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Florida Department of Corrections (Florida Department of Corrections)

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Page 1 of 3
DC5-801 (Revised 6/14/19)
Florida Department of Corrections
Bureau of Applied Science, Research & Policy
Program Clearinghouse Application
APPLICANT CONTACT INFORMATION
Applicant Name:
Date:
LAST
FIRST
M.I.
Address:
STREET ADDRESS
UNIT #
STATE
ZIP CODE
Phone:
EMAIL:
PROGRAM INFORMATION
Title of Program/Service:
Intent of Program/Service:
What are you requesting from
the Florida Department of
Corrections? Please be specific
(program implementation
,
purchase material, etc.)
Has any portion of the program, or the program in its entirety, been created by an inmate(s)?
YES
NO
Are there any potential copyright violations associated with the program being applied?
YES
NO
Are you receiving grant funding for implementation?
YES
NO
If YES, please provide the following information:
Grant Title:
Agency:
Have you already been in contact with a representative from the facility regarding this program?
YES NO
If YES, please provide the following information:
Name:
Title:
Facility:
Application Number: _____________
(For internal use, only.)
Page 2 of 3
DC5-801 (Revised 6/14/19)
SUMMARY OF PROGRAM
Please provide a response to the following questions regarding the program/service being applied for and attach all
applicable material.
1. Is there a structured curriculum, lesson plan, facilitator’s guide, or outline that shows the overall objective of the
program and the modules or topics covered in each session? If yes, please briefly describe and attach all applicable
material.
2. Will any modifications be made to this program? (e.g., shortened or lengthened, changed topics/activities, or
changed in any way). If yes, please explain.
3. What is the total number of program hours? Include number of days per week and number of hours per day.
4. What is the criteria for program completion?
5. What is the minimum and maximum number of participants in a group/class?
6. Who is your target audience/participants? Are there any exclusions or specific inclusion criteria?
7. Will you be providing the staff to deliver the program? If no, please describe who will facilitate the program.
8. Is training and/or credentialing required to facilitate the program? Please detail training requirements and/or
possible credentials.
9. What teaching method(s) will be used to deliver the program?
10. How will the program delivery be monitored to ensure fidelity, by whom and what frequency? Attach any applicable
monitoring tools.
Do you intend for any portion of the curriculum to be taught or facilitated by an inmate?
YES NO
At what institution(s) are you proposing to offer this program or service?
Page 3 of 3
DC5-801 (Revised 6/14/19)
11. How will you monitor the outcomes and/or completion of the program? (e.g., surveys, pre/post-tests, and/or
interviews).
12. D
escribe any benefits to the community, participant, and/or the Florida Department of Corrections.
13. Please list any other states or agencies that are currently (or previously) using this program.
14. I
s there any other pertinent information you wish to provide?
EVALUATION STUDIES
In the field below, please provide any/all citations of evaluation studies conducted specifically on the program currently
being applied. If you cannot provide evaluation studies, please explain.
SUBMISSION OF APPLICATION AND MATERIALS
Please ensure all supporting documentation and materials are included with the submission. Check any of the boxes below
to indicate what materials are being submitted.
Applications will only be reviewed once all applicable material is received.
Complete Application Curriculum or lesson plans Facilitator’s guide
Pre-test and/or Post-test Letter of support from institution Participant manual/guide
Credential, license, or training documentation for facilitator Fidelity monitoring tool
Other program materials. Please specify:
The completed application
and applicable materials can be emailed to:
ProgramClearinghouse@fdc.myflorida.com
OR sent by U.S. Mail to:
Florida Department of Corrections
Division of Development: Improvement and Readiness
Bureau of Applied Science, Research and Policy
501 South Calhoun Street
Tallahassee, FL 32399-2500
CERTIFICATION
Signature:
DATE:
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Completed 16 December 2020

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