| Address |
Mandatory - Street or box number of the administrative office of the agency. (Two lines available) |
| Age Groups |
Mandatory - The percentage of individuals projected to be served in each of these age groups: 0-3, 4-12, 13-17, 18-22, 23-64, 65+. The total must equal 100% |
| Agency Name |
Mandatory - Legal name of the agency |
| Agency Site/Unit/Program Name |
Optional - The name of the program service |
| Annual Salary |
Required, if applicable - The annual salary that each of the individuals receive that work in the program service. |
| City |
Mandatory - Community |
| Contact Person |
Mandatory - Primary person to contact |
| Cost of Production |
Mandatory - The total cost of production for the program service. |
| Days and Time of Program Service Operations |
Mandatory - Indicates the daily operating schedule of the program service during the normal work week. |
| Depreciation |
Optional - Amount of depreciation of physical assets. |
| Fee for Service |
Required, if applicable - Any fees received on a reimbursement basis for services provided to specific, eligible individuals. |
| Agency FEIN |
Mandatory - Federal Employer's Identification Number assigned to your agency. |
| Fiscal Year |
Display - Fiscal Year |
| FTE |
Mandatory - Total hours per week an individual works. |
| Funding Indicator |
Mandatory - This field is used to reflect the predominant source or type of DHS funding for the specific program cost center, including identification of funding which ''flows through'' another DHS funded entity (and identified using the ''Contract FEIN'' within the service reporting component of ROCS). The valid codes are:
1 - DHS Grant Funded
2 - Donated Funds Initiative (DFI) or Certified Funds Initiative (CFI)
3 - DHS Contract for Services
4 - Special Programs - Includes programs funded through the state hospital transition line, special federally funded projects, etc.)
5 - Non DHS Funded - Funded by DHS through another DHS funded entity (e.g. funding passed through from one agency to this agency, requiring the use of the Contract FEIN for service reporting on ROCS. |
| Fiscal Year |
Display - The state fiscal year for which grant funds are requested (July 1 - June 30). |
| Geographic Impact |
Mandatory - The County, and Township/Community Area, and Percentage of total service that this area represents. Total of percentages must equal 100%. Refer to the latest Directory of Geographic Information for codes. |
| Grants |
Required, if applicable - All grants should be specified by source and amount. |
| Key Statistic |
Mandatory - A service unit which is projected by the agency and monitored by MH/DD.
C - Client hours
E - Employee hours
R - Residential days
O - Other |
| Length of Program Service Day |
Optional - The number of hours the program service is open. |
| MH/DD Funded |
Mandatory - Percentage that your agency is funded by MH/DD. |
| Network |
Mandatory - The Mental Health or Developmental Disabilities network responsible for your agency.
MENTAL HEALTH
MHCA - Metro C & A
MHCE - Central
MHCS - Chicago - Suburban
MHMS - Metro-South
MHMN - Metro-North
MHMW - Metro-West
MHNC - North Central
MHNW - Northwest
MHSO - Southern
MHSM - Metro East Southern
DEVELOPMENTAL DISABILITIES
CE - Central City of Chicago -- City of Chicago
MCNS - North Suburban
MCSS - South Suburban
NC - North Central
NW - Northwest
SO - Southern |
| New Agency Plan |
Site - Optional - Site code to be copied/renumbered to
Unit - Optional - Unit code to be copied/renumbered to
Program Service - Mandatory - Program service code to be copied/renumbered to
Fiscal Year - Mandatory - Fiscal year to be copied/renumbered to |
| Number of Days Open |
Mandatory - Total days this program service is expected to be open for service during the fiscal year. |
| Old Agency Plan |
Site - Display - Site code to be copied/renumbered from
Unit - Display - Unit code to be copied/renumbered from
Program Service - Display - Program service code to be copied/renumbered from
Fiscal Year - Display - Fiscal year to be copied/renumbered from |
| Agency Site/Unit/Program Name |
Mandatory - Name of the program service |
| Other Sources |
Required, if applicable - The total amount from other sources. |
| Primary Service Population |
Mandatory - The percentage of total individuals projected to be served in each of these categories: MI, DD, and Other. The total must equal 100%. |
| Program Service |
Mandatory - The specific program service for which grant funds are being received. |
| Program Service Capacity |
Optional - Maximum number of individuals the program service can maintain at one time (For residential programs only) |
| Projected Surplus/Deficit Expense |
Mandatory - The projected accrued operating expenses (including depreciation) as they would be expected to occur over the course of the fiscal year. |
| Projected Revenue |
Mandatory - The projected income for the program service. |
| Projected Services Unit |
Total Projected Service - Mandatory - The number of service units projected for UNITS each month of the fiscal year.
Registered Individuals - Optional - For each month, the number of unduplicated INDIVIDUALS registered individuals to be served.
Average Units Per Registered Individual - Optional - For each month, the monthly average contacts REG IND per registered individual.
Contact Non-Reg - Optional - For each month, the total monthly contacts made to non-registered individuals. |
| Retire Qtr |
Display - Fiscal year and quarter the program service was retired. |
| State |
Mandatory - Post Office abbreviation for State. |
| Telephone Number |
Mandatory - Telephone number of contact person. |
| Tot and MH/DD - Unit Cost |
Display - The total unit cost and total MH/DD unit cost. |
| Tot Exps Net Cost Prod |
Display - The amount of total operating expenses minus the Cost of Production. |
| Tot Prj Opr Exp W/Dep |
Mandatory - The total projected accrued operating expenses, including depreciation. |
| Tot Prj Operating Exp |
Mandatory - The total projected accrued operating expenses, excluding depreciation. |
| Total Salary |
Required, if applicable - The total salary of the individuals working in this program service. |
| Total FETs |
Required, if applicable - Total FTEs that work in this program service. |
| Total Grant Disbursements |
Mandatory - The projected monthly MH/DD grant disbursements to be received for the operation of this program service over the course of the fiscal year. |
| Total Revenue |
Mandatory - The total of fees for services, grants, and other miscellaneous sources. |
| Unit |
Required, if applicable - If used, a unique number which may be used to differentiate among program service locations or functions. NOTE: Beginning with FY1999 Agency Plans, this field is mandatory for Office of Mental Health (OMH) funded programs. Please refer to your OMH Agency Plan Instructions for further guidance |
| ZIP Code |
Mandatory - Post Office designation (5 or 9 digits). |
