This Checklist must accompany your submission.
To be submitted by Tuesday, January 12, 2065 to:
Eastside Promise Neighborhood Office
1023 N. Pine, San Antonio, Texas 78202
(on the 2nd floor of the Ella Austin Community Center)
EASTSIDE PROMISE NEIGHBORHOOD CHECKLIST
2016 HEALTH AND WELLNESS – ASTHMA PROJECT
PURCHASE OF SERVICE PROPOSAL REQUEST
Agency Name
Contact Person
Program Name
Title
Address
Contact Number
Main Number
Contact Email Address
Applicants are to submit one original copy of their documentation and ten complete paper copies of their application. Applicants are also
required to submit one electronic version of the application on a CD or flash drive. Applicants may not use any substitute forms or
recreate these forms separately.
□
Required:
_____ Most recent Annual Financial and Federal Audit Reports (if applicable) any and all
program review reports issued by any federal or state funder (for the most recent fiscal period)
___Included
Completed and verified
Indicate Completed with date
and initial
(INTERNAL USE ONLY)
___Does Not Apply
Signature of authorized personnel & date
1 Original copy of completed application
1 Electronic version of completed application on CD or flash drive
10 three-hole punched copies of completed application
Attendance at the Information Session on 12/14/15 or 12/15/15
Letter of Support from Campus Principal or Agency Representative
Job Descriptions for each position which funding is requested
Memorandum of Understanding and/or letters of Support for Collaborative Programs
For collaborative programs, a flow chart describing the collaboration
20% Match verification from agency or funding source
Section I. – Organizational Information Section (1 page limit)
Section II. – Program Overview (2 page limit)
Section III. – Scope of Work (4 page limit)
Section IV. – Outcomes Evaluation (2 page limit)
Section V. – Program Budget, Narrative & Matching Funds
Budget Narrative
Budget Summary and Detailed Budget (Excel workbook)
Match/In-Kind Section complete
Eastside Promise Neighborhood Asthma Project Purchase of Service Proposal Solicitation #H&W-2016
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EASTSIDE PROMISE NEIGHBORHOOD PURCHASE OF SERVICE PROPOSAL REQUEST
POS Solicitation: Health and Wellness – Asthma Project
Solicitation #: H&W-2016
SECTION I: Organizational Information (5 points maximum)
If any section of this application packet is incomplete, the proposal is subject to disqualification if not
Immediately corrected upon notice.
1) Proposed Program Name:
2) Legal Name of Applicant Organization:
3) d.b.a. (if applicable):
4) Mailing Address:
5) Phone:
6) Fax:
7) Executive Director’s Name:
8) Executive Director’s e-mail and phone number:
9) Name and title of contact person for this
proposal. If Executive Director is contact, enter
“same”
10) Phone and e-mail address for contact , if different:
11) Organization Mission Statement:
12) Total Proposed Program Cost: (sum of #14 and
#15): $
14) Eastside Promise Neighborhood
13) Total Agency Budget: $
15) Source and amount of required 20% Match Funds:
Amount Requested: $
By signing below you:
 indicate you are in agreement with the attached proposal.
 serve as the authorized official of the applicant organization with permission to submit proposals on their behalf.
 certify to United Way of San Antonio & Bexar County that the applicant agency has not been suspended and/or
debarred from providing services under federal awards as defined under 2CFR200.212.
 certify you understand EPN is a federally funded U.S. Department of Education research based project and all
implementation models used to achieve performance outcomes must be evidence based.
Print Name/Title
Signature
Date
Print Name/Title
Signature
Date
Eastside Promise Neighborhood Asthma Project Purchase of Service Proposal Solicitation #H&W-2016
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SECTION II: PROGRAM OVERVIEW (Limit to 2 pages – 5 points maximum)
16) Program Summary: Describe your program the way that you would like it to appear in UWSA/EPN public
documents and on our website.
17) Proposed Program Site Name and Address:
a. Is this site in the EPN geographic area?
18) Total number of unduplicated children proposed
to serve (February - July 2016):
Total number of unduplicated families proposed
to serve (February – July 2016):
19) Estimated number of unduplicated children
proposed to serve on a daily basis
(February – July 2016):
Estimated number of unduplicated families
proposed to serve on a daily basis
(Feb – July 2016)
20) Accepted Age/Grade Level Range:
21) Program Days:
a. Total number of Program Days for each
month of programming? If applicable,
provide total number of program days per
site.
Feb.
2016
March
2016
April
2016
May
2016
b. What days of the week will program operate
(school months and summer)?
Please fill out 2016 Program Schedule Calendar (attached)
June
2016
July
2016
22) TRANSPORTATION: (Check all that apply)
 Transportation Provided  Near Public Transportation
 Walking Distance to School
 Bus Tickets
23) MEALS/SNACKS: (Check all that apply)
 Breakfast
 Lunch
 Afternoon Snack
 Dinner
 USDA Food program
24) DAILY SCHEDULE: Submit a detailed daily schedule of your complete proposed program to include times
children will arrive, eat meals, depart, and participate in activities or instruction.
Eastside Promise Neighborhood Asthma Project Purchase of Service Proposal Solicitation #H&W-2016
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SECTION III: SCOPE OF WORK
(Limit to 4 pages – 20 points maximum)
Attach responses to the following questions in a separate document. Utilize the questions as the heading for
each section. Use a 12 point font and no less than 1 (one) inch margins.
I.
Statement of Interest. Provide a detailed description of the proposed program and the services for
which funding is requested. Within your response address the following questions.
a.
b.
c.
d.
e.
f.
Describe the lead applicants’ capacity to manage and implement an education program.
Describe your experience if any in managing federal awards. (financial and programmatic)
Describe program services to include activities, strategies, goals, and innovative ideas.
What has your agency done in the past or currently to address asthma?
Describe and provide a sample of an asthma action plan.
Describe the applicant experience in conducting home visits and working one on one with
families.
g. Describe the promotion and recruitment of the program in detail.
h. How will the agency determine the success of the program?
II.
Family Engagement. Through this funding opportunity we highly encourage family engagement. The
family exchange factor is the parent or guardian’s co-investment which may include: Sliding scale copay; Volunteering a minimum of four hours in the campus parent room or with the program; attend a
minimum of three sessions at the Financial Empowerment Center; or be enrolled in job training,
GED/ESL/Adult Education Program.
a. How will you ensure family engagement is incorporated into your program and how will you track
this?
III.
Sustainability Plan. How does this request fit your organizations long term goals? We define long term
as the time period beyond this grant. What is your plan for sustainability, to continue services to the
Eastside Promise Neighborhood, after this award period has ended?
IV.
Program Collaboration.* If collaborative partnerships will be utilized, describe roles and responsibilities
of applicant and partner(s). Include a flow chart describing the collaboration, memorandum of
understanding and/or letters of support. * Up to 10 bonus points for program collaboration.
Eastside Promise Neighborhood Asthma Project Purchase of Service Proposal Solicitation #H&W-2016
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SECTION IV: OUTCOMES EVALUATION
(Limit to 2 pages – 10 points maximum)
UWSA/EPN is committed to ensuring that purchase of service agreements help lead to demonstrable outcomes for
children. Upon program completion UWSA/EPN will evaluate participating children to determine the relationship
between service provision and student performance. This evaluation will be conducted by UWSA/EPN and does not
require effort from the program. Analysis will be used for informational purposes and shared with the program to help
identify areas of potential programming growth.
Focus Area
Metric
Medical Home
#/% of children 0-5 years old with a medical home
Data and Reporting: Agency must document and report UWSA/EPN Results and Indicators, including collecting data
and reporting results for individual participants, as well as an aggregate level for all participants including the
performance measures identified below. Complete the performance measure table below for each program site,
especially if program schedules vary between program sites.
Eastside Promise Neighborhood Asthma Project Purchase of Service Proposal Solicitation #H&W-2016
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SECTION V. – PROGRAM BUDGET, NARRATIVE & MATCHING FUNDS (10 points maximum)
Budget must be submitted for program proposal.
Complete the Budget Narrative, Detailed Budget and Match/In-Kind Section of the attached forms

Track the required 20% program match of requested funds on the budget workbook.

Calculate the cost per child for the overall program.

The budget workbook should be signed and dated by a certified representative.
Utilize the following formulas to complete the top section of the budget narrative:

Total Program Cost = EPN Funding Request plus (+) Match Amount

Percentage of Match of Requested Funds = Match Amount divided by (/) EPN Funding Request

Cost Per Child (all funds) = Total Program Cost divided by (/) # Children Served

Cost Per Child Per Day (all funds) = Cost Per Child (all funds) divided by (/) # Program Days

EPN Cost Per Child = EPN Request divided by (/) # of EPN eligible Children Served **

EPN Cost Per Child Per Day = EPN Cost Per Child divided by (/) number of Program Days
Eligible Children – must reside in 78202 or 78208 or attend one of the six EPN Schools (Tynan, Bowden
Elem, Pershing Elem, Washington Elem, Wheatley MS, or Sam Houston HS.
100 participants (x) cost per child per day, amount not to exceed award amount. Agencies will have to
complete the contract period regardless of when the funds are exhausted.
Eastside Promise Neighborhood Asthma Project Purchase of Service Proposal Solicitation #H&W-2016
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Eastside Promise Neighborhood
Spring 2016 Asthma Project Purchase of Service Proposal Request
Budget Narrative- February 2016 thru July 2016
Agency Name: _________________________
EPN Request: $
Match: $
Percentage of Match of Requested Funds:
Total Program Cost: $
Cost Per Child: $
Cost Per Child Per Day: $
* EPN Cost Per Child: $
EPN Cost Per Child Per Day: $
(1A) Personnel Salaries – Provide each staff title, if part time or FTE, percent of their time on this contract, how
many months, and salary per month
Total Salaries: $_________
(1B) Personnel Fringe Benefits – Provide the number of employees, titles, and percentage of benefits. Each fringe
benefit should be calculated and described separately for each employee on this contract.
Total Fringe: $_____________
(2) Travel- Describe and calculate mileage per staff and any lodging or travel requirements for this contract.
Total Travel $_________
(3) Materials and Supplies – Describe and calculate the budget for all material and supplies for this contract.
Total Materials and Supplies $________
(4) Equipment – Describe and calculate cost for equipment to be used by program participants.
Total Equipment $________
(5) Other Costs: Provide calculations and descriptions for all other costs associated with this contract.
Total Other Costs: $___________
Eastside Promise Neighborhood Asthma Project Purchase of Service Proposal Solicitation #H&W-2016
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