2.1 CSBG Annual Report - FY25

OMB #0970-0492

Expiration Date: XX/XX/XXXX

Community Services Block Grant

Annual Report Version 2.1

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.

CSBG Annual Report Table of Contents

State Administration – Module 1 1

Section A - CSBG Lead Agency, CSBG Authorized Official, CSBG Point of Contact 2

Section B - Statewide Goals and Accomplishments 3

Section C - CSBG Eligible Entity Update 5

Section D - Organizational Standards for Eligible Entities 6

Section E - State Use of Funds 9

Section F - State Training and Technical Assistance 13

Section G - State Linkages and Communication 15

Section H - Monitoring, Corrective Action, and Fiscal Controls 17

Section I - Results Oriented Management and Accountability (ROMA) 19

Eligible Entity Expenditures, Capacity, and Resources – Module 2 20

Section A: Eligible Entity Expenditures 22

Section B: Eligible Entity Capacity 23

Section C: Eligible Entity Resources Administered by the CSBG Network 24

Community Level – Module 3 26

Section A: Community Initiatives Status Form 28

Section B: Community Level National Performance Indicators (NPIs) 29

Section C: Community Strategies List 40

Individual and Family Level – Module 4 43

Section A: Individual and Family National Performance Indicators (NPIs) 45

Section B: Individual and Family Services 53

Section C: All Characteristics Report 61

State Administration – Module 1

Note: The reporting timeframes for all information in the state administration module is based on the FEDERAL FISCAL YEAR, which runs from October 1 of a given calendar year until September 30 of the following calendar year. When completing the annual report, respondents will first indicate the Federal Fiscal Year for which the state is submitting data. The On-Line Data Collection (OLDC) will then pre-populate the State Administration module with information from the appropriate year (year 1 or year 2, as applicable) in the accepted CSBG State Plan. States will be able to update information in these sections, as necessary.

CSBG Annual Report V2 Module 1

Community Services Block Grant (CSBG) Annual Report – State Administration Module

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

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

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

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.

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 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.

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

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.

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.

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

1. Changes to Eligible Entities: The table below includes a list of CSBG eligible entities receiving 90% 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% 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%” of their CSBG allocation, under

Section 675B, to the eligible entities.

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

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 CSBG 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.

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
1. Consumer Input & Involvement	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
2. Community Engagement	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
3. Community Assessment	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
4. Organizational Leadership	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
5. Board Governance	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
6. Strategic Planning	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
7. Human Resource Management	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
8. Financial Operations & Oversight	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]
9. Data and Analysis	[Auto-populated from Module 1, D.2.]	[Insert a number between 0 – 99]	[Auto-calculated]

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 reporting period. Please ensure that any allocations, obligations, and carry-over amounts reported below are for funds awarded in this FFY and are reconciled with the amounts reported in the FFR.

An electronic version of the FFR is available for reference.

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

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 the assurances provided in Question 14.8 of the CSBG State Plan as required under Section 676(b)(8) of the State CSBG Act.

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 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- awards 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

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]

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]

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]

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]

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, allocate 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/acti vities (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]

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/acti vities (Briefly describe the actual services and activities)
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

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

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.

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.

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.

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)).

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.

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.

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.

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

1. Monitoring Schedule: Update the monitoring schedule below. 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 visit 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.

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]

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)

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

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

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 for any CSBG eligible entity Single Audit in the Federal Audit Clearinghouse (FAC) submitted during the Federal Fiscal Year (FFY).

2 CFR 200.521 requires pass-through entities to provide a 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 in 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 Managemen t Decision Required? (As Applicable)	Date Managemen t 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.

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

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.

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.

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).

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).

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.

Eligible Entity Expenditures, Capacity, and Resources – Module 2

CSBG Annual Report V2 Module 2

Instructional Notes

Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity

Section A: CSBG Expenditures by CSBG Eligible Entity Data Entry Form meets the Congressional requirement for an explanation of the total amount of CSBG funding expended during the reporting period (identified below) based on categories referenced in the CSBG Act.

CSBG funding expended during the reporting period should be identified in the domain that best reflects the services delivered and strategies implemented, as well as the administrative costs associated with the domains.

Module 2, Section B: CSBG Eligible Entity Capacity Building

Section B: CSBG Eligible Entity Capacity Building Data Entry Form provides detail on agency capacity building funded by CSBG and other funding sources.

Module 2, Section C: Allocated Resources per CSBG Eligible Entity

Section C: Allocated Resources per CSBG Eligible Entity data entry form provides data on resources allocated to, administered through, and generated by the CSBG Eligible Entity. This report provides valuable information on how CSBG leverages funds from multiple federal, state, local, and private sources as required in the CSBG Act.

CSBG Annual Report V2 Module 2, Instructional Notes

Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity

Name of CSBG Eligible Entity Reporting:
State:	UEI:
A.1. CSBG Eligible Entity Reporting Period	"X"
A.1a. July 1 - June 30
A.1b. October 1 - September 30
A.1c. January 1 - December 31

A.2. CSBG Expenditures Domains	CSBG Funds
A.2a. Employment
A.2b. Education and Cognitive Development
A.2c. Income, Infrastructure, and Asset Building
A.2d. Housing
A.2e. Health and Social/Behavioral Development (includes nutrition)
A.2f. Civic Engagement and Community Involvement
A.2g. Services Supporting Multiple Domains
A.2h. Linkages (e.g. partnerships that support multiple domains)
A.2i. Agency Capacity Building (detailed below in Table A.4)
A.2j. Other (e.g. emergency management/disaster relief)
A.2k. Total CSBG Expenditures (auto calculated)	$0

A.3. Of the CSBG funds reported above, report the total amount used for Administration. For more information on what qualifies as Administration, refer to IM37.

A.4. Details on Agency Capacity Building Activities Funded by CSBG:

1. Please identify which activities were funded by CSBG under Agency Capacity in Table A.2. Please check all that apply.

^{Community Needs Assessment Data Management & Reporting} Other* Strategic Planning Training & Technical Assistance

*Below please specify Other Activities funded by CSBG under Agency Capacity:

CSBG Annual Report V2 Module 2, Section A: Eligible Entity Expenditures

Module 2, Section B: CSBG Eligible Entity Capacity Building

Name of CSBG Eligible Entity Reporting:
State:	UEI:
B.1. CSBG Eligible Entity Reporting Period	"X"
B.1a. July 1 - June 30	auto-populated from Module 2, Section A
B.1b. October 1 - September 30
B.1c. January 1 - December 31

B.2. Hours of Agency Capacity Building (e.g. training, planning, assessment):	Hours
B.2a. Hours of Board Members in capacity building activities
B.2b. Hours of Agency Staff in capacity building activities

B.3. Volunteer Hours of Agency Capacity Building (e.g. program support, service delivery, fundraising):	Hours
B.3a. Total number of volunteer hours donated to the agency
B.3a.1. Of the above, the total number of volunteer hours donated by individuals with low-incomes

B.4. The number of staff who hold certifications that increase agency capacity to achieve family and community outcomes, as measured by one or more of the following:	Number
B.4a. Number of Nationally Certified ROMA Trainers
B.4b. Number of Nationally Certified ROMA Implementers
B.4c. Number of Certified Community Action Professionals (CCAP)
B.4d. Number of Staff with a child development certification
B.4e. Number of Staff with a family development certification
B.4f. Number of Pathways Reviewers
B.4g. Number of Staff with Home Energy Professional Certifications
B.4g.1. Number of Energy Auditors
B.4g.2. Number of Retrofit Installer Technicians
B.4g.3. Number of Crew Leaders
B.4g.4. Number of Quality Control Inspectors (QCI)
B.4h. Number of LEED Risk Certified assessors
B.4i. Number of Building Performance Institute (BPI) certified professionals
B.4j. Number of Classroom Assessment Scoring System (CLASS) certified professionals
B.4k. Number of Certified Housing Quality Standards (HQS) Inspectors
B.4l. Number of American Institute of Certified Planners (AICP)
B.4m. Other (Please specify others below):

B.5. Number of organizations, both public and private, that the CSBG Eligible Entity actively works with to expand resources and opportunities in order to achieve family and community outcomes:	Unduplicated Number of Organizations
B.5a. Non-Profit
B.5b. Faith Based
B.5c. Local Government
B.5d. State Government
B.5e. Federal Government
B.5f. For-Profit Business or Corporation
B.5g. Consortiums/Collaborations
B.5h. School Districts
B.5i. Institutions of Post-Secondary Education/Training
B.5j. Financial/Banking Institutions
B.5k. Health Service Organizations
B.5l. Statewide Associations or Collaborations

CSBG Annual Report V2 Module 2, Section B: Eligible Entity Capacity

Name of CSBG Eligible Entity Reporting:
State:	UEI:
C.1. CSBG Eligible Entity Reporting Period		"X"
C.1a. July 1 - June 30		auto-populated from Module 2, Section A
C.1b. October 1 - September 30
C.1c. January 1 - December 31

2. Amount of FY 20XX CSBG allocated to reporting entity

3. 

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   C.3a. Weatherization (DOE) (include oil overcharge $$ ) C.3b. Health and Human Services (HHS)			C.3a.
   C.3b.1. LIHEAP - Fuel Assistance (include oil overcharge $$ )			C.3b.1.
   C.3b.2. LIHEAP - Weatherization (include oil overcharge $$ )			C.3b.2.
   C.3b.3. Head Start			C.3b.3.
   C.3b.4. Early Head Start			C.3b.4.
   C.3b.5. Older Americans Act			C.3b.5.
   C.3b.6. Social Services Block Grant (SSBG)			C.3b.6.
   C.3b.7. Medicare/Medicaid			C.3b.7.
   C.3b.8. Assets for Independence (AFI)			C.3b.8.
   C.3b.9. Temporary Assistance for Needy Families (TANF)			C.3b.9.
   C.3b.10. Child Care Development Block Grant (CCDBG)			C.3b.10.
   C.3b.11. Community Economic Development (CED)			C.3b.11.
   C.3b.12. Other HHS Resources
   C.3b.12.i.	CFDA #:		C.3b.12.i.
   C.3b.12.ii.	CFDA #:		C.3b.12.ii.
   C.3b.12.iii.	CFDA #:		C.3b.12.iii.
   C.3b.12.iv.	CFDA #:		C.3b.12.iv.
   C.3b.12.v.	CFDA #:		C.3b.12.v.
   C.3b.12.vi.	CFDA #:		C.3b.12.vi.
   C.3b.12.vii.	CFDA #:		C.3b.12.vii.
   C.3b.12.viii.	CFDA #:		C.3b.12.viii.
   C.3b.12.ix.	CFDA #:		C.3b.12.ix.
   C.3b.12.x.	CFDA #:		C.3b.12.x.
   C.3b.13. Total Other HHS Resources (autocalculated)			C.3b.13.

   
   

   Federal Resources Allocated (Other than CSBG)

$	-

C.3c. Department of Agriculture (USDA)

C.3c.1. Special Supplemental Nutrition for Women, Infants, and Children (WIC) C.3c.2. All USDA Non-Food programs (e.g. rural development)

C.3c.3. All other USDA Food programs

C.3d. Department of Housing and Urban Development (HUD)

C.3c.1.

C.3c.2.

C.3c.3.

C.3d.1.	Community Development Block Grant (CDBG) - Federal, State, and Local	C.3d.1.
C.3d.2.	Section 8	C.3d.2.
C.3d.3.	Section 202	C.3d.3.
C.3d.4.	Home Tenant-Based Rental Assistance (HOME TBRA)	C.3d.4.
C.3d.5.	HOPE for Homeowners Program (H4H)	C.3d.5.
C.3d.6.	Emergency Solutions Grant (ESG)	C.3d.6.
C.3d.7.	Continuum of Care (CoC)	C.3d.7.
C.3d.8.	All other HUD programs, including homeless programs	C.3d.8.

C.3e. Department of Labor (DOL)

C.3e.1. Workforce Innovation and Opportunity Act (WIOA) *previously WIA C.3e.2. Other DOL Employment and Training programs

C.3e.3. All other DOL programs

C.3f. Corporation for National and Community Service (CNCS) programs C.3g. Federal Emergency Management Agency (FEMA)

C.3h. Department of Transportation C.3i. Department of Education

C.3j. Department of Justice C.3k. Department of Treasury C.3l. Other Federal Resources

C.3l.i.		CFDA #:
C.3l.ii.		CFDA #:
C.3l.iii.		CFDA #:
C.3l.iv.		CFDA #:
C.3l.v.		CFDA #:
C.3l.vi.		CFDA #:
C.3l.vii.		CFDA #:
C.3l.viii.		CFDA #:
C.3l.ix.		CFDA #:
C.3l.x.		CFDA #:

C.3m. Total Other Federal Resources (autocalculated)

C.3n. Total: Non-CSBG Federal Resources Allocated (autocalculated)

C.3e.1.

C.3e.2.

C.3e.3. C.3f.

C.3g.

C.3h.

C.3i.

C.3j.

C.3k.

$	-
$	-

C.3l.i.

C.3l.ii.

C.3l.iii.

C.3l.iv.

C.3l.v.

C.3l.vi.

C.3l.vii. C.3l.viii. C.3l.ix.

C.3l.x. C.3m.

C.3.n.

CSBG Annual Report V2 Module 2, Section C: Eligible Entity Resources Administered by the CSBG Network

2. State Resources Allocated

C.4a. C.4b.		State appropriated funds used for the same purpose as Federal CSBG funds State Housing and Homeless programs (include housing tax credits )	C.4a. C.4b.
C.4c. C.4d.		State Nutrition programs State Early Childhood Programs (e.g. Head Start, Day Care )	C.4c. C.4d.
C.4e.		State Energy programs	C.4e.
C.4f.		State Health programs	C.4f.
C.4g.		State Youth Development programs	C.4g.
C.4h.		State Employment and Training programs	C.4h.
C.4i.		State Senior programs	C.4i.
C.4j.		State Transportation programs	C.4j.
C.4k.		State Education programs	C.4k.
C.4l.		State Community, Rural and Economic Development programs	C.4l.
C.4m.		State Family Development programs	C.4m.
C.4n.		Other State Resources
	C.4n.i.		C.4n.i.
	C.4n.ii.		C.4n.ii.
	C.4n.iii.		C.4n.iii.
	C.4n.iv.		C.4n.iv.
	C.4n.v.		C.4n.v.
	C.4n.vi.		C.4n.vi.
	C.4n.vii.		C.4n.vii.
	C.4n.viii.		C.4n.viii.
	C.4n.ix.		C.4n.ix.
	C.4n.x.		C.4n.x.

C.4o. Total Other State Resources (autocalculated)

C.4p. Total: State Resources Allocated (autocalculated)

C.4o.

$	-

C.4p.

C.4q. If any of these resources were also reported under Item C.3n. (Federal Resources), C.4q.

please estimate the amount.

2. Local Resources Allocated

C.5a.	Amount of unrestricted funds appropriated by local government	C.5a.
C.5b.	Amount of restricted funds appropriated by local government	C.5b.
C.5c.	Value of Contract Services	C.5c.
C.5d.	Value of in-kind goods/services received from local government	C.5d.

C.5e. Total: Local Resources Allocated (autocalculated)

If any of these resources were also reported under Item C.3n. or C.4p. (Federal or State

^C.5f. Resources), please estimate the amount.

C.5e.

$ -

C.5f.

2. Private Sector Resources Allocated

C.6a.	Funds from foundations, corporations, United Way, other nonprofits	C.6a.
C.6b.	Other donated funds	C.6b.
C.6c.	Value of other donated items, food, clothing, furniture, etc.	C.6c.
C.6d.	Value of in-kind services received from businesses	C.6d.
C.6e.	Payments by clients for services	C.6e.
C.6f.	Payments by private entities for goods or services for low income clients or communities	C.6f.

C.6g. Total: Private Sector Resources Allocated (autocalculated)

C.6h. ^{If any of these resources were also reported under Item C.3n., C.4p. or C.5e. (Federal, State} or Local Resources), please estimate the amount.

C.6g.

$ -

C.6h.

C.7. Total Non-CSBG Resources Allocated: (Federal, State, Local & Private) (autocalculated)	C.7.	$	-
C.8. Total Resources in CSBG Eligible Entity (including CSBG) (autocalculated)	C.8.	$	-

Note : * All totals are autocalculated

CSBG Annual Report V2 Module 2, Section C: Allocated Resources per CSBG Eligible Entity

Community Level – Module 3

Note: The data collected in this module relates to Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity and Goal 3: People with low incomes are engaged and active in building opportunities in communities.

CSBG Annual Report V2 Module 3

Instructional Notes

Module 3, Section A: Community Initiative Status Form

Section A: Community Initiatve Status Form is where CSBG Eligible Entities identify initiatives intended to achieve community level outcomes. This form provides a central place to report valuable information about a single community initiative that started, continued, or ended during the current reporting period. The information reported on the status form will be selected via a dropdown menu or written as a narrative.

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form

Section B: Community NPIs Data Entry Form provides an opportunity for CSBG Eligible Entities to enter data for the community level outcomes reported in Section A, Line 14. Entities may select from the indicators outlined in this section, or create their own indicator if none of the provided indicators captures what the CSBG Eligible Entity is trying to achieve. To facilitate the reporting, use, and learning from Community NPIs the Annual Report provides two types of indicators (Counts of Change and Rates of Change).

The first way to report impact is the Counts of Change indicators. These are basic measures that provide the number of units being measured, e.g. jobs, houses, resources, etc. that have been added (created) or subtracted (eliminated), and in some cases maintained, in the community the CSBG Eligible Entity has targeted.

The second way to report impact is the Rates of Change indicators. While requiring a bit more information, these indicators tell the full story of the magnitude of the impact a community initiative (usually involving multiple organizations) has had in a community.

Module 3, Section C: Community Strategies List

Section C: Community Strategies List provides a basic identification of strategies, arranged by Domain and by topic area. The list cannot be all-inclusive; as such, an “other” category is included. This standardized list will aid in local and state analysis of the relationship between community-level strategies and outcomes.

^{CSBG Annual Report V2} Module 3, Instructional Notes

Module 3, Section A: Community Initiative Status Form

Name of CSBG Eligible Entity Reporting:
State:	UEI:
	Use the dropdown menu to select the response where appropriate.
1. Initiative Name
2. Initiative Year	1-7+ years
3. Problem Identification	Narrative (Provide a narrative on the scope of the problem)
4. Goal/Agenda	Narrative (Provide a narrative on the goal/agenda)
5. Issue/CSBG Community Domains	Employment; Education and Cognitive Development; Income, Infrastructure, and Asset Building; Housing; Health and Social/Behavioral Development; or Civic Engagement and Community Involvement
6. Ultimate Expected Outcome	Community Level National Performance Indicators (NPIs) (Reference the Community NPIs listed in Section B)
7. Identified Community	Neighborhood, City, School District, County, Service Area, State, Region, or Other
8. Expected Duration	Narrative (Provide the range in years, e.g. 1-3 years)
9. Partnership Type	Independent CAA Initiative, CAA is the core organizer of multi-partner Initiative, or CAA is one of multiple active investors and partners
10. Partners	Narrative (Provide a narrative on the key 1-3 partners)
11. Strategy(ies)	Select from the Community Level Strategies listed in Section C
12. Progress on Outcomes/Indicators	No Outcomes to Report, Interim Outcomes, Final Outcomes
13. Impact of Outcomes	Narrative (Provide additional information on the scope of the impact of these outcomes. e.g. If an initiative created a health clinic, please describe how many individuals and families are expected to be impacted.)
14. Outcomes/Indicators to Report	Community Level National Performance Indicators (NPIs) (Reference the Community NPIs listed in Section B)
15. Final Status	Initiative Active, Initiative Ended Early, Initiative Ended as Planned, Completed Still Delivering Value
16. Lessons Learned	Narrative

^{CSBG Annual Report V2} Module 3, Section A: Community Initiative Status Form

Employment Indicators

Name of CSBG Eligible Entity Reporting:
State:		UEI:
Counts of Change	Counts of Change for Employment Indicators (CNPI 1)		I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 1a Number of jobs created to increase opportunities for people with low incomes in the identified community.					#DIV/0!
	CNPI 1b Number of job opportunities maintained in the identified community.					#DIV/0!
	CNPI 1c Number of “living wage ” jobs created in the identified community*.					#DIV/0!
	CNPI 1d Number of “living wage” jobs maintained in the identified community*.					#DIV/0!
	CNPI 1e Number of jobs created in the identified community with a benefit package.					#DIV/0!

*When reporting on indicators related to living wage, agencies can provide their own definition or select from national or locally-defined models. Please indicate the living wage definition used in the General Comment box.

Other	Other Counts of Change for Employment Indicators (CNPI 1z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
Counts of	CNPI 1z.1 Other				#DIV/0!
Change	CNPI 1z.2 Other				#DIV/0!
	CNPI 1z.3 Other				#DIV/0!

Rates of Change	Rates of Change for Employment Indicators (CNPI 1)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
	CNPI 1f Percent decrease of the unemployment rate.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 1g Percent decrease of the youth unemployment rate.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 1h Percent decrease of the underemployment rate.				#DIV/0!		#DIV/0!	#DIV/0!

Other Rates of	Other Rates of Change for Employment Indicators (CNPI 1z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 1z.4 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 1z.5 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 1z.6 Other				#DIV/0!		#DIV/0!	#DIV/0!

General comments:

Name of CSBG Eligible Entity Reporting:
State:		UEI:
Counts of Change	Counts of Change for Education and Cognitive Development Indicators (CNPI 2)		I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 2a Number of accessible and affordable early childhood or pre-school education assets or resources added to the identified community.					#DIV/0!
	CNPI 2b Number of accredited or licensed affordable child care facilities added in the identified community.					#DIV/0!
	CNPI 2c Number of new Early Childhood Screenings offered to children (ages 0-5) of families with low-incomes in the identified community.					#DIV/0!
	CNPI 2d Number of accessible and affordable education assets or resources added for school age children in the identified community. (e.g., academic, enrichment activities, before/after school care, summer programs)					#DIV/0!
	CNPI 2e Number of accessible and affordable post secondary education assets or resources added for newly graduating youth in the identified community. (e.g. college tuition, scholarships, vocational training, etc.)					#DIV/0!
	CNPI 2f Number of accessible and affordable basic or secondary education assets or resources added for adults in the identified community. (e.g. literacy, ESL, ABE/GED, etc.)					#DIV/0!

Other Counts of Change	Other Counts of Change for Education and Cognitive Development Indicators (CNPI 2z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 2z.1 Other				#DIV/0!
	CNPI 2z.2 Other				#DIV/0!
	CNPI 2z.3 Other				#DIV/0!

	Rates of Change for Education and Cognitive Development Indicators (CNPI 2)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Rates of Change	CNPI 2g Percent increase of children in the identified community who are kindergarten ready.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 2h Percent increase of children in the identified community at (or above) the basic reading level.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 2i Percent increase of children in the identified community at (or above) the basic math level.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 2j Percent increase in high school (or high school equivalency) graduation rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 2k Percent increase of the rate of youth in the identified community who attend post-secondary education.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 2l Percent increase of the rate of youth in the identified community who graduate from post-secondary education.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 2m Percent increase of adults in the identified community who attend post-secondary education.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 2n Percent increase of adults in the identified community who graduate from post-secondary education.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 2o Percent increase in the adult literacy rate in the identified community .				#DIV/0!		#DIV/0!	#DIV/0!

Other Rates of	Other Rates of Change for Education and Cognitive Development Indicators (CNPI 2z) - Please specify below.	I.) Identified Community (auto populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 2z.4 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 2z.5 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 2z.6 Other				#DIV/0!		#DIV/0!	#DIV/0!

General comments:

Name of CSBG Eligible Entity Reporting:
State:		UEI:
Counts of Change	Counts of Change for Infrastructure and Asset Building Indicators (CNPI 3)		I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 3a Number of new accessible assets/resources created in the identified community:
	CNPI 3a.1 Commercial					#DIV/0!
	CNPI 3a.2 Financial					#DIV/0!
	CNPI 3a.3 Technological/ Communications (e.g. broadband)					#DIV/0!
	CNPI 3a.4 Transportation					#DIV/0!
	CNPI 3a.5 Recreational (e.g. parks, gardens, libraries)					#DIV/0!
	CNPI 3a.6 Other Public Assets/Physical Improvements					#DIV/0!
	CNPI 3b Number of existing assets/resources made accessible to the identified community:
	CNPI 3b.1 Commercial					#DIV/0!
	CNPI 3b.2 Financial					#DIV/0!
	CNPI 3b.3 Technological/ Communications (e.g. broadband)					#DIV/0!
	CNPI 3b.4 Transportation					#DIV/0!
	CNPI 3b.5 Recreational (e.g. parks, gardens, libraries)					#DIV/0!
	CNPI 3b.6 Other Public Assets/Physical Improvements					#DIV/0!

Other Counts of Change	Other Counts of Change for Infrastructure and Asset Building Indicators (CNPI 3z) - Please specify below.	I.) Identified Community (auto populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 3z.1 Other				#DIV/0!
	CNPI 3z.2 Other				#DIV/0!
	CNPI 3z.3 Other				#DIV/0!

	Rates of Change for Infrastructure and Asset Building Indicators (CNPI 3)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	VII.) Performance target accuracy (% auto calculated)
Rates of Change	CNPI 3c Percent decrease of abandoned or neglected buildings in the identified community.				#DIV/0!	#REF!
	CNPI 3d Percent decrease in emergency response time measured in minutes in the identified community. (EMT, Police, Fire, etc.).				#DIV/0!	#REF!
	CNPI 3e Percent decrease of predatory lenders and/or lending practices in the identified community.				#DIV/0!	#REF!
	CNPI 3f Percent decrease of environmental threats to households (toxic soil, radon, lead, air quality, quality of drinking water, etc.) in the identified community.				#DIV/0!	#REF!
	CNPI 3g Percent increase of transportation services in the identified community.				#DIV/0!	#REF!
Other Rates of	Other Rates of Change for Infrastructure and Asset Building Indicators (CNPI 3z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 3z.4 Other				#DIV/0!	#REF!
	CNPI 3z.5 Other				#DIV/0!	#REF!
	CNPI 3z.6 Other				#DIV/0!	#REF!

General comments:

Name of CSBG Eligible Entity Reporting:
State:		UEI:
Counts of Change	Counts of Change for Housing Indicators (CNPI 4)		I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 4a Number of safe and affordable housing units developed in the identified community (e.g. built or set aside units for people with low incomes).					#DIV/0!
	CNPI 4b Number of safe and affordable housing units maintained and/or improved through WAP or other rehabilitation efforts in the identified community.					#DIV/0!
	CNPI 4c Number of shelter beds created in the identified community.					#DIV/0!
	CNPI 4d Number of shelter beds maintained in the identified community.					#DIV/0!

Other	Other Counts of Change for Housing Indicators (CNPI 4z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
Counts of Change	CNPI 4z.1 Other				#DIV/0!
	CNPI 4z.2 Other				#DIV/0!
	CNPI 4z.3 Other				#DIV/0!

	Rates of Change for Housing Indicators (CNPI 4)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Rates of Change	CNPI 4e Percent decrease in the rate of homelessness in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 4f Percent decrease in the foreclosure rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 4g Percent increase in the rate of home ownership of people with low incomes in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 4h Percent increase of affordable housing in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 4i Percent increase of shelter beds in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
		I.) Identified	II.) Baseline	III.) Target	IV.) Expected %	V.) Actual Results	VI.) Actual %	VII.) Performance
		Community	existing starting	(%)	change from	(%)	change from	target accuracy
	Other Rates of Change for Housing Indicators (CNPI 4z)	(auto populated)	point used for		baseline		baseline	(% auto calculated)
Other Rates of	- Please specify below.		comparisons (%)		(Target % auto calculated)		(% auto calculated)
Change
	CNPI 4z.4 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 4z.5 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 4z.6 Other				#DIV/0!		#DIV/0!	#DIV/0!

General comments:

Name of CSBG Eligible Entity Reporting:
State:		UEI:
Counts of Change	Counts of Change for Health and Social/Behavioral Indicators (CNPI 5)		I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 5a Number of accessible and affordable physical health assets or resources created in the identified community.					#DIV/0!
	CNPI 5b Number of accessible and affordable behavioral and mental health assets or resources created in the identified community.					#DIV/0!
	CNPI 5c Number of public safety assets and resources created in the identified community.					#DIV/0!
	CNPI 5d Number of accessible and affordable healthy food resources created in the identified community.					#DIV/0!
	CNPI 5e Number of activities designed to improve police and community relations within the identified community.					#DIV/0!

Other Counts of	Other Counts of Change for Health and Social/Behavioral Indicators (CNPI 5z) - Please specify below.				I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
Change	CNPI 5z.1 Other							#DIV/0!
	CNPI 5z.2 Other							#DIV/0!
	CNPI 5z.3 Other							#DIV/0!
	Rates of Change for Physical Health, Wellbeing, and Development Indicators (CNPI 5)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Rates of Change	CNPI 5f Percent decrease in infant mortality rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5g Percent decrease in childhood obesity rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5h Percent decrease in adult obesity rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5i Percent increase in child immunization rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5j Percent decrease in uninsured families in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!

	Rates of Change for Behavioral and Mental health, Emotional Wellbeing, and Development Indicators (CNPI 5)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Rates of Change	CNPI 5k Percent decrease in the teen pregnancy rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5l Percent decrease in unplanned pregnancies in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5m Percent decrease in substance abuse rate in the identified community.(e.g. cigarettes, prescription drugs, narcotics, alcohol).				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5n Percent decrease in domestic violence rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5o Percent decrease in the child abuse rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5p Percent decrease in the child neglect rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5q Percent decrease in the elder abuse rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5r Percent decrease in the elder neglect rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	Rates of Change for Public Safety Indicators (CNPI 5)	I.) Identified Community (auto populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Rates of Change	CNPI 5s Percent decrease in recidivism rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5t Percent decrease in non-violent crime rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5u Percent decrease in violent crime rate in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5v Percent decrease in teens involved with the juvenile court system in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
Other Rates of	Other Rates of Change for Health and Social/Behavioral Indicators (CNPI 5z) - Please specify below.	I.) Identified Community (auto populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 5z.4 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5z.5 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 5z.6 Other				#DIV/0!		#DIV/0!	#DIV/0!

General comments:

Name of CSBG Eligible Entity Reporting:
State:		UEI:
	Rates of Change for Civic Engagement and Community Involvement Indicators - Goal 2 (CNPI 6)	I.) Identified	II.) Baseline	III.) Target	IV.) Expected %	V.) Actual Results	VI.) Actual %	VII.) Performance
		Community (auto-populated)	existing starting point used for comparisons	(%)	change from baseline (Target % auto	(%)	change from baseline (% auto	target accuracy (% auto calculated)
			(%)		calculated)		calculated)
Rates of Change	CNPI 6 G2a Percent increase of donated time to support the CSBG Eligible Entity's delivery of services and/or implementation of strategies to address conditions of poverty in the identified community.				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 6 G2b Percent increase of donated resources to support the CSBG				#DIV/0!		#DIV/0!	#DIV/0!
	Eligible Entity's delivery of services and/or implementation of strategies
	to address conditions of poverty in the identified community.
	CNPI 6 G2c Percent increase of people participating in public hearings,				#DIV/0!		#DIV/0!	#DIV/0!
	policy forums, community planning, or other advisory boards related to the CSBG Eligible Entity's delivery of service and/or implementation of
	strategies to address conditions of poverty in the identified community.

Other Rates of	Other Rates of Change for Civic Engagement and Community Involvement Indicators - Goal 2 (CNPI 6 G2z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 6 G2z.4 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 6 G2z.5 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 6 G2z.6 Other				#DIV/0!		#DIV/0!	#DIV/0!
Other Counts of Change	Other Counts of Change for Civic Engagement and Community Involvement Indicators - Goal 2 (CNPI 6 G2z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
	CNPI 6 G2z.1 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 6 G2z.2 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 6 G2z.3 Other				#DIV/0!		#DIV/0!	#DIV/0!

General comments:

Name of CSBG Eligible Entity Reporting:
State:		UEI:
Rates of	Rates of Change for Civic Engagement and Community Involvement Indicators - Goal 3 (CNPI 6)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 6 G3a Percent increase of people with low incomes who support				#DIV/0!		#DIV/0!	#DIV/0!
	the CSBG Eligible Entity's delivery of service and/or implementation of
	strategies to address conditions of poverty in the identified community.
	CNPI 6 G3b Percent increase of people with low incomes who acquire				#DIV/0!		#DIV/0!	#DIV/0!
	and maintain leadership roles with the CSBG Eligible Entity or other
	organizations within the identified community.

Other Rates of	Other Rates of Change for Civic Engagement and Community Involvement Indicators - Goal 3 (CNPI 6 G3z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 6 G3z.4 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 6 G3z.5 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 6 G3z.6 Other				#DIV/0!		#DIV/0!	#DIV/0!
Other Counts of Change	Other Counts of Change for Civic Engagement and Community Involvement Indicators - Goal 3 (CNPI 6 G3z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
	CNPI 6 G3z.1 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 6 G3z.2 Other				#DIV/0!		#DIV/0!	#DIV/0!
	CNPI 6 G3z.3 Other				#DIV/0!		#DIV/0!	#DIV/0!

General comments:

Name of CSBG Eligible Entity Reporting:
State:	UEI:
	Employment Strategies (STR 1)
STR 1a	Minimum/Living Wage Campaign
STR 1b	Job Creation/Employment Generation
STR 1c	Job Fairs
STR 1d	Earned Income Tax Credit (EITC) Promotion
STR 1e	Commercial Space Development
STR 1f	Employer Education
STR 1g	Employment Policy Changes
STR 1h	Employment Legislative Changes
STR 1i	Other Employment Strategy: (please specify)

	Education and Cognitive Development Strategies (STR 2)
STR 2a	Preschool for All Campaign
STR 2b	Charter School Development
STR 2c	After School Enrichment Activities Promotion
STR 2d	Pre K-College/Community College Support
STR 2e	Children’s Trust Fund Creation
STR 2f	Scholarship Creation
STR 2g	Child Tax Credit (CTC) Promotion
STR 2h	Adoption Child Care Quality Rating
STR 2i	Adult Education Establishment
STR 2j	Education and Cognitive Development Policy Changes
STR 2k	Education and Cognitive Development Legislative Changes
STR 2l	Other Education and Cognitive Development Strategy: (please specify)

	Infrastructure and Asset Building Strategies (STR 3)
STR 3a	Cultural Asset Creation
STR 3b	Police/Community Relations Campaign
STR 3c	Neighborhood Safety Watch Programs
STR 3d	Anti-Predatory Lending Campaign
STR 3e	Asset Building and Savings Promotion
STR 3f	Develop/Build/Rehab Spaces
STR 3g	Maintain or Host Income Tax Preparation Sites
STR 3h	Community-Wide Data Collection Systems Development
STR 3i	Local 211 or Resource/Referral System Development
STR 3j	Water/Sewer System Development
STR 3k	Community Financial Institution Creation
STR 3l	Infrastructure Planning Coalition
STR 3m	Park or Recreation Creation and Maintenance
STR 3n	Rehabilitation/Weatherization of Housing Stock
STR 3o	Community Center/Community Facility Establishment
STR 3p	Asset Limit Barriers for Benefits Policy Changes
STR 3q	Infrastructure and Asset Building Policy Changes
STR 3r	Infrastructure and Asset Building Legislative Changes
STR 3s	Other Infrastructure and Asset Building Strategy: (please specify)

	Housing Strategies (STR 4)
STR 4a	End Chronic Homelessness Campaign
STR 4b	New Affordable Single Unit Housing Creation
STR 4c	New Affordable Multi- Unit Housing Creation (Single Resident Occupancy (SRO), temporary housing, transitional housing)
STR 4d	Tenants’ Rights Campaign
STR 4e	New Shelters Creation (including day shelters and domestic violence shelters)
STR 4f	Housing or Land Trust Creation
STR 4g	Building Codes Campaign
STR 4h	Housing Policy Changes
STR 4i	Housing Legislative Changes
STR 4j	Other Housing Strategy: (please specify)

	Health and Social/Behavioral Development Strategies (STR 5)
STR 5a	Health Specific Campaign
STR 5b	Farmers Market or Community Garden Development
STR 5c	Grocery Store Development
STR 5d	Gun Safety/Control Campaign
STR 5e	Healthy Food Campaign
STR 5f	Nutrition Education Collaborative
STR 5g	Food Bank Development
STR 5h	Domestic Violence Court Development
STR 5i	Drug Court Development
STR 5j	Alternative Energy Source Development
STR 5k	Develop or Maintain a Health Clinic
STR 5l	Health and Social/Behavioral Development Policy Changes
STR 5m	Health and Social/Behavioral Development Legislative Changes
STR 5n	Other Health and Social/Behavioral Development Strategy: (please specify)

	Civic Engagement and Community Involvement Strategies - Goal 2 (STR 6 G2)
STR 6 G2a	Development of Health and Social Service Provider Partnerships
STR 6 G2b	Recruiting and Coordinating Community Volunteers
STR 6 G2c	Poverty Simulations
STR 6 G2d	Attract Capital Investments
STR 6 G2e	Build/Support Increased Equity
STR 6 G2f	Equity Awareness Campaign
STR 6 G2g	Coordinated Community-wide Needs Assessment
STR 6 G2h	Civic Engagement and Community Involvement in Advocacy Efforts
STR 6 G2i	Civic Engagement Policy Changes
STR 6 G2j	Civic Engagement Legislative Changes
STR 6 G2k	Other Civic Engagement and Community Involvement Strategy: (please specify)

	Civic Engagement and Community Involvement Strategies - Goal 3 (STR 6 G3)
STR 6 G3a	Empowerment of Individuals/Families with Low-Incomes
STR 6 G3b	Campaign to Ensure Individuals with Low-Incomes are Represented on Local Governing Bodies
STR 6 G3c	Social Capital Building Campaign for Individuals/Families with Low-Incomes
STR 6 G3d	Campaign for Volunteer Placement and Coordination
STR 6 G3e	Civic Engagement Policy Changes
STR 6 G3f	Civic Engagement Legislative Changes
STR 6 G3g	Other Civic Engagement and Community Involvement Strategy: (please specify)

	Community Support Strategies (STR 7)
STR 7a	Off-Hours (Non-Traditional Hours) Child Care Development
STR 7b	Transportation System Development
STR 7c	Transportation Services Coordination and Support
STR 7d	Community Support Policy Changes
STR 7e	Community Support Legislative Changes
STR 7f	Other Community Support Strategy: (please specify)

	Emergency Management Strategies (STR 8)
STR 8a	State or Local Emergency Management Board Enhancement
STR 8b	Community wide Emergency Disaster Relief Service Creation
STR 8c	Disaster Preparation Planning
STR 8d	Emergency Management Policy Changes
STR 8e	Emergency Management Legislative Changes
STR 8f	Other Emergency Management Strategy: (please specify)

Individual and Family Level – Module 4

Note: The data collected in this module relates to Goal 1: Individuals and families with low incomes are stable and achieve economic security.

CSBG Annual Report V2 Module 4

Instructional Notes

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form

Section A: Individual and Family NPIs Data Entry Form is comprised of indicators to report outcomes that fall under National Goal 1: Individuals and families with low incomes are stable and achieve economic security. The indicators are the vehicle by which CSBG Eligible Entities measure and report the outcomes they have achieved for individuals and families. All Individual and Family NPIs are optional, and there is a category for "Other Outcome Indicator".

Module 4, Section B: Individual and Family Services - Data Entry Form

Section B: Individual and Family Services Data Entry Form provides information on the work CSBG Eligible Entities did to help individuals and families achieve the outcomes listed in Section A. This standardized Individual and Family Services list will aid in analysis of the relationship between people, services, and outcomes.

Module 4, Section C: All Characteristics Report - Data Entry Form

Section C: The All Characteristics Report Data Entry Form collects data on all individuals and households, whether or not funded directly by CSBG. This demographic information strengthens the CSBG Annual Report by demonstrating who is being served by CSBG Eligible Entities.

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Employment (FNPI 1)	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
FNPI 1a The number of unemployed youth who obtained employment to gain skills or income.				#DIV/0!	#DIV/0!
FNPI 1b The number of unemployed adults who obtained employment (up to a living wage).				#DIV/0!	#DIV/0!
FNPI 1c The number of unemployed adults who obtained and maintained employment for at least 90 days (up to a living wage).				#DIV/0!	#DIV/0!
FNPI 1d The number of unemployed adults who obtained and maintained employment for at least 180 days (up to a living wage).				#DIV/0!	#DIV/0!
FNPI 1e The number of unemployed adults who obtained employment (with a living wage or higher).				#DIV/0!	#DIV/0!
FNPI 1f The number of unemployed adults who obtained and maintained employment for at least 90 days (with a living wage or higher).				#DIV/0!	#DIV/0!
FNPI 1g The number of unemployed adults who obtained and maintained employment for at least 180 days (with a living wage or higher).				#DIV/0!	#DIV/0!

Employment (FNPI 1)	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
FNPI 1h The number of employed participants in a career- advancement related program who entered or transitioned into a position that provided increased income and/or benefits.				#DIV/0!	#DIV/0!
FNPI 1h.1 Of the above, the number of employed participants who Increased income from employment through wage or salary amount increase.				#DIV/0!	#DIV/0!
FNPI 1h.2 Of the above, the number of employed participants who increased income from employment through hours worked increase.				#VALUE!	#DIV/0!
FNPI 1h.3 Of the above, the number of employed participants who increased benefits related to employment.				#DIV/0!	#DIV/0!

Name of CSBG Eligible Entity Reporting:
Other Employment Outcome Indicator (FNPI 1z)	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
FNPI 1z.1 The number of individuals .				#DIV/0!	#DIV/0!

Comments:

Education and Cognitive Development Indicators

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Education and Cognitive Development (FNPI 2)	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
FNPI 2a The number of children (0 to 5) who demonstrated improved emergent literacy skills.				#DIV/0!	#DIV/0!
FNPI 2b The number of children (0 to 5) who demonstrated skills for school readiness.				#DIV/0!	#DIV/0!
FNPI 2c The number of children and youth who demonstrated improved positive approaches toward learning, including improved attention skills. (auto total).	0	0	0	#DIV/0!	#DIV/0!
FNPI 2c.1 Early Childhood Education (ages 0-5)				#DIV/0!	#DIV/0!
FNPI 2c.2 1st grade-8th grade				#DIV/0!	#DIV/0!
FNPI 2c.3 9th grade-12th grade				#DIV/0!	#DIV/0!
FNPI 2d The number of children and youth who are achieving at basic grade level (academic, social, and other school success skills). (auto total)	0	0	0	#DIV/0!	#DIV/0!
FNPI 2d.1 Early Childhood Education (ages 0-5)				#DIV/0!	#DIV/0!
FNPI 2d.2 1st grade-8th grade				#DIV/0!	#DIV/0!
FNPI 2d.3 9th grade-12th grade				#DIV/0!	#DIV/0!
FNPI 2e The number of parents/caregivers who improved their home environments.				#DIV/0!	#DIV/0!
FNPI 2f The number of adults who demonstrated improved basic education.				#DIV/0!	#DIV/0!
FNPI 2g The number of individuals who obtained a high school diploma and/or obtained an equivalency certificate or diploma.				#DIV/0!	#DIV/0!
FNPI 2h The number of individuals who obtained a recognized credential, certificate, or degree relating to the achievement of educational or vocational skills.				#DIV/0!	#DIV/0!
FNPI 2i The number of individuals who obtained an Associate’s degree.				#DIV/0!	#DIV/0!
FNPI 2j The number of individuals who obtained a Bachelor’s degree.				#DIV/0!	#DIV/0!

Other Education and Cognitive Development Outcome Indicator (FNPI 2z)	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
FNPI 2z.1 The number of individuals .				#DIV/0!	#DIV/0!

Comments:

Income and Asset Building Indicators

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Income and Asset Building (FNPI 3)	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
FNPI 3a The number of individuals who achieved and maintained capacity to meet basic needs for 90 days.				#DIV/0!	#DIV/0!
FNPI 3b The number of individuals who achieved and maintained capacity to meet basic needs for 180 days.				#DIV/0!	#DIV/0!
FNPI 3c The number of individuals who opened a savings account or IDA.				#DIV/0!	#DIV/0!
FNPI 3d The number of individuals who increased their savings.				#DIV/0!	#DIV/0!
FNPI 3e The number of individuals who used their savings to purchase an asset.				#DIV/0!	#DIV/0!
FNPI 3f The number of individuals who purchased a home.
FNPI 3g The number of individuals who improved their credit scores.				#DIV/0!	#DIV/0!
FNPI 3h The number of individuals who increased their net worth.				#DIV/0!	#DIV/0!
FNPI 3i The number of individuals engaged with the Community Action Agency who report improved financial well-being.				#DIV/0!	#DIV/0!

Other Income and Asset Building Outcome Indicator (FNPI 3z)	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
FNPI 3z.1 The number of individuals .				#DIV/0!	#DIV/0!

Comments:

Housing Indicators

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Housing (FNPI 4)	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
FNPI 4a The number of individuals experiencing homelessness who obtained safe temporary shelter.				#DIV/0!	#DIV/0!
FNPI 4b The number of individuals who obtained safe and affordable housing.				#DIV/0!	#DIV/0!
FNPI 4c The number of individuals who maintained safe and affordable housing for 90 days.				#DIV/0!	#DIV/0!
FNPI 4d The number of individuals who maintained safe and affordable housing for 180 days.				#DIV/0!	#DIV/0!
FNPI 4e The number of individuals who avoided eviction.				#DIV/0!	#DIV/0!
FNPI 4f The number of individuals who avoided foreclosure.				#DIV/0!	#DIV/0!
FNPI 4g The number of individuals who experienced improved health and safety due to improvements within their home (e.g. reduction or elimination of lead, radon, carbon monoxide and/or fire hazards or electrical issues, etc).				#DIV/0!	#DIV/0!
FNPI 4h The number of individuals with improved energy efficiency and/or energy burden reduction in their homes.				#DIV/0!	#DIV/0!

Other Housing Outcome Indicator (FNPI 4z)	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
FNPI 4z.1 The number of individuals .				#DIV/0!	#DIV/0!

Comments:

Health and Social/Behavioral Development Indicators

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Health and Social/Behavioral Development (FNPI 5)	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
FNPI 5a The number of individuals who demonstrated increased nutrition skills (e.g. cooking, shopping, and growing food).				#DIV/0!	#DIV/0!
FNPI 5b The number of individuals who demonstrated improved physical health and well-being.				#DIV/0!	#DIV/0!
FNPI 5c The number of individuals who demonstrated improved mental and behavioral health and well-being.				#DIV/0!	#DIV/0!
FNPI 5d The number of individuals who improved skills related to the adult role of parents/ caregivers.				#DIV/0!	#DIV/0!
FNPI 5e The number of parents/caregivers who demonstrated increased sensitivity and responsiveness in their interactions with their children.				#DIV/0!	#DIV/0!
FNPI 5f The number of seniors (65+) who maintained an independent living situation.				#DIV/0!	#DIV/0!
FNPI 5g The number of individuals with disabilities who maintained an independent living situation.				#DIV/0!	#DIV/0!
FNPI 5h The number of individuals with a chronic illness who maintained an independent living situation.				#DIV/0!	#DIV/0!
FNPI 5i The number of individuals with no recidivating event for six months.	0	0	0	#DIV/0!	#DIV/0!
FNPI 5i.1 Youth (ages 14-17)				#DIV/0!	#DIV/0!
FNPI 5i.2 Adults (ages 18+)				#DIV/0!	#DIV/0!

Other Health and Social/Behavioral Development Outcome Indicator (FNPI 5z)	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
FNPI 5z.1 The number of individuals .				#DIV/0!	#DIV/0!

Comments:

Civic Engagement and Community Involvement Indicators

Name of CSBG Eligible Entity Reporting:
State:	UEI:
	I.) Number of	II.) Target (#)	III.) Actual Results	IV.) Percentage	V.) Performance
Civic Engagement and Community Involvement Indicators (FNPI 6)	Individuals Served in program(s) (#)		(#)	Achieving Outcome [III/ I = IV ] (% auto	Target Accuracy (III/II = V] (% auto calculated)
				calculated)
FNPI 6a The number of individuals who increased skills, knowledge, and abilities to enable them to work with Community Action to improve conditions in the community.				#DIV/0!	#DIV/0!
FNPI 6a.1 Of the above, the number of Community Action program participants who improved their leadership skills.				#DIV/0!	#DIV/0!
FNPI 6a.2 Of the above, the number of Community Action program participants who improved their social networks.				#DIV/0!	#DIV/0!
FNPI 6a.3 Of the above, the number of Community Action program participants who gained other skills, knowledge and abilities to enhance their ability to engage.				#DIV/0!	#DIV/0!

Other Civic Engagement and Community Involvement Outcome Indicator (FNPI 6z)	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
FNPI 6z.1 The number of individuals .				#DIV/0!	#DIV/0!

Comments:

Module 4, Section A: Individual and Family National Performance Indicators (FNPIs) - Data Entry Form

Goal 1: Individuals and Families with low incomes are stable and achieve economic security.

Outcomes Achieved Across One or More Domains

Name of CSBG Eligible Entity Reporting:
State:	UEI:
	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
Outcomes Across Multiple Domains (FNPI 7)
FNPI 7a The number of individuals who achieved one or more outcomes in the identified National Performance Indicators in one or more domains.				#DIV/0!	#DIV/0!

	I.) Number of Individuals Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV ] (% auto calculated)	V.) Performance Target Accuracy (III/II = V] (% auto calculated)
Other Outcome Indicator (FNPI 7z)
FNPI 7z.1 The number of individuals .				#DIV/0!	#DIV/0!

Comments:

Employment Services

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Employment Services (SRV 1)	Unduplicated Number of Individuals Served
Skills Training and Opportunities for Experience (SRV 1a-f)
SRV 1a Vocational Training
SRV 1b On-the-Job and other Work Experience
SRV 1c Youth Summer Work Placements
SRV 1d Apprenticeship/Internship
SRV 1e Self-Employment Skills Training
SRV 1f Job Readiness Training
Career Counseling (SRV 1g-h)
SRV 1g Workshops
SRV 1h Coaching
Job Search (SRV 1i-n)
SRV 1i Coaching
SRV 1j Resume Development
SRV 1k Interview Skills Training
SRV 1l Job Referrals
SRV 1m Job Placements
SRV 1n Pre-employment physicals, background checks, etc.
Post Employment Supports (SRV 1o-p)
SRV 1o Coaching
SRV 1p Interactions with employers
Employment Supplies (SRV 1q)
SRV 1q Employment Supplies

Education and Cognitive Development Services

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Education and Cognitive Development Services (SRV 2)	Unduplicated Number of Individuals Served
Child/Young Adult Education Programs (SRV 2a-j)
SRV 2a Early Head Start
SRV 2b Head Start
SRV 2c Other Early-Childhood (0-5 yr. old) Education
SRV 2d K-12 Education
SRV 2e K-12 Support Services
SRV 2f Financial Literacy Education
SRV 2g Literacy/English Language Education
SRV 2h College-Readiness Preparation/Support
SRV 2i Other Post Secondary Preparation
SRV 2j Other Post Secondary Support
School Supplies (SRV 2k)
SRV 2k School Supplies
Extra-curricular Programs (SRV 2l-q)
SRV 2l Before and After School Activities
SRV 2m Summer Youth Recreational Activities
SRV 2n Summer Education Programs
SRV 2o Behavior Improvement Programs (attitude, self- esteem, Dress-for-Success, etc.)
SRV 2p Mentoring
SRV 2q Leadership Training
Adult Education Programs (SRV 2r-z)
SRV 2r Adult Literacy Classes
SRV 2s English Language Classes
SRV 2t Basic Education Classes
SRV 2u High School Equivalency Classes
SRV 2v Leadership Training
SRV 2w Parenting Supports (may be a part of the early childhood programs identified above)
SRV 2x Applied Technology Classes
SRV 2y Post-Secondary Education Preparation
SRV 2z Financial Literacy Education
Post-Secondary Education Supports (SRV 2aa)
SRV 2aa College applications, text books, computers, etc.
Financial Aid Assistance (SRV 2bb)
SRV 2bb Scholarships
Home Visits (SVR 2cc)
SRV 2cc Home Visits

Income and Asset Building Services

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Income and Asset Building Services (SRV 3)	Unduplicated Number of Individuals Served
Training and Counseling Services (SRV 3a-f)
SRV 3a Financial Capability Skills Training
SRV 3b Financial Coaching/Counseling
SRV 3c Financial Management Programs (including budgeting, credit management, credit repair, credit counseling, etc.)
SRV 3d First-time Homebuyer Counseling
SRV 3e Foreclosure Prevention Counseling
SRV 3f Small Business Start-Up and Development Counseling Sessions/Classes
Benefit Coordination and Advocacy (SRV 3g-l)
SRV 3g Child Support Payments
SRV 3h Health Insurance
SRV 3i Social Security/SSI Payments
SRV 3j Veteran's Benefits
SRV 3k TANF Benefits
SRV 3l SNAP Benefits
Asset Building (SRV 3m-o)
SRV 3m Saving Accounts/IDAs and other asset building accounts
SRV 3n Other financial products (IRA accounts, MyRA, other retirement accounts, etc.)
SRV 3o VITA, EITC, or Other Tax Preparation programs
SRV 3p Loans And Grants (SRV 3p-q)
SRV 3p Micro-loans
SRV 3q Business incubator/business development loans

Housing Services

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Housing Services (SRV 4)	Unduplicated Number of Individuals Served
Housing Payment Assistance (SRV 4a-e)
SRV 4a Financial Capability Skill Training
SRV 4b Financial Coaching/Counseling
SRV 4c Rent Payments (includes Emergency Rent Payments)
SRV 4d Deposit Payments
SRV 4e Mortgage Payments (includes Emergency Mortgage Payments)
Eviction Prevention Services (SRV 4f-h)
SRV 4f Eviction Counseling
SRV 4g Landlord/Tenant Mediations
SRV 4h Landlord/Tenant Rights Education
Utility Payment Assistance (SRV 4i-l)
SRV 4i Utility Payments (LIHEAP-includes Emergency Utility Payments)
SRV 4j Utility Deposits
SRV 4k Utility Arrears Payments
SRV 4l Level Billing Assistance
Housing Placement/Rapid Re-housing (SRV 4m-p)
SRV 4m Temporary Housing Placement (includes Emergency Shelters)
SRV 4n Transitional Housing Placements
SRV 4o Permanent Housing Placements
SRV 4p Rental Counseling
Housing Maintenance & Improvements (SRV 4q)
SRV 4q Home Repairs (e.g. structural, appliance, heating systems. etc.) (Including Emergency Home Repairs)
Weatherization Services (SRV 4r-t)
SRV 4r Independent-living Home Improvements (e.g. ramps, tub and shower grab bars, handicap accessible modifications, etc.)
SRV 4s Healthy Homes Services(e.g. reduction or elimination of lead, radon, carbon monoxide and/or fire hazards or electrical issues, etc.)
SRV 4t Energy Efficiency Improvements (e.g. insullation, air sealing, furnace repair, etc.)

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Health and Social/Behavioral Development Services (SRV 5)	Unduplicated Number of Individuals Served
Health Services, Screening and Assessments (SRV 5a-j)
SRV 5a Immunizations
SRV 5b Physicals
SRV 5c Developmental Delay Screening
SRV 5d Vision Screening
SRV 5e Prescription Payments
SRV 5f Doctor Visit Payments
SRV 5g Maternal/Child Health
SRV 5h Nursing Care Sessions
SRV 5i In-Home Affordable Seniors/Disabled Care Sessions (Nursing, Chores, Personal Care Services)
SRV 5j Health Insurance Options Counseling
Reproductive Health Services (SRV 5k-o)
SRV 5k Coaching Sessions
SRV 5l Family Planning Classes
SRV 5m Contraceptives
SRV 5n STI/HIV Prevention Counseling Sessions
SRV 5o STI/HIV Screenings
Wellness Education (SRV 5p-q)
SRV 5p Wellness Classes (stress reduction, medication management, mindfulness, etc.)
SRV 5q Exercise/Fitness
Mental/Behavioral Health (SRV 5r-x)
SRV 5r Detoxification Sessions
SRV 5s Substance Abuse Screenings
SRV 5t Substance Abuse Counseling
SRV 5u Mental Health Assessments
SRV 5v Mental Health Counseling
SRV 5w Crisis Response/Call-In Responses
SRV 5x Domestic Violence Programs
Support Groups (SRV 5y-aa)
SRV 5y Substance Abuse Support Group Meetings
SRV 5z Domestic Violence Support Group Meetings
SRV 5aa Mental Health Support Group Meeting

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Health and Social/Behavioral Development Services (Cont'd.)	Unduplicated Number of
	Individuals Served
Dental Services, Screenings and Exams (SRV 5bb-ee)
SRV 5bb Adult Dental Screening/Exams
SRV 5cc Adult Dental Services (including Emergency Dental Procedures)
SRV 5dd Child Dental Screenings/Exams
SRV 5ee Child Dental Services (including Emergency Dental Procedures)
Nutrition and Food/Meals (SRV 5ff-jj)
SRV 5ff Skills Classes (Gardening, Cooking, Nutrition)
SRV 5gg Community Gardening Activities
SRV 5hh Incentives (e.g. gift card for food preparation, rewards for participation, etc.)
SRV 5ii Prepared Meals
SRV 5jj Food Distribution (Food Bags/Boxes, Food Share Program, Bags of Groceries)
Family Skills Development (SRV 5kk-mm)
SRV 5kk Family Mentoring Sessions
SRV 5ll Life Skills Coaching Sessions
SRV 5mm Parenting Classes
Emergency Hygiene Assistance (SRV 5nn-oo)
SRV 5nn Kits/boxes
SRV 5oo Hygiene Facility Utilizations (e.g. showers, toilets, sinks)

Civic Engagement and Community Involvement

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Civic Engagement and Community Involvement Services (SRV 6a-f)	Unduplicated Number of Individuals Served
SRV 6a Voter Education and Access
SRV 6b Leadership Training
SRV 6c Tri-partite Board Membership
SRV 6d Citizenship Classes
SRV 6e Getting Ahead Classes
SRV 6f Volunteer Training

Services Supporting Multiple Domains

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Services Supporting Multiple Domains (SRV 7)	Unduplicated Number of Individuals Served
Case Management (SRV 7a)
SRV 7a Case Management
Eligibility Determinations (SRV 7b)
SRV 7b Eligibility Determinations
Referrals (SRV 7c)
SRV 7c Referrals
Transportation Services (SRV 7d)
SRV 7d Transportation Services (e.g. bus passes, bus transport, support for auto purchase or repair; including emergency services)
Childcare (SRV 7e-f)
SRV 7e Child Care subsidies
SRV 7f Child Care payments
Eldercare (SRV 7g)
SRV 7g Day Centers
Identification Documents (SRV 7h-j)
SRV 7h Birth Certificate
SRV 7i Social Security Card
SRV 7j Driver's License
Re-Entry Services (SRV 7k)
SRV 7k Criminal Record Expungements
Immigration Support Services (SRV 7l)
SRV 7l Immigration Support Services (relocation, food, clothing)
Legal Assistance (includes emergency legal assistance) (SRV 7m)
SRV 7m Legal Assistance
Emergency Clothing Assistance (SRV 7n)
SRV 7n Emergency Clothing Assistance
Mediation/Customer Advocacy Interventions (debt forgiveness, negotiations or issues with landlords, coordinating with other services or government) (SRV 7o)
SRV 7o Mediation/Customer Advocacy Interventions

^A. Total unduplicated number of all INDIVIDUALS about whom one or more characteristics were obtained:

B. Total unduplicated number of all HOUSEHOLDS about whom one or more characteristics were obtained:

C. INDIVIDUAL LEVEL CHARACTERISTICS
1. Gender Number of Individuals
a.	Male
b.	Female
c.	Other
d.	Unknown/not reported
e.	TOTAL (auto calculated)	0

6. Ethnicity/Race Number of Individuals

a. Ethnicity

a.1. Hispanic, Latino or Spanish Origins

a.2. Not Hispanic, Latino or Spanish Origins

a.3. Unknown/not reported

a.4. TOTAL (auto calculated) ⁰

2. Age Number of Individuals
a.	0-5
b.	6-13
c.	14-17
d.	18-24
e.	25-44
f.	45-54
g.	55-59
h.	60-64
i.	65-74
j.	75+
k.	Unknown/not reported
l.	TOTAL (auto calculated)	0

b. Race

b.1. American Indian or Alaska Native

b.2. Asian

b.3. Black or African American

b.4. Native Hawaiian and Other Pacific Islander

b.5. White

b.6. Other

b.7. Multi-race (two or more of the above)

b.8. Unknown/not reported

b.9. TOTAL (auto calculated)

0

1. Disabling Condition

2. Health Insurance*

Yes No Unknown

8. Work Status (Individuals 18+)	Number of Individuals
a. Employed Full-Time
b. Employed Part-Time
c. Migrant or Seasonal Farm Worker
d. Unemployed (Short-Term, 6 months or less)
e. Unemployed (Long-Term, more than 6 months)
f. Unemployed (Not in Labor Force)
g. Retired
h. Unknown/not reported
i. TOTAL (auto calculated)		0

3. Education Levels Number of Individuals

[ages 14-24] [ages 25+]

1. Grades 0-8

2. Grades 9-12/Non-Graduate

3. High School Graduate

4. GED/Equivalency Diploma

5. 12 grade + Some Post-Secondary

6. 2 or 4 years College Graduate

7. Graduate of other post-secondary school

8. Unknown/not reported

9. ^{TOTAL (auto calculated)} 0 0

Yes No Unknown

7. Military Status Number of Individuals
a. Veteran
b. Active Military
c. Never Served in the Military
d. Unknown/not reported
e. TOTAL (auto calculated)	0

Module 4, Section C: All Characteristics Report - Data Entry Form

Goal 1: Individuals and Families with low-incomes are stable and achieve economic security.

*If an individual reported that they had Health Insurance please identify the source of health insurance below.

Health Insurance Sources

1. 

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   0

   
   

   Medicaid

2. Medicare

3. State Children’s Health Insurance Program

4. State Health Insurance for Adults

5. Military Health Care

6. Direct-Purchase

7. Employment Based

8. Unknown/not reported

9. TOTAL (auto calculated)

Module 4, Section C: All Characteristics Report - Data Entry Form

Goal 1: Individuals and Families with low-incomes are stable and achieve economic security.

D. HOUSEHOLD LEVEL CHARACTERISTICS
9. Household Type	Number of Households
a. Single Person
b. Two Adults NO Children
c. Single Parent Female
d. Single Parent Male
e. Two Parent Household
f. Non-related Adults with Children
g. Multigenerational Household
h. Other
i. Unknown/not reported
j. TOTAL (auto calculated)		0

13. Sources of Household Income	Number of Households
a. Income from Employment Only
b. Income from Employment and Other Income Source
c. Income from Employment, Other Income Source,
and Non-Cash Benefits
d. Income from Employment and Non-Cash Benefits
e. Other Income Source Only
f. Other Income Source and Non-Cash Benefits
g. No Income
h. Non-Cash Benefits Only
i. Unknown/not reported
j. TOTAL (auto calculated)		0

11. Housing Number of Households
a. Own
b. Rent
c. Other permanent housing
d. Homeless
e. Other
f. Unknown/not reported
g. TOTAL (auto calculated)	0

14. Other Income Source	Number of Households
a. TANF
b. Supplemental Security Income (SSI)
c. Social Security Disability Income (SSDI)
d. VA Service-Connected Disability Compensation
e. VA Non-Service Connected Disability Pension
f. Private Disability Insurance
g. Worker’s Compensation
h. Retirement Income from Social Security
i. Pension
j. Child Support
k. Alimony or other Spousal Support
l. Unemployment Insurance
m. EITC
n. Other
o. Unknown/not reported

10. Household Size Number of Households
a. Single Person
b. Two
c. Three
d. Four
e. Five
f. Six or more
g. Unknown/not reported
h. TOTAL (auto calculated)	0

Below, please report the types of Other income and/or non-cash benefits received by the households who reported sources other than employment

0

12. Level of Household Income

(% of HHS Guideline)

a. Up to 50%

b. 51% to 75%

c. 76% to 100%

d. 101% to 125%

e. 126% to 150%

f. 151% to 175%

g. 176% to 200%

h. 201% to 250%

i. 251% and over

j. Unknown/not reported

k. TOTAL (auto calculated)

15. Non-Cash Benefits

a. SNAP

b. WIC

c. LIHEAP

d. Housing Choice Voucher

e. Public Housing

f. Permanent Supportive Housing

g. HUD-VASH

h. Childcare Voucher

i. Affordable Care Act Subsidy

j. Other

k. Unknown/not reported

Number of Households Number of Households

E. Number of Individuals Who May or May Not be Included in the Totals Above (due to data collection system integration barriers)
a. Please list the unduplicated number of INDIVIDUALS served in each program*:	Program Name	Number of Individuals

Module 4, Section C: All Characteristics Report - Data Entry Form

Goal 1: Individuals and Families with low-incomes are stable and achieve economic security.

Program Name		Number of Households

Name of CSBG Eligible Entity Reporting:
State:	UEI:
F. Number of Households Who May or May Not be Included in the Totals Above (due to data collection system integration barriers) a. Please list the unduplicated number of HOUSEHOLDS served in each program*: *The system will add rows to allow reporting on multiple programs.