Form 1 CSBG Module 1

OMB #0970-0492

Expiration Date: XX/XX/XXXX

Community Services Block Grant (CSBG)

Annual Report – State Administration Module

Section A: CSBG Lead Agency, CSBG Authorized Official, CSBG Point of Contact

A.1. Lead Agency: Review and update (as applicable) the following information in relation to the lead agency designated to administer the CSBG in the state, as required by Section 676(a) of the CSBG Act.

A.1a. Lead Agency

A.1b. Cabinet or administrative department of this lead agency

A.1c. Cabinet or Administrative Department Name: Provide the name of the cabinet or administrative department of the CSBG authorized official

A.1d. Authorized official of the lead agency

Name Title

A.1e. Street Address

A.1f. City

A.1g. State

A.1h. Zip code

A.1i. Work Telephone number and Extension (if applicable)

A.1j. Fax Number

A.1k. Email Address

A.1l. Lead Agency Website

A.2. Please check additional programs administered by the state CSBG Lead Agency during the reporting year (FFY).

 Weatherization Assistance Program (WAP)

 Low Income Home Energy Assistance Program (LIHEAP)

 Social Services Block Grant (SSBG)

 U.S. Department of Agriculture programs (Specify)

 U.S. Department of Housing and Urban Development (HUD) programs (Specify)

 U.S. Department of Labor (Specify)

 Other (Specify)

Section B: Statewide Goals and Accomplishments

B.1. Progress on State Plan Goals: Describe progress in meeting the state’s CSBG-specific goals for state administration of CSBG as described in the CSBG State Plan.

State Plan Goals: [This will auto-populate from the CSBG State Plan and will not be revisable]

Select the status that best fits the current status of your CSBG state goals as provided in your CSBG State Plan, and provide additional details.

 All Goals Accomplished – describe how all goals were accomplished, including outcomes:

 Goals Partially Accomplished – describe which goals were met and how, and provide an update on goals that have not yet been met:

 Not Accomplished – explain why goals were not met:

Note: This information is associated with State Accountability Measure 1Sa(i) and will be used in assessing overall progress in meeting state goals.

B.2. CSBG Eligible Entity Overall Satisfaction Targets: In the table below, provide the state’s most recent target for CSBG Eligible Entity Overall Satisfaction during the performance period (FFY).

Prior Year Target	Most Recent American Customer Satisfaction Index Survey Result	Future Target
This auto-populates from the CSBG State Plan 3.5

Instructional Note: Because the CSBG State Plan may cover two fiscal years, annual updates related to CSBG Eligible Entity satisfaction should be provided in this annual report. The state’s target score will indicate improvement or maintenance of the state’s Overall Satisfaction score from the most recent American Customer Survey Index (ACSI) survey of the state’s CSBG eligible entities. States that did not receive ACSI scores (i.e. states with only a single CSBG eligible entity) should not complete B.2, but should provide narrative descriptions of other sources of customer feedback and customer feedback and the state’s response to that feedback in question B.3. For more information on the ACSI and establishment of targets, see CBSG Information Memorandum #150 Use of the American Customer Satisfaction Index (ACSI) to improve Network Effectiveness.

B.3. CSBG Eligible Entity Feedback and Involvement: How has the state considered feedback from CSBG eligible entities, OCS, public hearings, and other sources, and/or customer satisfaction surveys such as the American Customer Satisfaction Index (ACSI)? What actions have been taken as a result of this feedback?

B.4. State Management Accomplishment: Describe what you consider to be the top management accomplishment achieved by your state CSBG office during the reporting year (FFY). Provide examples of how administrative or leadership actions led to improvements in efficiency, accountability, or quality of services and strategies.

B.5. CSBG Eligible Entity Management Accomplishments: Describe three notable management accomplishments achieved by CSBG eligible entities in your state during the reporting year (FFY). Describe how responsible, informed leadership, and effective, efficient processes led to high-quality, accessible, and well-managed services and strategies.

B.6. Innovative Solutions Highlights: Provide at least three examples of ways in which a CSBG eligible entity addressed a cause or condition of poverty in the community using an innovative or creative approach. Provide the agency name, local partners involved, outcomes, and specific information on how CSBG funds were used to support implementation.

Section C: CSBG Eligible Entity Update

C.1. Changes to Eligible Entities: The table below includes a list of CSBG eligible entities receiving 90 percent funds within the state, as reported within the CSBG State Plan for this reporting period.

Did the list of eligible entities change during the reporting year (FFY)? If yes, briefly describe the changes. Please also update the Master List prior to the submission of your next CSBG State Plan.

If the eligible entity was designated or re-designated, de-designated or voluntarily relinquished, or merged with another eligible entity(ies), provide additional details in the next submission of the CSBG State Plan.

CSBG Eligible Entity	Geographical Area Served (by county)	Public or Nonprofit	Type of Entity	A change occurred during the reporting period (FFY)	Briefly describe changes
[Read-only]	[Read-only]	[Read-only]	[Read-only]	 Yes, please describe  No  Designated or re-designated  De-designated or voluntarily relinquished  Merged

Instructional Note: Limited Purpose Agency refers to a CSBG eligible entity that was designated as a limited purpose agency under Title II of the Economic Opportunity Act of 1964 for the fiscal year 1981, that served the general purposes of a community action agency under Title II of the Economic Opportunity Act as a result of failure to comply with that Act; and has not lost its designation as a CSBG eligible entity under the CSBG Act.

Instructional Note: 90 percent funds are the funds a state provides to eligible entities to carry out the purposes of the CSBG Act, as described under Section 675C of the CSBG Act. A state must provide “no less than 90 percent” of their CSBG allocation, under Section 675B, to the eligible entities.

C.2. Total number of CSBG Eligible Entities:

Section D: Organizational Standards for CSBG Eligible Entities

Note: Reference CSBG Information Memorandum #138 State Establishment of Organizational Standards for CSBG Eligible Entities

D.1. Assessment of Organizational Standards: In the CSBG State Plan, the state indicated whether it would implement the Center of Excellence (COE) organizational standards, a modified version, or an alternative set of standards for its oversight of CSBG:

The state’s original response is provided below:

 COE CSBG Organizational Standards

 Modified version of COE CSBG Organizational Standards

 Alternative set of organizational standards

Note: A change to the type of Organizational Standards chosen in the original submission of the CSBG State Plan during the reporting period would require an updated CSBG State Plan.

D.1a. Organizational Standards Assessment: Review and update, as applicable, how the state assessed CSBG eligible entities against organizational standards, as described in IM 138.

 Peer-to-peer review (with validation by the state or state-authorized third party)

 Self-assessment (with validation by the state or state-authorized third party)

 Self-assessment/peer review with state risk analysis

 State-authorized third party validation

 Regular, on-site CSBG monitoring

 Other

D.1b. Describe the assessment process as implemented by the state. Please describe any changes in the assessment process that occurred since the time of the state plan submission. Please note that with the exception of regular on-site CSBG monitoring, all assessment options above may include either on-site or desk review (or a combination). The specific state process should be described in this narrative.

D.2. Organizational Standards Performance: In the table below, please provide the percentage of CSBG eligible entities that met all state-adopted organizational standards in the reporting period (FFY). The target set in the CSBG State Plan is provided in the left-hand column. For more information on the CSBG Organizational Standards, see CSBG Information Memorandum #138.

Note: This information is associated with State Accountability Measures 6Sa.

Total Number of Entities Assessed

Note: The states should assess all eligible entities unless the state exempted the eligible entities per guidance in IM #138, as originally reported in the CSBG State Plan.

Total Number of Entities within the State	Number of Entities Exempted	Number of Assessable Entities	Number of Entities Assessed
[Auto-populated C.2]	[Insert a number between 0 – 99]	[Auto-calculated]	[Insert a number between 0 – 99]

Target vs. Actual Performance on the Organizational Standards

State CSBG Plan Target	Number that Met All (100%) of State Standards
Auto-populated target from CSBG State Plan	[Insert a number between 0 – 99]

Progress Indicators

Indicate the number of entities that met the following percentages of Organizational Standards.

Note: While the state targets the percent of CSBG Eligible Entities to meet 100 percent of the Organizational Standards, targets are not set in the State Plan for 90, 80, 70, and 60 percent progress indicators.

Number of Entities Assessed	Number that Met All (100%) of State Standards	Actual Percentage
[Auto-populated from table above]	[Insert a number between 0 – 99]	[Auto-calculated]
Number of Entities Assessed	Number that Met between 90% and 99% of state standards	Actual Percentage
[Auto-populated from table above]	[Insert a number between 0 – 99]	[Auto-calculated]
Number of Entities Assessed	Number that Met between 80% and 89% of state standards	Actual Percentage
[Auto-populated from table above]	[Insert a number between 0 – 99]	[Auto-calculated]
Number of Entities Assessed	Number that Met between 70% and 79% of state standards	Actual Percentage
[Auto-populated from table above]	[Insert a number between 0 – 99]	[Auto-calculated]
Number of Entities Assessed	Number that Met less than 69% of state standards	Actual Percentage
[Auto-populated from table above]	[Insert a number between 0 – 99]	[Auto-calculated]

D.2a. In the space below, identify the challenges and factors contributing to the difference between the target and actual results provided in the topo row of Table D.2 (above).

D.2b. Percentage Meeting Organizational Standards by Category: In the table below, provide the number of eligible entities that met each category of the Organizational Standards. The percentage that meet all standards in each category will be automatically calculated and totaled in the bottom row.

Category	Number of Entities Assessed	Number that Met All Standards in Category	Actual Percentage
Consumer Input & Involvement	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
Community Engagement	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
Community Assessment	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
Organizational Leadership	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
Board Governance	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
Strategic Planning	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
Human Resource Management	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
Financial Operations & Oversight	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
Data and Analysis	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]

D.3. Technical Assistance Plans for Unmet Organizational Standards: As outlined in IM 138, states are expected to develop a Technical Assistance Plan (TAP) where needed to assist an eligible entity to meet the standard in a reasonable timeframe.

Did the state develop any TAPs specifically for eligible entities with unmet organizational standards to assist in meeting the standard(s) in a reasonable timeframe?  Yes  No

If yes, how many eligible entities are on a TAP, specifically for unmet organizational standards? Provide a numerical amount between 0 – 99.

D.3a. If the state identified CSBG eligible entities with unmet organizational standards for which it was determined that TAPS would not be appropriate, please provide a narrative explanation below.  Yes  No

Note: D.3 is associated with State Accountability Measure 6Sb.

Section E: State Use of Funds

Note: The purpose of this section is to report on the funds received and spent during the Federal Fiscal Year (FFY), October 1 – September 30. Please review the final award letter received during the Federal Fiscal Year for the reporting period and the Federal Financial Report (FFR) submitted using standard form 425 (SF-425) for this for this reporting period. Please ensure that any allocations, obligations, and carry-over amounts reported below are for funds awarded in this federal fiscal year and are reconciled with the amounts reported in the FFR.

An electronic version of the FFR is available for reference on the following web address:

CSBG Eligible Entity Allocation (90 Percent Funds) [Section 675C(a) of the CSBG Act]

E.1. State Distribution Formula: Did the state institute any changes in the distribution formula for the CSBG eligible entities during the reporting period covered by this report?  Yes  No

E.1a. If yes, please describe any specific changes and describe how the state complied with assurances provided in Question 14.8 of the CSBG State Plan as required under Section 676(b)(8) of the State CSBG Act.

E.2. Planned vs. Actual Allocation and Expenditures: Using the table below, specify the actual allocation of 90 percent of CSBG funds to CSBG eligible entities, as described under Section 675C(a) of the CSBG Act. This table must be based on actual dollars allocated, obligated to, and expended (liquidated) for each CSBG eligible entity during the Federal Fiscal Year (FFY). For each CSBG eligible entity receiving CSBG funds, provide the Funding Amount allocated to the CSBG eligible entity during the FFY.

Note: The Amount Allocated and the Amount Obligated are going to be an exact match the majority of the time. Amounts expended (liquidated) should reflect actual payments made to eligible entities.

CSBG Eligible Entity	Planned Allocations	Actual Amount of Allocations (The Amount Allotted to each entity based on State Formula from current FFY funding)	Actual Amount of Obligations (The actual amount made available through sub-award to each entity during the FFY from current FFY funding)	Actual Expenditures (The actual amount liquidated to each entity during the FFY from current FFY funding)	Carryover Expenditures (The actual amount liquidated to each entity during the FFY from prior FFY funding)
Auto-populated from the CSBG State Plan, Table 5.1, Column 1 and cannot be revised.	Auto-populated from the CSBG State Plan Table 7.2 and cannot be revised.	[Numeric response, specify $ amount]	[Numeric response, specify $ amount]	[Numeric response, specify $ amount]	[Numeric response, specify $ amount]
Total	Total will be auto-calculated	Total will be auto-calculated	Total will be auto-calculated	Total will be auto-calculated	Total will be auto-calculated

E.3. Actual Distribution Timeframe: Did the state make funds available to CSBG eligible entities no later than 30 days after OCS distributed the federal award.  Yes  No

E.3a. If no, did the state implement procedures to ensure funds were made available to CSBG eligible entities consistently and without interruption?  Yes  No

E.3b. If the state was not able to make CSBG funds available within 30 calendar days after OCS distributed the federal award and was not able to ensure that funds were made available consistently and without interruption, provide an explanation of the circumstances below along with a description of planned corrective actions.

Note: Item E.3 is associated with State Accountability Measure 2Sa.

Administrative Funds [Section 675C(b)(2) of the CSBG Act]

E.4. State Administrative Funds: What amount of state CSBG funds did the state obligate for administrative activities during the FFY? The amount must be based on actual dollars allocated during the FFY. If you provided a percentage in Question 7.6 in the CSBG State Plan, please convert to dollars.

CSBG State Plan Target	Actual Amount of Allocation (The amount allotted for state administrative activities)	Actual Amount of Obligation (The actual amount formally committed for procurement or direct expenditure activities during the FFY through state)	Actual Amount of Expenditures (The actual amount liquidated through procurement or direct expenditure activities during the FFY through state)	Actual Carryover Expenditures (The actual amount liquidated through procurement or direct expenditure activities from prior year FFY through state)
[Auto-populated target from the CSBG State Plan Question 7.6]	[Numeric Response, specify $ amount]	[Numeric response, specify $ amount]	[Numeric response, specify $ amount]	[Numeric response, specify $ amount]

E.5. State Staff Positions Funded: How many state staff positions were funded in whole or in part with CSBG funds in the reporting period (FFY)?

CSBG State Plan	Actual Number
[Auto-populated target from the CSBG State Plan Question 7.7]	[Insert a Number between 0 – 99]

E.6. State FTEs: How many state Full Time Equivalents (FTEs) were funded with CSBG funds in the reporting period (FFY)?

CSBG State Plan	Actual Number
[Auto-populated target from the CSBG State Plan Question 7.8]	[Insert a Number between 0 – 99]

Remainder/Discretionary Funds [Section 675C(b) of the CSBG Act]

E.7. Describe how the state used remainder/discretionary funds in the table below.

Instructional Note: This table in the administrative report must be based on actual dollars obligated to each budget category using funds awarded in this federal fiscal year. States that do not have remainder/discretionary funds will not complete this item. If a funded activity fits under more than one category in the table, allocated the funds among the categories.

For example, if the state provides funds under a contract with the state Community Action Association to provide T/TA to CSBG eligible entities and to create a statewide data system, the funds for that contract should be allocated appropriately between Row a and Row c. If an allocation is not possible, the state may allocate the funds to the main category with which the activity is associated.

Note: This information is associated with State Accountability Measures 3Sa.

Remainder/Discretionary Fund Uses (See 675C(b)(1) of the CSBG Act)	Planned Allocation (Pre-populated from CSBG State Plan)	Actual Allocation (The Actual Amount Allotted)	Actual Obligation (The Actual Amount formally committed)	Actual Expenditure (The actual amount liquidated)	Actual Carryover Expenditure (The actual amount liquidated from prior FFY funding)	Brief Description of services/activities (Briefly describe the actual services and activities)
E.7a. Training/technical assistance to eligible entities	[Pre-populated from the state plan]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Provide a Narrative]
E.7b. Coordination of state-operated programs and/or local programs	[Pre-populated from the state plan]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Provide a Narrative]
E.7c. Statewide coordination and communication among eligible entities	[Pre-populated from the state plan]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Provide a Narrative]
E.7d. Analysis of distribution of CSBG funds to determine if targeting greatest need	[Pre-populated from the state plan]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Provide a Narrative]
E.7e. Asset-building programs	[Pre-populated from the state plan]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Provide a Narrative]
E.7f. Innovative programs/activities by eligible entities or other neighborhood groups	[Pre-populated from the state plan]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Provide a Narrative]
E.7g. State charity tax credits	[Pre-populated from the state plan]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Provide a Narrative]
E.7h. Other activities, specify	[Pre-populated from the state plan]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	[Enter a numeric response]	Narrative 2500 characters
Totals	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated	Auto-calculated

E.8. What types of organizations, if any, did the state work with (by grant or contract using remainder/discretionary funds) to carry out some or all of the activities in Table E.7 (above). Check all that apply and provide a narrative where applicable.

 CSBG Eligible Entities (if checked, include the expected number of CSBG eligible entities to receive funds)

 Other community-based organizations

 State Community Action Association

 Regional CSBG technical assistance provider(s)

 National technical assistance provider(s)

 Individual consultant(s)

 Tribes and Tribal Organizations

 Other

 None (the state will carry out activities directly)

E.9 Total Obligations and Expenditures: Total CSBG funds obligated and expended from CSBG funds awarded for the FFY. Review and confirm from the chart below).

Category	Actual Obligations	Actual Expenditures
E.9a. CSBG eligible entities Funds (from State CSBG 90% formula funds)	Auto-populated from Table E.2 (total actual obligations in contracts and sub-awards)	Auto-populated from Table E.2 (total actual liquidations)
E.9b. State Administrative Costs	Auto-populated from Table E.4 (total actual obligations of administrative funds)	Auto-populated from Table E.4 (total actual liquidations)
E.9c. Remainder/Discretionary Funds	Auto-populated from Table E.7 (total actual obligations of state remainder/discretionary funds)	Auto-populated from Table E.7 (total actual liquidations)
E.9d. Total	Total will be auto-calculated from three rows above	Total will be auto-calculated from three rows above

E.10. Total Award Amount and Unobligated Balance: In the table below, provide the unobligated balance for the federal fiscal year. The amount provided should be identical to the unobligated balance of federal funds as reported in LINE H of the FFR for this reporting year. This is the amount that was unobligated and will carry forward to the next federal fiscal year.

Note: The total award amount should be identical to the amount reported in LINE D of the FFR. If this amount does not reconcile, please review.

Category	Totals
E.10a. Total Obligations	Auto-populated from Table E.9 (total actual obligations)
E.10b. Total Expenditures	Auto-populated from Table E.9 (total actual expenditures)
E.10c. Unobligated Balance from the FFY	[Numeric response, specify $ amount]
E.10d. Total Award Amount	Total will be auto-calculated from E.10b and E.10c above

Section F: State Training and Technical Assistance

F.1. Training and Technical Assistance Plan: Describe how the state delivered CSBG-funded training and technical assistance to CSBG eligible entities by completing the table below. Add a row for each activity: indicate the timeframe; whether it was training, technical assistance, or both; and the topic.

(CSBG funding used for this activity is referenced under Item E.7a, Use of Remainder/Discretionary Funds. State should also describe any training and technical assistance activities performed directly by state staff, regardless of whether these activities are funded with remainder/discretionary funds.)

Note: F.1 is associated with State Accountability Measures 3Sc.

Training, Technical Assistance, or Both	Topic	Start Date	End Date	Brief Description
Auto-populated from Table 8.1 of the CSBG State Plan Training Technical Assistance Both	Auto-populated from Table 8.1 of the CSBG State Plan Fiscal Governance/Tripartite Boards Organizational Standards – General Organizational Standards – for Eligible Entities with unmet standards on TAPs or QIPs Correcting Significant Deficiencies Among CSBG Eligible Entities Reporting ROMA Community Assessment Strategic Planning Monitoring Communication Technology Other	[Enter Date]	[Enter Date]	[Narrative, 2500 characters] Provide additional brief explanation of the technical assistance activities implemented. If “Other” was selected in Column 3, describe in this column.

Note: this table will allow you to add additional rows as needed.

F.2. Training and Technical Assistance Organizations: Indicate the types of organizations through which the state provided training and/or technical assistance as described in Item F.1, and briefly describe their involvement? (Check all that apply and provide a narrative where applicable.)

 CSBG Eligible Entities (if checked, provide the expected number of CSBG eligible entities to receive funds) [Narrative, 3 characters]

 Other community-based organizations

 State Community Action Association

 Regional CSBG Technical Assistance Provider(s)

 National Technical Assistance Provider(s)

 Individual consultant(s)

 Tribes and Tribal Organizations

 Other [Provide the types of organizations]

Section G: State Linkages and Communication

Note: This section describes activities that the state supported with CSBG remainder/discretionary funds, described under Section 675C(b)(1) of the CSBG Act.

Note: This section is associated with State Accountability Measure 7Sa.

G.1. State Linkages and Coordination at the State Level: Please review and confirm the areas for linkages and coordination that were outlined in the CSBG State Plan.

 State Low Income Home Energy Assistance Program (LIHEAP) office

 State Weatherization office

 State Temporary Assistance for Needy Families (TANF) office

 State Head Start office

 State public health office

 State education department

 State Workforce Innovation and Opportunity Act (WIOA) agency

 State budget office

 Supplemental Nutrition Assistance Program (SNAP)

 State child welfare office

 State housing office

 Other

G.1a. Describe the linkages and coordination at the state-level that the state created or maintained to ensure increased access to CSBG services by communities and people with low-incomes that avoid duplication of services (as required by the assurance under Section 676(b)(5) and identified in the CSBG State Plan. Describe or attach additional information as needed and provide a narrative describing activities including an explanation of any changes from the original CSBG State Plan.

G.2. State Linkages and Coordination at the Local Level: Review and update the actual activities for linkages and coordination at the local level that the state created or maintained during the FFY, including an explanation of any changes from the original CSBG State Plan.

Include linkages with governmental and other social services, especially antipoverty programs, to assure the effective delivery of and coordination of CSBG services to people with low-incomes and communities and avoid duplication of services (as required by assurances under Section 676(b)(5) – (6)).

G.3. CSBG Eligible Entity Linkages and Coordination

G.3a. State Assurance of CSBG Eligible Entity Linkages to Fill Service Gaps: Review and update how the state assured that the CSBG Eligible Entities coordinated and established linkages to assure the effective delivery and coordination of CSBG services to people with low-incomes and communities and avoid duplication of services (as required by the assurance under Section 676(b)(5)). Attach additional information as needed.

G.3b. State Assurance of CSBG Eligible Entity Linkages to Fill Service Gaps: Review and update how the CSBG eligible entities developed linkages to fill identified gaps in the services, through the provision of information, referrals, case management, and follow-up consultations, according to the assurance under Section 676(b)(3)(B) of the CSBG Act.

G.4. Workforce Innovation and Opportunity Act (WIOA) Employment and Training Combined Plan Activities (if applicable): If the state included CSBG employment and training activities as part of a WIOA Combined State Plan, as allowed under the Workforce Innovation and Opportunity Act, provide a brief narrative describing the status of WIOA coordination activities, including web links, if available, to any publicly accessible combined plans and reports.

G.5. Coordination among CSBG Eligible Entities and the State Community Action Association: Review and update state activities that took place to support coordination among the CSBG eligible entities and the State Community Action Association.

G.6. Feedback to CSBG Eligible Entities and State Community Action Association: Review and update how the state provided feedback to local entities and the State Community Action Association regarding its performance on State Accountability Measures.

Note: This information is associated with State Accountability Measure 5S(iii). The measure indicates feedback should be provided within 60 calendar days of the state receiving feedback from OCS.

Section H: Monitoring, Corrective Action, and Fiscal Controls

H.1. Monitoring Schedule: Update the monitoring Briefly describe the actual monitoring visits conducted during the FFY, including: full on-site reviews; on-site reviews of newly designated entities; follow-up reviews – including return visits to entities that failed to meet state goals, standards, and requirements; and other reviews as appropriate.

If a monitoring visits was planned during the year but not implemented, provide a brief explanation in the far right column of the table below.

Note: This information is associated with State Accountability Measure 4Sa(i).

CSBG Eligible Entity	Monitoring Type	Review Type	Monitoring Start Date	Monitoring End Date	Brief Description of Purpose
[Auto-populated from CSBG State Plan 10.1]	Dropdown Options: Full onsite Newly Designated Follow-up Other No Review	Dropdown Options: Onsite Review Desk Review	[Enter Date]	[Enter End Date]	[Narrative, 500 characters] Note: If the visit was not a part of the original monitoring plan, provide a brief explanation for the purpose of the visit (e.g. a follow-up regarding a special issue). This section should not be used to outline findings.

Note: this table will allow you to add additional rows as needed, but you will not be able to delete rows from your CSBG State Plan submission.

H.2. Monitoring Policies: Were any modifications made to the state’s monitoring policies and procedures during the reporting period (FFY)?  Yes  No

If changes were made to state monitoring policies and procedures, attach and/or provide a hyperlink to the modified documents. [Attach a document or provide a link]

H.3. Initial Monitoring Reports: Were all state monitoring reports conducted in a manner consistent with state monitoring policies and procedures and disseminated to CSBG eligible entities within 60 calendar days?  Yes  No

Note: This item is associated with State Accountability Measure 4Sa(ii).

Corrective Action, Termination, and Reduction of Funding and Assurance Requirements (Section 678C of the CSBG Act)

H.4. Technical Assistance Plans (TAPs)

H.4a. Technical Assistance Plans (TAPs): Are there any CSBG eligible entities within the state that are on a TAP due to issues of noncompliance identified during a monitoring review during the FFY?  Yes  No

H.4b. Creating Technical Assistance Plans (TAPs): Did the state work with all monitored CSBG eligible entities with issues of noncompliance to create a TAPs, as necessary?  Yes  No

H.4c. Reporting TAPs: Did the state report all TAPs to the Office of Community Services within 30 calendar days of creation?  Yes  No

H.5. Quality Improvement Plans (QIPs)

H.5a. Quality Improvement Plans (QIPs): Are there any CSBG eligible entities within the state that are on a QIP due to unresolved issues of noncompliance identified in the TAP?  Yes  No

H.5b. Creating Quality Improvement Plans (QIPs): Did all CSBG eligible entities on Quality Improvement Plans resolve issues of noncompliance within the schedule agreed upon by the state and eligible entity?  Yes  No

H.5c. Reporting QIPs: Did the state report all CSBG eligible entities with serious deficiencies from a monitoring review to the Office of Community Services within 30 calendar days of the state approving a QIP?  Yes  No

Fiscal Controls and Audits

H.6. Single Audit Review: Pass through entities are required by 2 CFR 200.331(f) to verify that every sub-recipient is audited as required by 2 CFR 200.501. In the table below, provide the information of any CSBG eligible entity Single Audits in the Federal Audit Clearinghouse (FAC) submitted during the Federal Fiscal Year (FFY).

2 CFR 200.521 requires pass-through entities to provide the management decision for findings related to federal awards the pass-through makes to the sub-recipients. If applicable, provide the information regarding these decisions.

Note: Per 2 CFR 200.501, each eligible entity that receives at least $750,000 of all federal funds, is required to submit a Single Audit within the FAC annually. A State Management Decision is required within 6 months (2 CFR 200.521(d)), if there is a CSBG finding within the Single Audit.

Eligible Entity	Eligible Entity Required to Report Single Audit in FAC	Eligible Entity Submitted a Single Audit in FAC?	Date Audit was Accepted by Federal Audit Clearinghouse	If Entity did not submit as required, has the state taken steps to ensure compliance?	State Management Decision Required? (As Applicable)	Date Management Decision Issued (As applicable)
Auto-populated from Eligible Entity Master List	[Yes or No]	[Yes, No, or Late]	[Enter Date]	[Yes or No]	[Yes or No]	[Enter Date]

Note: Rows may be added for each additional Single Audit accepted by the Federal Audit Clearinghouse during the fiscal year.

H.7. Single Audit Management Decisions: Briefly describe any management decisions issued according to state procedures of CSBG eligible entity single audit. Provide the audit finding reference number from the Federal Audit Clearinghouse and describe any required actions and timelines for correction.

Note: This information is associated with State Accountability Measure 4Sd.

Section I: Results Oriented Management and Accountability (ROMA) System

I.1. Performance Management System Participation: Confirm the performance measurement system that the state and CBSG eligible entities use, as required by Section 678E(a) of the CSBG Act and the assurance under Section 676(b)(12) of the CSBG Act.

 The Results Oriented Management and Accountability (ROMA) System

 Another performance management system that meets the requirements of Section 678E(b) of the CSBG Act

 An alternative system for measuring performance and results

I.1a. If ROMA was selected in I.1, provide an update on any changes in procedures or to data collection systems that were initiated or completed in the reporting period.

I.1b. If ROMA was not selected in Item I.1, describe the system the state used for performance measurement. Provide an update on any changes in procedures or to data collection systems that were initiated or completed in the reporting period.

I.2. State ROMA Support: How did the state support the CSBG eligible entities in using the ROMA system or alternative performance measurement system in promoting continuous improvement? For example, describe any data systems improvements, support for community needs assessment, support for strategic planning, data analysis, etc.

I.3. State Review of CSBG Eligible Entity Data: Describe the procedures and activities the state used to review the ROMA data (i.e. all data from elements of the ROMA cycle) from CSBG eligible entities for completion and accuracy (e.g. methodology used for validating the data submitted annually by the local agencies).

I.4. State Feedback on Data Collection, Analysis, and Reporting: State Accountability Measure 5S(ii) requires states to submit written feedback to each CSBG eligible entity regarding the entity’s performance in meeting ROMA goals, as measured through National Performance Indicator (NPI) data, within 60 calendar days of submitting the state’s Annual Report. Has the state provided each CSBG eligible entity with timely feedback (within at least 60 days of the submission) regarding the entity’s performance in meeting ROMA goals as measured through national performance data?

 Yes  No

If yes, please describe.

Note: This information is associated with State Accountability Measure 5S(ii).

I.5. State and CSBG Eligible Entity Continuous Improvement: Provide 2 – 3 examples of changes made by CSBG eligible entities to improve service delivery and enhance impact for individuals, families, and communities with low-incomes based on their in-depth analysis of performance data.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this collection is to meet the requirement of the Community Services Block Grant (CSBG) Act (42 U.S.C. § 9901, et seq) that all states that receive CSBG funding participate in a performance management system (Section 678E(a)(1)(A))) and submit a report to the Secretary on an annual basis (Section 678E(a)(2)). Public reporting burden for this collection of information is estimated to average 198 hours per grantee and 697 hours per sub-grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information per the Community Services Block Grant (CSBG) Act (42 U.S.C. § 9901, et seq) Section 678E(a)(1)(A)) and Section 678E(a)(2). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information, please contact CSBGStates@acf.hhs.gov.