Feedback Form

Rating Scale: 80 total points possible

0 = Not demonstrated, 1 = Poor, 2 = Average, 3 = Good, 4 = Excellent

Agency Name *

Program *

The management/supervisory structure is appropriate for the program *

Agency incorporates diversity in staff, volunteers and client base *

Agency is in good financial standing and providing monthly reports to UWCL *

Agency secures funds or resources outside of United Way of Central Louisiana *

Application provides a thorough rational for dollars requested *

United Way fund request does not exceed 50% of program budget *

Please Total Score Part A *

Program aligns with one or more of UW impact areas and goals *

Target population is clearly defined *

There is documented need for the program services *

Client outcomes are collected and measured effectively *

Program is effective in helping clients achieve desired outcomes *

Board is actively involved and monitors program effectiveness and stability *

The need for UW support to deliver the desired results is demonstrated *

Program outcomes are realistic and achievable within the timeframe specified *

Please Total Score Part B *

Agency visit was well-organized; presenter were prepared *

Visit included active participation by Board member(s) *

Agency offices and materials display the UWCL logo prominently *

The facilities and equipment adequately serve program needs *

Questions were answered completely; either at the initial Agency Visit or on individual follow-up visits *

Please Total Score Part C *

Agency participates in UWCL campaign and fulfills pledge *

Total Score for Program *

Notes/Comments:

Your Name *

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