Community Partnership Questionnaire

Community Partnership Questionnaire

CSBG
Community Resource Inventory
What direct services does your organization provide?
What service gaps do you most frequently encounter that your organization cannot fill?
What outside agencies do you most commonly refer clients to?
Does your organization have formal MOUs or written agreements with other agencies? If yes, list them.
What financial assistance could YCAN provide that would expand — not duplicate — what your clients already have access to?
Funding and Financial Capacity
What are your primary funding sources?
Do you receive any funding tied to client referrals or outcomes such as child support referral fees? If yes, describe.
Do you have funding dedicated to direct financial assistance for clients?
If yes, what types and what is your approximate annual budget?
What are your eligibility criteria for clients to receive direct financial assistance from your organization?
What is the maximum a single client can receive per year or per incident from your organization?
How do you verify client income or eligibility?
How do you document that assistance has not been duplicated by another agency for the same need?
List all federal, state, and other grant or contract funding sources and approximate amounts from last fiscal year.
Date of your most recent independent financial audit.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Was your most recent audit qualified or unqualified?
Were any audit findings identified?
If yes describe the findings and how they were resolved.
Yellowstone Country Assistance Network, a non-profit focused on aiding low-income clients in Park and Hot Springs County, invites local agencies to become community partners. By completing our questionnaire and signing the Community Partnership Agreement, partners can access a secure portal for processing aid applications.

We are currently updating our community needs assessment, so some questions are specific to help us determine available community resources.
The Name of Your Organization
Primary Contact Name

First NameLast Name
Primary Contact Email
example@example.com
This is the address where clients will come for appointments to complete applications with your staff.
Organization Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Days and Hours of Operation at location 1 (for customers to apply, or put by appointment only)
Secondary Location if Applicable

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Days and Hours of Operation at location 2 (for customers to apply, or put by appointment only)
Location 2 Phone Number (if not the same as location 1)
Please enter a valid phone number.Format: (000) 000-0000.
Your Organization's Website Address
Tell us about your services
What kinds of case management services does your organization offer?

Other
Approximately how many low-income clients, defined as those at or below 200% of the Federal Poverty Level, does your organization serve each year?
What kind of services does your organization offer to support low-income individuals and families?
Looking to the future what financial assistance services can YCAN offer to your low-income clients that they currently do not have access to?
What is the average duration of a client's enrollment in your case management services or program?

Other
What is the typical frequency with which your average client seeks financial assistance from community organizations within a year?

Other
Does your organization have any funding sources to provide direct financial assistance services to low-income individuals?
If yes, what services can you provided and what is the approximate budget?
Service Agreement
We kindly request a list of your case workers, including their names, phone numbers, and email addresses, who will be referring to this program.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Who You Serve
What counties does your organization serve?
What is the primary population your organization serves?
Approximately how many unduplicated individuals or households do you serve per year?
How do clients typically find out about your organization?
What are the top reasons clients come to your organization?
How You Work With Clients
Do you meet with clients in person, virtually, or both?
Describe what a typical client appointment looks like — who does the intake, what happens, and how long does it take?
Do you maintain an ongoing case management relationship with clients or are services one-time/short-term?
What is the average length of time a client is enrolled or actively served by your organization?
What is your internal policy for referring clients to outside agencies? Please describe your process.
Do you provide child support referrals to Wyoming Child Support Enforcement?
If a staff member or board member contacts YCAN on behalf of a client to ask YCAN to approve, expedite, or influence a referral or payment decision — how does your organization handle that?
Internal Controls and Segregation of Duties
YCAN is a federally funded CSBG-eligible entity required to assess the internal controls of partner organizations. These questions help us understand how your organization manages financial decisions and protects against conflicts of interest. Your answers are confidential and used solely for partnership evaluation.
Does your organization have written accounting policies and procedures?
Does your organization maintain a separate bank account for grant or contract funded awards?
Are bank accounts reconciled monthly?
Does your organization have written policies for processing vendor or client payments?
For each of the following duties please list the name and title of the person responsible and note any duties performed by the same person: (1) Approve expenses (2) Sign checks or authorize ACH payments (3) Process or prepare payments (4) Review and approve client referrals to outside agencies like YCAN (5) Help clients complete assistance applications (6) Make eligibility determinations for your own agency financial assistance (7) Sign purchase orders (8) Conduct bank reconciliation (9) Open bank statements (10) Handle petty cash
Are any of the above duties performed by the same person? If yes explain your oversight process for overlapping duties.
Does your organization have a written conflict of interest policy?
How do staff handle situations where they have a personal relationship with a client seeking assistance?
How does your organization handle situations where a staff member or board member has a personal or financial relationship with an outside agency to which you refer clients?
Does your organization have a written whistleblower policy?
Do you have property and liability insurance?
Is your organization accredited by any external body? If yes who is the accreditor?
Client Complaints and Grievances
Does your organization have a formal client grievance or complaint process?
Describe how a client would file a complaint about how they were treated or a decision your organization made.
Is the complaint process handled independently from the staff member involved in the complaint?
Has your organization had any formal complaints findings sanctions or corrective actions from a funder or regulatory body in the past 3 years?
If yes describe what occurred and how it was resolved.
Partnership Readiness and Agreement
Does your organization have staff who would serve as designated YCAN referral coordinators?
Please list the names phone numbers and email addresses of staff authorized to submit referrals to YCAN.
Do you understand and agree that your clients remain your clients and that YCAN provides supplemental one-time financial assistance only and does not provide ongoing case management or direct client services?
Do you understand that submitting a referral does not guarantee approval or payment and that YCAN makes all eligibility and allowability determinations independently?
Do you understand that YCAN cannot discuss individual client cases referral status or payment details with anyone other than the designated referral coordinator in the official case record?
Is there anything else you would like YCAN to know about your organization or your interest in this partnership?
Should be Empty:

Community Partnership Questionnaire

Community Resource Inventory

Funding and Financial Capacity

Tell us about your services

Service Agreement

Who You Serve

How You Work With Clients

Internal Controls and Segregation of Duties

Client Complaints and Grievances

Partnership Readiness and Agreement