Program Evaluation Form
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4PROGRAM EVALUATION FORM
EACH MEMBER of the Review Team should complete a form based on application review and site visit experience.
Agency:
________________________________________________________________________
Program:
________________________________________________________________________
Reviewer:
_________________________________________________ Date:_________________
APPLICATION SECTION 2 – Program Information
0
1
2
3
4
The program addresses community needs and the “root causes” of
A
11 & 12
problems.
B
Program uses research-based methods or best practices.
13
The organization and program management is qualified to deliver this
C
14
program.
The target population aligns with the focus area and outcomes
D
identified, and the geographic area served is in Chippewa and/or Eau
15 - 17
Claire counties.
The number of individuals served by the program is appropriate, based
18 &
E
Attachment A
on the grant request.
Subtotal (add all points for this section)
Comments:
(This field will be larger on the actual form)
APPLICATION SECTION 3 – Program Goals & Outcomes
0
1
2
3
4
This program aligns with one or more of United Way’s community-wide
Section 7:
A
41 & 42
outcomes.
The strategies used align with the strategies identified in United Way’s
B
community action plan, and will meet the needs of the target
20
population.
Outcome measurement is clearly defined (includes program level
C
19, 21 & 22
outcomes and statistical indicators).
Program outcomes appropriately align with the scope of the program
D
21
described in Section 2.
Achievement of program outcomes will contribute to achievement of
21 &
E
Section 7: 42
the United Way outcome(s) identified.
The programs outcomes are realistic and achieveable within the
F
21
timeframe specified.
Outcome measurement results are (or will be) used to evaluate and
G
23 & 24
improve the program.
The program has an appropirate plan for communicating results
H
25
outside of its organization.
Subtotal (add all points for this section)
Comments:
(This field will be larger on the actual form)
SUBTOTAL – Sections 2+3
If subtotal score is less than ___, the program should be eliminated from further consideration.
Approved to move forward in the process? Yes No
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