United Way of Bartholomew County
Agency Certification Form
Required Indicators
All NO indicators on the required items will either result in an automatic stipulation or in
an agency being denied certification.
Yes
or No
Answer yes or no to each indicator
A. Articles of Incorporation & Bylaws (including board operations and procedures) are current.
B. 501(c) (3) Determination Letter and current Form 990 on file.
C. Written mission statement is relevant and clearly defined.
D. Governing authority is held by a volunteer Board of Directors of at least 6 members who are
generally reflective of the communities and population served and meets at least quarterly.
D. Written budget and financial reports are approved by the Board.
E. Annual financial audit (or review) is approved by the Board.
F. Meets all requirements in the Funded Partners Standards and Policies.
G. The Chief Professional Officer’s (CPO) employment is actively managed by the Board. The CPO is
reviewed on an annual basis.
H. Written policies and procedures have been developed and adhered to, including fiscal, conflict of
interest, diversity and operating policies.
I. Insurance, including risk, officers, property is in place. (May have a Board resolution stating that the
Board is aware of the risk of not having D&O insurance and has decided not to purchase it, thus
personally assuming the risk to themselves.
J. Agency mission and goals fit into at least one of United Way’s impact areas (Education, Health, or
Financial Stability). Explain *
K. CPO shares United Way communications with board leadership.
L. A budgeted volunteer program is in place. **
M. If applicable: National or regional affiliations are in good standing.
*Explain how your agency fits into one or more of United Way’s impact areas. (See J.)
**What are your line item amount and the percentage of agency budget of your volunteer program? (See L.)
Any NO indicators on the required items will either result in an automatic stipulation or in an agency being
denied certification. Explain all NO answers on a separate page.
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Agency Certification Form
Board Governance
Score each indicator with a 0, 1, 2, or 3. Attach a written explanation for any score of 0 or 1.
A. Written Strategic Plan is developed, approved and periodically reviewed.
3-Strategic plan has been developed, approved and is reviewed by the Board, and the plan is followed to direct the work of the organization.
2-Plan is in place and up to date but is not reviewed by the Board.
1-Plan and results are not reviewed by the Board and/or are not a significant influence in the direction of the organization.
0-No written plan has been developed or it is out of date.
B. Quorum, as your by-laws define it, is achieved at the majority of board meetings.
3-Quorum, is achieved at >90% of meetings.
2-Quorum is achieved at 75-90% of meetings.
1-Quorum is achieved at 50-75% of meetings.
0-Quorum is achieved at <50% of meetings or no established quorum has been defined.
C. Board development activities are conducted on a regular basis.
3-Board development activities are conducted throughout the year, AND there is a program for new board member orientation.
2-Board development activities are conducted for board members, OR there is a program for new board member orientation.
1-Board development activities are conducted on an as needed basis.
0-No board development activities are conducted.
Agency Management
E. Professional development opportunities are available and funded.
3-Professional development opportunities are provided annually to all staff members.
2-Professional development opportunities are available to staff on a limited, first come basis.
1-Professional development opportunities are encouraged, but not funded.
0-No professional development is offered.
F. No legal issues or lawsuits against the agency are pending
3- No legal issues or lawsuits are pending
2-One minor problem – explain in detail
1. Multiple minor legal problems – explain in detail
0- At least one serious problem – explain in detail
Finances
G. Adequate cash flow and fund balances are on hand.
3-Cash flow and fund balances are adequate to operate and survive a short term reduction in revenue.
2-Cash flow and fund balances are borderline too low or too high.
1-Cash flow and fund balances are dangerously low (less than 1 month) or extraordinary high (more than 1 year).
0-Inadequate cash on hand.
H. Comprehensive and diverse funding strategy has been developed and implemented.
3-Funding strategy that is comprehensive and diverse has been developed and implemented.
2-Funding strategy has been developed, but is incomplete and not fully implemented.
1-No formal strategy exists, but fund raising activities are conducted.
0-United Way is the only funder.
Partnerships / Collaborations
I. Collaboration with other local or state organizations.
3-Strong collaborations exist to help serve clients needs that are beyond the agency’s scope.
2-Collaborations exist that are focused on developing good working relationships with other agencies.
1-Some collaborations are being developed.
0-No collaboration with other organizations.
Volunteer Management
J. Program planning – Written plan directs the goals and activities of the agency’s volunteer program.
3-Utilize volunteers and have a written plan that is reviewed and assessed on an annual basis.
2-Utilize volunteers and have a general plan, but it is not well documented.
1-Utilize volunteers, but we don’t have a written plan.
0-We don’t utilize volunteers except our board of directors.
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Agency Certification Form
K. Volunteer program has goals and measureable outcomes.
3-Work related goals and objectives for volunteers are coordinated annually with the goals and objectives of the entire organization and are
approved by the Board.
2-We have written goals and outcome measurements for volunteers that, in addition to the numerical targets, relate to accomplishing
meaningful work that supports the clients and staff.
1-We have goals/objectives and outcome measurements that relate mainly to the volunteer program’s growth, such as targeted number of
volunteers.
0-No formal goals/outcomes exist for the volunteer program or for the work of volunteers
L. Volunteer program staffing.
3-A staff person or AmeriCorps member has been trained and is focused on volunteer management with duties included in position description.
2-A staff person is assigned to volunteer management along with other duties that take priority.
1-Volunteer management is assigned to current staff on an as needed basis.
0-We do not have a staff person responsible for volunteer management.
M. Volunteer program assessment.
3-We participate in the Volunteer Management Audit annually and use the results to evaluate and update our program.
2-We utilize outside resources to assess out volunteer program and have made program improvements because of those resources.
1-We utilize outside resources and/or have participated in the Volunteer Management Audit but have not implemented program improvements.
0-We do not use the Volunteer Management Audit or outside resources to evaluate our volunteer program.
By signing this page, we, hereby certify that the information provided herein is true, accurate and complete. We
further certify that our organization is prepared to meet all of the UWBC funding requirements stipulated in the
2013 Certified Agency Standards and Policies booklet.
___________________________________
_____________________________________
Board Chair Signature
CPO/Executive Director Signature
___________________________________
Printed Name of Board Chair
_____________________________________
Printed Name of CPO/Executive Director
___________________________________
Date
_____________________________________
Date
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United Way of Bartholomew County
Agency Certification Form
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