Contracting Forms

This area includes miscellaneous forms that are referenced in FCADV contracts and agreements with providers.

·         Budget Adjustment/Amendment Form (Excel)

This form shall be used to notify the FCADV Contract Manager when changes are made to the approved operating budget. Changes under 10% do not need approval, but FCADV should be notified. Changes over 10% require written Contract Manager approval prior to incurring any expenditures.

·         Budget entered by percentage (Excel)

 Line item budget template for certified domestic violence centers. Funding amount may be entered into by percentage in this template.

·         Civil Rights Checklist form (CF 946) (PDF)

This form shall be completed yearly in accordance with CFOP 60-16 and 45 CFR Part 89. This form is required for all providers that have fifteen or more employees.

·         Death Reporting Form (Word)

This is the official form in which any death that occurs on center property as described in the FCADV Incident Reporting Procedure shall be documented. Death on center property requires immediate notification to FCADV.

·         Fiscal Back-up Documentation Detail Worksheet- DV (Excel) 

This form shall be used in conjunction with Exhibit G and Exhibit F (only in 4th quarter)Quarterly/Monthly Financial Report. This form contains two worksheets. One worksheet is for salary & fringe and the other worksheet is to detail operating expenditures. Exhibit G and Exhibit F, contains a roll-up of the expenditures and this worksheet contains the detail of the expenditures.

·         Fiscal Back-up Documentation Detail Worksheet- VAWA (Excel) 

This form shall be used in conjunction with Exhibit G and Exhibit F (only in 4th quarter)Quarterly/Monthly Financial Report. This form contains two worksheets. One worksheet is for salary & fringe and the other worksheet is to detail operating expenditures. Exhibit G and Exhibit F, contains a roll-up of the expenditures and this worksheet contains the detail of the expenditures.

·         Fiscal Back-up Documentation Detail Worksheet- L&C (Excel) 

This form shall be used in conjunction with Exhibit G and Exhibit F (only in 4th quarter)Quarterly/Monthly Financial Report. This form contains two worksheets. One worksheet is for salary & fringe and the other worksheet is to detail operating expenditures. Exhibit G and Exhibit F, contains a roll-up of the expenditures and this worksheet contains the detail of the expenditures.

·         Incident Reporting Procedures – QAOP 700-002 (PDF)

The Incident Reporting guidelines establishes procedures and guidelines for identifying and reporting information related to incidents that may be defined as major or critical.

·         General Incident Reporting Form (Word)

This is the official form in which incidents that occur on center property as described in the FCADV Incident Reporting Procedure shall be documented. Reports shall be submitted within 24 hours from the time of incident or upon being made aware of such incident.

·         Property Purchase Request Form (Word)

This form must be submitted for any purchase of "property", as defined in the provider's contract. Requests must be submitted prior to property being purchased. Any property purchased with contract funds must be included on the inventory list in accordance with the requirements of the provider's contract.

·         TANF Eligibility Determination Form in English (Word)

A portion of funding for certified domestic violence centers comes from Temporary Assistance for Needy Families (TANF). Centers are required to complete a TANF Eligibility Determination Form for each participant served. The completed form shall be maintained in the participant's file. The form is updated on a yearly basis based on the Federal Poverty Guidelines.

·         TANF Eligibility Determination Form in Spanish (Word)

A portion of funding for certified domestic violence centers comes from Temporary Assistance for Needy Families (TANF). Centers are required to complete a TANF Eligibility Determination Form for each participant served. The completed form shall be maintained in the participant's file. The form is updated on a yearly basis based on the Federal Poverty Guidelines.

·         IRR Form (Word)

This is the official form to be used when requesting to purchase Information Technology Resources. Written approval shall be obtained from the FCADV Contract Manager prior to making a purchase using the Information Resource Request (IRR) Form.