Fillable Printable Program Proposal Form for Service Providers

Program Proposal Form for Service Providers

New Expansion to Additional Facilities

Texas Department of Criminal Justice

Rehabilitation Programs Division Phone: 936-437-2180

861B IH-45 Fax: 936-437-6299

Huntsville, TX 77320 Email: prog[email protected].us

In order to best understand the activity you are proposing, please complete this form and attach documentation as necessary. The completed form can be submitted electronically to

program.proposal.for[email protected]

s or mailed to the above address:

Agency Name

Job Title

Facilitator Name (Last, First, Middle)

Driver’s License # (Last Four Numbers Only)

Office Telephone No.

Address

City/State

Zip

Web Address

E-Mail Address

Fax No.

Type (please check appropriate box): Literacy/Education  Employment/Job Skills  Substance Abuse/Education  Reentry/Life Skills  Parenting 

Medical Issues/Prevention  Arts/Crafts  Victim Awareness  Support Groups  Religious/Faith-Based  Other 

(explain)

Name of Acti v i ty/ P ro gram:

Geographic Preference or Facility Name:

To the degree possible, the TDCJ will accommodate the scheduling needs of providers; however, the secure and orderly operation of the facility is imperative to the safety of offenders,

staff and guests. For that reason, please indicate your scheduling preference in the boxes below:

Preferred Length: 60 minutes  90 minutes  120 minutes 

Other 

(explain)

Preferred Duration: 6 weeks  12 weeks  18 weeks 

Other  (explain)

Preferred Time Schedule:

A.M.  P.M. 

Preferred Hours:

Capacity:

Preferred Cycle: Weekly  Bi-Weekly  Monthly  Quarterly  Annually 

Other 

(explain)

Target Population : State Jail  Institution 

No Preference 

Male  Female 

No Gender Preference 

Is there selection criteria for offenders? Y N (If yes, please explain)

For new proposals only. Activity/Program Components: Please list goals, objectives, and intended benefit to offenders, as well as evaluation methods or outcome measures to be

utilized (you may attach additio n al pages, if needed). Please list your ex pectation of services to be provided by the TDCJ. If your activity/p rogr am includes a cu rriculu m, workboo ks or

handouts, please attach those items when submitting this request. You may use additional paper if necessary.

Volunteer Application: In order to provide regularly scheduled services within secure facilities of the TDCJ, you must be an approved volunteer. For information on becoming an

approved volunteer, go to the TDCJ website: http://www.tdcj.state.tx.us and click on Volunteer Services or you may call Volunteer Services at 936-437-4961.

For RPD Office Use Only

Received Date: Database Tracking #: Date Forwarded: Forward to Appropriate Dept: Due Date:

Unit Chaplain Notified: Y N

Chaplains Name:

Date: Approved

Y N

ED Code: Chaplaincy Track #: VS00 Dept Code Approved by Authority: Date:

Unit Warden Notified: Y N

Wardens Name :

Date: Approved

Y N

Meeting Needed: Y N

To Include:

Effective/Begin Date:

Revised 2-2011