
program.
HOW IS THE APPLICATION FOR A 21ST CCLC GRANT PREPARED?
The following information describes eligibility, required activities, application contents and
application review criteria.
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Applications must comply with the following format:
the application narrative section must not exceed 25 typed and numbered pages, (not
including appendices) using a 12-point,Times New Roman font; double line spacing and
one-inch margins;
chart format may be used in appropriate sections;
the application must be on plain white paper (one side only) held together with a binder
clip or stapled (no notebooks or coverings) and must not include unsolicited designs,
headings, appendices, news clippings or other materials; and
the application should respond to the exact sequence, outline form, headings and
information requested herein.
citations must be in correct American Psychological Association (APA) format.
According to the non-regulatory guidance for 21st CCLC, a public school or other public or private
organization that is awarded a grant must provide equitable services to private school students and
their families. In designing a program that meets this requirement, grantees must provide
comparable opportunities for the participation of both public- and private-school students in the
area served by the grant. Grantees must consult with private school officials during the design and
development of the 21st CCLC program on issues such as how the children's needs will be
identified and what services will be offered. Services and benefits provided to private school
students must be secular, neutral, and non-ideological. This communication must be verified by
completing the form that comprises Appendix D. This form MUST be completed and signed,
even if there are no private schools in your service area.
If plagiarism is found, or brought to the attention of officials at the West Virginia Department of
Education during a grant competition, then at the discretion of the Department, the WVDE has the
right to remove the grant application for funding consideration.
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CONTENT OF APPLICATION
To be eligible for 21st CCLC funding, a completed 21st CCLC application MUST contain all the
following sections in the sequence provided:
1. Cover Pages
The applicant must provide all contact and descriptive information requested on the two required
cover pages. These pages must be the first two sheets of the application (see pp.18-19).
2. Application Checklist
Include a copy of the completed checklist (see page 20).
3. Program Summary and Abstract
Complete the required Project Summary and Abstract form describing the community needs being
addressed, the participants to be served, the program objectives, the activities proposed to meet the
objectives, the intended outcomes, program evaluation activities and all other requested
information. (see pp. 21-24).
4. Table of Contents
Include a table of contents with all sections and page numbers clearly identified for the application
reviewers.
5. Application Narrative
Respond to the following required application information using a maximum of 25 pages.
A.
Need for Program (20 points)
Describe the needs of the populations to be served by the grant program. Tell how the proposed
program will help meet these needs by providing services and opportunities not currently
available. It is vital that the applicant clearly show specific, identified needs that connect to the
goals and measurable objectives of the application, the proposed activities and services, and the
program evaluation.
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Describe the needs of the community in which the students and families to be served by the
grant reside. Explain why this community was selected and how the program to be
provided will be of value.
Define the needs of students to be served by the grant program by subgroup, using current,
specific data to document those needs. Data may include, but are not limited to,
information of attendance, achievement, dropout rate, free/reduced lunch rate and risky
behaviors.
Define the data-based needs of the community to be served by the grant program, focusing
on parents and families. Data may include, but are not limited to, poverty rates, literacy
rates and education levels.
Describe the gaps in community services and opportunities for those living in the area
included in the proposed program area. Tell how the grant will help provide services and
activities not available at this time for participants in the program.
Cite any research information shared in this section using APA citation of the data source.
Request for Proposal Document 9
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B.
Tell how the applicant consulted with private school officials during the design and
development of the application as to the needs to be addressed and the services to be
offered. If there is no private school within the applicant’s attendance area, this needs to be
stated by the applicant.
Include data from a community needs assessment conducted within the last three years to
support identified needs.
Reapplying organizations must provide no more than a one-page summary of data
/evidence in Appendix B of having met the objectives of their last 21st CCLC grant.
Goals and Objectives (15 points)
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Develop broad program goals that address identified needs from section A. One goal must
address raising academic achievement for students with a second goal addressing
raising the education or skill levels of adults. Other goals may be added if needed. Goals
are statements of what you are working to achieve. They do not have to be measurable.
(Please consider school and district goals when developing goals for your program.)
List the measurable objective(s) the proposed program will use to remedy the risk factors
(needs) described for the target populations in the goals identified. Effective measurable
objectives are considered SMART objectives, with that acronym standing for Specific,
Measurable, Attainable, Realistic and Time-bound. (Be sure to consider how you will
evaluate the objectives. That information must be included in the evaluation section of the
application.)
Be sure that grant goals and objectives have been created to sufficiently meet the critical
data-based needs of the students, parents and families in the community.
Those applicants who have previously received 21st CCLC funding, MUST provide no
more than a one-page summary of data/evidence in Appendix B documenting the
improvement of student achievement.
Those applicants who have previously received 21st CCLC funding, MUST provide no
more than a one-page summary of data/evidence in Appendix B documenting the
utilization of partner organizations to enhance academic performance, achievement
and positive youth development of students.
These are Federal Targets to be considered when developing program objectives.
Federal Target*
Forty-eight percent of students participating in this program will improve their
reading and language arts grades.
Forty-eight percent of students participating in this program will improve their
mathematics grades.
Seventy-five percent of students participating in this program will demonstrate
improvement in homework completion and class participation.
Seventy-five percent of students participating in this program will demonstrate
improvement in behavior.
Eighty-five percent of out-of-school time centers emphasize programming in at least
one core academic subject area.
Eighty-five percent of out-of-school time centers offer academic enrichment and
support activities related to technology.
Eighty-five percent of out-of-school time centers offer academic enrichment, support
activities, and programming to support student learning outside of core subject areas
and technology.
Federal Targets are subject to change based on federal guidelines.
Request for Proposal Document 10
C.
Student Program Activities & Implementation (20 points)
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Describe the components and related activities that your program will offer to students to
meet the needs previously identified. Include information on time allotted to program
components and activities, as well as partner involvement.
Identify scientifically-based research that provides evidence that the programs or activities
you include in this section will help students meet state and local student academic
achievement standards.
Describe plans for implementing optional summer programs, if desired. Programs will not
receive credit for having a summer program if sufficient funds are not included in the
budgets for years 1-3 and in the budget narrative.
Explain how students will be recruited and retained in the program.
Describe how program services in centers will be available to any participating student a
minimum of three days for high school programs and four days per week for elementary
and middle school students. All programs must begin by October 15 and meet a minimum
of 25 weeks during the regular school year.
A mandatory pre-site meeting with WVDE Staff, co-applicant partner (if applicable)
program director, site coordinator, community partners, principal, and central office
administrator representing the schools of participating students must be held with first-time
subgrantees prior to the start of the program.
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D.
Explain how project staff will vary their approaches to help meet the individual needs of
students and improve their achievement in core academic areas to meet or exceed local and
state standards. Include the steps you propose to ensure equitable access to, and
participation by, students and program personnel with special needs.
Describe how the proposed program will provide hands-on, problem-based or project-based
learning activities that support state and local learning standards and contribute to academic
performance for all students.
Include plans to provide supper for participating students each day the program meets. A
snack may also be offered.
Collaboration (15 points)
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Explain how the program was developed and will be carried out in active collaboration
with the schools the students attend. Include how joint planning time and professional
development opportunities will be available for school staff, program staff and partners that
will help meet both program goals and objectives, as well as school and district goals and
objectives. Those applicants who have previously received 21st CCLC funding must
describe in no more than one page in Appendix B, the collaboration between their
previously-funded program and the schools that students attended.
Explain the data-sharing plan for your program: how you will access student records and
individual and aggregate achievement data for use in program planning, implementation
and evaluation; as well as how you will share program data with the schools served.
Include the process you will use to gain individual parent consent to access and use an
individual student’s data.
Describe the partnership details between a local educational agency and community-based,
faith-based, or other public or private organization(s) submitting MOUs that focus on
Request for Proposal Document 11
aspects of the program beyond activities offered (for example, training, supplies, funding,
etc.)
 Describe the prior experience and/or capacity of the lead organization and co-applicant
partner, if applicable, to provide educational and related activities that will complement and
enhance the academic performance, achievement, and positive youth development of
students.
 Attach Memoranda of Understanding or letters that clearly indicate the role, capacity,
specific contributions and in-kind value of each partnering organization. A letter from the
principal of each participating school must be included.
 If you have identified a partner agency on the cover sheet, be sure to address the definition
of “submitted jointly” found in the competitive priorities section of the application.
E.
Facility Plan (10 points)
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Describe how the program provides a safe, welcoming environment for participants.
Include specific information that describes the interior and exterior environment of the site.
List the required agency inspections that are conducted at non-school based sites(s),
including the State Fire Marshall Report and a county-level Health Department inspection.
During the pre-site visit of each new subgrantee, an environmental rating will be done to
assess program facilities and inspection reports. This checklist is posted on the applications
resources page of the 21st CCLC WVDE web site.
http://wvde.state.wv.us/21stcclc/resources.html
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Tell how the program will ensure that the students will travel safely to and from the 21st
CCLC and home from school–based and/or off- site programs. State the number of buses
needed to adequately serve the target participants, based on data provided by the county
board of education and/or principal.
 Tell how the emergency exit plan and emergency readiness plan will be communicated to
the staff, students and parents, and how fire drills will be conducted during afterschool
hours.
F.
Program Personnel (15 points)
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Describe procedures for managing the program.
Use a chart to describe the staff structure (roles and responsibilities). Include position
descriptions for key community and school staff. Due to hiring requirements and personnel
procedures, it is not necessary to name in the application a specific person to serve as the
program director. However, position descriptions for the personnel you intend to employ
with 21st CCLC funding should be included.
Staffing is to be at a level that assures participant safety, as well as the highest quality of
program delivery based on the type of activity, programmatic level and number of
participants. Suggested guidelines, such as those from West Virginia Department of Health
and Human Resources, state:
A center shall group children and consider their ages when determining the staff: child ratio
as follows:
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9.2.a. For programs that operate with Pre-K children, the program shall ensure that:
 9.2.a.1. A 1:12 staff to child ratio is maintained; and
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9.2.a.2. Group sizes are limited to 24 for any group that mixes older children
with a pre-k child.
9.2.b. For programs that operate with school age children only, the program shall
ensure that:
 9.2.b.1. A 1:16 staff to child ratio is maintained;
 9.2.b.2. The group size is determined by the activity and is limited to
facilitate staff/child interaction and safe, constructive participation by
children; and
9.2.c. During water activity such as swimming, canoeing, and fishing the staff: child
ratio is maintained at 1:8 for groups of school age children and is maintained at 1:4
for any group with a Pre-k child.
9.3. Groups of children must be distinct with staff persons knowing to which group
they are assigned.
9.4. Staff: child ratio and group size are always maintained based on the age of the
youngest child in the group.
Describe plans and budget for on-going staff training for the program. Expenses may
include payment of staff for time to plan and attend the training. The budget must include
funding for the following required professional development opportunities at a minimum:
1. The program director to attend the Multi-State Fall Conference annually
(Include $150 for registration cost per person, plus travel, food and lodging.)
2. The program director and one program staff member who is responsible for planning
and implementing daily programming to attend one WVDE-sponsored 21st CCLC
conference annually (Include $150 for registration cost per person, plus travel, food
and lodging.)
3. New directors to attend four partial-day, drive-in meetings throughout the year (travel
only)
Inclusion of other state, regional and national training is optional. The USDE 21st CCLC
office may conduct a regional conference. Other organizations conduct national
conferences annually.
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Describe how qualified volunteers will be used to support proposed activities.
Require the Program Director to allocate a minimum of 10 hours per week to carry out
grant responsibilities. Time and effort sheets will be submitted as verification.
It may also be useful to designate a staff member as a school liaison to make necessary
connections between the regular school day and the afterschool program to create a
“learning day”.
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Require at least one full-time staff member per site to be certified in both CPR and first aid
(within one month of employment).
Ensure that all out-of-school-time staff and regular volunteers have passed an approved
state-level background check prior to working in the program to assure that the program
does not hire employees that may pose a danger to children. Include funds in the budget
and budget narrative for this expense. Suggested guidelines, such as those from West
Virginia Department of Health and Human Resources, state:
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Convictions 5.1 The applicant shall not be approved, employed, utilized nor considered for a waiver
if ever convicted of:
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5.1.1 Abduction;
5.1.2 Any violent felony crime including but not limited to rape, sexual assault, homicide,
malicious wounding, unlawful wounding, felonious domestic assault or battery;
5.1.3 Child/adult abuse or neglect;
5.1.4 Crimes which involve the exploitation of a child or an incapacitated adult;
5.1.5 Misdemeanor domestic battery or domestic assault;
5.1.6 Felony arson;
5.1.7 Felony or misdemeanor crime against a child or incapacitated adult which causes
harm;
5.1.8 Felony drug related offenses within the last ten (10) years;
5.1.9 Felony DUI within the last ten (10) years;
5.1.10 Hate crimes;
5.1.11 Kidnapping;
5.1.12 Murder/homicide;
5.1.13 Neglect or abuse by a caregiver;
5.1.14 Pornography crimes involving children or incapacitated adults including but not
limited to, use of minors in filming sexually explicit conduct, distribution and exhibition of
material depicting minors in sexually explicit conduct or sending, distributing, exhibiting,
possessing, displaying or transporting material by a parent, guardian or custodian,
depicting a child engaged in sexually explicit conduct;
5.1.15 Purchase or sale of a child; CIB Background Checks Revised March 15, 2015 9
5.1.16 Sexual offenses including but not limited to incest, sexual abuse, or indecent
exposure.
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G.
Further information can be found here:
http://www.dhhr.wv.gov/bcf/Providers/Documents/CIB%20Policy.pdf
Describe a program Advisory Council that will meet at least quarterly and consist of
program staff, co-applicant partner and school/district administrative staff, parents, students
and community members.
Sustainability (15 points)
Since grant funding is intended as an incentive to promote the long-range establishment of
out-of-school-time community programs, the application must include the following:
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Describe how the budget is reasonable in relation to the number of average daily attendees
to be served, services to be provided and anticipated results and benefits. The budget and
budget narrative will be judged against the scope of the program and its anticipated
benefits.
Describe how other sources of funding will be leveraged to supplement the grant award and
to support services, including coordination with other federal, state and local programs with
compatible/complementary services (i.e. Title I, Adult Basic Education etc.)
Explain how the program will ensure that funds will not be used to supplant federal, state,
local or non-federal funds.
Applicants who choose to establish a fee structure must provide a narrative that explains
the fee structure and how they will assure that income and or ability to pay will not deter
families from enrolling their children in the program. Additionally, they must describe how
the funds will be administered and managed. Anticipated income from collection of fees
must be reported in the budget as an additional source of revenue.
Request for Proposal Document 14
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Provide a reasonable plan for sustaining the community learning center(s) after grant
funding ends.
Beginning with the 2012 subgrantee cohort, if reapplication is made for the same sites
included in this grant in five years (or if 50% or more of the sites remain the same), the
maximum funding would be figured at 70% of the year one of the previous grant award.
However, at no time may a grant be awarded for less than $50,000.
H.
Parent, Family and Community Involvement (15 points)
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6.
Describe the components and related activities that your program will offer to parents,
families and community members to meet the needs previously identified in section A.
These activities MUST be aimed at improving the education or skill level of adults or at
involving parents in their children’s learning, either at home, at programs sponsored by the
center, or elsewhere.
Include the steps you propose to ensure equitable access to, and participation by family
members and other program beneficiaries with special needs.
Describe how students, parents and community members will be involved in planning,
implementation of services, program evaluation and decision-making in the program.
Explain how your program will disseminate information about the center(s) to the
community in a manner that is understandable and accessible.
Program Monitoring and Evaluation (20 points)
It is important that each applicant engage in internal monitoring that will help track continuous
progress toward meeting grant goals and objectives. This shall be accomplished via a two-step
process. First, grantees will develop a Program Logic Model that provides a roadmap for the
proposed program. This model must include measureable objectives that align to CCLC program
goals, activities, inputs, outputs, outcomes and data-based indicators. Good logic models will
include both process and outcome measures. Process measures should include the documentation
of significant project milestones/completion of key tasks (e.g., number of participants, number of
events sponsored, etc.). Outcome measures should reflect the intended results of your project (e.g.,
indicators of progress in impacting student learning).
Second, all applicants must provide a narrative that indicates how continuous self-monitoring will
be employed to improve and strengthen their program. This narrative should describe the steps that
grantees will take to collect evidence of completing program activities, objectives, and outcomes,
the process for reviewing this information, and how such information will drive changes in
program decision-making. The internal monitoring plan should also include a time line of
monitoring activities that clearly aligns to the information provided in the Program Logic Model.
Detailed requirements for the Program Logic Model and Internal Monitoring Plan are described
below. These need to be put into the application at the end of the narrative section. They will not
be counted in the 25 page maximum.
Program Logic Model and Internal Monitoring Plan
The purpose of the project logic model and internal monitoring plan component of the 21st Century
Community Learning Centers program is to help guide applicants’ in the planning of their projects
and to ensure grantees are continuously using data to assess progress toward meeting project goals
and to engage in continuous improvement. All applications must include the following
components:
Request for Proposal Document 15
1. Program Logic Model:

A logic model is a tool used to depict the logical relationships that exist among program
goals, objectives, activities, inputs, and outputs/outcomes. It also describes the data-based
indicators that will be used to provide evidence of the program’s effectiveness. All
applicants must submit a completed program logic model using the template provided
on p. 45 (use the template for each program goal; make additional copies as needed).
It is strongly recommended that grantees complete the logic model prior to writing the
application narrative as it can greatly assist with preparing a quality application. Please
note, applicants must use the definitions below when completing the program logic model.
Goal- a broad statement of intended outcomes for the program
Objective – a detailed statement of intended outcomes that includes the population,
outcome, target, measure, and time frame (all Objectives must be Specific, Measurable,
Attainable, Realistic, and Time-bound. See SMART objective guiding questions on the
application resource page of the WV 21st CCLC website,
http://wvde.state.wv.us/21stcclc/resources.html).
Activities – actions needed to meet objectives
Inputs - resources needed to design and implement activities
Outputs - tangible services and products that are direct results of activities
Outcomes – specific, attainable, measurable changes that are likely to occur as a result of
the activities
Indicators – data to monitor implementation and measure progress, as well as success of
the initiative

An example of a high quality logic model submitted by a previous CCLC grantee is
provided on p. 47.
2. Internal Monitoring Plan:

The internal monitoring plan is a narrative that describes the methods that will be used
throughout the program to monitor accomplishment of the objectives included in the logic
model. This narrative must include a description of: (a) the applicant’s capacity to access,
collect, and analyze the data necessary to effectively document program objectives and
outcomes; (b) the specific action steps that will be taken to monitor the activities included
in the logic model, including a time line for completion of these activities; (c) assurances
that monitoring results will be documented quarterly; and (d) how monitoring results will
be continuously reviewed and used to inform program decision-making. All applicants
must submit a completed internal monitoring plan narrative addressing all program
goals. This will not count toward the 25 page maximum.
The quality of the program logic model and internal monitoring plan narrative will be considered
major factors when selecting grantees.
During the course of the program’s implementation the logic model and monitoring plan may be
amended upon WVDE 21st CCLC administrative approval.
Request for Proposal Document 16
State and Federal Evaluation Requirements
All applicants must provide an assurance that they will participate meaningfully in mandated
annual evaluation activities consisting of the following:




Collection of a completed Annual Performance Report (APR) data through a
WVDE data system
Completion of Grantee Profile information in USDOE 21 APR SYSTEM
Completion of the annual Teacher Survey by the regular classroom
reading/language arts or mathematics teacher of regular attendees of the
program.
Submission of the completed annual Program Director Survey
Applicants must also provide an assurance that they will participate in program monitoring
conducted by WVDE 21st CCLC staff consisting of the following:


Submission of required documentation, and
Arrangement of focus group interviews with key stakeholders.
Please Note:
Awarded subgrantees will be held to the following standards, unless a waiver has been approved
by the state office based on extenuating circumstances. Programs must be successful in at least
three of the identified areas or they are considered a “high-risk” subgrantee.

Attendance – Based on 21st CCLC student registration, sites will have at least 70%
of enrolled students attending a minimum of 20 days and at least 50% attending a
minimum of 30 days.

Goal/objective attainment—Programs will have met, or made significant progress
toward, goal attainment. In year one, when programs are being established, progress
will be made toward meeting objectives as stated in the grant application; in year
two and three at least 50 percent of stated goals/objectives will be met; and by years
four and five all goals and objectives will be met.

Grant program implementation—Subgrantees will implement the program as
described in the approved application.

Adequate, qualified staffing—Staffing is to be at a level that assures participant
safety, as well as the highest quality of program delivery based on the type of
activity, programmatic level and number of participants. (suggested guidelines in
Program Personnel section)
 Program management—Staff is organized by clearly defined roles and
responsibilities that are adequate to carry out the program successfully. Staff
members and individuals or entities providing goods or services are selected based
on prior experience, qualifications and, where applicable, specialized training
and/or certification. Staff has received training in regard to their responsibilities and
Request for Proposal Document 17
understand their role in the overall program
7. Budget and Budget Narrative (10 points)


Complete a WVDE Budget Form (see pp. 25-26) for each of the first three years of the
project.
Provide a detailed budget narrative for the first year only using the form provided on page
27 that clearly explains:
-
-
the mathematical basis for estimating the costs of professional personnel salaries, fringe
benefits, project staff travel, student transportation, materials and supplies, consultant
and subcontract fees, indirect costs and other program expenditures; (Be sure to name
each staff position and provide the formula for rate of pay and the duration of
services.)
detailed description explaining in-kind support and/or funding/resources provided by
co-applicant partners (if applicable) and other collaborating partners in the program.
(Funded programs reporting successful implementation will be asked to provide
continuation applications and budgets for each of the five years of the program if federal
funding continues. Year four funding will be, at maximum, 80% of the year one amount.
Year five will be, at maximum, 70% of the year one amount.)

indirect costs must align with the applying organization’s approved restricted indirect cost
rate.
Please keep in mind that there is a policy relating to average daily attendance and funding. In grant
years three through five, if the program average daily attendance is less than 80% of the average
daily attendance number set forth in the original budget, the grantee's budget will be
proportionately reduced by the amount of the percentage deficiency from the original budget.
Examples: Based on a total program average daily attendance of 50, 80% would be 40 students. If
a program said it would serve an Average Daily Attendance of 50, but only had an ADA of 35
students, based on a single-site grant of $120,000, that would be a cut of $12,000. If a program
said it would have an ADA of 90, 80% would be 72 students. If they only had 60 students, based
on a grant of $220,000, it would be cut $28,600.
Note: grant funds cannot be used to purchase food, facilities or vehicles, or to support
construction.
Federal regulations that apply to the 21st CCLC program are: the U.S Education Department
General Administrative Regulations (EDGAR) in 34 CFR Parts 75, 77, 79, 80, 81, 82, 85, and 86,
and (b) 34 CFR Part 299. The EDGAR regulations can be found on the Department’s website:
http://www.ed.gov/about/offices/list/index.html?src+mr. Office of Management and Budget
Circulars A-21 for educational institutions and A-122 for non-profit programs also provide
guidance on cost principles.
8. Assurances Forms (see pp. 29-36)
Attach the properly signed and completed assurances forms.
9. Appendices (see pp. 38-44)
Request for Proposal Document 18
Attach only the following Appendices:
 Appendix A: a REQUIRED list of collaborating partners with contact names, addresses,
year-round telephone numbers, fax numbers and e-mail addresses; and a memorandum of
understanding or partner letter that clearly documents the role and contribution of the
partner, as well as the in-kind value if applicable (not a generic letter of support)
 Appendix B: documentation of previous grant success, as noted in the applicable sections
of grant directions (REQUIRED of previous applicants)
 Appendix C: a summary of any evaluation studies, reports, or research that documents the
effectiveness or success of the co-applicant partner (if applicable) and collaborating
partners and of the activities and services proposed in the narrative section of the
application (OPTIONAL)
 Appendix D: REQUIRED form to verify consultation with private school personnel
 Appendix E: REQUIRED form to verify sharing with the community
 Appendix F: evidence of planning application with grant co-applicant partner
(REQUIRED if submitting jointly)
Request for Proposal Document 19
COVER PAGES
WVDE 21st Century Community Learning Centers Grant Application
School Years 2016-2021
Local Project Title:
Lead Agency
Contact Person:
Phone #:
Address:
Fiscal Agency
Contact Person:
Phone #
Address:
Fax #:
Email:
Fax #:
Email:
Co-Applicant Partner Agency*:
Contact Person:
Phone #:
Fax #:
Address:
Email:
*Optional-This is a competitive priority as defined in application section, “What are
the Competitive Priorities?”
Other Collaborating Partnerships
Number of collaborating partners actively involved in the project
Schools
Community-Based Organizations ___Faith-Based Organizations
___Community/business ___Other (list)
School District(s) ________________________________________________________
Request for Proposal Document 20
Schools Served
Number of sites ________________
Funds Requested
Estimated number of students to be served:______ Proposed cost per student:________
FEIN Number
(Federal Employees Identification Number)
West Virginia Vendor Number
Proposed Program Dates
July, 2016
start date
6-30-19
end date
Matching (local) funds: $_________________
In-kind $
Cash $
Other (list)
Have you previously received 21st Century Community Learning Center funding from the
West Virginia Department of Education? Yes____
No _____
Date: ____________________
Agency Head’s/Superintendent’s Signature*
*Signature indicates that applicant agrees to all conditions in the proposal.
Request for Proposal Document 21
APPLICATION CHECKLIST FORM
One original copy of the application along, with an electronic copy on a USB flash drive must
be received by 12:00 p.m., Friday, May 13, 2016, at the office of Brittney Bostic, Office of
Federal Programs, West Virginia Department of Education, Building 6, Room 330, 1900
Kanawha Boulevard East, Charleston, WV 25305.
Five points will be deducted from the score of the application if the sections below are not
addressed in the order listed. (Check each of the following items as they are completed.)
1.) Cover Pages, fully completed and signed by an authorized official.
2.) Application Checklist, completed
3.) Program Summary and Abstract
4.) Table of Contents
5.) Program Narrative
6.) Logic Model and Internal Monitoring Plan
7.) Budget and Budget Narrative
8.) The required Assurances, Certifications, and Disclosure forms (must be signed by an
authorized official).
 Non-Construction Programs (Form OMB 424B)
 The certification regarding lobbying; debarment, suspension and other responsibility
matters and
 Drug-free workplace requirements (Form ED-80-0013)
9.) The Appendices
10.) Bibliography (APA Format)
11.) Electronic copy on a USB flash drive has been submitted along with the original copy
of the application
Request for Proposal Document 22
WV 21ST CCLC PROJECT SUMMARY AND ABSTRACT FORM
Student Populations to be Served (indicate number of schools in blank)
___ Elementary Schools
___ Middle Schools
___ Priority Schools
___ Focus Schools
___ High Schools ___ Title I schools
Co-applicant Partner(s) and Collaborating Organizations
___ National Organizations (e.g., Boys & Girl Clubs,
YMCA/YWCA, Big Brothers/Big Sisters)
___ Community-Based Organizations (local nonprofits or foundations)
___ Libraries or Museums
___ Businesses
(indicate number in blank)
___ County or Municipal Agencies (e.g.,
police, Parks & Recreation, Social
Services)
___ Colleges or Universities
___ Faith-Based Organizations
___ Hospitals/Clinics/Health Providers
___ other __________________________
Services to be Provided (check all that apply)
 Reading or Literacy
 Mathematics
 Physical Education
 Technology, Video or Media
 Health, Nutrition
 Youth Development
 Science
 Service Learning
 Services for Adults
 Art, Music, Dance,
 Cultural Activities, Social
 Homework Help
Theater
Studies
 Tutoring
 Other ___________
Times of Operation
Before school
After school
Summer
Weekend
Request for Proposal Document 23
Page 2 -- Program Summary and Abstract
Name & location of each
site
Totals for the entire
program
Estimated
number of
students to be
served
annually
Days and times of program
operation throughout week
Mon
Tues
Wed
Thur
Fri
Sat
Mon
Tues
Wed
Thur
Fri
Sat
Mon
Tues
Wed
Thur
Fri
Sat
Mon
Tues
Wed
Thur
Fri
Sat
Mon
Tue
Wed
Thur
Fri
Sat
Total estimate
of students to
be served
______
Estimated
average
daily
attendance
Estimated
total number
or attendees
30 days or
more
Student
Free/
Reduced
Lunch %
Estimated
adults/
family
members
served
Total
estimate of
attendees 30
days or
more
________
Average
% of
Free
Reduced
Lunch
students
________
Total
estimate of
adults/
family
members
served
________
*Start date of each site is no later than October 15th.
Estimated number to be served does not refer to the total school population but to the estimated students likely to
participate. Explain how that number of student and adult and/or family participants was determined:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Request for Proposal Document 24
Abstract. In the space below, briefly describe your program’s goals, services, activities, and planned participants.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Request for Proposal Document 25
Program Summary and Abstract for Summer (if applicable)
Days and times of program
operation throughout week
Name & location of each site
Totals for the entire program
Estimated
number of
students to be
served
annually
Mon
Tues
Wed
Thur
Fri
Sat
Mon
Tues
Wed
Thur
Fri
Sat
Mon
Tues
Wed
Thur
Fri
Sat
Mon
Tues
Wed
Thur
Fri
Sat
Mon
Tue
Wed
Thur
Fri
Sat
Total estimate
of students to
be served
______
Estimated
average
daily
attendance
Estimated
adults/
family
members
served
Total
estimate of
adults/
family
members
served
________
Request for Proposal Document 26
WVDE – 21st CCLC GRANT BUDGET FORM
County
Agency/School
_____________
Financial Contact Person
_______________________________________________
Complete Street Address
_______________________________________________
Phone #
Fax #
E-mail
__________________________
Federal Funding (Line Items)
Administrative Salary
Salary- Program Director
Salary- Secretary
Salary- Financial Officer
Salary-Assistant
Fringe Benefits-rate: _____
Funds Requested
Subtotal
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
Programmatic Salary
Salary- Site Coordinators
Salary- Site Staff (Tutor, Homework Help, Enrichment, Physical Activities)
Salary- Support Personnel (Cooks, Custodians, Bus Drivers, Aides)
Salary-Other ___________________
Fringe Benefits-rate: _____
Subtotal
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
Other Expenses
Supplies/Consumables
Equipment
Student Transportation
Administrative and Staff Travel
Training
Facility Rental
Background checks
Other (describe) __________________________________________
Subtotal
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
Total Direct Costs
$ _______
Indirect cost-approved rate: ______
$ _______
TOTAL FEDERAL FUNDING REQUESTED
Revised 2-27-14
Last Updated: May 13, 2016
$ _______
Request for Proposal Document 27
Local Funding & Contributions (Line Items)
Administrative
Salary- Program Director
Salary- Secretary
Salary- Financial Officer
Salary-Assistant
Fringe Benefits
Matching Funds
Subtotal
Programmatic
Salary- Site Coordinators
Salary- Site Staff (Tutor, Homework Help, Enrichment, Physical Activities)
Salary- Support Personnel (Cooks, Custodians, Bus Drivers, Aides)
Salary-Other ___________________
Fringe Benefits
Subtotal
Other Expenses
Supplies/consumables
Equipment
Student Transportation
Administrative and Staff Travel
Training
Program Evaluation
Facility Rental
Background checks
Other (describe) __________________________________________
Subtotal
LOCAL FUNDING CONTRIBUTIONS TOTAL
TOTAL PROGRAM BUDGET (FEDERAL + LOCAL)
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
_________________________________________________________ Date _______
Superintendent’s or Agency Director’s Signature
**************************************************************************************
STATE USE ONLY
Federal Funds Approved $
Account # 8712-13000
State Agency’s Signature
Revised 2-27-14
Last Updated: May 13, 2016
Program Code _______________
Revenue Code 04511
FIMS ID _________
Date_______________
Request for Proposal Document 28
BUDGET NARRATIVE ITEMS
Your proposal must have a budget narrative explaining each line item on your
2016-2017 Budget Form. List each of your requested budget items in the same
order they appear on the 2016-2017 Budget Form, whether it is federally funded or
a local contribution, the purpose, and the math used to estimate it. Double-click on
the table cell to enter data or to add additional rows if needed. The total cost
column will automatically calculate vertically to give you the total expenditures for
the application.
Budget Item
Funding Souce
Funding Purpose &Calculations
Total Cost
Total grant costs
Note: It is your responsibility to maintain documentation for 5 years to support expenditures.
Last Updated: May 13, 2016
0
Request for Proposal Document 29
EXAMPLE OF BUDGET NARRATIVE ITEMS
Budget Item
Funding
Salary
Federal
Federal
Federal
Local
Supplies
Transportation
Local
Federal
Federal
Federal
Local
Federal
Local
Travel
Federal
Federal
Examples of Funding Purposes & Calculations
1 Project Director x $2,500/month x 12 months = $30,000 +
fringe benefits (Social Security 7.65%, Workers Comp
1.32%) $2,691
2 VISTA workers x $10,000/year
1 Karate teacher x $20/hour x 2 hours/week x 8 weeks
1 Dentist x $300/day x12 days
1 Part-time secretary x $15/hour X 10 hours x 25 weeks
10 Basketballs x $10.00/ball
10 Modeling clay x 20.00/box
10 Magnifying glasses x $8/per
25 Watercolor paint x $2/set
1 Bus driver x$20/hour x 3 hours/day x 4 days/week x 25
weeks = $6,000 + fringe (Social Security 7.65%, Workers
Comp 1.32%)
1 Bus driver (field trips) x $20/hour x 12 hours =$240 +
fringe (Social Security 7.65%, Workers Comp 1.32%)
2 staff members X 2 WVDE training registration fees x
$250/training
2 staff members X 100 miles x $.50/mile
Total Cost
32,691
20,000
320
3,600
3,750
100
200
80
50
6,538
262
1000
100
Last Updated: May 13, 2016
Request for Proposal Document 30
ASSURANCE FORMS
Lobbying, Debarment, Suspension, etc. form ED 80-0013
CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION AND
OTHER RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE
REQUIREMENTS
Applicants should refer to the regulations cited below to determine the certification to which they
are required to attest. Applicants should also review the instructions for certification included in
the regulations before completing this form. Signature of this form provides for compliance with
certification requirements under 34 CFR Part 82, "New Restrictions on Lobbying," and 34 CFR
Part 85, "Government-wide Debarment and Suspension (Nonprocurement) and Governmentwide Requirements for Drug-Free Workplace (Grants)." The certifications shall be treated as a
material representation of fact upon which reliance will be placed when the Department of
Education determines to award the covered transaction, grant, or cooperative agreement.
1. LOBBYING
As required by Section 1352, Title 31 of the U.S. Code, and implemented at 34 CFR Part 82, for
persons entering into a grant or cooperative agreement over $100,000, as defined at 34 CFR Part
82, Sections 82.105 and 82.110, the applicant certifies that:
(a) No federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or employee of
any agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with the making of any federal grant, the entering into of any
cooperative agreement, and the extension, continuation, renewal, amendment, or modification of
any federal grant or cooperative agreement;
(b) If any funds other than federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this federal grant or cooperative agreement, the undersigned shall
complete and submit Standard Form - LLL, "Disclosure Form to Report Lobbying," in
accordance with its instructions;
(c) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subgrants, contracts under grants and
cooperative agreements, and subcontracts) and that all subrecipients shall certify and disclose
accordingly.
2. DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS
As required by Executive Order 12549, Debarment and Suspension, and implemented at 34 CFR
Part 85, for prospective participants in primary covered transactions, as defined at 34 CFR Part
85, Sections 85.105 and 85.110-A. The applicant certifies that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from covered transactions by any Federal department or agency;
Last Updated: May 13, 2016
Request for Proposal Document 31
(b) Have not within a three-year period preceding this application been convicted of or had a
civil judgment rendered against them for commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public (federal, state, or local)
transaction or contract under a public transaction; violation of federal or state antitrust statutes or
commission of embezzlement, theft, forgery, bribery, falsification or destruction of records,
making false statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental
entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph
(2)(b) of this certification; and
(d) Have not within a three-year period preceding this application had one or more public
transaction (federal, state, or local) terminated for cause or default; and
B. Where the applicant is unable to certify to any of the statements in this certification, he or she
shall attach an explanation to this application.
3. DRUG-FREE WORKPLACE (GRANTEES OTHER THAN INDIVIDUALS)
As required by the Drug-Free Workplace Act of 1988, and implemented at 34 CFR Part 85,
Subpart F, for grantees, as defined at 34 CFR Part 85, Sections 85.605 and 85.610 A. The applicant certifies that it will or will continue to provide a drug-free workplace by:
(a) Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the grantee's workplace
and specifying the actions that will be taken against employees for violation of such prohibition;
(b) Establishing an on-going drug-free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace;
(2) The grantee's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
(c) Making it a requirement that each employee to be engaged in the performance of the grant be
given a copy of the statement required by paragraph (a);
(d) Notifying the employee in the statement required by paragraph (a) that, as a condition of
employment under the grant, the employee will:
(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug
statute occurring in the workplace no later than five calendar days after such conviction;
(e) Notifying the agency, in writing, within 10 calendar days after receiving notice under
subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction.
Employers of convicted employees must provide notice, including position title, to: Director,
Grants Policy and Oversight Staff, U.S. Department of Education, 400 Maryland Avenue, S.W.
(Room 3652, GSA Regional Office Building No. 3), Washington, DC 20202-4248. Notice shall
include the identification number(s) of each affected grant;
Last Updated: May 13, 2016
Request for Proposal Document 32
(f) Taking one of the following actions, within 30 calendar days of receiving notice under
subparagraph (d)(2), with respect to any employee who is so convicted:
(1) Taking appropriate personnel action against such an employee, up to and including
termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local health, law
enforcement, or other appropriate agency;
(g) Making a good faith effort to continue to maintain a drug-free workplace through
implementation of paragraphs (a), (b), (c), (d), (e), and (f).
B. The grantee may insert below the site(s) for the performance of work done in connection
with the specific grant: Place of Performance (street address. city, county, state, zip code)
Check
if there are workplaces on file that are not identified here.
DRUG-FREE WORKPLACE (GRANTEES WHO ARE INDIVIDUALS)
As required by the Drug-Free Workplace Act of 1988, and implemented at 34 CFR Part 85,
Subpart F, for grantees, as defined at 34 CFR Part 85, Sections 85.605 and 85.610A. As a condition of the grant, I certify that I will not engage in the unlawful manufacture,
distribution, dispensing, possession, or use of a controlled substance in conducting any
activity with the grant; and
B. If convicted of a criminal drug offense resulting from a violation occurring during the
conduct of any grant activity, I will report the conviction, in writing, within 10 calendar days
of the conviction, to: Director, Grants Policy and Oversight Staff, Department of Education,
400 Maryland Avenue, S.W. (Room 3652, GSA Regional Office Building No. 3),
Washington, DC 20202-4248. Notice shall include the identification number(s) of each
affected grant.
As the duly authorized representative of the applicant, I hereby certify that the applicant will
comply with the above certifications.
NAME OF APPLICANT:
PROJECT NAME:
PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE:
SIGNATURE:
ED 80-0013
Last Updated: May 13, 2016
DATE:
10/08
Request for Proposal Document 33
ASSURANCES - 2
Non-Construction form SF 424B
OMB Approval No. 0348-0040
ASSURANCES - NON-CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average 15 minutes per
response, including time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the Office of Management and Budget,
Paperwork Reduction Project (0348-0040), Washington, DC 20503
Note: Certain of these assurances may not be applicable to your project or program. If you have
questions, please contact the awarding agency. Further, certain federal awarding agencies
may require applicants to certify to additional assurances. If such is the case, you will be
notified.
As the duly authorized representative of the applicant I certify that the applicant:
1. Has the legal authority to apply for federal assistance, and the institutional, managerial and
financial capability (including funds sufficient to pay the non-federal share of project cost) to
ensure proper planning, management, and completion of the project described in this
application.
2. Will give the awarding agency, the Comptroller General of the United States, and if
appropriate, the state, through any authorized representative, access to and the right to examine
all records, books, papers, or documents related to the award; and will establish a proper
accounting system in accordance with generally accepted accounting standards or agency
directives.
3. Will establish safeguards to prohibit employees from using their positions for a purpose that
constitutes or presents the appearance of personal or organizational conflict of interest, or
personal gain.
4. Will initiate and complete the work within the applicable time frame after receipt of approval
of the awarding agency.
5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. 004728-4763)
relating to prescribed standards for merit systems for programs funded under one of the 19
statutes or regulations specified in Appendix A of OPM's Standards for a Merit System of
Personnel Administration (5 C.F.R. 900, Subpart F).
6. Will comply with all federal statutes relating to nondiscrimination. These include but are not
limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits
discrimination on the basis of race, color or national origin; (b) Title IX of the Education
Amendments of 1972, as amended (20 U.S.C.
1681-1683, and 1685-1686), which prohibits
discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as
amended (29 U.S.C. 794), which prohibits discrimination on the basis of handicaps; (d) the
Age Discrimination Act of 1975, as amended (42 U.S.C.
6101-6107), which prohibits
discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L.
92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the
Last Updated: May 13, 2016
Request for Proposal Document 34
Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act
of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse
or alcoholism; (g)
523 and 527 of the Public Health Service Act of 1912 (42 U.S.C.
290 dd-3 and 290 ee 3), as amended, relating to confidentiality of alcohol and drug abuse
patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. 3601 et seq.), as
amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other
nondiscrimination provisions in the specific statute(s) under which application for federal
assistance is being made; and (j) the requirements of any other nondiscrimination statute(s)
which may apply to the application.
7. Will comply, or has already complied, with the requirements of Titles II and III of the uniform
Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which
provide for fair and equitable treatment of persons displaced or whose property is acquired as
a result of federal or federally assisted programs. These requirements apply to all interests in
real property acquired for project purposes regardless of federal participation in purchases.
8. Will comply, as applicable, with the provisions of the Hatch Act (5 U.S.C. 001501-1508 and
7324-7328), which limit the political activities of employees whose principal employment
activities are funded in whole or in part with federal funds.
9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. 00276a to
276a-7), the Copeland Act (40 U.S.C. 276c and 18 U.S.C.
874) and the Contract Work
Hours and Safety Standards Act (40 U.S.C.
327-333), regarding labor standards for
federally assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of
the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special
flood hazard area to participate in the program and to purchase flood insurance if the total cost
of insurable construction and acquisition is $10,000 or more.
11. Will comply with environmental standards which may be prescribed pursuant to the following:
(a) institution of environmental quality control measures under the National Environmental
Policy Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b) notification of violating
facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d)
evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved state management program developed under the Coastal
Zone Management Act of 1972 (16 U.S.C.
1451 et seq.); (f) conformity of Federal actions
to State (Clear Air) Implementation Plans under Section 176(c) of the Clear Air Act of 1955,
as amended (42 U.S.C.
7401 et seq.); (g) protection of underground sources of drinking
water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h)
protection of endangered species under the Endangered Species Act of 1973, as amended,
(P.L. 93-205).
12 Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. 001721 et seq.) related
to protecting components or potential components of the national wild and scenic rivers
system.
13. Will assist the awarding agency in assuring compliance with Section 106 of the National
Historic Preservation Act of 1966, as amended (16 U.S.C. 470), EO 11593 (identification
and protection of historic properties), and the Archaeological and Historic Preservation Act of
1974 (16 U.S.C.
469a-1 et seq.).
Last Updated: May 13, 2016
Request for Proposal Document 35
14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research,
development, and related activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7
U.S.C.
2131 et seq.) pertaining to the care, handling, and treatment of warm blooded
animals held for research, teaching, or other activities supported by this award of assistance.
16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C.
4801 et seq.),
which prohibits the use of lead-based paint in construction or rehabilitation of residence
structures.
17. Will cause to be performed the required financial and compliance audits in accordance with
the Single Audit Act Amendments of 1996 and OMB Circular No. A-133, Audits of States,
Local Governments, and Non-Profit Organizations.
18. Will comply with all applicable requirements of all other federal laws, executive orders,
regulations and policies governing this program.
NAME OF APPLICANT:
PROJECT NAME:
SIGNATURE:
DATE:
Standard Form 424B (Rev. 7-97) Back
Last Updated: May 13, 2016
Request for Proposal Document 36
ASSURANCES - 3
GEPA Equitable Access form 1890-0007
OMB Control No. 1890-0007 (Exp. 09/30/2004)
NOTICE TO ALL APPLICANTS
The purpose of this enclosure is to inform you about a new provision in the Department of
Education's General Education Provisions Act (GEPA) that applies to applicants for new grant
awards under Department programs. This provision is Section 427 of GEPA, enacted as part of
the Improving America's Schools Act of 1994 (Public Law (P.L.) 103-382).
To Whom Does This Provision Apply?
Section 427 of GEPA affects applicants for new grant awards under this program. ALL
APPLICANTS FOR NEW AWARDS MUST INCLUDE INFORMATION IN THEIR
APPLICATIONS TO ADDRESS THIS NEW PROVISION IN ORDER TO RECEIVE
FUNDING UNDER THIS PROGRAM.
(If this program is a state-formula grant program, a state needs to provide this description only
for projects or activities that it carries out with funds reserved for state-level uses. In addition,
local school districts or other eligible applicants that apply to the state for funding need to
provide this description in their applications to the state for funding. The state would be
responsible for ensuring that the school district or other local entity has submitted a sufficient
section 427 statement as described below.)
What Does This Provision Require?
Section 427 requires each applicant for funds (other than an individual person) to include in its
application a description of the steps the applicant proposes to take to ensure equitable access
to, and participation in, its federally-assisted program for students, teachers, and other
program beneficiaries with special needs. This provision allows applicants discretion in
developing the required description. The statute highlights six types of barriers that can impede
equitable access or participation: gender, race, national origin, color, disability, or age. Based on
local circumstances, you should determine whether these or other barriers may prevent your
students, teachers, etc. from such access or participation in, the federally-funded project or
activity. The description in your application of steps to be taken to overcome these barriers need
not be lengthy; you may provide a clear and succinct description of how you plan to address
those barriers that are applicable to your circumstances. In addition, the information may be
provided in a single narrative, or, if appropriate, may be discussed in connection with related
topics in the application.
Section 427 is not intended to duplicate the requirements of civil rights statutes, but rather to
ensure that, in designing their projects, applicants for federal funds address equity concerns that
may affect the ability of certain potential beneficiaries to fully participate in the project and to
achieve to high standards. Consistent with program requirements and its approved application,
an applicant may use the federal funds awarded to it to eliminate barriers it identifies.
What are Examples of How an Applicant Might Satisfy the Requirement of This
Provision?
The following examples may help illustrate how an applicant may comply with Section 427.
Last Updated: May 13, 2016
Request for Proposal Document 37
(1) An applicant that proposes to carry out an adult literacy project serving, among others,
adults with limited English proficiency, might describe in its application how it intends to
distribute a brochure about the proposed project to such potential participants in their native
language.
(2) An applicant that proposes to develop instructional materials for classroom use might
describe how it will make the materials available on audio tape or in Braille for students who
are blind.
(3) An applicant that proposes to carry out a model science program for secondary students
and is concerned that girls may be less likely than boys to enroll in the course, might indicate
how it intends to conduct "outreach" efforts to girls, to encourage their enrollment.
We recognize that many applicants may already be implementing effective steps to ensure equity
of access and participation in their grant programs, and we appreciate your cooperation in
responding to the requirements of this provision.
Estimated Burden Statement for GEPA Requirements
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless such collection displays a valid OMB control number. The valid
OMB control number for this information collection is 1890-0007. The time required to
complete this information collection is estimated to average 1.5 hours per response, including the
time to review instructions, search existing data resources, gather the data needed, and complete
and review the information collection. If you have any comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: Director, Grants
Policy and Oversight Staff, U.S. Department of Education, 400 Maryland Avenue, SW (Room
3652, GSA Regional Office Building No. 3), Washington, DC 20202-4248.
NAME OF APPLICANT
PROJECT NAME
PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
SIGNATURE
Last Updated: May 13, 2016
DATE
Request for Proposal Document 38
PRINCIPLES OF EFFECTIVENESS
(1) IN GENERAL- For a program or activity developed pursuant to this part to
meet the principles of effectiveness, such program or activity shall —
(A) be based upon an assessment of objective data regarding the need for
before and after school programs (including during summer recess
periods) and activities in the schools and communities;
(B) be based upon an established set of performance measures aimed at
ensuring the availability of high quality academic enrichment
opportunities; and
(C) if appropriate, be based upon scientifically based research that
provides evidence that the program or activity will help students meet
the State and local student academic achievement standards.
Last Updated: May 13, 2016
Request for Proposal Document 39
Appendix B
I. Evidence of having met goals and objectives.
Last Updated: May 13, 2016
Request for Proposal Document 40
Appendix B
II. Having improved student achievement.
Last Updated: May 13, 2016
Request for Proposal Document 41
Appendix B
III. Evidence of utilizing collaborating partners to enhance academic performance,
achievement and positive youth development.
Last Updated: May 13, 2016
Request for Proposal Document 42
Appendix B
IV. Evidence of collaboration with the school(s) that students attend.
Last Updated: May 13, 2016
Request for Proposal Document 43
Appendix D
VERIFICATION OF PRIVATE SCHOOL CONSULTATION
According to the non-regulatory guidance for 21st CCLC, a public school or other public or
private organization that is awarded a grant must provide equitable services to private school
students, and their families. In designing a program that meets this requirement, grantees must
provide comparable opportunities for the participation of both public- and private-school
students in the attendance area served by the grant. Grantees must consult with private school
officials during the design and development of the 21st CCLC program on issues such as how
the children's needs will be identified and what services will be offered. Services and benefits
provided to private school students must be secular, neutral, and non-ideological. This
communication must be verified by completing the form below. Double-click on the cell to enter
information.
Private School Name
Private School
Administrator Name and
Email Address
Date and
Method of
Contact
Participation
in Program
Yes or No
Reason for Not
Participating
* Private schools whose students will participate in the program should be listed on the Summary
and Abstract form as a participating school.
_______There are no private schools in the attendance area(s) of the school(s) to be served by this
grant.
Applicant Signature: _______________________________ Date: _________________________
County Superintendent (s) of Schools: __________________________
Last Updated: May 13, 2016
Date: _____________
__________________________
Date:______________
__________________________
Date: _____________
Request for Proposal Document 44
Appendix E
Verification of Sharing Intent/Application with Community
To comply with ESEA Title IV Part B Section 4204 (b)(2)(L), each applicant must sign an
assurance that the community was given notice of its intent to submit an application and that the
application and any waiver request be available for public review after submission of the
application. To verify that this has been done, please complete the form below:
Please explain how the community was informed:
Applicant Signature: _______________________________
Last Updated: May 13, 2016
Date: __________________
Request for Proposal Document 45
Appendix F
Evidence of Joint Planning with Co-Applicants
In determining whether an application has been “submitted jointly,” States should look for
evidence in the application that the LEA and at least one other organization collaborated in
the planning and design of the program, each have substantial roles to play in the delivery of
services, share grant resources to carry out those roles, and have significant ongoing
involvement in the management and oversight of the program. States may want to consider
what organization(s) wrote the application, what organization will be the fiscal agent,
whether there is a history of these organizations working together, and whether there is
evidence in the application of integration of the after-school program activities with the
regular school day program. Letters of endorsement are not by themselves sufficient
evidence that organizations or school districts have substantially been involved in the
design of a program. (This clarification comes from the USDOE Nonregulatory Guidance
for 21st CCLC programs.)
Evidence such as meeting agendas, sign-in sheets and planning documents should be included in
the pages after the Appendix F signature sheet.
Applicant Signature: _______________________________
List of what will be done by the lead, the co-applicant partner, and both.
Last Updated: May 13, 2016
Date: __________________
Request for Proposal Document 46
Goal 1:
Objectives
Activities
Inputs/Resources
Outputs
Outcomes
(Specific,
Measurable,
Achievable, Realistic,
and Time-bound)
(what we do to achieve
objectives/goals)
(human,
financial,
technology, etc…
resources needed
for activities)
(tangible and direct
products of
activities that lead
to desired
outcomes)
(short-, medium-, and
long- term desired results
of activities)
1.1
1.2
1.3
Last Updated: May 13, 2016
1.1.1
1.1.1
1.1.1
1.1.2
1.1.2
1.1.2
1.1.3
1.1.3
1.1.3
1.2.1
1.2.1
1.2.1
1.2.2
1.2.2
1.2.2
1.2.3
1.2.3
1.2.3
1.3.1
1.3.1
1.3.1
1.3.2
1.3.2
1.3.2
1.3.3
1.3.3
1.3.3
Indicator/Data
Source
(indicators we look
for to measure
implementation,
progress and
success)
Request for Proposal Document 47
Goal 2:
Objectives
Activities
Inputs/Resources
Outputs
Outcomes
(Specific,
Measurable,
Achievable,
Realistic, and Timebound)
(what we do to achieve
objectives/goals)
(human,
financial,
technology, etc…
resources needed
for activities)
(tangible and direct
products of
activities that lead
to desired
outcomes)
(short-, medium-, and
long- term desired results
of activities)
2.1
2.2
2.3
2.4
Last Updated: May 13, 2016
2.1.1
2.1.1
2.1.1
2.2.2
2.2.2
2.2.2
2.1.3
2.1.3
2.1.3
2.2.1
2.2.1
2.2.1
2.2.2
2.2.2
2.2.2
2.3.1
2.3.1
2.3.1
2.3.2
2.3.2
2.3.2
2.4.1
2.4.1
2.4.1
2.4.2
2.4.2
2.4.2
Indicator/Data
Source
(indicators we look
for to measure
implementation,
progress and
success)
Request for Proposal Document 48
Example of a Well-Completed CCLC Project Logic Model
Goal 1: To increase academic achievement among regular student attendees on an annual basis.
Objectives
Activities
Inputs/Resources
Outputs
Outcomes
(Specific, Measurable,
Achievable, Realistic, and Timebound)
(what we do to achieve
objectives/goals)
(human, financial,
technology, etc…
resources needed for
activities)
(tangible and direct
products of activities that
lead to desired outcomes)
(short-, medium-,
and long- term
desired results of
activities)
1.1 – By spring 2017, at least
70% of all students enrolled in
participating schools will attend
the CCLC for a minimum of 20
days/year, with at least 50% of
students attending at least 30
days.
1.1.1 – Teachers and CCLC staff
provide targeted, ongoing
outreach to encourage CCLC
attendance
Human: RESA 2
Project Director, 2
Site Coordinators, 6
teacher/tutors
1.1.2 – Participating students and
their guardians sign attendance
agreement
Technology: iPads
1.1.3 – Parents and students are
given a voice into CCLC
activities to support ownership,
relevance to participants, and
enthusiasm.
Transportation:
busing
Enrichment supplies
Last Updated: May 13, 2016
1.2.1 – Students meet with tutors
to establish unique literacy and
reading goals and a plan to
achieve them.
Social media for CCLC:
Facebook
Attendance agreement
drafted and shared with
students & guardians for
signing.
Student and parent surveys
written.
1.1.4 – CCLC outreach is
consistent, supportive, and
regular via multiple channels.
1.2 – At least 55% of students
who attend CCLC for at least 30
days will increase their reading
scores by 5% on the
CCLC website
developed/regularly
updated.
95% of parents
sign and students
sign attendance
agreement.
Indicator/Data
Source
(indicators we look for
to measure
implementation,
progress and success)
CCLC attendance
Records
Student Surveys
Daily attendance
shows evidence of
consistent
improvement.
Student attendance
at CCLC remains
stable or increases
every quarter.
Outreach materials
written/created and
distributed: press releases,
mailings, email scripts,
flyers, posters, and
brochures.
Human:
teachers/tutors
Technology: iPads,
Daily literacy and language
arts tutoring logs updated by
tutors.
Daily progress
made in language
arts and reading.
Acuity
SRI
Request for Proposal Document 49
Acuity/Scholastic Reading
Inventory or DIBELS from
October 2016 to spring 2017.
Read180, etc.
1.2.2 – Students will receive
daily 1:1 individualized academic
tutoring in literacy, language arts,
and reading.
iPad apps utilized for
reading and language arts
DIBELS
Tutoring supplies
Tutoring Logs
1.2.3 – Acuity/SRI is
administered; progress mapped
for each student.
1.3 – By October 2017, at least
50% of all regular attendees will
be performing at grade level
(proficient) in reading as
measured by the WESTEST 2.
1.3.1 – Students meet with tutors
to establish unique literacy and
reading goals plus a plan to
achieve them.
1.3.2 – Students will receive
daily, 1:1, individualized
academic tutoring in literacy,
language arts, and reading.
1.3.3 WESTEST is administered;
results are longitudinally
compared to past year’s results
per student.
1.4 – At least 55% of students
who attend for at least 30 days
will increase their math scores by
a minimum of 5% as measured
by Acuity benchmarking from
October 2016 to spring 2017.
1.4.1 – Students meet with tutors
to establish unique math goals
plus a plan to achieve them.
1.4.2 – Students receive daily,
1:1, individualized academic
tutoring in math.
1.4.3 – STEAM and PBL
embedded into math activities to
the extent possible.
1.5 By October 2017, at least
45% of all regular attendees will
be performing at grade level
(proficient) in math as measured
by the WESTEST 2.
1.5.1 Students meet with tutors
to establish unique math goals
plus a plan to achieve them.
1.5.2 Students will receive daily,
1:1, individualized academic
tutoring in math.
Last Updated: May 13, 2016
Human
(teacher/tutors)
Technology (iPads,
Read 180, etc.)
Tutoring supplies
Human
(teacher/tutors)
Technology (iPads,
math apps, STEAMrelated resources, etc.)
STEAM and projectbased learning
supplies.
Daily Literacy and language
arts tutoring logs updated by
tutors.
iPad apps utilized for
reading and language arts
WESTEST administered.
Daily progress
made in language
arts and reading.
WESTEST 2
Evaluation matrices
developed as-needed for
reading assessment.
Daily math tutoring logs
updated by tutors.
iPad apps utilized for math
Acuity benchmarking
administered.
Evaluation matrices
developed as-needed for
math assessment.
Human
(teacher/tutors)
Daily math tutoring logs
updated by tutors.
Technology (iPads,
math apps, STEAMrelated resources,
iPad apps utilized for math
WESTEST administered.
Daily progress
made in math
homework,
quizzes, exams,
etc.
STEAM and
project-based
learning activities
integrate math and
reflect local
curriculum.
Daily progress
made in math
homework,
quizzes, exams,
etc.
Acuity benchmarking
WESTEST 2
Request for Proposal Document 50
1.5.3 WESTEST is
administered; results are
longitudinally compared to past
year’s results per student.
etc.)
STEAM and projectbased learning
supplies
1.6 By spring 2017, at least 75%
of all regular attendees will
demonstrate improved
homework completion and class
participation. (As measured by
homework completion matrix,
teacher survey, After School
Matters survey.)
1.6.3 Students will receive 1-2
hours of 1:1 homework
assistance from tutors daily at
each site, based on need.
1.6.4 Students attend enrichment
modules and recreation based on
interests
Human: all CCLC
staff, especially
enrichment module
leaders
Enrichment supplies
(arts and crafts,
recreation, STEAM,
etc.).
Tutoring supplies,
including technology.
Last Updated: May 13, 2016
1.7.1 Students attending CCLC
participate in enrichment and
PBL activities including (1)
social skill development and
service learning; (2) art, music,
drama, recreation; (3)
entrepreneurship; and (4) other
List of potential enrichment
module leaders compiled.
Communication/outreach
with potential adult
enrichment modules
documented (email, phone
records)
Background checks
completed. Supplies
purchased (receipts =
evidence)
Enrichment schedules
updated.
Busing home.
Daily homework
completion logs
show
improvement.
Enrichment and
recreation modules
boost student
attendance,
interest,
engagement,
and enthusiasm
for learning.
Student engagement
matrices developed for
classroom teachers to track
daily homework completion
and participation rates.
1.6.5 Project-based learning and
STEAM embedded in afterschool activities.
1.7 By spring 2017 at least 75%
of regular employees will
demonstrate improvement in
behavior. (As measured by
school disciplinary records).
STEAM, tutoring,
and project-based
learning activities
integrate math and
reflect local
curriculum and
instructional
strategies.
Student enrichment interest
surveys developed and
administered. Results
tabulated and shared with
CCLC staff.
1.6.1 Students are referred for
CCLC support by classroom
teachers, parents, and counselors.
1.6.2 CCLC Tutors develop
individual progress folders for
each student and outline specific
unique learning goals based on
each student’s needs.
Evaluation matrices
developed as-needed for
math assessment.
Human all CCLC
staff, especially
enrichment module
leaders
Enrichment supplies
(arts and crafts,
Surveys developed for
classroom teachers.
Student enrichment interest
surveys developed and
administered.
Results tabulated and shared
with CCLC staff.
Daily behavior
tacking shows
improvement.
Student code-ofconduct referrals
decrease.
Homework completion
matrix, class
participation survey
(teacher completed),
After School Matters
survey.
Request for Proposal Document 51
interest-based activities.
1.7.2 Students are given a voice
to provide feedback into CCLC
activities.
recreating, STEAM
etc.).
List of potential enrichment
module leaders compiled.
Tutoring supplies,
including technology.
Communication/outreach
with potential adult
enrichment modules
documented (email, phone
records).
Busing Home
Background checks
completed.
Supplies purchased (receipts
= evidence)
Enrichment schedules
updated.
Student engagement
matrices developed for
classroom teachers to track
daily homework completion
and participation rates.
Surveys developed for
classroom teachers.
Last Updated: May 13, 2016
Out-of-school
suspensions
decrease.
In-school
suspensions
decrease.
Enrichment and
recreation modules
boost student
attendance,
interest,
engagement, and
enthusiasm for
learning.
Request for Proposal Document 52
Goal 2: To increase the education and skill level of adults and parents.
Objectives
Activities
Inputs/Resources
Outputs
Outcomes
(Specific,
Measurable,
Achievable, Realistic,
and Time-bound)
(what we do to achieve
objectives/goals)
(human, financial, technology,
etc… resources needed for
activities)
(tangible and direct
products of activities that
lead to desired outcomes)
(short-, medium-, and
long- term desired
results of activities)
2.1 By spring 2017, at
least 85% of
parents/adults who
have participated in
adult CCLC programs
will report increased
family-school
connectedness as well
as improved skills and
knowledge in the
specific program in
which they
participated.
2.1.1 Parents are
surveyed to determine
interests, schedules and
availability.
Human: instructors of adult
programming, CCLC Director to
coordinate and conduct outreach,
Site supervision of extended hours at
computer labs and libraries.
Pre-and post-surveys
developed and
administered to
determinate areas of adult
interest and need.
Adult attendance at
CCLC-coordinated
programs at least 60% of
anticipated.
2.1.2 Existing classes
identified, meeting
scheduled with staff and
partners.
Financial: purchase of resources,
supplies and consumables.
2.1.3 New classes
designed and scheduled,
based on survey
feedback.
Outreach strategies
analyzed and improved to
increase attendance
(meeting minutes, lists,
brochures, mailings).
2.1.4 Publicity is
targeted and stresses
benefits to adult
participants.
Electronic medial
updated (social mediate,
websites).
2.1.5 Surveys and focus
groups are designed and
administered pre-and
post-events.
2.2 By spring 2017 at
least 85% of parents
will report that CCLC
services are helpful,
accessible,
Last Updated: May 13, 2016
2.2.1 Adult activities
are scheduled based on
participant feedback on
convenience schedules.
Existing classes
identified, meeting with
scheduled staff and
partners (meeting
minutes, lists)
Human: instructors of adult
programming, CCLC Director to
coordinate and conduct outreach,
Site supervision of extended hours at
computer labs and libraries.
New programs developed
and scheduled (instructor
contracts, schedule
posted via identified
venues)
Pre-and post-surveys
developed and
administered to determine
areas of adult interest and
need.
Indicator/Data Source
(indicators we look for
to measure
implementation,
progress and success)
Participant surveys
Focus group results
Adult literacy measures
Attendee
recommendations
contribute to continual
improvement.
Attendance logs
Event feedback forms
Families report increased
school engagement.
More parents
volunteering at school
More parents attending
conferences and school
events.
More adults completing
GEDs and other postsecondary coursework.
Adult literacy rates
increase.
Adult attendance at
CCLC-coordinated
programs at least 60% of
anticipated.
Participant surveys
Focus group results
Attendance logs
Request for Proposal Document 53
conveniently
scheduled, and
targeted to their needs.
2.2.2 Adult services are
designated around
participant interests and
needs.
2.2.3 Surveys and focus
groups are designed and
administered pre and
post-events.
Financial: purchase of resources,
supplies, and consumables
Existing classes
identified, meeting
scheduled with staff and
partners (meeting
minutes, lists)
Outreach strategies
analyzed and improved to
increase attendance
(meeting minutes, lists,
brochures, mailings).
Electronic media updated
(social media, websites).
New programs developed
and scheduled (instructor
contracts, schedule
posted via identified
venues)
Adult attendance remains
stable or increases each
quarter.
Attendee
recommendations
contribute to continual
improvement.
Families report increased
school engagement.
More parents
volunteering at school.
More parents attending
conferences and school
events.
More adults completing
GEDs and other postsecondary coursework.
Adult literacy rates
increase.
Last Updated: May 13, 2016
Event feedback forms
Request for Proposal Document 54
2016 21ST CENTURY COMMUNITY LEARNING CENTER GRANT
COMPETITION
NOTIFICATION OF INTENT TO APPLY
DUE APRIL 1st
The following organization will be submitting a 21st Century Community Learning
Center Grant application:
Name of Organization:
Lead Administrator Name:
Email:
Phone:
Grant Application Contact Name:
Email:
Phone:
Number of Applications:
Individual Submitting Form:
Email (if different from any above):
A list of all organizations intending to submit a 2016 application will be emailed to organizations
submitting this form. If you submit the intent form and later decide not to apply, it would be
greatly appreciated if you would send an email informing Benitez Jackson at
bljackso@k12.wv.us. Having an accurate number of applications to be scored helps secure the
appropriate number of reviewers.
Last Updated: May 13, 2016