OCFS-5003 (12/2/2010) Page 1 of 8

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

INDIVIDUAL PROGRAM APPLICATION

Program Summary-Program Components

IMPLEMENTING AGENCY:

PROGRAM TITLE:

Life Area 1:

(Enter Code)	GOAL 1:

(Enter Code)

OBJECTIVE 1:

(Enter Code)	SOS 1:

(Enter Code)

Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages.

Gender of program Participants: (Enter number participants per gender)	MALE

FEMALE
ETHNICITY:

(Enter number of participants per ethnic group)	WHITE	BLACK OR AFRICAN AMERICAN	HISPANIC OR LATINO
AMERICAN INDIAN OR ALASKAN NATIVE	ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	TWO OR MORE RACES
AGES	0-4	5-9	10-14	15-17	18-20	21+
Is Target Population serving Disconnected Youth:

(Enter number of participants per population described)	No	Yes
If “Yes”,	Youth aging out of foster care	Children of incarcerated parents
Youth in the juvenile justice system who re-enter the community	Runaway and Homeless Youth

If Applicable

OBJECTIVE 1:

(Enter Code)	SOS 2:

(Enter Code)

Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages.

Gender of program Participants: (Enter number participants per gender)	MALE

FEMALE
ETHNICITY:

(Enter number of participants per ethnic group)	WHITE	BLACK OR AFRICAN AMERICAN	HISPANIC OR LATINO
AMERICAN INDIAN OR ALASKAN NATIVE	ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	TWO OR MORE RACES
AGES	0-4	5-9	10-14	15-17	18-20	21+
Is Target Population serving Disconnected Youth:

(Enter number of participants per population described)	No	Yes
If “Yes”,	Youth aging out of foster care	Children of incarcerated parents
Youth in the juvenile justice system who re-enter the community	Runaway and Homeless Youth

OCFS-5003 (12/2/2010) Page 2 of 8

IMPLEMENTING AGENCY:

PROGRAM TITLE:

If Applicable

OBJECTIVE 2:

(Enter Code)	SOS 1:

(Enter Code)

Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages.

Gender of program Participants: (Enter number participants per gender)	MALE

FEMALE
ETHNICITY:

(Enter number of participants per ethnic group)	WHITE	BLACK OR AFRICAN AMERICAN	HISPANIC OR LATINO
AMERICAN INDIAN OR ALASKAN NATIVE	ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	TWO OR MORE RACES
AGES	0-4	5-9	10-14	15-17	18-20	21+
Is Target Population serving Disconnected Youth:

(Enter number of participants per population described)	No	Yes
If “Yes”,	Youth aging out of foster care	Children of incarcerated parents
Youth in the juvenile justice system who re-enter the community	Runaway and Homeless Youth

If Applicable

OBJECTIVE 2:

(Enter Code)	SOS 2:

(Enter Code)

Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages.

Gender of program Participants: (Enter number participants per gender)	MALE

FEMALE
ETHNICITY:

(Enter number of participants per ethnic group)	WHITE	BLACK OR AFRICAN AMERICAN	HISPANIC OR LATINO
AMERICAN INDIAN OR ALASKAN NATIVE	ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	TWO OR MORE RACES
AGES	0-4	5-9	10-14	15-17	18-20	21+
Is Target Population serving Disconnected Youth:

(Enter number of participants per population described)	No	Yes
If “Yes”,	Youth aging out of foster care	Children of incarcerated parents
Youth in the juvenile justice system who re-enter the community	Runaway and Homeless Youth

OCFS-5003 (12/2/2010) Page 3 of 8

IMPLEMENTING AGENCY:

PROGRAM TITLE:

If Applicable

OBJECTIVE 3:

(Enter Code)	SOS 1:

(Enter Code)

Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages.

Gender of program Participants: (Enter number participants per gender)	MALE

FEMALE
ETHNICITY:

(Enter number of participants per ethnic group)	WHITE	BLACK OR AFRICAN AMERICAN	HISPANIC OR LATINO
AMERICAN INDIAN OR ALASKAN NATIVE	ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	TWO OR MORE RACES
AGES	0-4	5-9	10-14	15-17	18-20	21+
Is Target Population serving Disconnected Youth:

(Enter number of participants per population described)	No	Yes
If “Yes”,	Youth aging out of foster care	Children of incarcerated parents
Youth in the juvenile justice system who re-enter the community	Runaway and Homeless Youth

If Applicable

OBJECTIVE 3:

(Enter Code)	SOS 2:

(Enter Code)

Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages.

Gender of program Participants: (Enter number participants per gender)	MALE

FEMALE
ETHNICITY:

(Enter number of participants per ethnic group)	WHITE	BLACK OR AFRICAN AMERICAN	HISPANIC OR LATINO
AMERICAN INDIAN OR ALASKAN NATIVE	ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	TWO OR MORE RACES
AGES	0-4	5-9	10-14	15-17	18-20	21+
Is Target Population serving Disconnected Youth:

(Enter number of participants per population described)	No	Yes
If “Yes”,	Youth aging out of foster care	Children of incarcerated parents
Youth in the juvenile justice system who re-enter the community	Runaway and Homeless Youth

OCFS-5003 (12/2/2010) Page 4 of 8

IMPLEMENTING AGENCY:

PROGRAM TITLE:

Life Area 2:

(Enter Code)	GOAL 1:

(Enter Code)

OBJECTIVE 1:

(Enter Code)	SOS 1:

(Enter Code)

Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages.

Gender of program Participants: (Enter number participants per gender)	MALE

FEMALE
ETHNICITY:

(Enter number of participants per ethnic group)	WHITE	BLACK OR AFRICAN AMERICAN	HISPANIC OR LATINO
AMERICAN INDIAN OR ALASKAN NATIVE	ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	TWO OR MORE RACES
AGES	0-4	5-9	10-14	15-17	18-20	21+
Is Target Population serving Disconnected Youth:

(Enter number of participants per population described)	No	Yes
If “Yes”,	Youth aging out of foster care	Children of incarcerated parents
Youth in the juvenile justice system who re-enter the community	Runaway and Homeless Youth

If Applicable

OBJECTIVE 1:

(Enter Code)	SOS 2:

(Enter Code)

Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages.

Gender of program Participants: (Enter number participants per gender)	MALE

FEMALE
ETHNICITY:

(Enter number of participants per ethnic group)	WHITE	BLACK OR AFRICAN AMERICAN	HISPANIC OR LATINO
AMERICAN INDIAN OR ALASKAN NATIVE	ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	TWO OR MORE RACES
AGES	0-4	5-9	10-14	15-17	18-20	21+
Is Target Population serving Disconnected Youth:

(Enter number of participants per population described)	No	Yes
If “Yes”,	Youth aging out of foster care	Children of incarcerated parents
Youth in the juvenile justice system who re-enter the community	Runaway and Homeless Youth

OCFS-5003 (12/2/2010) Page 5 of 8

IMPLEMENTING AGENCY:

PROGRAM TITLE:

If Applicable

OBJECTIVE 2:

(Enter Code)	SOS 1:

(Enter Code)

Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages.

Gender of program Participants: (Enter number participants per gender)	MALE

FEMALE
ETHNICITY:

(Enter number of participants per ethnic group)	WHITE	BLACK OR AFRICAN AMERICAN	HISPANIC OR LATINO
AMERICAN INDIAN OR ALASKAN NATIVE	ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	TWO OR MORE RACES
AGES	0-4	5-9	10-14	15-17	18-20	21+
Is Target Population serving Disconnected Youth:

(Enter number of participants per population described)	No	Yes
If “Yes”,	Youth aging out of foster care	Children of incarcerated parents
Youth in the juvenile justice system who re-enter the community	Runaway and Homeless Youth

If Applicable

OBJECTIVE 2:

(Enter Code)	SOS 2:

(Enter Code)

Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages.

Gender of program Participants: (Enter number participants per gender)	MALE

FEMALE
ETHNICITY:

(Enter number of participants per ethnic group)	WHITE	BLACK OR AFRICAN AMERICAN	HISPANIC OR LATINO
AMERICAN INDIAN OR ALASKAN NATIVE	ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	TWO OR MORE RACES
AGES	0-4	5-9	10-14	15-17	18-20	21+
Is Target Population serving Disconnected Youth:

(Enter number of participants per population described)	No	Yes
If “Yes”,	Youth aging out of foster care	Children of incarcerated parents
Youth in the juvenile justice system who re-enter the community	Runaway and Homeless Youth

OCFS-5003 (12/2/2010) Page 6 of 8

IMPLEMENTING AGENCY:

PROGRAM TITLE:

If Applicable

OBJECTIVE 3:

(Enter Code)	SOS 1:

(Enter Code)

Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages.

Gender of program Participants: (Enter number participants per gender)	MALE

FEMALE
ETHNICITY:

(Enter number of participants per ethnic group)	WHITE	BLACK OR AFRICAN AMERICAN	HISPANIC OR LATINO
AMERICAN INDIAN OR ALASKAN NATIVE	ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	TWO OR MORE RACES
AGES	0-4	5-9	10-14	15-17	18-20	21+
Is Target Population serving Disconnected Youth:

(Enter number of participants per population described)	No	Yes
If “Yes”,	Youth aging out of foster care	Children of incarcerated parents
Youth in the juvenile justice system who re-enter the community	Runaway and Homeless Youth

If Applicable

OBJECTIVE 3:

(Enter Code)	SOS 2:

(Enter Code)

Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages.

Gender of program Participants: (Enter number participants per gender)	MALE

FEMALE
ETHNICITY:

(Enter number of participants per ethnic group)	WHITE	BLACK OR AFRICAN AMERICAN	HISPANIC OR LATINO
AMERICAN INDIAN OR ALASKAN NATIVE	ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER	TWO OR MORE RACES
AGES	0-4	5-9	10-14	15-17	18-20	21+
Is Target Population serving Disconnected Youth:

(Enter number of participants per population described)	No	Yes
If “Yes”,	Youth aging out of foster care	Children of incarcerated parents
Youth in the juvenile justice system who re-enter the community	Runaway and Homeless Youth

OCFS-5003 (12/2/2010) Page 7 of 8

New York State

Office of Children and Family Services

INDIVIDUAL PROGRAM APPLICATION

Program Summary-Program Components (OCFS 5003) Instructions

The only change to the 5003 is the addition of the age category 21+

There is now an age category – 21+ that should be used for programs, like parenting programs or professional development, where it can be documented that the end result has a positive impact on the youth of your community. Please use whole numbers, not percentages.

Implementing Agency: Enter name of incorporated agency responsible for program.

Program Title: Enter the title of the program.

Each program can have a maximum of:

Two Life areas

Two Goals per Life Area

Three Objectives per Goal

Two Services, Opportunities and Supports per Objective

Step 1: For the Primary Program Component, identify the Life Area to be addressed and the appropriate code.

1 ES:	Economic Security

You would enter code 1ES.

Step 2: Select the GOAL to be targeted and its code.

11 Goal: Youth will be prepared for their eventual economic self sufficiency.

You would enter code 11.

Step 3: Select the objective to be achieved. Choices under this goal include:

111 Objective: Youth will have skills, attitudes and competencies to enter college, the work force or other meaningful activities.

112 Objective: Young adults who can work will have opportunities for employment.

113 Objective: Youth seeking summer jobs will have employment opportunities.

If you selected Objective 111 - Youth will have skills, attitudes and competencies to enter college, the work force or other meaningful activities

You would enter code 111.

Step 4: Select from the following choices the Services Opportunities and Supports that your program offers.

Services, Opportunities, and Supports

011.	Career Counseling

0110.	Interest & Skills Assessment

012.	Career Days/Fairs

0111.	Job Shadowing

013.	Career Research & Planning

0112.	Job Training/Employment Skills Development

014.	College Exploration & Readiness

0113.	Matching with Employers for Internships/Work

015.	College Research & Planning

0114.	Resume & Job Assistance

016.	Computer/Internet Skills

0115.	Self-sufficiency Skills Development

017.	Employment

0116.	Summer Employment

018.	GED Preparation

0117.	Vocational Training

019.	Independent Living Skills

0118.	Work Readiness Skills

OCFS-5003 (12/2/2010) Page 8 of 8

If you selected Services, Opportunities and Supports 011 Career Counseling

You would enter code 011.

Step 5: Enter the following data on your projected target population (in whole numbers not percentages) for those youth participating in - Career Counseling:

○ Gender	○Ethnicity	○Ages

○ And if serving Disconnected Youth identify the number (not percentages) in each group (i.e. Youth aging out of foster care, Children of incarcerated parents, Youth in juvenile justice system who re-enter community, Runaway and Homeless Youth)

Step 6: (IF APPLICABLE): If your program offers a Secondary Services, Opportunities and Supports for Objective 1 you would:

Re-enter code for Objective 1, 111 (from example above).

At this point you would repeat step 4 as outlined above, entering the code for the Secondary Services, Opportunities and Supports that your program offers.

Objective 1: 111 SOS 2: 019 (Independent Living Skills)

Next you would repeat step 5 as outlined above entering that data for those youth participating in- Independent Living Skills

Step 7: (IF APPLICABLE): If your Program chooses to address a 2nd Objective for GOAL 1, you would follow steps 3-5. Step 6 would be applicable as well; if there were a secondary Services, Opportunities and Supports that your program offers for the 2nd objective.

Step 8: (IF APPLICABLE): If your Program chooses to address a 3rd Objective for GOAL 1, you would follow steps 3-5. Step 6 would be applicable as well; if there were a secondary Services, Opportunities and Supports that your program offers for the 3rd objective.

If this Program addresses a 2nd Life Area and 2nd Goal you would repeat Steps 1-5 entering your new codes. Steps 6-8 would be followed as outlined above, if applicable.

Special Notes:

If the program checked the box on the OCFS-5002, Direct Services will not be provided by this program, follow steps 1-4 for each life area selected.

Each Life area has its own set of Goal(s), Objectives and Services, Opportunities and Supports. Once you identify the Life Area your program is addressing you must use the Goal(s), Objectives and Services, Opportunities and Supports listed under it.

OCFS-5003

Individual Program Application - Program Summary - Program Component

OCFS-5003; Program Summary; Program Application; Program Component; 5003 form

ax9740

2011-06-28

afoy

Youth Development

OCFS