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Evaluation
Report Form Tutorial
Use
the sample Evalutation Report Form to report grant usage.
Click on highlighted links for helpful tips.
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SISTERS
OF MERCY OF NORTH CAROLINA FOUNDATION, INC.
GRANT
EVALUATION REPORT
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Organization Name:
_____________________
Address: _____________________________
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Contact Person:
_______________________
Title: _______________________________
Telephone: __________________________
Email: _______________________________
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| Please
refer to your Evaluation Report notification letter
to complete the information below: |
Report Due Date:
_______________________
Approval Date of
Grant: __________________
Amount of Grant:
$ _____________________
Payment Schedule:
_____________________
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Grant #: _______________________
Type of Report: □ Final □ Interim
Telephone: __________________________
Email: _______________________________
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| Please
refer to the Evaluation Plan that was approved with
your Grant Application. |
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1. What
did you propose to accomplish for the target population
with this request?
Did
you accomplish your original intent? Yes □ No □ If
no, tell us what prevented your success in the
Comments field:
2. How
many unduplicated individuals were served during
the past year? ________
2.
How
many individuals did you expect to serve according
to your Evaluation Plan? ________
If the participation level you
are reporting varies significantly from what you
indicated in your Evaluation Plan, please provide
some information explaining the variance in the
Comments field below.
3. What
activities/services were provided that helped
move participants toward the outcomes that were
proposed in your Evaluation Plan? Include the
frequency of the activities/services and the
number served.
4. Provide the actual
result for each of the outcomes you proposed
in the Evaluation Plan submitted with your grant
application. Select the Outcome Category that
you expected to change (Knowledge, Skill, Condition,
Behavior, or Other) and state the corresponding
Outcome and Method of Measurement.
If the outcome results you are
reporting vary significantly from what you indicated
in your Evaluation Plan, please provide some
information explaining the variance in the Comments
field below.
5. What
did you learn? Did you encounter any challenges
or opportunities during the grant term that
resulted in your organization doing business
differently? What would you tell others who
are involved in a similar program or effort?
6. Has the program or
project contributed to systemic
change? □ Yes □ No
- If yes, name the "system,"
such as education, healthcare, social service,
etc. and;
System: ___________
- Indicate what barriers (specific,
problematic policies, procedures, commonly
held beliefs or common practices) have been
altered or removed within this system.
Barriers removed: ___________
- How have accessibility and/or
opportunity improved or increased within this
system as a result of program or project efforts?
- Longer-term
impact: If applicable, what are
the expected organizational, community-level,
or systemic changes that will result in improved
conditions and quality of life for your target
population beyond this grant term?
7. Were
additional funds or in-kind support leveraged
as a result of this funding?
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GRANT
BUDGET REPORT
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Please refer to the Instructions
that accompanied the Evaluation Report notification
letter to determine the
amount paid to your organization this past year.
For purposes of this report, the
Foundation is only evaluating the $_______ paid
to your organization this past year. Your numbers
below should reflect only that amount. If there
are questions about how grant funds should have
been spent, please review the Grant Award Letter
to your organization.
Multi-year grants only: Please
note that this Evaluation Report must be approved
by the Foundation, including a possible site visit,
before any additional grant funds will be released
to your organization.
| Expense
Items |
Amount |
Percent |
| Personnel: |
$ |
|
|
$ |
|
|
$ |
|
|
$ |
|
|
$ |
|
| Subtotal: |
$ |
% |
| Other Operating: |
$ |
|
|
$ |
|
|
$ |
|
|
$ |
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|
$ |
|
|
$ |
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| Subtotal: |
$ |
% |
| Building Renovation
and/or Equipment Purchase: |
$ |
|
|
$ |
|
|
$ |
|
|
$ |
|
|
$ |
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| Subtotal: |
$ |
% |
| Total: |
$ |
100% |
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If
a balance exceeding $2,500 remains at the
end of the grant term, please contact the Foundation
to make arrangements to return the remaining balance
or send a letter via U.S. Mail signed by your
Chief Executive Officer requesting permission
to retain the fund balance. The letter should
explain the reasons for the balance and how the
organization proposes to use the remaining funds.
Note that the Foundation's decision on remaining
balances, if any, will be communicated to the
organization in writing.
I certify that the grant funds
have been expended consistent with the terms of
the original grant award and as reported above.
I agree to supply substantiation of any expenditure
greater than $500.00 upon request.
| Name |
_______________________________________ |
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Date: _______________ |
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Chief Executive Officer |
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(A typed name is acceptable
for email submission and an original signature
is required for hard copy submissions.)
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Back
to Reporting page
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© Sisters
of Mercy of North Carolina Foundation, Inc.
2115 Rexford Road, Suite 314
Charlotte, North Carolina 28211
704.366.0087
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The information that you will need to complete the items in the box below can be found in the Foundation's letter to your organization requesting submission of the Evaluation Report.
Completion of this Report will require reference to the original Evaluation
Plan that was submitted and accepted as part of your Grant Application.
Referring to your original Evaluation Plan, restate your response to Question
#1 of the Plan.
If you were unable, or only partially able to accomplish your purpose, please
give us a brief description of what prevented your success.
If you accomplished what you intended to, no comments are necessary.
We would like the actual number of individuals served by the program
or organization. When providing an unduplicated number, count any individuals
who may have received services multiple times as one individual.
Referring to your original Evaluation Plan, restate the proposed number from Question #2.
Refer to your original Evaluation Plan and respond to this question by indicating
the actual activities that were provided, the frequency and/or duration, and
how many individuals were served through each activity.
If this request was for equipment or renovation, restate the proposed timeline
and include actual dates of accomplishment.
Refer to your original Evaluation Plan, Question #4. Copy your projected outcome
percentage(s) onto the first column "Eval Plan Estimate" for each outcome proposed.
Indicate the actual outcome percentage in this column for each outcome.
Referring to your original Evaluation Plan, select the category(ies) that you
chose for your outcome(s).
Referring to your original Evaluation Plan, copy the proposed outcome description
into this column.
State the measurement tool(s) that you used to verify the outcome(s).
You need only comment here if your outcome results were substantially different
than your estimate (over or under). If so, briefly describe the reason for the
variance.
Hopefully you were able to identify ways in which you could improve the services
provided or the manner in which you measure impact. Perhaps you encountered
unexpected barriers or opportunities during the year; how did you respond? If
someone else were engaged in a similar effort, what advice (or caution) would
you offer?
Systemic change occurs when a policy, procedure, commonly held belief or common
practice within a community, which has historically created a barrier to certain
quality of life benefits, is changed or removed resulting in increased accessibility
and opportunity.
If you suspect, or know based on published research of other, similar programs
that the services you provided with this grant will have impact beyond this
grant term, please offer a brief description. For example, a school-based intervention
may have impact on student behavior and grade improvement during the grant term,
but a long-term impact may be improvement in graduation rates or lowered drop-out
rates within the school system.
Please let us know if you were able to use this grant as a challenge or match
for additional support. In addition, let us know if this grant influenced a positive decision from any other funders.
The expense items and amount should closely resemble the Budget Form submitted
and approved in your original Grant Application.
This amount is identified in the Instructions that accompanied the Letter of
Notification of Evaluation Report Due.
If you have a remaining grant balance in excess of $2,500, you must notify
the Foundation in writing via U.S. Mail. The letter must contain the original
signature of the organization's Chief Executive Officer or Board Chairperson.
The letter must explain the reason for the balance and identify the organization's
intent to return the remaining funds or request authorization to retain the
balance. Foundation staff will communicate to you in writing the procedure for
return of the funds, or a decision regarding the request to retain the balance.
Please refer to the Instructions that accompanied the Letter of Notification
of Evaluation Report Due to determine if a hard copy submission is required
