Form Approved
OMB No. 0990-0460
Exp. Date XX/XX/20XX
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0460. The time required to complete this information collection is estimated to average 3 hours 8 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Candidate Pregnancy Assistance Fund Performance Measures
FY2017-2019 Cohort, Revision
Partnerships and Sustainability Form
How many program partners from each sector listed below were actively engaged in the PAF project of the federal grant year? [Actively engaged partners should include both state-level and local/community partner organizations who either serve as a PAF program implementation site, provide core services to the expectant and parenting PAF participants, serve on the advisory group for a PAF project, and/or provide technical assistance, or advice related to the PAF program such as to a PAF grantee or sub-grantee]
Education (K-12, Institutions of Higher Education) ____
Labor/Workforce Development Agencies ____
Health Care and Public Health (Hospitals, providers, public health departments) ____
Mental & Behavioral Health Care Providers (including substance abuse prevention and treatment) ____
Housing Agencies ____
Child Care/Early Education (including Child Care Resource & Referrals, Day Care centers, Head Start, etc.) ____
Faith-Based Organizations ____
Social Services or Human Services Agencies ____
Adoption or Foster Care Agencies ____
Juvenile Justice ____
Other Agencies _________
Total Number of Partners (unduplicated): ______________
Provide the Name and Address for Each Partner (new to this ICR)
How many program implementation sites (subawardees) were funded by the PAF grant during the grant year (July 1-June 30), by type:
High Schools (high school, charter school, any secondary school) ____
Institutes of Higher Education (2 yr. colleges, community colleges) ____
Institutes of Higher Education (4 yr. colleges/universities, public or private) ____
Community Service Organizations ____
Other (specify) ____
Total ____
How many program implementation sites (sub-recipients) were funded by the PAF grant in each of the following categories of urbanicity. [Specific definitions will be provided to grantees based on the 2013 National Center for Health Statistics Urban–Rural Classification Scheme for Counties]:
Urban ____
Rural ____
Suburban ____
(Question 4 will be asked only in the final data collection, at the end of grant year )
How many of the program sites (subawardees) report having plans to continue implementation of the core services for the expectant and parenting population after the end of OAH funding? (Firm plans includes having a work plan to continue implementation of services at the site, formal agreements with program providers to continue core program services at the site) ____
| File Type | application/msword |
| File Title | Form Approved |
| Author | DHHS |
| Last Modified By | SYSTEM |
| File Modified | 2018-12-21 |
| File Created | 2018-12-21 |