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2016-619-E Finance - Planned Parenthood South Atlantic - Outside Agency Performance Agreement
DocuSign Envelope ID: CBOC1343-06EB-4BE7-9AF6-62EE77BD69FE OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2016, ("Effective Date")by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ("County") and Planned Parenthood South Atlantic, a not-for-profit corporation, located at 1765 Dobbins Drive, Chapel Hill,NC 27514("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Planned Parenthood South Atlantic agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2016 to June 30, 2017. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit"A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 20000. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $5,000. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Planned Parenthood South Atlantic) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID: CBOC1343-06EB-4BE7-9AF6-62EE77BD69FE e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 —December 31; January 1 —March 31 and April 1 - June 30. Reports are due on January 13,April 14, and July 14 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services,upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default"), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten(10)business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (Planned Parenthood South Atlantic) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: CBOC1343-06EB-4BE7-9AF6-62EE77BD69FE c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury,bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A- Statutory State NC& Coverage B -Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability)required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough,NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Planned Parenthood South Atlantic) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: CBOC1343-06EB-4BE7-9AF6-62EE77BD69FE 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 13.15 per hour. To the extent possible, Orange County recommends that Planned Parenthood South Atlantic provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (Planned Parenthood South Atlantic) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: CBOC1343-06EB-4BE7-9AF6-62EE77BD69FE County: Finance&Administrative Services Provider: Planned Parenthood South Orange County Atlantic Post Office Box 8181 1765 Dobbins Drive Hillsborough,NC 27278 Chapel Hill,NC 27514 16. E ntire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For and on l__,r,,.. sq et .//P''rovider C) (14-CL- 11/2/2016 Date For and o:: - •, r,•ftkange County Government 156lAkuit, tka"mt-IrStt 11/2/2016 ---.--8637991 B755E177... Bonnie Hammersley, County Manager Date (Planned Parenthood South Atlantic) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: CBOC1343-06EB-4BE7-9AF6-62EE77BD69FE ATTACHMENT "A" Orange County Certifications—FY 2016-17 Outside Agency Performance Agreement Chief Contact,Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title,residential address;phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing,with the name, physical address,mailing address and if possible,phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. DocuSigned by: Certified by: OCFF,IR9042Z42IL_ Presi dent and CEO Title: Date:11/2/2016 (Provider's Signature) (Planned Parenthood South Atlantic) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: CBOC1343-06EB-4BE7-9AF6-62EE77BD69FE Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Date/Time Agency Planned Parenthood South Atlantic Complete Y/N Program(s) Sexual Health Education and Outreach Teurtutrummumummututuummuumumummutuummuume Section Subsection For CDBG & HOME - HUD Regulations 1. Cover Page a. X Applicant Contact Information b. X Project/Program Contact Information c. X Funding Requests Identified d. X Signed Application Cover Page 2. Agency a. x Agency's Years in operation 24 CFR 570.506, Information - b. x Agency's Purpose/Mission 570.507, 570.610; 24 c. x Agency's Types of Services Provided CFR Parts 84 or 85 d. x Agency's Experience e. x Other Pertinent Information 3. Program/ a. x Type of Application and Program Identified 24 CFR 570.200(a), Project b. x Summary of Program 570.201-570. 208, Information - 507.503 (for each c. x Description of Identified Need program/ d. x Description of Population to be Served project for e. x Activity Manager and Location Description which funding f. x Activity Implementation Timeline is requested) g. x Agency Collaboration h. x Describe Impact of Reduced/No Allocation i. Other Pertinent Information j. x Complete Target Population/Beneficiary Chart k. x Complete Schedule of Positions I. x Signed Conflict of Interest Disclosure m. x Complete Work Statement 1 IF") DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION 24 CFR 570.200(a), 4. Financial (for Program Budget Worksheet and Detail should reflect 570.201-570. 208, each program/ expenses for the entire program and ALL sources of 507.503 project for funding. 24 CFR 570.506, which funding 570.507, 570.601, is requested) a. X Program Budget Worksheet 570.602, 570.607(b), b. X Program Budget Detail 570.611 24 CFR c. X Cost Per Unit 570.502-570.504, d. X Agency Operating Budget Worksheet 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circulars A-87 or A- 122; Treasury Circular 1075 5. Supplemental A. Part A: CDBG & HOME NA Sections (as B. Part B: Construction/Rehab NA applicable) 6. Attachments a. X Audit: Organizations receiving $300,000 or OMB Circular A-133 more in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. X IRS Federal Form 990 c. X NC Solicitation License d. X IRS Federal Tax-Exemption Letter e. X Certificate of Insurance 24 CFR Parts 84 or 85 f. X List of Board of Directors 24 CFR 570.208, g. X Articles of Incorporation/Bylaws 570.500(c), 570.611 h. X Authorization to Request Funds i. X Authorized official designation j. X Solid Waste Program Fee (SWPF) Verification Main Application 1/21/2016 18:35:26 a1/p1 I:' c 2 of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION 1. COVER PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: Planned Parenthood South Atlantic Applicant Organization's Physical Address: 1765 Dobbins Dr, Chapel Hill,NC 27514 Applicant Organization's Mailing Address: 1765 Dobbins Dr, Chapel Hill,NC 27514 Applicant Organization's Web Address: www.ppsat.org Executive Director: Jenny Black Telephone Number: 919-833-7526 x6140 E-Mail:jenny.black @ppsat.org DUNS Number: 110314622 (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) b) Project/Program Contact Information Project/Program Name: Sexual Health Education and Outreach Project/Program Primary Contact and Title: Lisa Garland, Community Health Educator Telephone Number: 919-818-7760 E-Mail: lisa.garland @ppsat.org c) Funding Request Identification Total Project/Program Cost: $ 37.886Total Amount of Funds Requested: $23,500 Proposed Use of Funds Requested (2-3 Line Maximum): Funds will be used to support the salary costs of a Community Health Educator in Orange County,who will conduct programs intended to reduce the rates of unintended pregnancy and sexually transmitted infection in the Orange County. Please check all types, sources, and amounts of funding being requested. You must submit an application package for each funding source. *The Participating Jurisdiction reserves the right to fund projects from any funding source, subject to eligibility and funding constraints. CDBG Non-Construction (CH) $ Grant Loan CDBG Construction (CH) $ Grant Loan HOME CHDO (OC) $ Grant Loan HOME Other (OC) $ Grant Loan X Human Services: ,X Carrboro $1.000 x Chapel Hill $2.500 x Orange County $20.000 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: 4 it.. l/ 1/21/2016 !j 4 -etor Date Signature: S4 1/21/2016 •ard Chairperson Date M ih Application 1/21/2016 18:35:26 a1/p1 Page 3 of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION 2. AGENCY INFORMATION Please provide the following information about your agency (Limit of 2 pages total): a) Years in Operation, Date of Incorporation (Month/Year) 35 years, incorporated July 1980 b) Agency's Purpose/Mission Planned Parenthood South Atlantic (PPSAT) proactively ensures comprehensive reproductive health care: by providing services in settings that preserve and protect the individual's right to privacy and reproductive choice; by advocating public policies that advance these rights and expand access to such services; by providing educational programming that fosters a culture of healthy sexuality; by working with and meeting the needs of diverse communities and the under-served; and by leading broad-based strategies that further these fundamental rights. c) Types of Services the Agency Provides PPSAT works to reduce the incidence of unintended pregnancy, HIV/AIDS, and other STIs, especially among teens, emerging adults (19-29), those with limited financial resources, and uninsured clients. We operate 14 health centers throughout North Carolina, South Carolina, West Virginia, and the Blue Ridge of Virginia. Our Chapel Hill health center provides a wide range of safe, reliable health care—and the majority is preventive care, which helps reduce unintended pregnancies through contraception, reduce the spread of sexually transmitted infections through testing and treatment, and screen for cervical and other cancers. We reduce barriers to accessing care by offering same-day and by-appointment visits, evening and weekend hours, bilingual staff, and fees that are typically less than those of private providers. Our Orange County community health educator uses evidence-based curricula to equip adolescents with training and information about reproductive health and/or teen pregnancy prevention so that they can become accurate sources of information for their friends, family, and acquaintances. Our educator also provides single-session programs that serve to convey information and encourage utilization of family planning services. d) Agency's Experience with Similar Programs as the Funding Request For more than 35 years, PPSAT has provided high-quality education that reflects the needs of young people, their families, our patients, and the communities we serve. Last year,more than 25,000 young people benefited from our education programs. Programming ranges from health-center based projects like enrolling patients in health care coverage through the Affordable Care Act; to delivering model, Planned Parenthood South Atlantic-branded sex education programs; to offering professional training in the affiliate and in partnership with other nonprofit organizations; to teaching healthy living curricula in local schools. While community education is as diverse as the locations where it is offered, we place an emphasis on multi-session sex education programs that are scoped, sequenced, and proven to meet the needs of participants better than one-time presentations. Main Application 1/21/2016 18:35:26 a1/p1 Page 41 of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION PPSAT has offered Teen Voices and Smart Girls in the Orange County community for the past three years. e) Other Pertinent Agency Information Starting in July 2015, an opposition group calling itself the "Center for Medical Progress"released a series of deceptively edited videos intended to mislead the public and discredit Planned Parenthood. The videos have since been debunked, but they have bred an increase in hateful rhetoric from anti- women's health advocates, which culminated most recently in an attack on a Planned Parenthood health center in Colorado Springs. We have discussed these issues with Orange County education alumni. They understand that these fraudulent videos are part of a decade long campaign by extreme opposition groups to cut off access to safe and legal abortion and shut Planned Parenthood's doors. Despite the attack in Colorado Springs, teens report that they continue to feel safe in our health centers and off-site locations. Main Application 1/21/2016 18:35:26 a1/p1 Page 5 of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Sexual Health Education and Outreach As you complete your application, complete only those sections that pertain to the type of application you are submitting. The application is divided into several sections and not all sections apply to every project. Every applicant MUST complete the main application. a) Check the type of funding request for this application package submittal and complete the required application and required supplemental sections (Parts) as specified below: X Human Services (Main Application Only) CDBG Non-Construction —(Main Application AND Part A) CDBG Construction —(Main Application AND Part A AND Part B) HOME CHDO Set-aside —(Main Application AND Part A) HOME Other —(Main Application AND Part A AND Part B) Program Category Youth Adult Elderly Disabled Public Housing (not elderly) Neighborhoods/Residents Education X X Health and Nutrition X X Job Training Sports and Arts Activities Pre-School Activities After-School Activities X Mentoring Transportation Housing Other: Please specify Indicate the type of program for which you are requesting funding: Main Application 1/21/2016 18:35:26 a1/p1 I:' c 6 of 241 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION Program/Project Description (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: b) Summarize the program services proposed and how the program will address the chosen Town/County priority? In FY 17, our education department will provide Orange County teens and young adults with medically accurate, intensive, and balanced sexuality education programs that promote positive sexuality,healthy behavior, and responsible choices—with the goal of reducing the rates of unintended pregnancy and sexually transmitted infection. In doing so, we are addressing the Town of Chapel Hill's budgeting priority to fund education, mentorship, and afterschool programming for youth facing a variety of challenges. PPSAT will provide Teen Voices, a sexual education program for teens that uses the evidence-based Becoming a Responsible Teen (BART) BART is a comprehensive curriculum specifically designed to increase many of the knowledge and skill-based protective factors about contraception use and negotiation skills. PPSAT will also offer Smart Girls, a science-based, intensive adolescent pregnancy prevention program for middle school girls. The goal of both programs is to build self- esteem and healthy decision-making to delay initiation of sex, increase condom use of sexually active teens, and reduce the number of sexual partners for those teens. We will invite graduates of our teen education programs to participate in our alumni group. Through the alumni group, we will look at the larger community to identify other needs and design and implement appropriate service projects. This service-learning component will work to increase community involvement. Parent workshops will improve parents' confidence in talking to their children about sex and will increase parent-child communication about sex and contraception. Alumni will lead workshop sessions so that parents have the opportunity to practice talking to teens about these sensitive topics. Our program will also include a series of charlas or chats aimed at young women (aged 19—25) who do not qualify to participate in our after-school program. These workshops will engage them in a dialogue about family planning and pregnancy prevention. c) Describe the local need or problem to be addressed in relation to the Consolidated Plan or other community priorities (i.e. Council/Board Goals). Cite local data to support the need for this program and the population being served. The Town of Chapel Hill has identified education, mentorship, and afterschool programming for youth facing a variety of challenges as a budgeting priority. The consequences of adolescent pregnancy and childbearing are serious and numerous. Teen mothers are less likely to graduate from high school and more likely to live in poverty and to rely on welfare. The children of teenage mothers are often born at low birth weight, experience health and developmental problems, and are likely to be poor, abused, and/or neglected The educational programs PPSAT offers influence specific behaviors related to sexual risk-taking and reinforce protective factors to prevent teen pregnancy. Main Application 1/21/2016 18:35:26 a1/p1 Page / of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION In 2013, the most recent year for which data is available,North Carolina's teen pregnancy rate fell 11% to 35.2 out of every 1,000 15-19 year old girls, which is a record low in the state's history. Orange County's teen pregnancy rate dropped 35% from 2012 - from 14.8 to 9.6 in 2013. This number represents 102 teen pregnancies in 2012 down to 68 in 2013. Orange County has historically had one of the lowest rates in the state, but this large reduction year-to-year is notable and a positive step. Even with this lowest and dropping overall rate, rate disparities exist by race and ethnicity. Orange County demonstrates a greater racial and ethnic disparity when it comes to teen pregnancy rates than the state as a whole. In our community, 4.8 out of every 1,000 White teens experience teen pregnancy,whereas 21.3 out of 1,000 African American and 41.3 out of 1,000 Hispanic teens are faced with this challenge. According to the 2013 Youth Risk Behavior Survey(YRBS) for North Carolina, over 47% of high school students report having had sexual intercourse. That includes 57.5% of juniors and 63.9% of seniors. This demonstrates that many adolescents are confronted at some point during their teen years with choices about whether or not to have sex and, if they do, whether or not to use condoms and/or other contraceptives. Research shows that teens who begin having sex at an earlier age are less likely to use contraception and more likely to become pregnant and to become a parent. They are also more likely to accumulate a greater number of lifetime sexual partners. Of those that reported having had sex, only 60.8%used a condom the last time they had sex. In addition, 21.2%reported using drugs or alcohol before sex. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. This project will primarily serve middle and high school aged teens living in Orange County, Chapel Hill and Carrboro. Our Community Health Educator works with social workers and counselors in the schools and community partners to promote the program and receive direct referrals. Teen Voices and Smart Girls are available to any teen that meets the age requirements for the curricula. Interested teens complete an application and interview with the educator to demonstrate their interest in the program. When there are more applicants than spaces available, the educator gives priority to older teens that many age out of the program sooner and reserves a space the following year for teens that she cannot accommodate. In addition, we will implement parent workshops to benefit parents of teens,promoting this project with our community partners and among our teen program participants. Through our charlas/workshops our community health educator reaches a variety of women of reproductive age (10-44) e) Who specifically will carry out the activities and in what location will they be carried out? Our programs will be carried out by two part-time community health educators. Lisa Garland has seven years of work and volunteer experience with at-risk youth. She is a former Planned Parenthood peer educator,has been working at PPSAT for three years, and is fluent in English and Spanish. The other educator position is vacant, but we are recruiting now and are looking for a bilingual (English/Spanish) applicant with a degree in a related field preferred, at least one year experience working with youth, and previous experience in Public Health. Main Application 1/21/2016 18:35:26 a1/p1 Page of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION Activities take place at community center-like locations. Past sites have included the Chapel Hill Public Library,the Unitarian Universalist Church, and the Cedar Ridge Parks Department. f) Describe specifically the period over which the activities will be carried out, the frequency with which the activities will be carried out, and the frequency with which services will be delivered. Include an implementation timeline. August 2016 Begin preparation for programming (buying supplies, getting in touch with schools, writing MOAs, etc.) January 2017 Set up dates/time for spring health fair, workshops, other activities February 2017 Begin recruitment process through guidance counselors, social workers, and referrals for Smart Girls and Teen Voices March 2017 Teen Voices and Smart Girls start • Teen Voices— 12 weeks, 12 sessions • Smart Girls— 10 weeks, 10 sessions March-April 2017 Parent session in between the program dates for both Teen Voices and Smart Girls (Other parents are allowed to attend) May/June 2017 Graduation for Smart Girls and Teen Voices Throughout the year-workshops, health fairs, Teen Voices Alumni meets once a month g) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. • Compass Center—participant recruitment • Orange County Library Systems—hosting workshops, sessions, and alumni meetings • Chapel Hill, Carrboro, and Orange County Schools—participant recruitment • El Centro Hispano—participant recruitment h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. PPSAT is committed to maintaining these education programs in Orange County. In addition to County and Town support, PPSAT receives funding for its educational programs from a number of private foundations. All of these foundations have a long history of supporting our programs and we anticipate their renewed support for FY16. If requested funding is not awarded, we will have to make a larger institutional investment in the programs - designating funds raised for general operating support. i) Include any other pertinent information. Program/Project Information Main Application 1/21/2016 18:35:26 a1/p1 Page of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION Information to Complete j.) Target Population Complete the following tables to the best of your ability. Show numbers of participants and percentages, as applicable, in each category. Please indicate whether this project/program will serve: X Persons Households Units Program: Sexual Health Education and Outreach Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 82 110 Female 153 253 Total 235 _ 363 _ 0 Of the females, how many are single- female Head of Households (Omit for Human Services) NA NA NA Ethnicity African-American 44 95 95 American Indian or Alaska Native Asian Caucasian 181 187 187 Native Hawaiian or other Pacific Islander Other 10 81 81 Total 235 363 363 Of the above, how many Hispanic/Latino 58 100 100 Of the above, how many non- Hispanic/Latino 177 263 263 Total 235 _ 363 _ 363 Age 0-5 years 6-18 years 151 233 233 19-50 years 84 130 130 51-61 years 62+ years Total 0 363 363 Geographic Location Durham City Durham County Carrboro 58 90 90 Chapel Hill 152 235 235 Chapel Hill Public Housing Residents Orange County 25 38 38 Raleigh Main Application 1/21/2016 18:35:26 a1/p1 Page 10 of 2 " DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION Wake County Total 235 363 363 Income Level—See following chart (Omit for HS) < 30%Area Median Income 31-50%Area Median Income 51-80%Area Median Income > 80%Area Median Income Total NA NA NA Special Needs(Omit for HS) Elderly(Over 62) Disabled (not elderly) Homeless People with HIV/Aids Total NA _ NA _ NA CDBG & HOME ONLY- Area Benefit Activities (Infrastructure and Public Facilities) Street Census Tract Block Group Total Persons #LMI Persons Main Application 1/21/2016 18:35:26 a1/p1 Page 11 of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION 2015 Area Median Family income Limits U.S. Department of Housing & Urban Development (HUD) 2015 Area Median Family Income Limits Effective March 15, 2015 Income 1 2 3 4 5 6 7 8 Level person people people people people people people people $14,15 $16,20 $20,09 $24,25 $28,41 $32,57 $36,73 30%AMI 0 0 0 0 0 0 0 $40,890 $23,60 $27,00 $30,35 $33,70 $36,40 $39,10 $41,80 50%AMI 0 0 0 0 0 0 0 $44,500 $37,75 $43,15 $48,55 $53,90 $58,25 $62,55 $66,85 80%AMI 0 0 0 0 0 0 0 $71,150 $47,18 $53,93 $60,68 $67,37 $72,81 $78,18 $83,56 100% AMI 8 8 8 5 3 8 3 $88,937 115%AMI $54,26 $62,02 $69,79 $77,48 $83,73 $89,91 $96,09 $102,27 6 8 1 1 4 6 7 8 http://www.huduser.org/portal/datasets/il/i115/FY2015_IL_nc.pdf Main Application 1/21/2016 18:35:26 a1/p1 I:' c 12 of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION k.) Schedule of Positions Please include program staff positions followed by volunteer positions; these financial figures should match the personnel figures in your Agency Comparative Budget Excel Form. Similar positions can be combined. (i.e., 8 Occupational Therapists can be inserted as one line item). If provided, indicate: Position Titles % (R) *= Position FTE* Program Actual Estimated Projected %Total Retirement Vacant Staff+ 2014-15 2015-16 2016-17 Budget Plan (H) Health Plan Community Health Educator 1 50 35,950 35,360 35,360 .2% Senior Director of Education 1 5 49,171 43,636 61,800 .3% H Notes: • Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item. • ** Full Time Equivalent staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • + Denotes the percentage of staff time involved with this program. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 1,960 Main Application 1/21/2016 18:35:26 a1/p1 Page 1 3 of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Are any of the Board Members or employees of the agency which will be carrying out this project, or members of their immediate families, or their business associates: YES NO X a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? X c) Current beneficiaries of the project/program for which funds are requested? X d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: JLL 1 ,..: ..C.,LA.._ 1/21/2016 Elf ve Dir+tor. Date lik viii,Signature: LS 1/21/2016 :,oard Chairperson Date Main Application 1/21/2016 18:35:26 a1/p1 I:' c 14 of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION m.) Work Statement This form is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. • Program Activities should outline major activities the agency implements to accomplish its program goals. • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. SMART Goals • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. Actual Estimated Projected 2014-2015 2015-2016 2016-2017 Using the Becoming a Using the Becoming a Using the Becoming a Responsible Teen Responsible Teen curriculum, Responsible Teen curriculum, curriculum,provide a diverse provide a diverse group of provide a diverse group of group of teens with training teens with training around teens with training around Program around issues of sexuality, issues of sexuality,healthy issues of sexuality,healthy Activity 1 healthy relationships, relationships,abstinence and relationships,abstinence and abstinence and contraceptive contraceptive options, contraceptive options, options,communication and communication and decision- communication and decision- decision-making skills and making skills and goal making skills and goal goal setting. setting. setting. Recruit at least 15 teens Recruit at least 15 teens(ages Recruit at least 15 teens(ages (ages 14— 18).All 14— 18).All participants will 14— 18).All participants will Program participants will demonstrate demonstrate at least a demonstrate at least a Goal at least a 10%increase 10%increase in knowledge 10%increase in knowledge in knowledge about about preventing pregnancy about preventing pregnancy preventing pregnancy and and STIs. and STIs. STIs. PPSAT will measure the PPSAT will measure the PPSAT will measure the competency levels of competency levels of competency levels of participants through pre-and participants through pre-and participants through pre-and post-program tests.The pre- post-program tests.The pre- post-program tests.The pre- test will be administered at test will be administered at test will be administered at Performance the beginning of the first the beginning of the first the beginning of the first session,and the post-test will session,and the post-test will session,and the post-test will Measures be administered immediately be administered immediately be administered immediately following the conclusion of following the conclusion of following the conclusion of the program.Measurable the program.Measurable the program.Measurable outcomes include a change outcomes include a change in outcomes include a change in in knowledge,attitudes,and knowledge, attitudes,and knowledge,attitudes,and behaviors. behaviors. behaviors. Program 15 participant,7%increase- Results students entered with a high TBD TBD baseline understanding Program Peer-educators will work Peer-educators will work Peer-educators will work Activity 2 within their schools and within their schools and within their schools and communities to disseminate communities to disseminate communities to disseminate to others the information to others the information they to others the information they Main Application 1/21/2016 18:35:26 a1/p1 Page 15 of 2 " DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION they have learned. have learned. have learned. Program Each peer-educator will Each peer-educator will make Each peer-educator will make Goal make 20 contacts in their 20 contacts in their 20 contacts in their community. community. community. Peer-educators will maintain Peer-educators will maintain Peer-educators will maintain Performance contact logs so that the contact logs so that the contact logs so that the Community Educator can Community Educator can Community Educator can Measures review them for accuracy review them for accuracy and review them for accuracy and and completeness. completeness. completeness. 172 contacts-Many did not complete their required contacts.Community Program Educator has since TBD TBD Results incentivized by making completion of contacts mandatory to receive a full $300 gift card. Using the Smart Girls Using the Smart Girls Using the Smart Girls curriculum,provide a diverse curriculum,provide a diverse curriculum,provide a diverse group of middle school girls group of middle school girls group of middle school girls with training around issues with training around issues of with training around issues of Program of sexuality,healthy sexuality,healthy sexuality,healthy Activity 3 relationships,abstinence and relationships,abstinence and relationships,abstinence and contraceptive options, contraceptive options, contraceptive options, communication and communication and decision- communication and decision- decision-making skills and making skills and goal making skills and goal goal setting. setting. setting. PPSAT will recruit at least PPSAT will recruit at least 10 PPSAT will recruit at least 10 10 girls(ages 10— 14).All girls(ages 10— 14).All girls(ages 10— 14).All Program participants will demonstrate participants will demonstrate participants will demonstrate Goal at least a 10%increase at least a 10%increase at least a 10%increase in knowledge about in knowledge about in knowledge about preventing pregnancy and preventing pregnancy and preventing pregnancy and STIs. STIs. STIs. PPSAT will measure the PPSAT will measure the PPSAT will measure the competency levels of competency levels of competency levels of participants through pre-and participants through pre-and participants through pre-and post-program tests.The pre- post-program tests.The pre- post-program tests.The pre- test will be administered at test will be administered at test will be administered at Performance the beginning of the first the beginning of the first the beginning of the first session,and the post-test will session,and the post-test will session,and the post-test will Measures be administered immediately be administered immediately be administered immediately following the conclusion of following the conclusion of following the conclusion of the program.Measurable the program.Measurable the program.Measurable outcomes include a change outcomes include a change in outcomes include a change in in knowledge,attitudes,and knowledge, attitudes,and knowledge,attitudes,and behaviors. behaviors. behaviors. Program 10 participants,27%increase TBD TBD Results Program Create an alumni group for Create an alumni group for Create an alumni group for Activity 4 graduates of education graduates of education graduates of education programs who will conduct programs who will conduct programs who will conduct annual service-learning annual service-learning annual service-learning Main Application 1/21/2016 18:35:26 a1/p1 Page 16 of 2 " DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION activities. activities. activities. At least 8 graduates will At least 8 graduates will At least 8 graduates will Program participate in the alumni participate in the alumni participate in the alumni Goal group,and conduct an annual group,and conduct an annual group,and conduct an annual student-led service-learning student-led service-learning student-led service-learning project. project. project. PPSAT will seek out PPSAT will seek out PPSAT will seek out feedback from the groups feedback from the groups feedback from the groups that Performance that the alumni group works that the alumni group works the alumni group works with with during their service with during their service Measures learning activity to access learning activity to access the during their service learning the value of the participants' value of the participants' activity to access the value of contribution. contribution. the participants'contribution. Program 8 participants TBD TBD Results Provide a series of parent Provide a series of parent Provide a series of parent workshops that will include workshops that will include workshops that will include skill building and skill building and information skill building and information information on talking with on talking with their children on talking with their children Program their children about sex. about sex. Sessions will about sex. Sessions will Sessions will include:role include:role play discussing include:role play discussing Activity 5 play discussing relationships, relationships,contraception, relationships,contraception, contraception, STIs and peer STIs and peer pressure.One STIs and peer pressure.One pressure.One session will be session will be conducted in session will be conducted in conducted in English,one English,one session in English,one session in session in Spanish. Spanish. Spanish. At least 15 parents of middle At least 15 parents of middle At least 15 parents of middle and high school students will and high school students will and high school students will participate in parent participate in parent participate in parent workshops. workshops. workshops. At least 75%of parents will At least 75%of parents will At least 75%of parents will Program report increased comfort in report increased comfort in report increased comfort in Goal talking with their kids about talking with their kids about talking with their kids about sexuality issues. sexuality issues. sexuality issues. At least 75%of parents will At least 75%of parents will At least 75%of parents will report they intend to talk to report they intend to talk to report they intend to talk to their children about sex as a their children about sex as a their children about sex as a result of the workshop. result of the workshop. result of the workshop. Participants will provide Participants will provide Participants will provide Performance feedback on the quality of feedback on the quality of the feedback on the quality of the Measures the program by completing program by completing program by completing surveys. surveys. surveys. 22 participants, 72% Program reported increase in comfort, Results 100%intended to talk to TBD TBD their children Main Application 1/21/2016 18:35:26 a1/p1 Page I of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION Host a series of workshops Host a series of workshops Host a series of workshops Program (charlas or chats)to help g women of reproductive age (charlas or chats)to help (charlas or chats)to help Activity 6 assess their risk of women of reproductive age women of reproductive age pregnancy.. assess their risk of pregnancy. assess their risk of pregnancy. Teach at least 15 women of Teach at least 15 women of Teach at least 15 women of reproductive age about the reproductive age about the reproductive age about the benefits and availability of benefits and availability of benefits and availability of various contraceptive various contraceptive various contraceptive methods. methods. methods. Program Goal At least 75%of participants At least 75%of participants At least 75%of participants will report an increased will report an increased will report an increased understanding of their risk of understanding of their risk of understanding of their risk of pregnancy and have a plan pregnancy and have a plan pregnancy and have a plan for preventing unintended for preventing unintended for preventing unintended pregnancies. pregnancies. pregnancies. Participants will provide Participants will provide Participants will provide Performance feedback on the quality of feedback on the quality of the feedback on the quality of the Measures the program by completing program by completing program by completing surveys. surveys. surveys. Program 37 participants, 100% Results reported increase in TBD TBD understanding. Copies of data collection tools attached. Community Health Educator Lisa Garland will be responsible for monitoring progress toward goals with the supervision of Senior Director of Education Monika Thigpen. Main Application 1/21/2016 18:35:26 a1/p1 Page 1 of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION 4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form for each requested program. The Program Budget should reflect only figures and amounts associated with the Program(s) for which you are seeking funding and not the total agency budget. If the program's finances experienced significant changes that you would like to explain, please use the space below. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. • Supplies and Equipment Increase—We have depleted our supply of promotional materials (pens, lanyards, keychains) that we distribute during our events to promote Planned Parenthood. We are budgeting $600 more than last year to re-supply. • Travel and Training Increase—With the hiring of a new Educator, they will need to be trained in the program curricula. Main Application 1/21/2016 18:35:26 a1/p1 II I:' c 1 of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION PoanityWcgamc Sexual I r ErXratich aicl Outreach Actual Estimated Pr j d Percent PA3134CY REVENLE 2314-1 211115-16 946-17 Change Pri wale MAIM rm $ '1,'1'10 $ 241 0 Agency Generated Re rrw 0 Local Gamarinnent C mu ts,. C1 a Gouty $20,C00 $ 20,CCO $ 20,COO CP• TONI1cf+0" =1 Hill $ 2,500 $ 2,5C0 $ 2,5C0 090. Tonin cf Can $ 1,CCO $ 1,030 $ 1,CEO CicY. C l-le-Local: 0 al--Local: 0 al-rsr'-I rr al: 0 aII Nan-Local Gawrnmerit Garts 'I ii,ar Li-itacl'Ably 0 State C1a rrr r rE 0 F=ccrary Ga.,g-r-rn-ert 0 Other CI-arts: : icwO Rases - $ 5,0:1 $ 5,033 CP ahar C4 ts: F.M.I Hay Fo -dAio $ 5,000 $ '100O3 $ 0,383 Msc€llarnrnus^'Ctll-rerRevenue -- 0 Please Het 3 largest MscNlem.,rs ectroes Taal Agency R€ $28616 38,7141 37,/116 0 AGENCY EXPENSES Ocaripiensali cn $2 $ e?} $ 21,543 w"• Fdert&Lliliti $ ' 4 $ 1,'1 $ 1,183 CP Supplies&Egilanent $ 1 $ 2,2E5 $ 2,034 Travel &Training $ $ 2,483 $ 3,040 C,llh€i Experiseist $ 5,; $ 0,430 $ 0,210 " Reber 11 et 3largest"Mier na a perise': FE4ilashr el s $2 pi.2.00 Inca-i $5X00 Mac. $ 30O1100 Total Agency Egarl s $28616 $ 38741 $ 3 EF16 {I 1C11FCRxPEF4Cet $ - I$ - I$ - I q Main Application 1/21/2016 18:35:26 a1/p1 II,' age 20 of 2 DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION b.) Program Budget Detail What is the cost to deliver your project/program? List each project/program element in the table below, including the cost of each element, the quantity and unit of measure, and the subtotal for each element. Where necessary, allocate costs to the use of shared space, vehicles or equipment. Example Program: Credit Counseling Class Cost Elements Cost($) Quantity/Unit of Measure Subtotal (S.) Credit Counseling Teacher–in class $25 96 hours(8 hrs/mth x 12 months) $2,400 Credit Counseling Teacher—class prep $25 48 hours(4hrs/mth x 12 mths) $1,200 Credit Counselor—one-on-one $20 120 hours(10 hrs/mth x12 mths $2,400 Materials $25 120 course packets/credit reports $3,000 Total $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: Sexual Health Education and Outreach Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) Refreshments—Teen Voices(TV), Smart Girls, $7 TV— 15 participants x 12 sessions $2,632 Alumni Smart Girls— 10 participants x 10 sessions Refreshments—Parents,charlas/chats $7 5-15 participants per workshop x 2 parent $280 workshops and 2 charlas/chats Incentives—Gift Cards $300+$2 fee TV- 15 participants $4,530 $100+$2 fee Smart Girls— 10 participants $1,020 $50 1 drawing per workshop x 2 parent $200 workshops and 2 charlas/chats Incentives—T-shirts $7.50 TV— 15 participants $247.50 Smart Girls— 10 participants Alumni—8 participants Rental Variable TV and Smart Girls-$300 each $1,150 Parents and chats-$200 each Alumni-$150 Mileage—Community Educator $0.54 175 miles per month x 12 $1,134 Training—New Educator on curriculum $995 1 participant $995 Copies $0.50 800 copies for worksheets,promotional $400 Office Supplies $40 Per month x 12 $480 Brochures $40 Per 100 x 10 topics $400 Promotional materials-swag $2 3 promotional items(keychains,pens, $900 carbineers,etc) x 150 of each Guest Trainers- TV $100 2 speakers $200 Peer Assistant - TV $100 1 assistant $100 Main Application 1/21/2016 18:35:26 a1/p1 Page 21 of 2 " DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION Supplies for Child Care $40 Per workshop,2 parent workshops and 2 $160 charlas/chats Field Trip—Bus rental for Youth Advocacy Day $420 1 day $420 APPCNC Conference $250 2 registrants $500 Education Materials- TV $20 Worksheets x 15 participants $300 Postage $0.49 50 stamps per month x 12 $294 Salary—Community Health Educator 2 educators x 50%of time each Salary—Sr.Director of Education 1 director x 5%of time Benefits—25%of Director of Ed Salary 1 director x 5%of time Total $37,886 C.) Cost per Unit: Actual 2014-15 Estimated 2016-16 Projected 2016-17 Total Cost of Program $29,616 $38,741 $37,886 Total # of Units 235 363 363 Cost Per Unit $126.03 $106.72 $104.37 This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 1/21/2016 18:35:26 a1/p1 Page 22 of 2 " DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION d.) Agency Operating Budget Please show all sources and amounts of funding for your entire current fiscal year. What is your agency's fiscal year? Example: July 1, 2016 through June 30, 2017. Submit operating budget in your own format. Do not include funds that have been applied for but not yet awarded: If the total revenue is not the same amount as the budget for any fiscal year, please attach a statement explaining the deficit or surplus. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. • Agency fiscal year is July 1, 2016 to June 30, 2017 • FY15 represents the first six months of Planned Parenthood South Atlantic's operations. On January 1, 2015, Planned Parenthood Health Systems (PPHS) and Planned Parenthood of Central North Carolina(PPCNC) merged to become Planned Parenthood South Atlantic. Prior to that, PPHS and PPCNC operated as separate organizations with separate budgets. Main Application 1/21/2016 18:35:26 a1/p1 Page 2 3 of 2 " DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued Provider's Outside Agency Application MAIN APPLICATION S€dtion'1A_Financial Data Ana BL It for B1ir e Arienogf AGEN2Yliattli Rained P,a 1So1,f>MMantic AIGEMYFENdEtiLE 21041.15 211315.1G 2IYI 17 Charge Pri a Cyan to $ 493 $ 6,554 744 $ E 6845 8M 111111111111M Agency 113enaralad xwp $ 5,D'1$888 $1 0,TM,OW $1Q945,647 Local G04.09111111311 Granter Orange Carty $ 1 Q 00 $ 20,CCD $ 2:,C M .. Tba^t cf awe Fill $ 1,2250 $ 2 500 $ 2 500 MR 1M Toon or C5rrlxra $ 500 $ 1,DOD $ 1,COJ ah c Local: larta-r1C arty $ 8,623 $ 17,245 $ 17,245 Other Local. --- 0 Otr'rerLOCat --- 0 r rrvrevra�asavcc,mama rrarerem separate I@t flan-Local Goilaninrarilt Grants.... TMaltgel_IYtetl Jam, --- 0 Mate Gwen-in/ft $ 55,074 $ 1.35,CCC $ 135,COO 11111111 1=. Fettral C,00rrr'ert $ 921,237 $ 1,955500 $ 2 602 COD °tlterGrarts --- 0 CII ter Carts --- 0 Iulrcell retrl lea 1e1 ROW811.118 $ 83 226 $ 65,145 $ 31,2010 Reese Lt3 largest F t oetznaz sauces: Ft-search $ 33, .00 F5rt 4 Irrcarr $ 31,Z1010 DJ - Total Aganast Fi xle $ 3W38410 $'16t4BLs42 a 43 t432 Conperwallon $ 5 360 3.7 $11,3M,864 $11,734,650 Hatt&Ittillttlea $ 602184 $ 704, $ 726 455 4a FJles&E4p.IImrB1't $ 1,731,012 $ 4,478605 $ 4,61 2851 Towel&Training $ 209,C1743 $ '.551,72'^7 $ 565.279 attar Expenses $ 2 431,977 $ 2 532 973 $ 2 7543 462 Feaae tt 3Ia rgest"Other Ebr.parses°': A€tettleng $ /710 O rtracted Sent aes $Brad.era Total Amity Eventeas ) 104 5f13 I$186111336 /72114047W I 3561 SUIR LLIGICE Ic1T)F+t.1111:3 I$ (1354086132Et $ 34.723 111 Main Application 1/21/2016 18:35:26 a1/p1 II I:' c 241 of 2 DocuSign Envelope ID: CBOC1343-06EB-4BE7-9AF6-62EE77BD69FE EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Planned Parenthood South Atlantic Funding Award: $20,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel—Salaries 20,000 Program Services For assistance with this or the following section, please reference the Exhibit A instructions and example, located within the contract and reporting memorandum. Outline the major activities the agency will employ to attain the Anticipated Outcomes below,by June 30,2016. • Becoming a Responsible Teen(BART), and evidence-based, comprehensive curriculum designed to increase knowledge and skill-based protective factors about contraception use. • Smart Girls, a science based, intensive adolescent pregnancy prevention program for middle school girls desinged to build self-esteem and health decision making. • Alumni group for graduates of our teen education programs. • Parent workshops to improve parents' confidence in talking to their children about sex. • Workshops for women of reproductive age about family planning and pregnancy prevention. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Recruit teens(ages 14-18)for the Becoming a Responsible Teen program 15 teens Participants will demonstrate increase in knowledge about preventing pregnancy and STIs 10% Peer educators will make contact in their community 20 contacts PPSAT will recruit girls(ages 10-14)for the Smart Girls program 10 girls #of parents of middle and high school students will participate in parent workshops 15 parents Parents will report increased comfort in talking with ehir kids about sexuality isuses 75 % #of women reproductive age)taught about the benefits and availablity of various contraceptive 15 women r7e d President and CEO 11/2/2016 \---DCFE23B90427490... DocuSigned by: Certified by: `�iw � Title: Director of Development frlpuniiA �0I6and Grants RRRR7ggf1F5q9dFF (Provider's Signature) DocuSign Envelope ID: CBOC1343-06EB-4BE7-9AF6-62EE77BD69FE A R CERTIFICATE OF LABILITY SU C DATE(MMIDD/YYYY) 12J'29/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION 18 WAIVED,subject to ' the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER —a.,-Act .. .. _ Marsh USA,Inc. P ON 1188 Avenue of the Americas Tr .,Erna: FAX No): NewYcrk,NY 10038 t. Attn:healthcare.accountscssDmarah.com Fax 212-048-1307 INSURERS)AFFORDING COVERAGE NAIC B 109210-NIP-CAS-16-17 ROA,V GAP �I INSURER:A:New Hampshire Insurance Company 23841 INSURED INSURER B:Nadonal Union Fire ins.Co.of Pittsburgh,PA 19445 PLANNED PARENTHOOD SOUTH ATLANTIC AN AFFILIATE OF PLANNED PARENTHOOD INSURER C: FEDERATION OF AMERICA,INC. INSURER D 2207 PETERS CREEK ROAD ROANOKE,VA 24017 ,INSU,RER E: l INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-008171122-04 REVISION NUMBER:4 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE EFF LIC1f EXP ILN"S I D:r ce -° A X... COMMERCIAL GENES©ILnY POLICY NUMBER ( O/I"YYYI UNITS 082695195 01/0112018 0110112017 EACH OCCURRENCE I$ 1,000,000 CLAIMS MADE OCCUR DAMAGE TO RENTED ,r.m one,��Soo $ X SIR:$100,000 MED EXP r $ 100,000 - – PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n JEOT © LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY MMBINED INGLE UNIT 1$ 1,000,000 b82695195 A ANYAUTO 01/01/2016 01/0112017 BODILY INJURY(Per person) �I ' ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident)AI HIRED AUTOS X ED A�OSWNED PROPERTY DAMAGE 1 ii 31R$100,000 $ UMBRELLA LIAR I�',OCCUR EACH OCCURRENCE $ ■ EXCESS LIAB °,CLAIMS-MADE DED ,I RETENTION! ;AGGREGATE $ WORKERS COMPENSATION 1J. I - AND EMPLOYERS'LIABILITY Y/N W1 I JL , ANY PROPRIETORIPARTNENEXECUTNE 0 E.L.EACH ACCIDENT I$ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLO t: $ If describe PROFESSIONAL 8793286 01/01/2016 01/01/2017 PER CLAIM S-POLICY UNIT $ $1,000,000 DESCRIPTION OF OPERATIONS b rnw.. B MEDICAL PROFESSIONAL CLAIMS-MADE COVERAGE Program Retro Date:11/1176 AGGREGATE $3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional?tornado;Schedule,may be attached If more apace Is required) RE:2015-16 OUTSIDE AGENCY PERFORMANCE AGREEMENT COUNTY OF ORANGE IS INCLUDED AS ADDITIONAL INSURED(EXCEPT WORKERS'COMPENSATION)AS THEIR INTERESTS MAY APPEAR. CERTIFICATE HOLDER CANCELLATION COUNTY OF ORANGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN:BONNIE HAMMERSLEY,COUNTY MANAGER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 SOUTH CAMERON STREET ACCORDANCE WITH THE POLICY PROVISIONS. HILLSBOROUGH,VA 27278 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. I Ricid Fitzsimmons —. /44 — (0 19882014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD