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Fillable Printable Program Proposal Form for Service Providers

Fillable Printable Program Proposal Form for Service Providers

Program Proposal Form for Service Providers

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
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