HEP Cover Sheet

Grantee Name: Grant Year: ☐ Y1 ☐ Y2 ☐Y3 ☐Y4 ☐Y5

PR Number: S14_ _ _ _ _ _ Reporting Period: 07/01/2016 — 06/30/2017

The Cover Sheet Form

U.S. Department of Education

Grant Performance Report Cover Sheet (ED 524B)

Check only one box per Program Office instructions.

[ ] Annual Performance Report [ ] Final Performance Report

General Information

1. PR/Award #: ____________________ 2. Grantee NCES ID#: _______________________

(Block 5 of the Grant Award Notification - 11 characters.) (See instructions. Up to 12 characters.)

3 Project Title: ___________________________________________________________________________

(Enter the same title as on the approved application.)

4. Grantee Name (Block 1 of the Grant Award Notification.):__________________________________

5. Grantee Address (See instructions.)

6. Project Director (See instructions.) Name:___________________________ Title: _______________________________

Ph #: ( ) ________ - __________ Ext: ( ) Fax #: ( ) ________ - __________

Email Address: _________________________________

Reporting Period Information (See instructions.)

7. Reporting Period(s):

a) Reporting Period (12-month budget period) From: __07_/_01_/_2016__ To: __06_ /_30_/_2017___ (mm/dd/yyyy)

b) Performance Period (5-year project period) From: _____/_____/_______ To: _____/_____/_______ (mm/dd/yyyy)

Budget Expenditures (To be completed by your Business Office. See instructions. Also see Section B.)

8. Budget Expenditures

	Federal Grant Funds	Non-Federal Funds (Match/Cost Share)
a. Previous Budget Period (previous 12-month Reporting Period)
b. Current Budget Period (12-month Reporting Period)
c. Entire Project Period (5-year) (For Final Performance Reports only)

Indirect Cost Information (To be completed by your Business Office. See instructions.)

9. Indirect Costs

a. Are you claiming indirect costs under this grant? ___Yes ___No

b. If yes, do you have an Indirect Cost Rate Agreement approved by the Federal Government? ___Yes ___No

c. If yes, provide the following information:

Period Covered by the Indirect Cost Rate Agreement: From: ___/ ___/____ To: ___/___/____ (mm/dd/yyyy)

Approving Federal agency: ___ED ___Other (Please specify): __________________________________________

Type of Rate (For Final Performance Reports Only): ___ Provisional ___ Final ___ Other (Please specify): _________

d. For Restricted Rate Programs (check one) -- Are you using a restricted indirect cost rate that:

___ Is included in your approved Indirect Cost Rate Agreement?

___ Complies with 34 CFR 76.564(c)(2)?

Human Subjects (Annual Institutional Review Board (IRB) Certification) (See instructions.)

10. Is the annual certification of Institutional Review Board (IRB) approval attached? ­___Yes ___ No ___ N/A

Performance Measures Status and Certification (See instructions.)

11. Performance Measures Status

a. Are complete data on performance measures for the current budget period included in the Project Status Chart? ___Yes ___ No

b. If no, when will the data be available and submitted to the Department? _____/_____/______ (mm/dd/yyyy)

12. To the best of my knowledge and belief, all data in this performance report are true and correct and the report fully discloses all known weaknesses concerning the accuracy, reliability, and completeness of the data.

_______________________________________________ Title: _______________________________________

Name of Authorized Representative:

________________________________________________ Date: _____/_____/_______

Signature:

OMB No. 1894-0003 Cover Sheet Page 3 of 3 Exp. 06/30/2017