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ORANGE COUNTY COMMUNITY EMPOWERMENT

FAITH & COMMUNITY BASED ORGANIZATIONAL
CAPACITY, COMPETENCY & SERVICE DELIVERY SURVEY

Organization Information
1. Legal name of organization applying: ____________________________________________________
(As shown on attached copies of IRS 501(c)(3) and 509(a) tax-exempt determination letters.)

2. If not 501(c)(3) or 509(a) tax exempt, please respond accordingly:

Organization’s fiscal authority: ________________________________________________________
Fiscal agent/entity: ________________________________________________________
Contact person name: ________________________________________________________
Telephone number: ________________________________________________________
E-mail address: ________________________________________________________
3. Federal Employer Identification Number (EIN): __________________________________________

4. Mailing Address (principal/administrative office): ________________________________________

City: ___________________County: __________________State: _______Zip Code: ____________

Telephone: ________________________________Fax: ____________________________________

Email: _________________________________ Website: _________________________________

5. Name/title of Organizations Leadership: ___________________________________________________

6. Please select Community Empowerment Service Area Zone: *(Maximum #of 3)

 32808 32805 32839

 32811 32818 32810
 32801 32703 32822

7. Select program service area delivery:

* Select one of the program service areas below based on your organization’s history of service.

 Juvenile Prevention / Diversion – Youth services aimed at preventing or diverting youth from the
juvenile justice system
 Mental & Physical Health – Services designed to address the mental and physical health needs of youth
and families, to include counseling, diet, nutrition, and hygiene.
 Early Childhood Education & Care – Services to address the educational and social development needs
of youth 4 – 18 years of age.
 Child & Student Homelessness – Services designed to provide family stabilization, and support. Services
may include coordinating, Job Training/Coaching, Employer Recruitment & Placement, Child Welfare
Liaison Coordination & Temporary Shelter and/or Shelter Assistance.

299 Loraine Drive, Suite. #1001  Altamonte Springs, FL 32714  Office. (407) 494-2406 - Fax. (866) 802-6856
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 8. Please provide a brief summary of your organization’s history and experience in providing
community-based services and partnerships developed in accomplishing successful outcomes.

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 Please review your summary to ensure that your organization’s service delivery objective(s) is clearly
articulated.
299 Loraine Drive, Suite. #1001  Altamonte Springs, FL 32714  Office. (407) 494-2406 - Fax. (866) 802-6856
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  This is a self-reporting organizational assessment which will be utilized to determine your
organization’s capacity to be a “Consortium Provider Affiliate”. This survey is a management
instrument to identify strengths as well as weaknesses. Please select as accurately as possible your
organization’s documented capacity and preparedness in each of the following areas. The results of
this assessment will assist in service implementation and the level of administrative training
integration.

ORGANIZATIONAL MANAGEMENT:
 Vision, Mission & Goals
 Organization Structure (Division of Corporations, Florida Department of State, IRS)
 Operational Policies, Procedures, and Information Systems
 Governing or Advisory Board

HUMAN RESOURCES:
 Management and Staff Knowledge, Skills & Abilities (KSAs)
 Staff Recruitment Process
 Job/Position Descriptions
 Compensation Rates (Compliance w/ Florida Minimum Wages)
 Volunteers and/or Interns Policies

FINANCIAL MANAGEMENT:
 Financial Policies
 Internal Controls
 Financial Record Keeping
 Financial Sustainability

PROGRAM MANAGEMENT:

 Community & Stakeholder Involvement

 Project/Program Operations & Implementation Plan
 Service Delivery Standards & Referrals Infrastructure
 Quality Assurance (QA) Improvement

299 Loraine Drive, Suite. #1001  Altamonte Springs, FL 32714  Office. (407) 494-2406 - Fax. (866) 802-6856
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 NON-PROSELYTIZING ATTESTATION

 I / organization agree as the authorized individual on behalf of the aforementioned organization that funding
contracted by the Florida Economic Consortium, Inc shall not be used directly or indirectly to fund religious
worship, instruction, or proselytization.

 I /organization agree as the authorized individual on behalf of the aforementioned organization to allow the
Florida Economic Consortium, Inc., or its designee, to conduct virtual or onsite monitoring and program/fiscal
review throughout the term of any potential contractual project/program to assure non-proselytization, program
integrity, and progress with program objectives as set forth in any potential future contracts.

NON-DISCRIMINATION & HARASSMENT ATTESTATION

It is the policy and commitment of the Florida Economic Consortium, Inc. that it nor any of its’ affiliates
NOT discriminate or exhibit any form of harassment on the basis of race, age, color, sex, national origin,
physical or mental disability, or religion. Therefore, Affiliates shall attest by acknowledgement their
organizations commitment to the Non-Discriminatory & Discriminatory Harassment Policies below,

 I / organization agree to comply with the Equal Employment Opportunity commitment to a policy of equal
employment opportunity and will not discriminate in the terms, conditions, or privileges of employment based
on race, age, color, sex, national origin, physical or mental disability, or religion or otherwise as prohibited by
federal and state law.

Any employee, board member, volunteer or client who believes that s/he or any other affiliate of the
organization has been discriminated against is strongly encouraged to report this concern promptly to the
organization’s chief executive leadership authority.

Discriminatory Harassment or intimidation of a client, staff person or guest because of that person’s race, age,
color, sex, national origin, physical or mental disability, or religion is specifically prohibited and may be
grounds for termination. Harassment and intimidation includes abusive, foul or threatening language or
behavior. This organization is committed to maintaining a workplace that is free of any such harassment and
will not tolerate discrimination against staff members, volunteers or agency clients. Issues of discriminatory
treatment, harassment, or intimidation on any bases should immediately be reported to the organization’s chief
executive leadership authority and, if substantiated, prompt action shall be taken.

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Name (Authorized Agency Representative) Date

299 Loraine Drive, Suite. #1001  Altamonte Springs, FL 32714  Office. (407) 494-2406 - Fax. (866) 802-6856
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