Agreement w/ Tania Perez ,urn- 7 - 7 f
PROFESSIONAL SERVICES AGREEMENT
BETWEEN THE CITY OF MIAMI BEACH, FLORIDA
AND TAN1A PEREZ
FOR YOUTH SERVICES
RELATED TO THE CITY'S SERVICE PARTNERSHIP INITIATIVE
THIS AGREEMENT made and .entered into this 1st day of November, 2011, by
and between the CITY OF MIAMI BEACH, FLORIDA (hereinafter referred to as City),
having its principal offices at 1700 Convention Center Drive, Miami Beach, Florida,
33139, and TAN.IA PEREZ, (hereinafter referred to as Contractor), whose address is
7955 Hawthorne Ave. Miami Beach, FL 33141
SECTION 1
1.1 DEFINITIONS
Agreement: This Agreement between the City and Contractor,- and any
exhibits and /or attachments hereto.
City Manager: The Chief Administrative Officer of the City.
Contractor: For the purposes of this Agreement, Contractor shall be
deemed to be an independent contractor, and not an. agent
or employee of the City:
Services: - All services, work and actions by the Contractor performed
pursuant to or undertaken under, this Agreement, 'as
described in Section 2 and Exhibit "A" hereto:'
Fee (Compensation): Amount paid to the Contractor to cover the costs of the
Services:
Risk Manager: The Risk Manager of the City, with offices at 1700
Convention Center Drive, Third Floor, Miami Beach, Florida
33139, telephone number (305)'673-7000, Ext. 6435, and
fax number (305) 673 - 7023..
City of Miami Beach - _TANIA PEREZ Page 1 of 20
Miami Beach Service Partnership
' y
SECTION 2
SCOPE OF WORK (SERVICES)
The Contractor will provide attendance tracking and truancy intervention services for
up to two hundred thirty (230) ' youth and their families in accordance with The
Children's Trust Miami Beach Service Partnership Grant, dated November 1, 2011.
The scope of work to be performed by Contractor is further detailed in Exhibit "A,"
entitled "Scope of Services." The Contractor shall report to the City of Miami Beach,
Neighborhood Services Department, Office of Community Services, Division Director.
SECTION 3
COMPENSATION
3.1 FIXED FEE
j Contractor shall be compensated for the Services, as set forth in Section 2
and Exhibit "A ", as follows: (a) Provision of attendance tracking, initial written
communication, follow -up communication, school or home meeting, assistance in
development of Care Coordination Plan services, and Care Coordination Plan
Meeting sessions for up to two hundred thirty (230) youth and their families at
Nineteen Dollars and Forty -Four Cents ($19.44) per each hour worked for up to one
hundred twenty (120) hours, for a maximum not to exceed Two Thousand Three
Hundred Thirty =Two Dollars and Eighty Cents ($2,332.80).
Contractor's compensation shall be further subject to and conditioned upon all
or any portion of the Services to be provided herein being allowable and within the
Scope of Services delineated in Exhibit "A ".
Notwithstanding - the preceding, Contractor's total compensation during the
term of this Agreement shall not exceed the maximum allowable sum of Two
Thousand Three Hundred Thirty -Two Dollars and Eighty.Cents ($2,332.80).
3.2 INVOICING
Contractor shall submit monthly invoices, a Monthly. Progress Report, and
accompanying Monthly Status Report, as set forth in Exhibit "B ", which includes an
itemized, detailed description of the Services, or portions thereof, provided (including
the clients served) and cost(s) for same. Invoices and supporting documentation shall
be submitted, to Maria Ruiz,, Division Director, Office of Community Services, 1700
Convention Center Drive, Miami Beach, Florida, 33139.
3.3 METHOD OF PAYMENT
Payments shall be made within thirty (30) days of the date of invoice, in a
manner satisfactory to and as approved and received by the City Manager and /or his
designee, who shall be the Division Director, Office of Community Services.
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SECTION 4
GENERAL PROVISIONS
4.1 RESPONSIBILITY OF THE CONTRACTOR
With respect to the performance of the Services the Contractor shall exercise
that degree of skill, care, efficiency and diligence normally exercised - by recognized
professionals with respect to the performance of comparable services. In its
performance of the Services, the Contractor shall comply with all applicable laws,
ordinances, and regulations of the City, Miami -Dade County, the State of Florida, and
the federal government, as applicable.
4.2 PUBLIC ENTITY CRIMES
A State of Florida Form PUR 7068 Sworn' Statement under Section
287.133(3)(a) Florida Statute on Public Entity Crimes shall be filed with the City's
Procurement Division, prior to commencement of the Services herein.
4.3 DURATION AND EXTENT OF AGREEMENT (TERM)
The'term of this Agreement shall commence upon execution of this Agreement
by all parties hereto, and shall terminate on July 31, 2012.
4.4 TIME OF COMPLETION
The Services to be rendered by the Contractor shall be commenced upon
receipt of a written Notice to Proceed from the City subsequent to execution of the
Agreement by the parties, and shall be completed no later than July 31, 2012.
4.5 INDEMNIFICATION
Contractor agrees to indemnify and hold harmless the City of Miami Beach and its
officers, employees and agents, from and against any and all actions, claims,
liabilities, Tosses, and expenses, including, but not limited to, attorneys' fees, for
personal; economic or bodily injury, wrongful death, loss of or damage to property, at
law or in equity, which may arise or be alleged to have arisen from the negligent acts,
errors, omissions or other wrongful conduct of the Contractor, its employees, agents,
sub- consultants, or any other person or entity acting under Consultant's control, in
connection with . the Contractor's performance of the Services pursuant to this
Agreement; and to that extent, the Contractor shall pay all such claims and losses
and shall pay all such costs and judgments which may issue from any lawsuit arising
from such claims and losses, and shall pay all costs and attorneys' fees expended by
the City in the defense of such claims and losses, including appeals.
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t
The Contractor's obligation under this Subsection -shall not include the obligation to
indemnify the City of Miami Beach and its officers, employees and agents, from and
against any actions or claims which arise or are alleged to have arisen from negligent
acts or omissions or other wrongful conduct of the City and its officers, employees
and agents. The parties each agree to give the other party prompt notice of any
claim coming to its knowledge that in any way directly or indirectly affects the other
party.
4.6 TERMINATION, SUSPENSION AND SANCTIONS
4.6.1 ' Termination for Cause
If the Contractor shall fail to fulfill in a timely manner, or .otherwise
violate any of the covenants, agreements, or stipulations material to this
Agreement, the City shall thereupon have the right to terminate the
Services then remaining to be performed. Prior to exercising its option
to terminate for cause, the City shall notify the Contractor of its violation
of the particular terms of this Agreement and shall grant Contractor
seven (7) days to cure such default. If such default remains uncured
after seven (7) days, the City, upon three (3) days' notice to Contractor,
may terminate. this Agreement and the City shall be fully discharged
from any and all liabilities, duties and terms arising out of /or by virtue of
this Agreement.
Notwithstanding the above, the Contractor shall not be relieved of
liability to the City for damages sustained by the City by any breach of
the Agreement by the Contractor. The City, at its sole option and
discretion, shall additionally be entitled to bring any and all
legal /equitable actions that it deems to be in its best interest in order to
enforce the City's right and remedies against the defaulting party. The
City shall be entitled - to recover all costs of such actions., including
reasonable aftorneys' fees. To the extent allowed by law, the defaulting
party waives its right to jury trial and its right to bring permissive counter
claims against the City in any such action.
4.6.2 ' Termination for Convenience of City
NOTWITHSTANDING SECTION 4.6.1, THE CITY MAY ALSO, FOR
ITS CONVENIENCE AND WITHOUT CAUSE, TERMINATE THIS
AGREEMENT AT ANY TIME DURING THE TERM HEREOF BY
GIVING WRITTEN NOTICE TO CONSULTANT OF SUCH
TERMINATION, WHICH SHALL BECOME EFFECTIVE SEVEN (7)
DAYS FOLLOWING RECEIPT BY 'THE CONSULTANT OF THE
WRITTEN TERMINATION NOTICE. IN THAT EVENT, ANY
FINISHED. OR UNFINISHED DOCUMENTS AND OTHER
MATERIALS PREPARED AND OR OTHERWISE COMPILED BY
CONSULTANT PURSUANT TO ITS PROVISION OF THE SERVICES
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Miami Beach Service Partnership
CONTEMPLATED IN SECTION 2 AND 'IN EXHIBIT "A ", SHALL BE
PROMPTLY ASSEMBLED AND DELIVERED TO THE CITY, AT
CONSULTANT'S SOLE COST AND EXPENSE. IF THE
AGREEMENT IS TERMINATED BY THE. CITY AS PROVIDED IN
THIS SUBSECTION, CONSULTANT SHALL BE PAID FOR ANY
SERVICES SATISFACTORILY PERFORMED, AS DETERMINED BY
THE CITY AT ITS SOLE DISCERTION, UP TO THE DATE OF
TERMINATION; PROVIDED, HOWEVER, THAT AS A CONDITION
PRECEDENT TO SUCH PAYMENT, CONSULTANT SHALL HAVE
DELIVERED ANY AND ALL DOCUMENTS, MATERIALS, ETC, TO
CITY, AS REQUIRED HEREIN.
4.6.3 Termination for Insolvency
The City.also reserves the right to terminate the remaining Services to
be performed in the the Contractor' placed either in voluntary
or involuntary bankruptcy or makes an asignment for the benefit of
creditors. In such event, the right and obligations for the parties shall
be the same as provided for in Section 4.6.2.
4.6.4 Sanctions for Noncompliance with. Nondiscrimination Provisions
In . the event of the Contractor's noncompliance with the
nondiscrimination provisions of'this Agreement, as applicable, the City
shall impose such sanctions as the City or the State of Florida may
determine to be appropriate, including but not limited to, withholding of
payments to the Contractor under the Agreement until the Contractor
complies and /or cancellation, termination or suspension of the
Services and /or the Agreement. In the event the City cancels or
terminates the Services and /or the Agreement pursuant to this
Subsection the rights and obligations of the parties shall be the same
as provided in Section 4.6.2.
4.7 CHANGES AND ADDITIONS
Any changes and additions to the- terms of this Agreement shall be by a written
amendment, signed by the duly authorized representatives of the City and Contractor.
No alteration, change, or modification of the terms of this Agreement shall be vapid
unless amended in writing, signed by the pasties hereto, and approved by the City.
4.6 OWNERSHIP OF DOCUMENTS
Any changes and additions to the terms of this Agreement shall be by a
written amendment, signed by the duly authorized representatives of the City and
Contractor. No alteration, change, or modification of the terms of this Agreement
shall be valid unless amended in writing, signed by the parties hereto, and
approved by the City.
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4.9 AUDIT AND INSPECTIONS
Upon 24- hour's written notice, the City Manager (on behalf of the City) and /or
such authorized representatives as the City may deem to act on the City's
behalf, may, during Contractor's normal business hours, audit, examine and make
audits of all contracts, invoices, materials, payrolls, records of personnel, conditions
'of employment, and any and all other data and /or records and /or documents
relating to all matters covered by this Agreement. Contractor shall maintain any and
all such records, as necessary to document compliance with the provisions of this
Agreement.
Contractor agrees to submit its agency financial audit to the City within 30
days of completion.
4.10 ACCESS TO RECORDS
!� Contractor agrees to allow access during normal business hours. to all
records including, without limitation, Contractor's financial records, to the City and /or
its authorized representatives, and agrees to . provide such assistance as may be
necessary to facilitate audit by the City and /or its representatives, when and as the
City Manager, in his sole and reasonable discretion, may deem necessary to ensure
compliance with the provisions of this Agreement including, without limitation, as
they pertain to. any financial audits (with applicable accounting and financial
standards)., Contractor shall allow access during normal business hours to any and
all records,, forms, files, and documents which have been generated in performance
of this Agreement, by the City and /or its authorized representatives.
4.11 INSURANCE REQUIREMENTS
The Contractor shall not commence any work and /or Services pursuant
to this Agreement until all insurance required under this Section has been obtained
and such insurance has been reviewed and approved by the City's Risk Manager.
Contractor shall maintain and carry in full force during the term of this Agreement the
following insurance:
1. Contractor General Liability, in the amount of $1,000,000.
2. Contractor Professional Liability, in the amount of $200,000.
3. Workers Compensation & Employers Liability, as required pursuant to Florida
Statutes.
All insurance required hereunder must be furnished by insurance companies
authorized to do business in the State of Florida.
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Miami Beach Service Partnership
Original certificates of insurance for the above coverage must be submitted to
the City's Risk Manager at the Office of the Risk Manager of the City of Miami Beach,
1700 Convention Center Drive, Miami Beach, Florida 33139..
The Contractor is solely responsible for obtaining and submitting all insurance
certificates for its sub- contractors.
All insurance policies must be issued by companies authorized to do business
under the Laws of the State of Florida. The companies must be rated no less than
"B +" as to management and not less than "Class VI" as to strength by the latest
edition of Best's Insurance Guide, published by A.M. Best Company, Oldwick, New
Jersey, or its equivalent.
Compliance with the foregoing requirements shall not relieve the Contractor of
the liabilities and obligations under this Section or under any other portion of this
Agreement, and the City shall have the right to obtain from the Contractor specimen
copies of the insurance policies in the event that submitted certificates of insurance
are inadequate to ascertain compliance with required overage.
All of Contractor's certificates, as required in this Section 4.11, shall contain
endorsements providing that written notice shall be given to the City at least thirty
(30) days prior to termination, cancellation or 'reduction in coverage in the policy.
The Contractor shall not commence any work and /or Services pursuant to this
Agreement until the City's Risk Manager has received, reviewed and approved, in
writing, certificates of insurance showing that the requirements of this Section (in its
entirety) have been met and provided for.
4.12 ASSIGNMENT, TRANSFER OR SUBCONTRACTING
The Contractor shall not subcontract, assign, or transfer any work under this
.Agreement without the prior written consent of the City Manager which consent, if
granted at all, shall be at the Manager's sole and absolute discretion.
4.13 SUB - CONTRACTORS
The Contractor shall be liable for Contractor's services, responsibilities and
liabilities under this Agreement, and the services, responsibilities and liabilities of
sub- contractors, and any other person or entity acting under the direction or control
of Contractor. When. the term "Contractor" is used in this Agreement, it shall be
deemed to include any sub - contractors and any other person or entity acting under
the direction or control of Contractor. All sub - contractors must be approved, in
writing by the City Manager, or his designee; prior to their engagement by
Contractor (which approval, if granted at all, shall be at the Manager's sole
discretion and judgment).
4.14 EQUAL EMPLOYMENT. OPPORTUNITY
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Miami Beach Service Partnership
In connection with the performance of this Agreement, the Contractor shall
not discriminate against any employee or applicant for employment because of
race, color, religion, ancestry, sex, age, and national origin, place of birth, marital.
status, or physical handicap. The Contractor shall take affirmative action to ensure
that applicants are employed and that employees are treated during their
employment. without regard to their race, color, religion, ancestry, sex, age, national
origin, place of birth, marital status, disability, or sexual orientation, as applicable.
4.15 _ NO CONFLICT OF INTEREST
The Contractor agrees to adhere to and be governed by the Metropolitan
Miami -Dade County Conflict of Interest Ordinance, as same may be amended from
time to time; and by City of Miami Beach Code, as same may be amended from
time to time.
The Contractor covenants that it presently has no interest and shall not
acquire any interest, direct or indirectly which should conflict in any manner or
degree with the performance of the Services. The Contractor further covenants that
in the performance of this Agreement, no person having any such interest shall
knowingly be employed by the Consultant. No member of or delegate to the
Congress of the United States shall be admitted to any share or part of this
Agreement or to any benefits arising .there from.
4.16 PATENT RIGHTS; COPYRIGHTS; CONFIDENTIAL FINDINGS
Any patentable result arising out of this Agreement, as well as all information,
design specifications, processes, data and findings, shall be made available in
perpetuity to the City, for public use.
No reports, other documents, articles or devices produced in whole or in part
under this Agreement shall be the subject of any application for copyright or patent
by or on behalf of the Contractor or its employees or subcontractors.
4.17 NOTICES
All notices and communications relating to the day -to -day activities shall be
exchanged between a project manager appointed by the Contractor and the
program coordinator designated by the City Manager, who shall be Neighborhood
Services Department, Office of Community Services, Division Director. The
Contractor's project manager shall be designated following execution of this
Agreement by the parties and prior to commencement of the Services.
All other notices and communications in writing required or permitted
hereunder may be delivered personally to the representatives of the Contractor and
the City listed below or may be mailed by registered mail.
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Miami Beach Service Partnership
Until changed by notice in writing, all such notices and communications shall
be addressed as follows:
TO CONTRACTOR:
Tania Perez
7955 Hawthorne Ave.
Miami Beach, FL 33141
(786) 797 -5051
TO CITY:
City of Miami Beach
Office of Community Services.
Attn: Maria L. Ruiz, Director
1700 Convention Center Drive
Miami Beach, Florida 33139
(305) 673 -7491
4.18 LITIGATION JURISDICTION/VENUE
This Agreement shall be governed by, and construed in accordance with, the
laws of the State of Florida, both substantive and remedial, without regard to
principles of conflict of laws. The exclusive venue for any litigation arising out of the
Agreement shall be Miami -Dade County, Florida, if. in State court, and the U.S.
District Court, Southern District of Florida, if in federal court.
BY ENTERING INTO THIS AGREEMENT, CONTRACTOR AND CITY
EXPRESSLY WAIVE ANY RIGHTS EITHER PARTY MAY HAVE TO A TRIAL BY
JURY OR ANY CIVIL LITIGATION RELATED TO, OR ARISING OUT OF, THIS
AGREEMENT.
4.19 ENTIRETY OF AGREEMENT
This writing and any exhibits and /or attachments incorporated (and /or
otherwise referenced for incorporation) herein embody the entire Agreement and
understanding between the parties hereto, and there are no other agreements and
understandings, oral or written, with reference to the subject matter hereof that are
not merged herein and superseded hereby.
4.20 LIMITATION OF CITY'S LIABILITY
The City desires to enter into this Agreement only if in so doing the City can
place a limit on the City's liability for any cause of action for money damages due to
an alleged breach by the City of this Agreement, so that its liability for any such
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Miami Beach Service Partnership
breach never exceeds the sum of $1,000. Contractor hereby expresses its
willingness to enter into this Agreement with Consultant's recovery from the City for
any damage action for breach of contract to be limited to a maximum amount of
$1,000.
Accordingly, and notwithstanding any other term or condition of this
Agreement, Contractor hereby agrees that the City shall not be liable to the
Contractor for damages in an amount in excess of $1,000 for any action or claim for
breach of contract arising out of the performance or non - performance of any
obligations imposed upon the City by this Agreement.- Nothing contained in this
paragraph or elsewhere in this Agreement is in any way intended to be a waiver
the limitation placed upon the City's liability as set forth in Section 768.28, Florida
Statutes.
[REMAINDER OF THIS PAGE LEFT INTENTIONALLY BLANK]
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Miami Beach Service Partnership
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to
be executed by their appropriate officials, as of the date first entered above.
FOR CITY: CITY OF MIAMI BEACH, FLORIDA
ATTEST:
B y :
b ' -
City Clerk Ma of
Date Date
FOR CONTRACTOR
ATTEST:
y: By:
15�2qF r
Witne Signature
Tania Perez / �, �
Witness Print6 Name
Date Date Date
APPROVED AS TO
FORM & LANGUAGE
& FOR EXECUTION
ity torn Date
City of Miami Beach - TANIA PEREZ Page 1 1 of 20
Miami Beach Service Partnership
EXHIBIT "A"
"SCOPE OF SERVICES"
The Contractor agrees to provide the following services to youth referred to the
Success University program:
Service S
D• e •
Client Identification & School Records from ISIS system
Recruitment
................. . ....................................... . . . ............... . ..................................... . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .............................. . ................. . ............................................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . .
..................................... ...............................
Enrollment Meetin g
Programmatic Sign'ln Form ^(attached)
_......__ ...... ........_.._...___ ..... .._.____..__. _._
Assistance with completion of Care Coordination Plan (attached)
Care Coordinatio ...
__.__..__ ...........
......_.._..._.___._._.._._......__..._..._._......._._._.___...._._ .._._...... .... __...._..__.____ _ .____.._........_.___._..___._...___.._._________ ..._._.__...____._.____._______
Ongoing communication with Care Plan Contact Form (attached)
parentsts and students _ __.__._._.__.._..._.._. __...__..__...:....__.._._._.._ ___._.. ......... .. .. _ ....... __ ..............._____..._ _._......____._ ......... _..__._._._.._..._._....__. ._._.__.._.._..:._._.....:...._
Care Plan Contact Completed Care Plan Contact Form (attached);
Documentation of service provided on Community OS
Software; Amended Care Plan uploaded to Community
OS if triaaered
Related Definitions:
Client Identification & Recruitment — Students attending Miami Beach Senior High
School are identified and recruited in accordance with the eligibility criteria deemed
by The Children's Trust. Documentation of client eligibility must be provided.
Recruitment is ongoing until the program is full. ISIS school records must include: (a)
Parent Information Page; (b) Student Information Page; (c) Previous School Year
Absences; and (d) Current School Year Absences.
Enrollment Meeting — The Enrollment Meeting takes place at the client's school or
home and must be attended by the youth student, parent or guardian of the youth,
Community Involvement Specialist and one representative from the City of Miami
Beach. At the Enrollment Meeting, the Intake & Assessment service is scheduled, to
the family's convenience. The Enrollment Meeting is documented by the
Programmatic Sign -In Form
Care Plan Contact - The' care plan contact service is conducted with the client and
his /her parent and can be done via phone call or in person. It is to take place
between seven (7) and thirty (30) days following the initial Intake & Assessment. The
purposes °.of tw - care . pla'h . contact are to: (a) review student absenteeism and
encourage" 'school "aattendance; (b) determine if referrals have been followed up on; (c)
P} -,i a g. d ie .ir s «;�
review, im me
plent, and .
am end the Care Plan as necessary;. and (c) continue to assist
participants in meeting their overall goals. Care Plan will be posted on Community
OS within "three business days of receipt of intake; the Care Plan must be consulted
prior to t el',j are , la i - ntacf, Once 30 days have passed following the initial Intake
7,
& Assessment, the' Plan Contact will become the responsibility of the City and
the Contractor will longer have the opportunity to complete or bill for said contact.
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Miami Beach Service Partnership
Referrals — Referrals include the identification of a specific client need and the
subsequent identification of a community- based resource to address the .need.
Referrals must be provided for all service needs recognized in the, intake and
assessment or. client- initiated requests. These . referrals must be documented using
the Miami Beach Service Partnership Referral Form (attached) with copies provided
to the client and City, via Community OS.
Services will be deemed as provided when the following documentation is provided
within the noted timeframes:
Service • • • • Dead
Client Identification ISIS school records: (a) Parent ' 48 business hours from
& Recruitment Information Page; (b) Student I provision of service
'Information Page; (c) Previous
School Year Absences; and (d)
Current Sc Year Absences _
Enrollment Meeting; Programmatic Sign -In. Form, TCT = 48 business hours from
Enrollment forms, Authorization & provision of service
Release Form f
Assistance with Care Plan Contact Form; Amended k . 72 ................. business hours from
completion of Care Care Plan; if triggered; Notification the identification of
Coordination Plan
Email to Program Coordinator client need
................................................................ ............................... a.................................... ............................... ......................................... ...............................
Ongoing Care Plan Contact Form; Amended :72 business hours from'
communication with Care Plan, if triggered; Notification '.provision of service
parents and Email to Program Coordinator
students...._. ............ ........_.......... ................ .......... .. ........ _ ....................__........ . .. _..........................
Care Plan Contact Care Plan Contact Form; Amended 72 business hours from
Care Plan, if triggered; Notification provision of service
Email to Pro Coordina
If, the contractor fails, to submit required, accurate service documentation in the
"1imeframe allotted more than two times in a calendar month, the Contractor will forfeit
two percent .(2 %) of the combined billed total for the month in question. These
forfeited funds will be used exclusively for client incentive materials as approved by
the Miami Beach Service Partnership Governing Board. These forfeited funds will be
submitted to the City by the Contractor via check within 30 days.
Service Deliverables
Location -
Client Identification & ' 1 for each of up to School or Client Ongoing
Recruitment 1 230 youth clients Home
........_........ ........... ...__.. . ............................... ............................ .....
'Enrollment Meeting 1 for each of up to School or Client ' Within 30 days of
I youth outh clients Home identification of need
:............................................._...................................................................... ........................... .............................................. ............................. _ . .............................. .. ........... ,.................. ..............................`
. ............... .
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Miami Beach Service Partnership
..................................... . ..................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . € ......................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Assistance with 1 for each of up to Client Home = Within 30 days of
completion: of Care ' 204 youth clients Intake & Assessment
Coordination Plan }
__._ ----- __....._...._.._.._.__........ ....___._.._.__- ..__.......__�.
Ongoing Ongoing for up to. By phone, email, Ongoing
communication with 230 youth clients and ' at school or at
parents and students ( their families home
G
Care Plan Contact 1 for each of up to Via Telephone or All Care Plan Contacts.
E 204 youth and their at Client Home will be completed
families within thirty (30) days
of Intake -
.................................................................................................................................:......................................................................................................................._.........................................................._...._..................................................................................................................:................... ...............................
Failure to meet contracted service units within the allocated timeframe may result in
the City subsequently reducing the Contractor's service level and allocated funding
j accordingly.
If the Contractor is unable to fulfill the contracted service level within the allocated
timeframe for each service component, the City reserves the right' to reduce service .
levels accordingly across the funded service spectrum.
If the Contractor is unable to fulfill the contracted service level and the City
subsequently reduces service and funding levels, the City reserves the right to select
another vendor to fulfill the remaining service units. The City will select the alternate
vendor at its sole discretion.
Engagement Strategies
The Contractor will adhere to the following engagement strategies in the delivery of
services:
• Evaluate and discuss school attendance with both the youth client and his /her
primary caregiver at every encounter, be in via phone or in person.
• Advise the client and his /her parents and /or guardians of the scheduled
appointment for Family Group Conference.
Provide client and his /her parents and /or guardians information regarding the
importance of adhering to school attendance policies.
Provide client and his /her parents and /or guardians information regarding the
Care Coordination process and other available services.
• Reintroduce the services available through the Program at each client
interaction.
• Document every interaction with client via Community OS.
Employee File Review
The following documentation must be included in the employee file for those
employees` providing services under this contract. The City of Miami Beach reserves
the right to 'inspect client files with due notice (at least 48 hours in advance of planned
City of Miami Beach - TANIA PEREZ Page 14 of 20
Miami Beach Service Partnership
site visit) to ensure adherence to contractual expectations as well as to ensure . pre -
screening prior to a monitoring visit by The Children's Trust. The following must be
included in the employee files:
• Employment Application
Evidence of degree /credentials
Job Description Signed by Employee
• Evidence of Required Experience
Florida Background Criminal Screening
• National FBI Background Criminal Screening (Level2)
• Affidavit of Good Moral Character
• Proof of Knowledge.of Policies & Procedures
• Confidentiality Agreement. Re: Client Information
• Documentation of Agency Training /In- Service Training
• 1 -9 Verification on File
Evaluation
In the scontinuing effort to ensure programming excellence, clients will be provided
with evaluation forms at the end of each programming component to gauge their
satisfaction with services provided. The evaluation forms will be provided by the City
and must be administered at the following time:
• Completion of Close Out Follow Up Contact
Governing Board Attendance
The Contractor is required to have representation at each calendared Governing
Board meeting. In the event that the designated representative cannot attend in
person, arrangements can be made for a telephonic connection.
If the Contractor fails to have representation at two meetings, the City reserves the
right to reduce contracted service levels at its sole discretion.
Master Calendar
The Contractor will notify the City of any client appointment or anticipated service
delivery at least 72 hours in advance of the appointment or service delivery and will
create the event in the Success University Master Calendar on the Community OS
Software.
City of Miami Beach - TANIA PEREZ Page 15 of 20
Miami Beach Service Partnership
The Contractor must provide its availability for intake services inclusive of the number
of staff members, the hours they are available and the languages they speak. This list
must be up -to -date at all times.
Monitoring & Performance Reviews
The City of Miami Beach reserves the right to inspect, monitor and /or audit the
Contractor to ensure contractual compliance. This includes, but is not limited to:
• Review of on -site service delivery
• Inspection and review of client, budgetary and employee files (for those
employees providing services under this contract)
The monitoring tool provided by The Children's.Trust, Subcontractor Monitoring Too/,
will be used to guide inspections and monitoring visits. (Copy included herein.)
Partner Performance Ratings
The Contractor agrees that its Partner Performance Rating, the score . awarded for
performance on the following measures, will be posted on the City's website on a
quarterly basis. One final Partner Performance Rating will be
• Timely and accurate submission of monthly progress report
• Timely and accurate submissions of monthly financial reports (reimbursement
requests)
• Delivery of contracted service units (percentage of services completed out of
referrals provided)
Attendance at Miami Beach Service Partnership Governing Board and related
committee(s) meetings
Ratings will be given for each performance measure based on the following:
• • • : Sco
Timely and accurate submission of ➢ "0 for failing to submit on time
month) progress report Y..._ p........:._ 9 ....................................... p...............................:................................................................... ...: _
e....➢.... 15 " ... for... submi tti_ n. g on me
.... :.. ti. .............................................. ...............................
Timely and accurate submissions of ➢ " 0" for failing to submit accurate report
monthly financial reports (reimbursement:
with back -up material on time
requests) ➢ "15" for submitting accurate report on
time
_.__...._.__.._._.__.....____.__.....__.
----- ------ _.-.. ._._.. ........ ..........._._... _........__------ _._.....__.. ...___._._..__.- ._.._._......._ .._ .......... ..........._....... .... .-........................_..-......_ ........ ._ ------ ----- _.._._.__..._.__.._........... ._.._._ ......... _ -------- _... __._._..._._....__..---- . - - - -
Delivery of contracted service units Possible score of 0 to 50 based upon
completion of projected service units.
Score is calculated by dividing the
completed number of service units by the
total number of referred service units.
......................... . . ................. . . . . . . . . . . . . . . . . .......... . .............................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . ..................
. . . . . . . . . . . . . . . . . . . . . . . . ......................... . ...........
Attendance at Miami Beach Service Possible score of 0 to 20:
Partnership Governing B oard an re 10 Points for attendance at Governin
City of Miami Beach - TANIA PEREZ Page 16 of 20
Miami Beach Service Partnership
...................... . . . . . . . . . . . ........................... . ...................................................... . ...................... . . . . .............................................. . .................... . ................................ . ................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......................
.
committee(s) meetings Board meetings; 10 points for Committee
attendance (In the event that there are no
committee meetings scheduled, the value
for attendance at the Governing Board
meeting will be 20.)
.
_ .............._........._................_...... ,...._............._...._....__ ...........__.._...._.................._..............._................._._....................._...... ................_._..........._ ......_.......................__......._......_.........._....._..... ..........._.._.._...._._ -__.._ ..............
Promotion & Public Relations Requirements
The Contractor. agrees to receive. Success University Program Brochures and make
them available to all clients during all in- person client interactions. The Contractor
agrees to link its website to the City's Success University webpage. Such link must
be in place prior to the execution of this contract.
The Contractor agrees to indicate its membership in the Partnership in all self -
produced marketing materials.that are produced for the benefit of youth and families.
Training Requirements
Frontline personnel (those conducting trainings) will be required to complete the
following trainings. prior to service provision:
Intake & Assessment, Care Plan Contact, ❑ Program Overview Training
& Close Out Follow Up Services ❑ Intake &Assessment Training
❑ Community OS Software Training
Client Evaluation Survey Training
❑ Care Coordination Training
❑ FGC Audit Training
While initial training expenses are covered by the City, the Contractor agrees to
reimburse the City for'the early departure (termination) of any trained staff member
prior to this contract's termination on a pro -rated basis as follows:
Program Overview Trainor $66
.
.g_ - .....- __...._._..._.._....... .__ .... . ................... ... _ g __..._......-- _..._ ...... . ..._.... ._.........._ ....
Intake & Assessment Training $133.12_
......................................................................................................................................................................................................................................................... ............................... ........................................................................................ ...............................
Community OS Training $133.12
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
w Client .. _
Evaluation Survey Training $16.64
..
.......... .............................._ _ ........ . .............. _
...... g_ _
...... _ _ _ _
.. ..._ .. _ .... ... .............._. _ .. __.......... f _ _
FGC A ud i t Trainin _ _ $66.56
Follow Up Training ", $66.56
The Contractor agrees to send at least one representative to attend a City - sponsored
grant writing workshop by July 31, 2012.
City of Miami Beach - TANIA PEREZ Page 17 of 20
Miami Beach Service Partnership
Additional Documentation
The following documentation must be submitted with this executed agreement:
• All required insurance certificates
• Copy of current audit
• Copy of required business licenses and permits
• Copy of notice as recipient of funding from The Children's Trust
• Updated Memorandum Of Understanding (MOU) reflecting scope of services
and leverage associated with Success University
City of Miami Beach - TANIA PEREZ Page 18 of 20
Miami Beach Service Partnership
EXHIBIT 961379
INVOICING
The Contractor agrees to provide the invoicing and services documentation as
indicated in the Monthly Progress Report, Monthly Invoice Report, and Status Report
Form, as attached to this Exhibit, by 5:00 PM on the third (3 of the subsequent
month.
City of Miami Beach - TANIA PEREZ Page 19 of 20
Miami Beach Service Partnership
EXHIBIT "C"
ATTACHMENTS
The following documents are attached:
• Referral Form (2 pages)
• Care Plan Contact Form (1 page)
• . Close Out Follow Up Form (2 pages)
• Program Evaluation Forms (2 pages)
• Monthly. Progress Report (1 page)
• Monthly Invoice Form (1 page)
• Programmatic. Sign -In Form (1 page)
• Subcontractor Monitoring Tool (4 pages)
City of Miami Beach - TANIA PEREZ Page 20 of 20
Miami Beach Service Partnership
Data Tracker #
Miami Beach.Service Partnership Referral Form
Client Information
Name (Check here if client is a minor ❑) Place of Birth/ Date of Birth
Social Security Legal Status
❑ US Citizen ❑ 'US Resident ❑ Status Pendin
Primary Language Race /Ethnicity
❑ English ❑ Spanish ❑ Creole ❑ Other ❑ White, Non - Hispanic ❑ Hispanic
❑ Black, Non - Hispanic ❑ Other
Address /Zip Code Home Telephone/ Work Telephone
Marital Status Housing Status
❑ Single ❑ Divorced ❑ Domestic Partnership ❑ Own ❑ Rent ❑ Live w /others
Married ❑ Separated ❑ Other ❑ Homeless ❑ Other
Others in Household Household Income
❑ Child . ❑ Adult ❑ Employment - $
❑ Child ❑ Adult ❑ SSA ❑ SSI ❑ SSDI $
❑ Child ❑ Adult ❑ Child Support $
❑ Child ❑ Adult ❑ Pension $
❑ Child ❑ Adult ❑ Other $
❑ Child ❑ Adult ❑ Other $
For youth only — For youth only —
Current Grade Level Current School
7 0 1. 7 7 3. 04 El ❑6 ❑7 7
❑ 9 ❑ 10 ❑ 11, ❑ 12 ❑ Biscayne Elementary ❑ North Beach Elementary
❑' Fienberg Fisher K -8 Center ❑ Nautilus Middle
M -DCPS ID #. ❑ North Beach Elementary ❑ Miami Beach Senior High
Services History
Food Stamp ❑ Yes ❑ Pending Section 8 ❑ Yes ❑ Pending
Recipient ❑ No Recipient ❑ No
SSA Benefits Medicaid /Medicare ❑ Yes ❑ Pending
❑ Yes _- Amount $ ❑ Pending Recipient ❑ No
Current Service Current Service Needs
Providers ❑ Child Care After Care
ASPIRA ❑ Lutheran. Services ❑ Disability Benefits
❑ AYUDA ❑ Miami Beach CHC ❑ Disability Services
❑ Barry University ❑ M -Dade Housing Authority ❑ Educational Services
❑ Boys & Girls Club ❑ SSA ❑ Employment Assistance
Catholic Charities ❑ So. Fl. Ctr. Family Counseling ❑ Food
❑ CAA ❑ Stand Up! For Those Can't ❑ Housing Services
❑ City of Miami Beach ❑ Switchboard of Miami ❑ Legal Services
Fj DCF ❑ Teen Job Corps ❑ Medical Services
❑ Douglas Gardens ❑ Veteran's Affairs ❑ Mental Health Services
HACOMB ❑ Volunteers of America ❑ Substance Abuse Services
❑ Institute for CFH ❑ UNIDAD ❑ Youth Intervention Services
❑ JCS ❑ Other ❑ Youth Prevention Services
❑ Legal Services of Miami ❑ Other ❑ Other
I understand a.nd have authorized this release and exchange of information between Service Partnership agencies in order to provide
me and /or my child(ren) with the most complete and thorough services available. The information I have provided is true and accurate
to the best of my knowledge.
Client Authorization Staff Signature Date
Miami Beach Service Partnership
Universal Referral Form — Revised February 2011
0
❑ Child ❑ Ayuda ($) • • -
El Medical E] Alliance for GLBTQ Youth
Care
❑ Miami Beach 1175 NE 125th St/1- 866 - 634 -8087
Aftercare ❑ Ayuda ($) Services Community Health ❑ Aspira 4100 NE 2nd Ave. 305.576.8494
❑ Boys /Girls Club Center ❑ Ayuda 7144 Byron Ave. 305.864.6885
❑ MB PAL ❑ Dental ❑ MBCH.0 ❑ Barry University - 305 -899 -3742
❑ MB Recreation Services ❑ Attached ❑ •Boys & Girls Club - 305.673.7760
• Brochure El The•Bridge 2810 N.W. South River
E] Mental Drive / 305 - 635 -8953
❑ Clothing ❑ Neat Stuff
❑ Douglas Gardens E] Central Intake 2500 NW 22" Ave.
❑ Dress for Success Health ❑ JCS #1 /305.638.6540
• • ❑ Institute CFH ❑ CINS /FINS 1825 NW 167 St. Ste. 102
❑ Youth ❑Institute CFH / 305.474.1707/ 305.474.1738
E] Community Action Agency #1
❑ JCS #1
❑Stand Up ($) F1 Rent F1 CAA #1 6100 NW 7 Avenue/305.756.2830
Assistance F CAA #2 F Community Action Agency #2
❑Barry University ❑ Edison /Little River 833 6th St 1 Fl. 33139 /305- 672 -1705
❑GLBTQ ❑.Alliance for GLBTQ ❑HAND Culmer Service Center
Youth Youth NW 3` Ave. 305 - 438 -4161
F Adult Douglas Gardens • • El Dept. of Children &Families
❑ Detox ❑ JMH Crisis 945 Pennsylvania Avenue/305.535.5401
❑ JCS: #1 ❑ Douglas Gardens CMHC
❑ Stand Up ($) ❑ Addiction ❑ Central Intake 1680 Meridian Ave. 305.531.5341
❑ Institute CFH Services ❑ EHEAEP 395 NW 1 St 305.347.4685
y ( ] El Edison /Little River Service Center
❑' Family
❑ Ayu Parents NoW - o • • 150 NW 79 Street/305.758.9662
❑ JCS #1 ❑ Disabled ❑ Miami - Dade El Fla. Immigrant Advocacy Center
❑ Stand Up ($) ❑Elder Transit 3000 Biscayne Blvd./305.573.1106
❑ Speech El Playing the Game [I HAND 1(877) 994 -4357
❑ E] Thera of Life ($) Elder Program ❑ EHEAEP Institute for Child & Family Health
❑ Emergency ❑Culmer Ctr. 430 West 66 St. Hialeah/305-558-2480
• - ❑ JMH Crisis Center
❑ Referral ❑ JCS " #3 Help ❑ Edison /Little River 1611 NW 12 Avenue/305.355.7377
❑ DHS Day Care ❑ LHEAP ❑ JCS #1 300 41 St. #21,61305.576.6550
LHANC - MB - - • • ❑ JCS #2 2056 NE 155 St.305.947.8093
❑ LHANC - RT L1 Academic L] MBSH Library El JCS #3 Access /Referrals 305.576.6550
❑ MB - OCS Tutoring El MDC Libraries [:1 LHEAP 2902 NW 2 Ave. 305.438.8614
❑Legal Services of Greater Miami
El UNIDAD
❑ Dial -A- Teacher 3000 Biscayne Blvd./305.576.0080
❑ Home ❑ MD — Human T1 Youth ❑ Ayuda (TALL] [I Legal Aid Society. 123 NW First
Care Services ' Development Avenue, Suite 214 (305) 579 -5733
p ❑ Aspira (C /ub] ❑ Little Havana /Rebecca Towers
° ° ❑ JCS #.3 150 Alton Road/305.572.3736
❑ Employment ❑ CAA #2 ❑TACOLCY ❑ Miami Beach CDC
(ADULT) ❑ JCS #1 [FA`S7 945 Pennsylvania Avenue /305.538.0090
F Unidad ❑MDC - El Miami Beach CHC #1
❑ Youth Co -Op � Prevention
710 Alton Road/305.538.8835
❑Employment F CAA #2 ❑ Miami Beach — Community Services
❑ .CINS /FINS' 1700 Convention Ctr. Dr. / 305 - 673 -7491
(YOUTH) ❑ JCS #1 '❑social/ ❑ Playing the
y g El Miami Beach - Homeless
❑ Teen Job Corps Emotional Dev. Game of Life ($) 55517 1h St. / 305 - 604 -4663
❑ Unidad El MB Police Athletic League
❑Youth ❑The Village 999
'' th
0 0 • - — Street/305.531.5636
11
Substance Abuse SoUth
El Miami Beach - Recreation
_ - .; .
F Emergency ❑ JCS #2 2100 Washington Avenue/305.673.7730
Food ❑St. Joseph's Church _ • _ _ El Miami -Dade Human Services
❑ 7 Habits
❑St. Patrick's Church Miami Beach — 4500 Biscayne Blvd./305,576.2511
❑ El Miami -Dade Transit
❑'Food Stamps ❑ DCF Teens OCS 111 NW 1 Street/305.770.3131
07 Habits ❑ Miami Beach — ❑ Playing the Game of Life 7144 Byron
❑ Discount ❑ Miami Beach - Families OCS Ave. 2" Fl. 305 - 864 -5237
Food OCS El St. Joseph's Church
❑Employment El Teen Job Corps 8670 Byron Avenue/305.866.6567
❑ Counseling ❑ Barry University ❑ St. Patrick's Church
❑ Emergency ❑ MB — Homeless ❑ Transportation ❑ Miami Beach — 3716 Garden Avenue/305.531.1124
Shelter
OCS ❑Stand Up! 305 - 864 -5237
F Affordable ❑ Miami Beach CDC ❑ Emergency ❑ Miami Beach - ❑ Switchboard (305) 358 -4357
Housing Ga Services OCS ❑ TACOLCY 6161 NW 9th Avenue (305)
398 -1770
• ❑ Teen Job Corps 305.868.0635
❑ Disability ❑ Legal Services ❑ UNIDAD 833 61h Street/305.532.5350
❑Landlord/Tenant ❑ The Village 400 NE 31 St 305 -573-
❑Family Law ❑ Legal Aid 3784
❑ Immigration ❑ F1AC ❑Youth Co -op 7900 NW 27 Ave. 305 -693-
2060 or 305 - 643 -3300
❑ Other
Miami Beach Service Partnership - Universal Referral Form Back — Revised December 2011 2
i '
Care Plan Contact Form
Success University Case Worker:
Partner Agency:
Contact Date:
Data Tracker Date:
j
4
Client Name 'rd' , dI
Client Address Ar- r"r €. # , : y.Jti
Home Telephone Cellular Telephone E -Mail Address
Contact Date Contact Location
73 Home 0 Other 7 Phone Contact
Indicate Persons Present 0 Client ® Mother/ Step - Mother 7) Father/ Step- Father.
0 Other Females # 71 Other Males #
Phone Call Log Date: Date: Date:
Time: Time: Time:
O Message O No Answer Q Message O No Answer ® Message 0 No Answer
Case Notes
Please provide an update on the status of referrals is sued at ti me of intake and progress on Care Plan.
Next Scheduled Encounter
Indicate your next scheduled encounter with client and location.
Date Time Location Purpose
O Family -Conferencing
0 Follow -up Home Visit
O No follow -up expected
The information I have provided is true and accurate to the best of my knowledge.
Client Authorization Staff Signature. Date
Success University Care Plan Contact Form 1
Revised December 2011
Close Out Follow -Up Fora Care Coordinator:
Success University Partner Agency:
Contact Date:
t �f Data Tracker Date:
q E 3 t i _. ✓ 5 .
Client Name i it _: l'•jii(Id I...a
Client Address At.,,artinen � �=`i � :���t:�£p .
Home Telephone Cellular Telephone E -Mail Address
Contact Date Contact Location
0 Home 0 Other 0 Phone Contact
Indicate Persons Present O Client O Mother/ Step - Mother 0 Father/ Step- Father
0 Other Females # 0 Other Males #
Phone Call Log Date: Date: Date:
Time: Time: Time:
0 Message 0 No Answer 0 Message 0 No Answer 0 Message 0 No Answer
(Referral Follow -up
Please indicate the service needs. recognized in prior visits and their subsequent follow -up.
Service Need Agency Referred Current Status
Current Home Status
Please provide an update on the client and family's status for each category below.
Housing
(Housing situation
including affordability)
Financial
(Employment, living costs,
etc.)
Familial
(Family dynamics,
relationships, etc.)
Educational
(Academic progress,
school attendance, etc.
Health
(Physical, mental and
dental
Success University Audit
Indicate the Success University comp onents/services that have been accessed by client as of this contact.
En 7 Intake & Assessment 0 Referral Services 0 Family Conferencing 0 Mental Health
Habits Teens /Families 0 Employment Services 0 MB Helpers Client/ Parent 0 Discount Food Program
Success University Close Out Follow Up Form 1
Revised December 2011
Truancy Reduction Update
Indicate the status of the client's truancy reduction goals. Reference the Care Coordination Plan and /or FGC
Attendance Contract
Additional Narrative /Observations
Indicate any additional com including observa regarding the client and /or family.
New Needs Identified
Indicate any new needs that require referral services.
Need Identified Referral Provided /Agency
Service Reminders
Please ensure you review all of the items below with client and family.
Service Reminder Yes No
Did you ensure that all contact information is accurate and up-to-date? p 71 .
Did you provide family with this month's Discount Food Program information? ® 0 .
Did you remind client and parent of the importance of adhering to the Attendance Contract? D 0
Next Scheduled Encounter
Indicate your next scheduled encounter with client and location.
Date Time Location Purpose
®Family Conferencing
® No, follow -up expected
® Other:
I understand and have authorized this release and exchange of information between Service Partnership agencies in order to
provide me and /or my child(ren) with the most complete and thorough services available. The information I have provided is true
and accurate to -the best of my knowledge. .
Client Authorization Staff Signature Date
Success University Close Out Follow Up Form 2
Revised December 2011
- E F S 1} Jul
SUCCESS Service Evaluation Form
UNIVERSITY Miami Beach Service Partnership
Intake Worker: Service /Training:
Date: Location:
Please take a moment to evaluate the Success University program. Rate each item from poor to
excellent. Your input is u to improve services. Thanks in advance for your feedback.
Content
N/A Poor Fair Good Excellent
Objective and scope of services ❑ ❑ ❑ ❑ ❑
Organization of events and agency staff ❑ ❑ ❑ ❑ ❑
Understandability of communications with staff ❑ ❑ ❑ ❑ ❑
Relevance of event /services to your objectives ❑ ❑ ❑ ❑ ❑
Program Staff
N/A Poor Fair Good Excellent
Presentation of information ❑ ❑ ❑ ❑ ❑
Participation by attendees encouraged ❑ ❑ ❑ ❑ ❑
Discussions managed well ❑ ❑ ❑ ❑ ❑
Questions responded to satisfactorily ❑ ❑ ❑ ❑ ❑
Overall Experience
N/A Poor Fair Good Excellent
Overall experience ❑ ❑ ❑ ❑ ❑
Please list any further questions you may have.
What was best about the program?
What aspect of the program did not m eet . our e xpectations?
c
K/ i I
CCE S Formulario de evaluacion de servicio
UNIVERSITY
tffs ;siRS °A�£4 #5 Miami Beach. Service Partnership
Encuestador: Entrenamiento:
Fecha: Lugar:
Por favor tome un momento de su tiempo para evaluar el programa de Success Univeristy.
Califique cada. objetivo de inferior a.excelente. La l informacion recibida sera utilizada para
mejorar los servicios ofrecidos. De aiztemano rnuchas gracias por su opinion.
Contenido
N/A Inferior Regular Bueno Excelente
Objetivo y proposito del entrenamiento ❑ ❑ ❑ ❑ ❑
Organizacion del evento y empleados de la agencia ❑ ❑ M ❑ El
Comprension de la inform acion'comunicada por el ❑ ❑ El ❑ ❑
empleado
Relevancia del evento /servicio a sus objetivos ❑ ❑ ❑ ❑ ❑
Instructor /a
N/A Inferior Regular Bueno Excelente
Presentacion de la informacion ❑ ❑ ❑ ❑ ❑
Participantes fueron alentados a participar ❑ ❑ ❑ ❑ ❑
Discusiones se manejaron apropiadamente ❑ ❑ ❑
Preguntas fueron respondidas satisfactoriamente ❑ ❑ ❑ ❑ ❑
Experiencia en general
N/A Inferior Regular Bueno Excelente
Experiencia en general del servicio ofrecido ❑ ❑ ❑ ❑
Por favor escriba cualquier pregunta que pueda tener sobre el programa.
�Que fue lo mejor del programa?
�Que aspecto del programa no cumpiio sus expectativas?
e
B E A`H'
Monthly Project Summary
/M I AM I ��Qo
Office of Community Services
Reportin .Ag e ncy
Project Success Universit
Reporting Period ❑ November /11 ❑ December /11 ❑ January /12
❑ February /12 ❑ March /12 ❑ April /12
❑ Ma /12 ❑ June /12 ❑ July /12
Please provide a narrative summary for each section, as applicable.
Services l�fiana ement Please ; rov�de narrative re ardin' .the adrnrnistranon /del(ve'. ofaerv.ices in'cludI
9 : ( P 9 9 rY 9
roblem&-confronted. in im lementation this a`st month
Client Success Story:,(Please include a(n) exam' le .of clients :success in'tlicatin hovuaervices.were beneficia'!
P O 9
or made a meanin fu4 gym' act
4
P repared By Signature Date
Office of Community Services /Grant Reimbursement Request
Grant Name Funder
Miami Beach Service Partnership /Success University The Children's Trust
Contract Number Awarded Amount
1179 -1090 Resolution 2012 -06 $ -
Reporting Period
_ Initials
Expended Thus Far $ Available Balance $
This Request $ -
Balance Remaining $ -
;Erne Item Category Accouna# Category Total Previous Requests Balance Available < This Request
Intake & Assessments ($140) $ - $ - $ - $
Care Plan Contact ($18) $ - . $ _ $ _ $ _
Close Out Follow -Up ($100) $ - $ - . $ - $
Family Group Conferencing ($175) $ - $ - $ _
Employment Services ($9.86/$24.44) $ - $
Mental Health Services ($195/$75) $ -
TOTALS $ $ - $ - $
Do cumentationCheckllist
Not
Documentation Submitted Submitted
Service delivery documentation
List of clients served and services provided
Leverage /Match
Staff Member Hourly Rate °Hourly Benefits # of:Hours Line Total
$ $ -
$ $ $
Space & Other it Kind Value /Unit Cost . Unit.Quantity Line.Total
.. $ _
I certify that the information provided above is accurate to the best of my knowledge and that I have included all documentation required to ascertain the
delivery of services as delineated in our contract with the City of Miami Beach.
Signature of Authorized Agency Representative Date
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