Attachment B: GenIC Example - Monitoring Activities - Assessment Survey

OMB Control No: 0970-0XXX

Expiration date: XX/XX/XXXX

Example Generic Information Collection for Monitoring Activities – Assessment Survey

Project Outcome Assessment Survey

Grantee Information (Pre-Filled by Federal Staff)

Grantee Name:

Project Title:

Grant Number:

Geographic Designation:

Number of Program Specialists during Project Period:

Grant Category: [DROP DOWN MENU]

Grant Sub-Category:

Original Project Duration:

Total Federal Funding Amount:

Objective Work Plan

1. Objective 1

Relevant Year(s); o Yr1 o Yr2 o Yr3 o Yr4 o Yr5

Percent Complete: 0, 25, 50, 75, 100, 100+%

Objective

Results (Outputs)/Benefits (Outcomes) Expected:

Criteria for Evaluating Results and Benefits Expected:

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering information about states’ compliance with activities as required in the XX regulations. Public reporting burden for this collection of information is estimated to average 6 hours per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required to retain a benefit, per XX authority. 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. The OMB # is 0970-0XXX and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact [contact information].

Deliverables

Product	Documentation Reviewed/Comments

Comments

Results (Outputs) and Benefits (Outcomes)

1. Community the project was designed to serve ___

2. Number of people the project was designed to serve_____

3. Number of people the project actually served_____

Indicator(s)	Baseline	Year 1	Year 2	Year 3	3-Year End of Project	Means of Measurement

4. Describe how your indicator was achieved throughout the project.

5. Was the indicator from the application the best measurement to capture the outcomes of your project?

6. If not how would you have identified or revised the indicator?

7. Name up to three achievements you are most proud of and would want to share about your project?

1)

2)

3)

8. What project outcomes would you like to sustain after ACF funds end, and what is needed to sustain such outcomes?

9. What factors will contribute to the continued sustainability of this project?

Factors	Comments

10. What obstacles are foreseen to project sustainability over the next 5 years?

Project Development

1. How was the project developed? Please describe how the community was involved in the development process.

2. Was the project’s target population involved during project planning prior to the grant award?

3. Is there anything you would have done differently in planning your project?

4. What marketing or outreach methods did you use to bring attention to your project? (Check any that apply.)

o Brochures and Pamphlets

o Email

o Festivals and Community Events

o Networking (with Other Tribes, Agencies, Organizations, Businesses)

o Newspaper Advertisements

o Newspaper Coverage

o Onsite Community Outreach (knock on doors)

o Phone Calls

o Posting Information in Public Spaces

o Radio (includes PSAs and other programming)

o Regular Mail

o Social Media (such as Facebook, Twitter, Youtube, etc.);

o Community Meetings

o Organizational Publications or Newsletters

o TV (includes PSAs and other programming)

o Website

o Word of Mouth

o Other: ________________________

5. In terms of marketing/outreach, what would you have done differently?

6. How was the project received by the community?

7. How did you keep the community engaged or updated throughout the project?

Project Challenges

1. Did you have any challenges that affected your ability to implement the project?

Rank	Challenge	Ability to Overcome Challenge?	Comments
	Staff turnover	
	Late start due to ACF notification	
	Late start due to hiring delays	
	Scope too ambitious	
	Geographic isolation/travel issues	
	Lack of expertise	
	Challenges with ACF processes	
	Challenges with OGM processes	
	Underestimated project cost	
	Underestimated personnel needs	
	Partnership fell through	
	Lack of community support (planning)	
	Lack of community support (implementation)	
	Insufficient Community Infrastructure	
	Personal or Community Loss/Hardship	
	Natural Disaster	
	Lack of Organizational Capacity	
	Other	

Project Economic Benefits

1. Were any businesses created by the project?

Yes o No o N/A o

Business Name	Type (eval instruction: use a one or two work descriptor)	Ownership Type Native, Women, Vet

2. Were any businesses expanded?

Yes o No o N/A o

3. If yes, how were they expanded?