Self-Evaluation and Attestation

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1 Legal Provider Name: Agreement No(s): Please submit this completed document with accompanying documentation by: Respond to all statements by placing a checkmark in the applicable box in the Provider Response column. For those items that are not applicable to the Provider, check N/A. Please attach any documentation that has been requested. If you need to provide additional information or cannot respond to a statement, please attach an explanation on a separate page. FCADV STAFF ONLY Provider Response: Compliance Verification: I. Administrative Yes No N/A Yes No N/A 1. Does the Provider maintain accurate records of all services incurred under this Contract for a period of 6 years after the termination or expiration of this Contract? Please provide documentation (record retention and disposal policy). 2. Does the Provider maintain all documents relating to the Support to the Deaf and Hard-of-Hearing for the 5-year term of the U.S. Department of Health and Human Services Office of Civil Rights settlement agreement (effective 1/26/10) and for the 5 years thereafter (expiring 1/26/20)? Please provide documentation. 3. Is the Provider aware that it must report child abuse, neglect, or exploitation as required by law? 1

2 II. Contract Review Yes No N/A Yes No N/A 4. Are Provider services limited to the survivors of domestic and dating violence, sexual assault, or stalking who are referred to the Provider by the certified domestic violence center(s) indentified in the Provider's contract? III. Program Review Yes No N/A Yes No N/A 5. Within 30 days of the execution of this contract, did the Provider meet with the Executive Director(s) of the Center(s) identified in this contract to discuss the obligations and requirements under this agreement and the expectations of the parties? a) As a result of the meeting, did the Provider, in conjunction with the Center s Executive Director, develop a plan to ensure that the Center s clients will receive the services required under this agreement? b) If the meeting was not scheduled to date, please explain. c) Will the meeting be scheduled? 6. Within 7 months of the execution of this contract, did the Provider have a 2 nd meeting with the Executive Director(s) of the Center(s) to ensure the Center s clients are receiving the services required, to evaluate the referral process, and to assess the Provider s progress towards meeting its agreement requirements? a) As a result of the meeting, did the Provider, in conjunction with the Center s Executive Director, develop a plan to address any concerns regarding the services provided to the Center s clients? b) If the meeting was not scheduled to date, please explain. c) Will the meeting be scheduled? 7. Did the attorney employed by the Provider and providing legal services under this contract meet with Center representatives within 60 days of the execution of this agreement? 2

3 a) If the meeting was not scheduled to date, please explain. b) Will the meeting be scheduled? 8. Did the attorney employed by the Provider and providing legal services under this contract meet with Center representatives within 7 months of the execution of this agreement? a) If the meeting was not scheduled to date, please explain. b) Will the meeting be scheduled? 9. Did an Attorney from the Provider attend the one-day Legal Clearinghouse Training offered during the term of this agreement? Who: a) If not yet offered, is an Attorney designated to attend when offered? Who: 10. Does the Provider give eligible clients priority status for representation in dissolution of marriage cases and for emergency representation in the types of cases allowable under this contract? 11. Does the Provider accept referrals of clients from all of the Centers listed in its contract? List Centers: 3

4 12. Does the Provider identify and track activities and demographics of victims served under this agreement in compliance with the requirements of the Federal Annual Progress Report? How: Please provide documentation. 13. Does the Provider track general consultation services? How: Please provide documentation. V. Support to Deaf and Hard-of-Hearing Yes No N/A Yes No N/A 14. Is the Provider aware it must comply with Section 504, the ADA, and CFOP 60-10, Chapter 4? 15. Does the Provider comply with the requirements listed in Section 14 of the contract: a) If the Provider employs 15 or more employees agency-wide, has a Single Point of Contact (SPOC) been designated to ensure effective communication with deaf or hard-of-hearing customers or companions? Please provide the Employee Roster (to include all employees). b) What is the current SPOC's name and title? c) What date was the current SPOC appointed? d) If the SPOC changed, was the FCADV grant or contract manager notified within 5 business days of the change? 16. Are the following notices conspicuously posted near where people enter or are admitted within the Provider's location(s)? Posters (size 11x17) are found at : 4

5 a) Interpreter Services for the Hearing-Impaired poster (provides information about the availability of appropriate auxiliary aids and services at no-cost to the deaf or hard-of-hearing customers or companions) and has the ADA/504 Coordinator and Single Point of Contact names and telephone numbers affixed as well as the TDD number? b) DCF Non-Discrimination poster? c) Limited English Proficiency poster? VI. Observation of Facility Yes No N/A Yes No N/A 17. Does the Provider s facility have designated, accessible parking? 18. Is there accessible entrance to the Provider s building? VII. Personnel Files Yes No N/A Yes No N/A 19. Is there an annual signed attestation regarding Section 504, the ADA, and CFOP 60-10, Chapter 4 for each employee? Applicable for Provider s with 15 or more employees agency-wide. Provide signed attestations for those working under this contract. 20. Did direct-service employees, working under this contract, sign the annual Attestation of Understanding regarding Serving our Customers who are Deaf or Hard-of-Hearing? Provide signed attestations for those working under this contract. 21. Did direct-service employees, working under this contract, complete the annual training certificates of completion for Serving our Customers who are Deaf or Hard-of-Hearing? Provide certificates of completion. CERTIFICATION: 5

6 I attest that I, the undersigned, have read the above-listed statements and attest that the answers I provided are true, accurate, and complete to the best of my knowledge. Signature Provider Date Print/Type Clearly Name Provider Title FOR FCADV STAFF ONLY This Self-Evaluation and Attestation, along with provided documentation has been reviewed for compliance by: Signature FCADV Monitor Print/Type Clearly Name FCADV Monitor Date Reviewed 6

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