Agreement with Adriana Mendes Fonseca '20//- d- 77�-y
PROFESSIONAL SERVICES AGREEMENT
BETWEEN THE CITY OF MIAMI BEACH, FLORIDA
AND ADRIANA MENDES FONSECA.
FOR YOUTH SERVICES
RELATED TO THE CITY'S SERVICE PARTNERSHIP INITIATIVE
THIS AGREEMENT made and entered into this 1 st 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 Adriana Mendes Fonseca, (hereinafter referred to as Contractor), whose
address is 1988 SW 175th Avenue, Miramar, Florida 33029.
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.
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SECTION 2
SCOPE OF WORK (SERVICES)
The Contractor will provide intake and assessment services for up to seventeen (17)
youth and their families, care plan contact services for up to seventeen (17) youth
and their families, and close out follow-up services for up to seventeen (17) 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
Contractor shall be compensated for the Services, as set forth in Section 2
and Exhibit "A", as follows: (a) Provision of intake and assessment services for up to
seventeen (17) youth and their families at One Hundred Forty Dollars ($140) per
each intake, for a maximum not to exceed Two Thousand Three Hundred Eighty
Dollars ($2,380); (b) Provision of care plan contact services for up to seventeen (17)
youth and their families at Eighteen Dollars ($18) per each care plan contact for a
maximum not to exceed Three Hundred Six Dollars ($306); (c) Provision of close out
follow up services for up to seventeen (17) youth and their families at One Hundred
Dollars ($100) per each follow-up contact for a maximum not to exceed One
Thousand Seven Hundred Dollars ($1,700).
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 Four
Thousand Three Hundred Eighty Six Dollars ($4,386).
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.
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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.
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, losses, 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
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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.
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 attorneys' 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)
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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
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 event the Contractor is placed either in voluntary
or involuntary bankruptcy or makes an assignment 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 valid
unless amended in writing, signed by the parties hereto, and approved by the City.
4.8 OWNERSHIP OF DOCUMENTS
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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.
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 Manager 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.
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All insurance required hereunder must be furnished by insurance companies
authorized to do business in the State of Florida.
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
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Contractor (which approval, if granted at all, shall be at the Managers sole
discretion and judgment).
4.14 EQUAL EMPLOYMENT OPPORTUNITY
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.
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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.
Until changed by notice in writing, all such notices and communications shall
be addressed as follows:
TO CONTRACTOR:
Adriana Mendes Fonseca
1988 SW 175th Avenue
Miramar, Florida 33029
305-479-6376
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
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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
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 of
the limitation placed upon the City's liability as set forth in Section 768.28, Florida
Statutes.
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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:
By: PoL � PaA,,
City Clerk Ma or
/ -3
Date Date
FOR CONTRACTOR:
ATTEST:
By: By:
Wit s Signature
Adriana Fonseca Mendes 161 000CA Lo I
Witness Prfinted Name
111011 a,
Date Date
APPROVED AS TO
FORM & LANGUAGE
& FOR EXECUTION
r
i
or �--- Date
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EXHIBIT "A"
SCOPE OF SERVICES
The Contractor agrees to provide the following services to youth referred to the
Success University program.
Service Documentation of
Intake & Assessment Completed Success University Intake & Assessment
Form via Communiity OS with executed consents and
releases containing original signatures (attached); Copy
of completed Referral Form(s) (attached);
3 Documentation of service provided on Community OS
........................................................................................................................................._......._......................._.
_Software
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 trigered
Close Out Follow-Up Contact ' Completed Close Out Follow-Up form including client
signature (attached); Documentation of service provided
on Communit OS software
Related Definitions:
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Intake & Assessment— An intake and assessment documents the natural supports
and needs of the client and his/her family. The intake and assessment form must be
completed accurately and completely and submitted to the City via Community OS
software. Notification of submission of intake and assessment must be provided via
email to the Program Coordinator. The client is assigned a number in The Children's
Trust Data Tracker system by the City. Intakes must be completed within thirty (30)
days of referral.
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 the care plan contact are to: (a) review student absenteeism and
encourage school attendance; (b) determine if referrals have been followed up on; (c)
review, implement, and amend 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 the Care Plan Contact. Once 30 days have passed following the initial Intake
& Assessment, the Care Plan Contact will become the responsibility of the City and
the Contractor will no longer have the opportunity to complete or bill for said contact.
Referrals — Referrals include the identification of a specific client need and the
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f community-based resource to address the need.
subsequent identification o a co ty ed es e
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.
Close Out Follow-Up Contact — The Close Out Follow-Up Contact is conducted in
person with the client and the client's primary caregiver. In the event that numerous
attempts to make in-person contact have failed, a phone contact may substitute for a
face—to—face meeting, only upon documentation of multiple failed in person attempts.
The contact will be no less than 30 minutes in duration and the document produced
must be completed accurately and in its entirety. Follow-up contacts must be
completed within ninety (90) days of intake but no earlier than forty-five (45) days
after intake date. The Program Evaluation Form (in English or Spanish) (attached)
must be completed by the client and his/her primary caregiver at the Close Out
Follow-Up Contact.
Services will be deemed as provided when the following documentation is provided
within the noted timeframes:
Service Documentation Submission - . •
Intake & Assessment Intake & Assessment Form on 72 business hours from
Community OS; Notification Email to provision of service
Program Coordinator
._.........__._- .-__ _...._.__. ........_......_.. .......
......................_......._........._......_...._....._...........
Care Plan Contact Case Note Form; Amended Care 72 business hours from
Plan, if triggered; Notification Email provision of service
to Pro ram Coordinator }
Referral Miami Beach Service Partnership 72 business hours from
Referral Form (front and back, with the identification of
separate back of referral form for client need
each agency to which referrals are
provided)
__..----..._._. __._.._.... _-._____.______ _.._ ........_..._......
Close Out Follow-Up Close Out Follow-Up Form; Program 72 business hours from
Contact Evaluation Form; Notification Email to provision of service
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Program Coordinator
If the contractor fails to submit required, accurate service documentation in the
timeframe 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
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Service Unit of Service Service Location
Intake & Assessment 1 for each of up to 17 Client Home All eligible intakes will
youth and their '; ` be completed within
families j thirty (30) days of
receipt of appointment
_ _
Care Plan Contact 1 for each of up to 17 Via Telephone or All Care Plan Contacts E
youth and their at Client Home will be completed
families within thirty (30) days
of Intake E
._._........................._.._ _- - _ .__..._.................................................-__ _...._ ........... ........_..._...._..___....__......__._._.
Close Out Follow-Up 11 1 for each of up to 17 ! Client Home All close out follow-ups
Contact ! youth and their will be completed
families within one hundred E
twenty (120) days of
completion of intake
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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
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
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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
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 continuing 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
Reporting Requirements
The Contractor will provide the City with a Monthly Progress Report and
reimbursement request utilizing the City's Reporting and Reimbursement Forms
(attached) by 5:00 PM on the third (3rd) of the following month. In the event that the
third of the month lands on a Saturday, Sunday or holiday, the report must be
submitted the following business day.
Monthly reports and reimbursement requests will be submitted via any of the
following methods:
• Electronic mail
• Facsimile
• Standard -mail
• Hand delivery
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Monthly reports will not be considered acceptable unless the following is met:
• Forms are completely and accurately filled. "N/A" and "no examples this
month" are not acceptable responses on Monthly Reports
• Necessary back-up materials are included (client documentation, monthly
client list, expense receipts, time logs, etc.)
• Reports bear the signature of the person submitting the report on behalf of
the Contractor
The City will document Contractor service level data and monthly reports via Active
Strategy software for inclusion in the monthly report to the Miami Beach Governing
Board as well as the City's website.
The failure to submit accurate required monthly reports and invoices in a timely
manner will result in the forfeiture of one (1%) percent 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.
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.
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.
Memoranda of Understanding
A Memorandum of Understanding (MOU) reflecting the terms of this agreement as
well as commitment to the Miami Beach Service Partnership will be provided and
City of Miami Beach-Adriana Mendes Fonseca Page 16 of 21
Miami Beach Service Partnership
updated as necessary. The MOU must be submitted to the City of Miami Beach prior
to execution of the service contract.
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 Tool,
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:
Performance . Rating Rationale . Score
Timely and accurate submission of ➢ "0" for failing to submit on time
monthly progress report___ _ ➢ "15" for submittn_q on time
e
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.
_..._..._._......__._.___.__.___....._..................._..____....._....__..........._.................._............__.. _..._._.__.___._.._._._.___._w._._..._._...................._..................................._........._....___._.....__.._.__.____..___._..____._.._.. . ,
Attendance at Miami Beach Service 1 Possible score of 0 to 20:
Partnership Governing Board and related 10 Points for attendance at Governing
committees meetings Board meetings; 10 points for Committee
City of Miami Beach-Adriana Mendes Fonseca Page 17 of 21
Miami Beach Service Partnership
...................................................................._......................................................_..._........................................................................................................................................................................................................................................................................................................................................................
attendance (In the event that there are no
committee meetings scheduled, the value
for attendance at the Governing Board
meetin g 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:
Training Cost
Program Overview Trainin $66.56
Intake & Assessment Training _ $133.12
Community OS Training $133.12
Client Evaluation Survey.._Train_ing....................................................................................................................... $16.64
_...................................................................................................................................... _........................_........................_................................................_...................................................................,
FGC Audit Training $66.56
................._._..._.._ ,
Follow Up Train'n $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-Adriana Mendes Fonseca Page 18 of 21
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-Adriana Mendes Fonseca Page 19 of 21
Miami Beach Service Partnership
EXHIBIT "B"
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 d) of the subsequent
month.
City of Miami Beach-Adriana Mendes Fonseca Page 20 of 21
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-Adriana Mendes Fonseca Page 21 of 21
Miami Beach Service Partnership
i
i
I
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 Pending
Primary Language Race/Ethnicity
❑ English ❑ Spanish ❑ Creole ❑ Other ❑ White, Non-Hispanic ❑ Hispanic
❑ Black, Non-His anic ❑ Other
Address/Zip Code Home Telephone/Work Telephone
Marital Status Housing Status
❑ Single ❑ Divorced ❑ Domestic Partnership ❑ Own ❑ Rent ❑ Live w/others
❑ Married ❑ Se crated ❑ 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
❑ K ❑ 1 ❑ 2 ❑ 3 04 05 76 77 08
❑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
❑ 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 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
Miami Beach Service Partnership
Universal Referral Form-Revised February 2011
❑Child Child Care/Aftercare❑ Ayuda ($) - • Contacts
E]Alliance for GLBTQ Youth
Care ❑ Medical
❑ Miami Beach 1175 NE 125th St/1-866-634-8087
❑ Aftercare ❑ Ayuda ($) 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 ❑ MBCHC ❑ Barry University-305-899-3742
❑ MB Recreation Services ❑ Attached ❑ Boys&Girls Club-305.673.7760
Clothing Services Brochure ❑The Bridge 2810 N.W.South River
❑ Clothing ❑ Neat Stuff ❑ Mental Drive/305-635-8953
❑ Douglas Gardens ❑Central Intake 2500 NW 22"d Ave.
❑ Dress for Success Health ❑ JCS#1 /305.638.6540
Counseling El Institute CFH [:1 CINS/FINS 1825 NW 16Th St.Ste. 102
❑ Youth Institute CFH Rent /305.474.1707/305.474.1738
❑ JCS#1 E]Community Action Agency#1
❑Stand 1 ($) ❑ Rent F1 CAA#1 6100 NW 7th Avenue/305.756.2830
Assistance ❑ CAA#2 ❑Community Action Agency#2
❑Barry University ❑ Edison/Little River 833 6th St 1s'Fl.33139 1305-672-1705
❑ GLBTQ ❑ Alliance for GLBTQ ❑ HAND ❑Culmer Service Center
Youth Youth 1600 NW 3`d Ave. 305-438-4161
Substance Abuse Services
❑ Adult ❑ Douglas Gardens ❑ Dept.of Children&Families
❑ Detox ❑ JMH Crisis 945 Pennsylvania Avenue/305.535.5401
❑ JCS#1 ❑ Douglas Gardens CMHC
❑ Stand Up($) ❑Addiction ❑ Central Intake 1680 Meridian Ave. 305.531.5341
❑ Institute CFH Services ❑ EHEAEP 395 NW 1st St 305.347.4685
El Family Ayuda[Parents Nowt
Transportation - El EdisoLittle River Service Center
F-1 JCS#1 El Disabled El Miami-Dade 150 NW 79th StreeU305.758.9662
❑ Elder Transit El Fla. Immigrant Advocacy Center
El Stand Up($) 3000 Biscayne Blvd./305.573.1106 Utilities ` ❑ HAND 1(877)994-4357
Speech ❑ Playing the Game ❑ Elder Program ❑ EHEAEP ❑ Institute for Child&Family Health
Thera of Life ($) 430 West 66th St. Hialeah/305-558-2480
Elder ❑ Emergency ❑ Culmer Ctr. ❑JMH Crisis Center
❑ Referral ❑ JCS#3 Help ❑ Edison/Little River 1611 NW 12th Avenue/305.355.7377
❑ DHS Day Care ❑ LHEAP ❑JCS#1 300 41St St.#2161305.576.6550
❑ LHANC-MB Youth Development [_1 JCS#2 2056 NE 155th St.305.947.8093
F-1 LHANC-RT F] Academic El MBSH Library ❑JCS#3 Access/Referrals 305.576.6550
❑ MB-OCS Tutoring ❑ MDC Libraries ❑ LHEAP 2902 NW 2"dAve.305.438.8614
❑ UNIDAD El Legal Services of Greater Miami
❑ Dial-A-Teacher 3000 Biscayne Blvd./305.576.0080
❑ Home ❑ MD-Human ❑Youth ❑ Ayuda[TALL] ❑ Legal Aid Society 123 NW First
Care Services Avenue, Suite 214(305)579-5733
Development ❑ Aspira[Club] ❑ Little Havana/Rebecca Towers
Employment ❑ JCS#3 150 Alton Road/305.572.3736
❑ Employment ❑ CAA#2 ❑TACOLCY ❑ Miami Beach CDC
(ADULT) ❑ JCS#1 (FAST] 945 Pennsylvania Avenue/305.538.0090
❑ Unidad ❑MDC— ❑Miami Beach CHC#1
❑ Youth Co-Op Prevention 710 Alton Road/305.538.8835
❑ Employment ❑ CAA#2 ❑ CINS/FINS ❑Miami Beach—Community Services
JCS#1 1700 Convention Ctr.Dr./305-673-7491
(YOUTH)
❑Social/ ❑ Playing the ❑Miami Beach-Homeless
❑Teen Job Corps Emotional Dev. Game of Life ($) 55517 1h St./305-604-4663
❑ Unidad ❑Youth ❑The Village ❑ MB Police Athletic League
Food ' , Substance Abuse South 999—11 Street/305.531.5636
F-1 Emergency _j JCS#2 ❑ Miami Beach—Recreation
Internal Referrals (Success 2100 Washington Avenue/305.673.7730
Food ❑St.Joseph's Church El Miami-Dade Human Services
❑St. Patrick's Church University direct services) 4500 Biscayne Blvd./305.576.2511
❑ Food Stamps ❑ DCF ❑ 7 Habits ❑ Miami Beach- ❑Miami-Dade Transit
Teens OCS 111 NW 1 s'Street/305.770.3131
❑7 Habits ❑ Miami Beach— ❑ Playing the Game of Life 7144 Byron
❑ Discount ❑ Miami Beach- Families OCS Ave.2nd Fl.305-864-5237
Food OCS ❑ Employment ❑Teen Job Corps ❑St.Joseph's Church
• • 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
❑Affordable ❑ Miami Beach CDC ❑ Emergency ❑ Miami Beach— ❑Switchboard(305)358-4357
Housing Gap Services I OCS ❑TACOLCY 6161 NW 9th Avenue(305)
398-1770
Legal - Other
❑Teen Job Cor�s 305.868.0635
❑ Disability ❑ Legal Services ❑ UNIDAD 833 6' Street/305.532.5350
❑Land lord/Tenant ❑The Village 400 NE 3151 St 305-573-
ElFamily Law ❑ Legal Aid 3784
❑ Immigration ❑ FIAC ❑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
Care Plan Contact Form
Success University Case Worker:
Partner Agency:
Contact Date:
Data Tracker Date:
1 V L) A N..w
Client Name First Middle L a S t
Client Address Ar)artrner.,', 7'�) r'r CIE,
Home Telephone Cellular Telephone E-Mail Address
Contact Date Contact Location
171 Home 71 Other 71 Phone Contact
Indicate Persons Present 71 Client 71 Mother/ Step-Mother 0 Father/ Step-Father
71 Other Females# 0 Other Males
Phone Call Log Date: Date.- Date:
Time: Time: Time:
0 Message 71 No Answer 71 Message 71 No Answer 71 Message 71 No Answer
Case Notes
Please provide an update on the status of referrals issued at time of intake and progress on Care Plan.
Next Scheduled Encounter
Indicate your next scheduled encounter with client and location.
Date Time Location Purpose
71 Family-Conferencing
71 Follow-up Home Visit
71 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
Revised December 2011
Close Out Follow-Up Form Care Coordinator:
Success University Partner Agency:$ jf' I y Contact Date:
Data Tracker Date:
I\ A I A
V
Client Name i-H ST Middle La
Client Address Apartmeni,# Zip o d e
Home Telephone Cellular Telephone E-Mail Address
Contact Date Contact Location
71 Home 71 Other 0 Phone Contact
Indicate Persons Present 71 Client 71 Mother/ Step-Mother 71 Father/Step-Father
0 Other Females# 71 Other Males#
Phone Call Log Date: Date: Date:
Time: Time: Time:
71 Message 71 No Answer 0 Message 0 No Answer 71 Message 71 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 components/services that have been accessed by client as of this contact.
71 Intake & Assessment 0 Referral Services 0 Family Conferencing 71 Mental Health
717 Habits Teens/Families 0 Employment Services 71 MB Helpers Client/Parent 0 Discount Food Program
Success University Close Out Follow Up Form
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 comments including observations 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? O 0
Did you provide family with this month's Discount Food Program information? 0 0
Did you remind client and parent of the importance of adhering to the Attendance Contract? 0 0
Next Scheduled Encounter
Indicate your next scheduled encounter with client and location.
Date Time Location Purpose
0 Family Conferencing
0 No follow-up expected
O 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
SUCCESS Service Evaluation Form
UNIVERSITY
dtAGttf3 HAi Ad aRNriE4i5 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 used 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 meet your expectations?
SUCCESS Formulario de evaluacion de servicio
UNIVERSITY
.�,,,�^�•°^ �¢i 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 informacion recibida sera utilizada para
mejorar los servicios ofrecidos. De antenzano muchas gracias por su opilzion.
Contenido
N/A Inferior Regular Bueno Excelente
Objetivo y proposito del entrenamiento ❑ ❑ ❑ ❑ ❑
Organizacion del evento y empleados de la agencia ❑ ❑ ❑ ❑ ❑
Comprension de la informacion comunicada por el ❑ ❑ ❑ ❑ ❑
empleado
Relevancia del evento/servicio a sus objetivos ❑ ❑ ❑ ❑ ❑
Instructor/a
N/A Inferior Regular Bueno Excelente
Presentacibn 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 pro rama.
Que fue to mejor del pro rama?
Que aspecto del pro rama no cumplio sus expectativas?
/\A I AM Monthly Project Summary�
Office of Community Services
Project Profile
-Reporting Agency
Project Success University
Reporting Period ❑ November/11 ❑ December/11 ❑ January/12
❑ February/12 ❑ March/12 ❑ April/12
❑ May/1 2 ❑ June/12 ❑ Jul /12
Please provide a narrative summary for each section, as applicable.
Services Management (Please provide narrative regarding the administration/delivery of services including
problems confronted in implementation this past month.
Percentage of Funds Expended to Date
Client Success Story (Please include a(n) example of client(s) success indicating how services were beneficial
or made a meaningful impact.)
i
Prepared By gnature Date
I
i,
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 $ -
Fiscal Summary
:Line ItQm"Category Account# Category Total Previous.Requestr 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 $ - $ - $ - $Documentation -
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
$ - 0 $ -
Space&Other in-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
Date Received by
Amount Authorized for Reimbursement
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