2013-2014 Commonwealth Corps Host Site Application
Section VIII
ATTACHMENTS
ATTACHMENT INSTRUCTIONS:
In the electronic copy of your application, all attachments (A, B, and C) should be submitted as
one “Attachments” document, using the following pages of section VIII as a template. This is
available in a separate Word document for editing. The application narrative and organizational
chart should each be sent as separate documents within the same email.
ATTACHMENT A: Title Page
 Applicants must complete the entire Title Page, including the signature from their
Executive Director, the signature(s) from member supervisor(s), and the calculation of
their cash match. Although the electronically submitted copy (due by March 1, 2013)
may contain electronic signatures, the complete original copy (received at MSA by March
7, 2013) must contain actual original signatures.
ATTACHMENT B: Performance Measure Worksheet
 Applicants must complete (1) the capacity-building section AND (2) the section
appropriate to their one selected focus area.
 Complete this attachment by providing appropriate targets that you expect to attain as a
direct result of your proposed Commonwealth Corps project, provide detail on the
instrument or tools you will use to measure these changes, and describe the overall
impact you expect to realize as a result of your Commonwealth Corps project.
 MSA will work with selected sites to finalize these performance measures during
negotiations, if necessary. For more details on the capacity building goals and goals in
each focus area, please see pages 8-11.
 Please delete the sections for the three focus areas for which you are not proposing
measures.
ATTACHMENT C: Commonwealth Corps Position Description
 Applicants must make sure that their position descriptions include the elements listed in
the template for this attachment and the phrase “Commonwealth Corps” in the overall
position title. Keep in mind that your expectations and requirements should be
reasonable for a program that is focused on member development and that you should
specify which functions are marginal versus essential.
o NOTE: Essential functions are those that are directly tied to the reason the
position exists. Therefore, these cannot be eliminated or reassigned. Marginal
functions are tasks that can be adjusted or reassigned without jeopardizing the
basic purpose of the position. For example, a member is engaged to tutor
students in small groups at a site-based program and conduct telephone followup with families. An essential function is to interact appropriately with students
on a regular schedule at the site. A marginal function is to accompany students
on periodic field trips.
 Make sure to include a clear sense of the required schedule, if there is a framework for
time of day and/or days per week. Be clear about any expectations for scheduling or
responsibilities that go beyond the common, MSA-specific guidelines listed in the
template.
 MSA will work with selected sites to finalize these position descriptions during
negotiations, if necessary.
21
ATTACHMENT A
TITLE PAGE
Indicate the focus area you are selecting (select one):
Economic Opportunity/Workforce Development
Health & Nutrition
Veterans’ Support
Education
Youth Violence Prevention
Please provide the requested information below.
APPLICANT INFORMATION
Legal Applicant Name:
Employer Identification Number:
Executive Director (ED):
ED Address:
ED Phone:
ED E-mail:
Commonwealth Corps Supervisor:
Supervisor Address:
Supervisor Phone:
Supervisor E-mail:
Has your organization received federal
funds?
Yes
No
If yes, please provide an estimate of the number of years and the amount received annually.
Has your organization received state
funds?
Yes
No
If yes, please provide an estimate of the number of years and the amount received annually.
How many years has your organization
engaged volunteers?
Are you a current or past Commonwealth
Corps Host Site?
Yes
No
Yes
No
Yes
No
If yes, year(s):
Does your organization currently engage
other service corps members, such as
If yes, type(s):
AmeriCorps or AmeriCorps VISTA?
Has your organization received funding
from MSA within the past 5 years? _____
If so, please indicate the type of support received (AmeriCorps, mentoring, mini-grant, etc.).
MEMBER REQUEST
(Note: Applicants may only request members of ONE slot type)
Slot Type
Number of Members Requested (only ONE type)
Full-time (1,500 hours)
Part-time (750 hours)
Cash Match from Your Agency
Total Cash Match (only ONE type)
Full-time: # members x $800 =
$
Part-time: # members x $550 =
$
In submitting this application for the 2013-2014 Commonwealth Corps Program, I certify
that the information is true and correct to the best of my knowledge.
I understand that if my organization is selected to host Commonwealth Corps members,
we are responsible for:
 Contributing a cash match of $550 per part-time member or $800 per full-time member;
 Working with MSA in April-June to finalize the partnership, performance measures,
position descriptions, and logic model;
 Active recruitment of our members in consultation with MSA, including selecting finalists
for submission to MSA by June 30th, 2013;
 Providing regular on-site supervision and support for the members, including site
orientation and training;
 Providing adequate work space (desk, phone, computer) and resources for successful
service;
 Participating in Commonwealth Corps evaluation, site visits, and other events;
 Attending mandatory supervisor meetings and orientation (minimum of 3);
 Making corps members available to attend orientation, trainings, and meetings (minimum
of 3);
 Collecting and reporting on evaluation data on a timely basis; and
 Promoting the Commonwealth Corps and our partnership with MSA.
Executive Director Name:
Executive Director Signature:
Date:
Names and Signatures of Agency Staff Who Will Be Directly Supervising Members
Member Supervisor Name:
Title:
Member Supervisor Signature:
Member Supervisor Name:
Date:
Title:
Member Supervisor Signature:
Member Supervisor Name:
Member Supervisor Signature:
Date:
Title:
Date:
(Please add additional signature lines if necessary)
ATTACHMENT B
PERFORMANCE MEASURE WORKSHEET
Applicants must complete (1) the capacity-building section AND (2) the section appropriate
to their one selected focus area.
See page 21 for details and instructions on completing this section. Please delete the sections
for the 3 focus areas for which you are not proposing performance measures.
CAPACITY BUILDING (Required for all sites)
Goal: To expand the scale, reach, efficiency, or effectiveness of programs and
organizations.
Please indicate your anticipated target for each indicator as a result of the Commonwealth Corps
members’ activities.
REQUIRED MEASURES:
Indicator
Target
Number of community volunteers recruited and/or managed
by projects/members.
Number of hours of service contributed by community
volunteers recruited and/or managed by projects/members.
Dollar value of cash and/or in-kind support leveraged by
members, including member-managed volunteers (DO NOT
include value of Commonwealth Corps members).
Describe the instrument(s) or tools you will use to track these data:
Number of member projects aimed at increasing
sustainability/documentation of program.
Describe at least one member activity aimed at increasing sustainability/documentation:
Describe the impact you expect in this area as a result of the Commonwealth Corps project:
ADDITIONAL MEASURES (select at least one):
Indicator
Number of new beneficiaries served as a result of the
project/member activities.
Number of additional activities completed and/or program
outputs produced by the program as a result of the
project/member activities (apart from those sustainability
projects listed above).
Number of existing beneficiaries reporting improved program
services as a result of the project/member activities.
Target
Describe the instrument(s) or tools you will use to track these data:
Describe the impact you expect in this area as a result of the Commonwealth Corps project:
ECONOMIC OPPORTUNITY/WORKFORCE DEVELOPMENT
Goal: To improve economic well-being and security of economically disadvantaged
individuals.
Please indicate your anticipated target for each indicator as a result of the Commonwealth Corps
members’ activities.
MEASURES (select at least two):
Indicator
Number of economically disadvantaged individuals
referred to job training and placement services.
Number of economically disadvantaged individuals
receiving job training or placement services.
Number of economically disadvantaged individuals
assisted in pursuing educational opportunities.
Number of economically disadvantaged individuals
assisted in receiving professional certification, licensure, or
credentials.
[A different performance measure of the host site’s
choosing that includes a clear, measurable target.]
Target
What specific instrument(s) will be used to measure results?
Describe the impact you expect in this area as a result of the Commonwealth Corps project:
EDUCATION
Goal: To improve school readiness and success for children and youth.
Early Childhood Education
Please indicate your anticipated target for each indicator as a result of the Commonwealth Corps
members’ activities.
EARLY CHILDHOOD EDUCATION REQUIRED:
Indicator
Target
Number of children participating in early childhood
education programs.
Number of children completing participation in early
childhood education programs.
Number of children served demonstrating gains in school
readiness in terms of social/emotional development,
literacy skills, or numeracy skills.
How will the project define and determine participation and completion?
What specific instrument(s) will be used to measure results?
Describe the impact you expect in this area as a result of the Commonwealth Corps project:
EARLY CHILDHOOD EDUCATION ADDITIONAL (select at least one of the first three):
Indicator
Number of parents/caregivers/guardians receiving referrals
to early childhood education programs/services.
Number of parents/caregivers/guardians increasing
engagement in their child(ren)’s early childhood education.
Number of activities supported by members aimed at
increasing family engagement in early childhood education.
[A different performance measure of the host site’s
choosing that includes a clear, measurable target.]
Target
How will the project define and determine increased engagement?
What specific instrument(s) will be used to measure results?
Describe the impact you expect in this area as a result of the Commonwealth Corps project:
GENERAL EDUCATION REQUIRED:
Indicator
Number of children/youth participating in education
programs.
Number of children/youth completing participation in
education programs.
Target
Number of children/youth demonstrating improved school
engagement through changes in at least two behaviors
and/or attitudes. Please specify the behaviors and/or
attitudes.
Behaviors/attitudes may include increased attendance,
increased completion of assignments including homework,
increased teacher-reported participation, decreased
disciplinary referrals, increased interest in school, improved
perspective on school climate, increased attachment to
school, or increased educational aspirations.
What specific instrument(s) will be used to measure results?
Describe the impact you expect in this area as a result of the Commonwealth Corps project:
GENERAL EDUCATION ADDITIONAL (select at least one of the first three):
Indicator
Number of parents/caregivers/guardians receiving referrals
to educational programs/services.
Number of parents/caregivers/guardians increasing
engagement in students’ learning and/or educational goals.
Number of activities supported by members aimed at
increasing family engagement in students’ learning and/or
educational goals.
[A different performance measure of the host site’s
choosing that includes a clear, measurable target.]
Target
How will the project define and determine increased engagement?
What specific instrument(s) will be used to measure results?
Describe the impact you expect in this area as a result of the Commonwealth Corps project:
HEALTH AND NUTRITION
Goal: To improve the physical and mental health of communities and individuals.
Please indicate your anticipated target for each indicator as a result of the Commonwealth Corps
members’ activities.
MEASURES (select at least two):
Indicator
Number of individuals utilizing preventive and primary
health care services and programs.
Number of clients to whom information on health
insurance, health care access, and health benefits
programs is delivered.
Number of clients enrolled in health insurance, health
services, and health benefits programs.
Number of individuals participating in health education
programs.
[A different performance measure of the host site’s
choosing that includes a clear, measurable target.]
Target
What specific instrument(s) will be used to measure results?
Describe the impact you expect in this area as a result of the Commonwealth Corps project:
VETERANS’ SUPPORT
Goal: To support or improve the physical, mental, and social wellbeing of veterans and
military families.
Please indicate your anticipated target for each indicator as a result of the Commonwealth Corps
members’ activities.
REQUIRED MEASURES:
Indicator
Number of veterans and/or active duty military personnel
that received assistance.
Number of family members of veterans and/or active duty
military personnel that received assistance.
Number of veterans and/or military family members
engaged as Commonwealth Corps members.
Target
What specific instrument(s) will be used to measure results?
Describe the impact you expect in this area as a result of the Commonwealth Corps project:
ADDITIONAL MEASURES (select at least two):
Indicator
Number of veterans received housing placement services.
Target
Number of veterans receiving services in one or more of
the Commonwealth Corps focus areas:
 Number of veterans receiving services to increase
access to primary and preventive health care
and/or receiving information on health benefits.
 Number of veterans receiving job training, skill
development, or job placement services.
 Number of veterans assisted in receiving
professional certification, licensure, or credentials.
 Number of veterans assisted in pursuing education
opportunities.
[A different performance measure of the host site’s
choosing that includes a clear, measurable target.]
What specific instrument(s) will be used to measure results?
Describe the impact you expect in this area as a result of the Commonwealth Corps project:
YOUTH VIOLENCE PREVENTION
Goal: To decrease youth involvement in risky behaviors including violent behaviors, gang
membership, and substance abuse.
Please indicate your anticipated target for each indicator as a result of the Commonwealth Corps
members’ activities.
REQUIRED MEASURES:
Indicator
Number of youth connected to resources and services
through outreach.
Number of youth enrolled in positive development activities
including job training and education/alternative education
programs.
Number of youth demonstrating decreased risk behaviors
including decreased substance abuse, arrest, gang
involvement, or disciplinary referrals and suspensions in
school.
(Optional) Number of individuals assisted in receiving
professional certification, licensure, or credentials.
(Optional) [A different performance measure of the host
site’s choosing that includes a clear, measurable target.]
Target
What specific instrument(s) will be used to measure results?
Describe the impact you expect in this area as a result of the Commonwealth Corps project:
ATTACHMENT C
COMMONWEALTH CORPS POSITION DESCRIPTION
Commonwealth Corps
Service Position Description
[INSERT CORPS SPONSOR AGENCY NAME]
[INSERT PROGRAM NAME]
Commonwealth Corps [INSERT SERVICE POSITION TITLE]
The mission of the Commonwealth Corps is to engage Massachusetts residents of all ages and
backgrounds in service to strengthen communities, address unmet community needs, and
increase volunteerism.
Commonwealth Corps members with [AGENCY NAME] will serve 10.5 months in a [SELECT
ONE: full-time or half-time] capacity. What they have in common is a desire to put their talents
and ideas to use in the service of their communities and the Commonwealth.
[INSERT SUMMARY PARAGRAPH ABOUT CORPS SPONSOR AGENCY AND
COMMONWEALTH CORPS PROJECT]
Responsibilities:
Essential
 Complete a minimum of [SELECT ONE: 1,500 or 750] hours of service, serving through
June 28, 2014.
 Attend all required Commonwealth Corps trainings and service events held by MSA and
[AGENCY NAME], including a new member orientation on August 15 & 16, 2013.


Participate in a minimum of 1 hour (full-time members) or 30 minutes (half-time
members) of MSA-related activities each week (in person or virtually).
[ADD IN SITE-SPECIFIC RESPONSIBILITIES HERE]
Marginal
 [ADD IN SITE-SPECIFIC RESPONSIBILITIES HERE]
Qualifications:
Required
 Massachusetts residency and legal authorization to work in the United States
 18 years of age or older
 Experience with or interest in volunteerism and community engagement
 Ability to balance service commitment with other family/work/school/community
commitments in a sustainable way
 [ADD IN SITE SPECIFIC QUALIFICATIONS HERE]
Preferred
 [ADD IN SITE SPECIFIC QUALIFICATIONS HERE]
Member Benefits:

Stipend of $434.78 (full-time) or $217.39 (part time) every other week while in service,
up to $10,000 (full-time) or $5,000 (half-time), minus taxes and withholdings; [ACTUAL
AMOUNT TO BE DETERMINED BY MSA UPON AWARD]

Health insurance (full-time members only, individual coverage only);

Completion award of up to $2,000 (full-time) or $1,000 (half-time) upon successful
completion of service, minus taxes and withholdings;

Training and other professional development opportunities;

Limited reimbursement for travel to Corps-wide MSA-sponsored activities;

Limited travel reimbursement from their host site for certain service-related travel away
from their usual service location, according to that agency's policies;

The opportunity for at least 10 (full-time) or 5 (part-time) days of planned absences; and

Opportunity to join with others with a common sense of purpose as part of the
Commonwealth Corps.
Please note that receipt of these stipends/benefits may impact an individual’s eligibility for certain
public benefits.
Term of Service:




Position Start Date: August 15, 2013
Position End Date: June 28, 2014
Service commitment will average ___ hours per week
[ADD IN ANY SITE SPECIFIC SCHEDULING REQUIREMENTS HERE]
Accepted members will be required to undergo (or instead ‘clear’) a criminal offender and sexual
offender background check.
[INSERT CORPS SPONSOR AGENCY NAME] will recruit and select persons in all positions to
ensure a diverse and inclusive climate without regard to race, religion, sex, sexual orientation,
age, veteran status, color, political affiliation, creed, national origin, marital status, or any other
status as protected by federal, state, and local laws. [INSERT CORPS SPONSOR AGENCY
NAME] welcomes applications from individuals with disabilities and will make reasonable
accommodations for interviews and for service upon request.