S
Public reporting burden for
this collection of information is estimated to be 1.5 hours to
complete this questionnaire. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number.
The control number for this project is 0970-0288. The control
number expires on X/X/XXXX.
Submission Instructions: Please provide a listing of your community’s Systems of Care collaborative members for three points in time in the life of your grant: At the end of year one, the end of year 3, and the end of year 5.
A. Name: Enter the first and last name of each Systems of Care collaborative member.
B. Title: Provide the member’s position/title within the organization he or she represents.
C. Role: Provide the role of the member in their employer organization (e.g., management, supervisory, contracts, finance, administrative, training, service provider).
D. Organization: List the name of the agency, organization, or company the member represents.
E. Community Sector: From the table below, identify the one community sector which best describes the member’s organization and enter that sector code in column E. If there are other sectors that the member’s organization relates to, please indicate so in Column F.
Community Sector |
Code |
Justice system/courts (e.g., dependency/juvenile courts, family courts, court-appointed special advocates, attorneys) |
JS |
Law enforcement |
LW |
Domestic violence (e.g., battered women’s shelters, advocacy agencies) |
DV |
Education/early childhood development (e.g., preschool, Head Start) |
ED |
Child care |
CC |
Child/youth serving organizations (e.g., YMCA, Boys and Girls Clubs) |
YS |
Child welfare agencies (e.g., Department of Children and Families, CPS) |
CW |
Faith community (e.g., church, synagogue) |
FC |
Health services (e.g., primary health care providers, hospitals, emergency medical services) |
HS |
Mental health services (e.g., mental health center, prevention and treatment services) |
MH |
Substance abuse services (e.g., prevention and treatment services) |
SA |
Civic/volunteer organizations (e.g., Lions Club, Junior League) |
CV |
Business and private sector |
BS |
Media |
MD |
Local government (e.g., Mayor’s office) |
LG |
Cultural/ethnic groups (e.g., NAACP) |
CU |
Existing collaboratives (e.g., ONDCP/OJJDP Community Anti-Drug Coalition) |
EC |
Senior citizens (e.g., AARP, senior centers) |
SC |
Youth members (persons under age 21) |
YM |
Parents (parents of youth) |
PT |
Other, specify:
|
OT1 |
Other, specify: |
OT2 |
SYSTEMS OF CARE COLLABORATIVE MEMBERS |
Please circle the appropriate time frame for this list of collaborative members
End of Year One End of Year Two End of Year 3
A. Name |
B. Title |
C. Role |
D. Organization |
E. Community Sector |
F. Other Comm. Sector |
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| File Type | application/msword |
| File Title | Systems of Care Collaborative Members |
| Author | Kathy Kopiec |
| Last Modified By | ICF |
| File Modified | 2008-06-20 |
| File Created | 2008-04-28 |