Activity Monitoring Form – after 12 months
Name of Organisation:
Name of Project:
Grant ID:
Period covered:
Grant year: year 1 / year 2 / year 3 (highlight as appropriate)
PLEASE READ - so you know what information you will need to supply to us when your monitoring is
due. This is annual monitoring and should reflect activity over a 12 month period. You also need to
supply: (delete as appropriate for grants under £20k)
 Storyboard (FADO needs to state how many)
 Outcome tools
 Involvement measure
 Six Survey results
 Evidence of how you have measured the outcomes you set on Form B, section B3
 Evidence of how you have met any conditions set when the grant was awarded
 A most recent set of annual accounts or evidence clearly showing income and expenses for the
period of the funding.
PLEASE KEEP AS A REMINDER OF THE INFORMATION TO BE RETURNED TO COMMUNITY
PARTNERSHIPS 12 MONTHS AFTER YOU RECEIVE YOUR GRANT
Please write only in the first column and do not write anything in any shaded box.
Section 1 – About the Project Activity
In this section we would like you to tell us about what you did, how you did it and who was involved.
Who took part in the project activities?
Older people
People living with dementia
People with learning disabilities/ autism
People with mental health issues
People with a sensory impairment
People with a physical disability
People with drug and/or alcohol issues
Carers
People with a long term condition
1
Please tick
(all that
apply)
Main group
(please tick
one only)
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Priority groups?
Yes ☐
No ☐
Points (1 or 0) =
Note: 0 points if project
works with none of these
groups; 1 point if project
works with one or more.
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Other (please state)
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How many people benefited from your project in total?
a=
(if you are running multiple projects, please provide a breakdown on a separate
sheet)
Did you receive referrals from the organisations you expected?
Please tick the following that applies to your
Yes
No
organisation
Other voluntary/community group
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Social Worker
Other social care e.g. Kirklees Care Navigators,
Gateway to Care, Single Point of Access and Health
Trainers
NHS Services including GPs, Health Visitors and
Practice Nurses
BIK (Better in Kirklees)
Other (please state –
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Actual
Numbers
Please tell us about the ethnicity of the people that attended the activity?
Ethnicity – please tick all that apply
Please tick
Asian or Asian British
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Black or Black British
Chinese
Mixed
White
Other Ethnic Group
Any other ethnic group: (please specify)
Did you run regular sessions?
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Yes ☐ If yes, please complete A below
No ☐ if no, please complete B below
A (only complete if you answered ‘yes’ above)
Estimated (This is what
you signed up to on your
grant agreement form)
(b) How many sessions
did you run this year?
(c) How many hours was
each session?
(d) On average, how
many people attended
Regular impact?
Actual
bxcxd=
2
(e)
each session?
B (only complete if you answered ‘no’ above)
Please describe what you did instead of regular sessions and what impact on
people’s lives you had.
Alternative impact?
Yes ☐
No ☐
Points (1-0) =
Section 2 – Project Contributions and Costs
In this section we would like you to tell us about what you brought to the project and what it cost.
What did you bring to the project – time?
Were volunteers or unpaid helpers involved in running or managing the project?
Yes ☐
Volunteer time?
Yes ☐
No ☐
Estimated Actual
If yes, how many volunteers or unpaid helpers were
involved? (f)
If yes, how many hours did the volunteers or unpaid
helpers contribute each to this project in total in this
year? (g)
What did you bring to the project – income and other funding?
Please list your financial contribution to the project below.
Estimated
Project Income
Income
Fees and charges
Fund-raising
Donations
3
Points (1-0) =
fxg=
Actual Income
No ☐
(h)
Income?
Yes ☐
No ☐
Other grants
Any other income or contribution from
parent organisation
Points (1-0) =
j =
Total
(j)
What did you/others bring to the project – ‘in kind’ contributions?
Did anyone contribute anything other than money or time to the project?
Yes ☐
In kind
No ☐
k=
If yes, please tell us what that was. Include anything you used but did not have to
pay for, e.g. free rooms, loaned equipment, free training, etc.
Total community
contribution:
(j + (h x NMW)) + k
=
If you can estimate the cash value of this ‘in kind’
contribution, please write the figure in this box: (we use a
nominal figure of NMW/hr to estimate the average value of
volunteer time)
Estimated Actual
(k)
Project costs for a 12 month period
Project Costs
Please give details in each box below
Participant costs (e.g. refreshments)
Grant Provided
Total Project Costs
(at 12 months)
Costs add up?
Yes ☐ No ☐
Volunteer Expenses (e.g. travel)
Points (1-0) =
Paid staff costs (Number of paid staff
x no. hours x no. weeks x hourly rate)
Sessional Workers (Number of hours
x number of sessions x number of
workers)
Equipment and materials
Costs ratio
Unit costs
Venue costs (e.g. room hire)
Type A
Insurance
Type B
Other costs (List each item)
Total cost (n)
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(l)
Tell us what progress you have made, what you have achieved and any difficulties you have encountered
Signature for the project:
I confirm that I am a member of the management committee and am authorised to sign this monitoring
form for the organisation named above. As far as I know the information given in this report is accurate.
Signature
Print name in full
Position within the organisation
Date
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For office use only
Have conditions been met?
Comments:
Signature for Kirklees Council
Print name in full
Position within the organisation
Date
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