CJCC Risk Assessment Questionnaire

This risk assessment ensures compliance with CJCC’s Grants Management policy and the Federal Office of Management and Budget (OMB) Uniform Guidance (200.331(b)) which require that we conduct a financial review and evaluate each sub-grantee’s risk of non-compliance (statute/regulations/terms of award) for purposes of monitoring. The information provided will be used to assess your compliance with financial and programmatic requirements in accordance with state and/or federal regulations. This questionnaire will require the following documents to be uploaded:

ORGANIZATIONAL STRUCTURE

List of Board of Directors (Non-Profits)
By-Laws (Non-Profits)
Board Minutes
Sustainability Plan
Succession Plan

FISCAL

Chart of Accounts
Financial Statements (previous quarter):
- Balance Sheet
- Income Statement (Profit & Loss)
- Statement of Cash Flow
A-133 Audit Report (If Applicable)
IRS Form 990

Name of Individual Completing this Assessment*

First Name

Last Name

Title/Position*

Email*

Phone*

Agency Profile

Agency Name*

Physical Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Agency Phone*

Agency Website Address

Name of Executive Director or Highest Official Within Agency*

First Name

Last Name

Name of Primary Fiscal/Financial Agent Within Agency*

First Name

Last Name

Agency/Project Budget

Please provide the total budget for all programs within your agency allocated to victim services for the prior fiscal year.

Federal: any funding independently obtained through direct application and award
State: any funding coming from a state funded grant
Local: any funding obtained through the community and/or fundraising
Other: any funding that does not meet any of the aforementioned criteria (please specify)

Federal Funds* $

State Funds* $

Local Funds* $

Other (Non-Federal)* $

Provide Brief Explanation of "Other Non-Federal" Funds*

Total Agency Budget $

Federal Funding %

Agency/Project Budget 2

Please provide the total amount in grant funding and the total amount of all other funding sources received within the past 5 years for victim services.

(“Other Funding Sources” includes all unrestricted funds, such as private donations and fundraising dollars. “Grant Funding” includes as all state, federal, foundation, and restricted grant funded dollars.)

Grant Funding: 2019* $

Other Funding Sources: 2019* $

Grant Funding: 2018* $

Other Funding Sources: 2018* $

Grant Funding: 2017* $

Other Funding Sources: 2017* $

Grant Funding: 2016* $

Other Funding Sources: 2016* $

Grant Funding: 2015* $

Other Funding Sources: 2015* $

Grant Funding: 2014* $

Other Funding Sources: 2014* $

Average Monthly Available Cash on Hand* $

Average Monthly Operating Expenses* $

Number

Single Audit Act

Did your agency expend $750,000 or more in federal funding during your agency's prior fiscal year?*

Yes No

Did your agency undergo a Single Audit (OMB A-133 Audit) covering your agency's prior fiscal year?*

Yes No

Did your agency submit your Single Audit to the Federal Audit Clearinghouse?*

Yes No

Georgia Department of Audits

Did your agency expend $100,000 or more in state funds during the prior fiscal/calendar year?*

Yes No

Did your agency conduct an annual audit of its financial records covering the prior fiscal/calendar year?*

Yes No

Did your agency submit your annual financial statements to the Georgia Department of Audits?*

Yes No

Did your agency submit your annual financial statements to the CJCC?*

Yes No

Is your agency required to complete the IRS Form 990?*

Yes No

Agency Personnel

State the total number of staff within the agency/organization.*

How many staff members have resigned or been terminated within the past 24 months?*

Were any of these resignations and/or terminations in key program leadership positions?*

Yes No

How many key program leadership staff resigned or were terminated from their position?*

Were any of these resignations and/or terminations in grant funded positions?*

Yes No

How many grant funded staff resigned or were terminated from their position?*

Separation of Duties

Record keeping: The process of creating and maintaining departmental records of revenues, expenditures, inventories, and personnel transactions.
Authorization: The process of reviewing and approving transactions.
Asset custody: Having access to or control over any physical asset such as cash, checks, equipment, supplies, or materials.
Reconciliation: Verifying the processing or recording of transactions to ensure that all transactions are valid, properly authorized, and properly recorded on a timely basis.

Are the duties listed above performed by different staff members?*

Yes No

State the titles of the positions/individuals responsible for these duties.*

What mitigating controls has the agency put in place to help reduce the risks associated with inadequately segregating essential functions/duties?*

Does your agency have written policies and procedures regarding separation of duties?*

Yes No

ACCOUNTING & BOOKKEEPING

What method of accounting does the agency use for record-keeping?*

Accural Cash Basis

What system/software does the agency use for accounting record-keeping?*

Does the accounting system have the ability to identify the receipt and expenditure of program funds separately for each grant? Please provide a brief explanation.*

Does the accounting system have the capability to document the recording of match, cash or inkind, for each grant?*

How often does the agency reconcile its bank statements?*

PROGRAM & SERVICE MANAGEMENT

What are the agency’s procedures regarding clients they are unable to serve?*

What outreach activities does the agency engage in?*

Who are the agency’s primary community partners?*

What type of system is used to track client data and/or statistics?*

PROGRAM & SERVICE MANAGEMENT

How does the agency plan to meet its match requirement? *

If not applicable write "N/A"

Describe how your agency serves clients who are not proficient in the English language, blind, deaf/hard of hearing, and/or lacking the ability to speak.*

Describe how client feedback or input is incorporated into the planning, design, delivery, and evaluation of services.*

If you receive referrals from third parties or other agencies, describe how the exchange of information ensures victim confidentiality during each interaction.*

If not applicable write "N/A"

SUSTAINABILITY

Does the agency currently have a written sustainability plan to ensure the continued growth and the long-term viability of the agency?*

Yes No Not Applicable

What is your agency doing to increase its non-federal funding sources?*

How will the victim service program(s) be sustained in the event of the reduction or elimination of grant funding?*

All CJCC administered federal funding is reimbursement-based. In the event of a delayed reimbursement, how will your agency maintain adequate cash flow? *

How long can your agency maintain adequate cash flow in the event of a delay.*

Less than 1 month 1 to 2 months 3 to 6 months More than 6 months