4 CSBG Disaster Supplemental Annual Report Module 4

---

Overview

Module4Instructions
Employment_NPIs
Ed_NPIs
Income_NPIs
Housing_NPIs
Health_NPIs
CivicEng&Comm_NPIs
Outcomes Across Mult Domains
Services_Employment
Services_Education
Services_Income
Services_Housing
Services_Health and Social
Services_Civic Eng. & Comm
Support Services
ALL Characteristics

---

Sheet 1: Module4Instructions

	CSBG Disaster Supplemental 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." For the CSBG Disaster Supplemental submission, please include only information on people, services and outcomes directly supported with CSBG Disaster Supplemental resources. This information may be determined based on a direct count of individuals for services and activities supported only with CSBG Disaster Supplemental funds or based on a proportional analysis for services supplemented with CBSG Disaster Supplemental funds and also funded through regularly-appropriated CSBG funds or other sources.
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. For the purposes of the CSBG Disaster Supplemental report, this information may be determined based on a direct count of services and activities supported only with CSBG Disaster Supplemental funds or based on a proportional analysis for services supplemented with CBSG Disaster Supplemental funds and also funded through regularly-appropriated CSBG funds or other sources.
Module 4, Section C: All Characteristics Report - Data Entry Form
Section C: While the regular submssion of the All Characteristics Report Data Entry Form collects data on all individuals and households, (whether or not funded directly by CSBG) this submission should focus only on the individuals and households that received services supported by CSBG Disaster Supplemental grant funds. This information may be determined based on a direct count of individuals for services and activities supported only with CSBG Disaster Supplemental funds or based on a proportional analysis for services supplemented with CBSG Disaster Supplemental funds and also funded through regularly-appropriated CSBG funds or other sources. This demographic information strengthens the CSBG Annual Report by demonstrating who is being served by CSBG Eligible Entities.
	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.

---

Sheet 2: Employment_NPIs

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.
Employment Indicators
Name of CSBG Eligible Entity Reporting:
State:	DUNS:
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.
FNPI 1b The number of unemployed adults who obtained employment (up to a living wage).
FNPI 1c The number of unemployed adults who obtained and maintained employment for at least 90 days (up to a living wage).
FNPI 1d The number of unemployed adults who obtained and maintained employment for at least 180 days (up to a living wage).
FNPI 1e The number of unemployed adults who obtained employment (with a living wage or higher).
FNPI 1f The number of unemployed adults who obtained and maintained employment for at least 90 days (with a living wage or higher).
FNPI 1g The number of unemployed adults who obtained and maintained employment for at least 180 days (with a living wage or higher).
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.
FNPI 1h.1 Of the above, the number of employed participants who Increased income from employment through wage or salary amount increase.
FNPI 1h.2 Of the above, the number of employed participants who increased income from employment through hours worked increase.
FNPI 1h.3 Of the above, the number of employed participants who increased benefits related to employment.
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 ______________.
Comments:

---

Sheet 3: Ed_NPIs

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.
Education and Cognitive Development Indicators
Name of CSBG Eligible Entity Reporting:
State:	DUNS:
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.
FNPI 2b The number of children (0 to 5) who demonstrated skills for school readiness.
FNPI 2c The number of children and youth who demonstrated improved positive approaches toward learning, including improved attention skills. (auto total).	0
FNPI 2c.1 Early Childhood Education (ages 0-5)
FNPI 2c.2 1st grade-8th grade
FNPI 2c.3 9th grade-12th grade
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
FNPI 2d.1 Early Childhood Education (ages 0-5)
FNPI 2d.2 1st grade-8th grade
FNPI 2d.3 9th grade-12th grade
FNPI 2e The number of parents/caregivers who improved their home environments.
FNPI 2f The number of adults who demonstrated improved basic education.
FNPI 2g The number of individuals who obtained a high school diploma and/or obtained an equivalency certificate or diploma.
FNPI 2h The number of individuals who obtained a recognized credential, certificate, or degree relating to the achievement of educational or vocational skills.
FNPI 2i The number of individuals who obtained an Associate’s degree.
FNPI 2j The number of individuals who obtained a Bachelor’s degree.
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 ______________.
Comments:

---

Sheet 4: Income_NPIs

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.
Income and Asset Building Indicators
Name of CSBG Eligible Entity Reporting:
State:	DUNS:
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.
FNPI 3b The number of individuals who achieved and maintained capacity to meet basic needs for 180 days.
FNPI 3c The number of individuals who opened a savings account or IDA.
FNPI 3d The number of individuals who increased their savings.
FNPI 3e The number of individuals who used their savings to purchase an asset.
FNPI 3f The number of individuals who purchased a home.
FNPI 3g The number of individuals who improved their credit scores.
FNPI 3h The number of individuals who increased their net worth.
FNPI 3i The number of individuals engaged with the Community Action Agency who report improved financial well-being.
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 ______________.
Comments:

---

Sheet 5: Housing_NPIs

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.
Housing Indicators
Name of CSBG Eligible Entity Reporting:
State:	DUNS:
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.
FNPI 4b The number of individuals who obtained safe and affordable housing.
FNPI 4c The number of individuals who maintained safe and affordable housing for 90 days.
FNPI 4d The number of individuals who maintained safe and affordable housing for 180 days.
FNPI 4e The number of individuals who avoided eviction.
FNPI 4f The number of individuals who avoided foreclosure.
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).
FNPI 4h The number of individuals with improved energy efficiency and/or energy burden reduction in their homes.
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 ______________.
Comments:

---

Sheet 6: Health_NPIs

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.
Health and Social/Behavioral Development Indicators
Name of CSBG Eligible Entity Reporting:
State:	DUNS:
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).
FNPI 5b The number of individuals who demonstrated improved physical health and well-being.
FNPI 5c The number of individuals who demonstrated improved mental and behavioral health and well-being.
FNPI 5d The number of individuals who improved skills related to the adult role of parents/ caregivers.
FNPI 5e The number of parents/caregivers who demonstrated increased sensitivity and responsiveness in their interactions with their children.
FNPI 5f The number of seniors (65+) who maintained an independent living situation.
FNPI 5g The number of individuals with disabilities who maintained an independent living situation.
FNPI 5h The number of individuals with a chronic illness who maintained an independent living situation.
FNPI 5i The number of individuals with no recidivating event for six months.	0
FNPI 5i.1 Youth (ages 14-17)
FNPI 5i.2 Adults (ages 18+)
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 ______________.
Comments:

---

Sheet 7: CivicEng&Comm_NPIs

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.
Civic Engagement and Community Involvement Indicators
Name of CSBG Eligible Entity Reporting:
State:	DUNS:
Civic Engagement and Community Involvement Indicators (FNPI 6)	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 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.
FNPI 6a.1 Of the above, the number of Community Action program participants who improved their leadership skills.
FNPI 6a.2 Of the above, the number of Community Action program participants who improved their social networks.
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.
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 ______________.
Comments:

---

Sheet 8: Outcomes Across Mult Domains

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:	DUNS:
Outcomes Across Multiple Domains (FNPI 7)	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 7a The number of individuals who achieved one or more outcomes in the identified National Performance Indicators in one or more domains.
Other Outcome Indicator (FNPI 7z)	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 7z.1 The number of individuals ______________.
Comments:

---

Sheet 9: Services_Employment

Module 4, Section B: Individual and Family Services
Employment Services
Name of CSBG Eligible Entity Reporting:
State:	DUNS:
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

---

Sheet 10: Services_Education

Module 4, Section B: Individual and Family Services
Education and Cognitive Development Services
Name of CSBG Eligible Entity Reporting:
State:	DUNS:
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

---

Sheet 11: Services_Income

Module 4, Section B: Individual and Family Services
Income and Asset Building Services
Name of CSBG Eligible Entity Reporting:
State:	DUNS:
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 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

---

Sheet 12: Services_Housing

Module 4, Section B: Individual and Family Services
Housing Services
Name of CSBG Eligible Entity Reporting:
State:	DUNS:
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 (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.)

---

Sheet 13: Services_Health and Social

Module 4, Section B: Individual and Family Services
Health and Social/Behavioral Development
Name of CSBG Eligible Entity Reporting:
State:	DUNS:
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
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)

---

Sheet 14: Services_Civic Eng. & Comm

Module 4, Section B: Individual and Family Services
Civic Engagement and Community Involvement
Name of CSBG Eligible Entity Reporting:
State:	DUNS:
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

---

Sheet 15: Support Services

Module 4, Section B: Individual and Family Services
Services Supporting Multiple Domains
Name of CSBG Eligible Entity Reporting:
State:	DUNS:
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

---

Sheet 16: ALL Characteristics

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

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

Name of CSBG Eligible Entity Reporting:

State:

DUNS:

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

6. Ethnicity/Race

Number of Individuals

a.

Male

a. Ethnicity

b.

Female

a.1. Hispanic, Latino or Spanish Origins

c.

Other

a.2. Not Hispanic, Latino or Spanish Origins

d.

Unknown/not reported

a.3. Unknown/not reported

e.

TOTAL (auto calculated)

0

a.4. TOTAL (auto calculated)

0

2. Age

Number of Individuals

b. Race

a.

0-5

b.1. American Indian or Alaska Native

b.

6-13

b.2. Asian

c.

14-17

b.3. Black or African American

d.

18-24

b.4. Native Hawaiian and Other Pacific Islander

e.

25-44

b.5. White

f.

45-54

b.6. Other

g.

55-59

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

h.

60-64

b.8. Unknown/not reported

i.

65-74

b.9. TOTAL (auto calculated)

0

j.

75+

k.

Unknown/not reported

7. Military Status

Number of Individuals

l.

TOTAL (auto calculated)

0

a. Veteran

b. Active Military

c. Never Served in the Military

3. Education Levels

Number of Individuals

d. Unknown/not reported

[ages 14-24]

[ages 25+]

e. TOTAL (auto calculated)

0

a.

Grades 0-8

b.

Grades 9-12/Non-Graduate

8. Work Status (Individuals 18+)

Number of Individuals

c.

High School Graduate

a. Employed Full-Time

d.

GED/Equivalency Diploma

b. Employed Part-Time

e.

12 grade + Some Post-Secondary

c. Migrant or Seasonal Farm Worker

f.

2 or 4 years College Graduate

d. Unemployed (Short-Term, 6 months or less)

g.

Graduate of other post-secondary school

e. Unemployed (Long-Term, more than 6 months)

h.

Unknown/not reported

f. Unemployed (Not in Labor Force)

i.

TOTAL (auto calculated)

0

0

g. Retired

h. Unknown/not reported

4. Disconnected Youth

Number of Individuals

i. TOTAL (auto calculated)

0

a. Youth ages 14-24 who are neither working or in school

5. Health

Number of Individuals

Yes

No

Unknown

a. Disabling Condition

Yes

No

Unknown

b. Health Insurance*

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

Health Insurance Sources

c.1. Medicaid

c.2. Medicare

c.3. State Children’s Health Insurance Program

c.4. State Health Insurance for Adults

c.5. Military Health Care

c.6. Direct-Purchase

c.7. Employment Based

c.8. Unknown/not reported

c.9. TOTAL (auto calculated)

0

D. HOUSEHOLD LEVEL CHARACTERISTICS

9. Household Type

Number of Households

13. Sources of Household Income

Number of Households

a. Single Person

a. Income from Employment Only

b. Two Adults NO Children

b. Income from Employment and Other Income Source

c. Single Parent Female

c. Income from Employment, Other Income Source,

d. Single Parent Male

and Non-Cash Benefits

e. Two Parent Household

d. Income from Employment and Non-Cash Benefits

f. Non-related Adults with Children

e. Other Income Source Only

g. Multigenerational Household

f. Other Income Source and Non-Cash Benefits

h. Other

g. No Income

i. Unknown/not reported

h. Non-Cash Benefits Only

j. TOTAL (auto calculated)

0

i. Unknown/not reported

j. TOTAL (auto calculated)

0

10. Household Size

Number of Households

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

a. Single Person

b. Two

14. Other Income Source

Number of Households

c. Three

a. TANF

d. Four

b. Supplemental Security Income (SSI)

e. Five

c. Social Security Disability Income (SSDI)

f. Six or more

d. VA Service-Connected Disability Compensation

g. Unknown/not reported

e. VA Non-Service Connected Disability Pension

h. TOTAL (auto calculated)

0

f. Private Disability Insurance

g. Worker’s Compensation

11. Housing

Number of Households

h. Retirement Income from Social Security

a. Own

i. Pension

b. Rent

j. Child Support

c. Other permanent housing

k. Alimony or other Spousal Support

d. Homeless

l. Unemployment Insurance

e. Other

m. EITC

f. Unknown/not reported

n. Other

g. TOTAL (auto calculated)

0

o. Unknown/not reported

12. Level of Household Income

Number of Households

15. Non-Cash Benefits

Number of Households

(% of HHS Guideline)

a. SNAP

a. Up to 50%

b. WIC

b. 51% to 75%

c. LIHEAP

c. 76% to 100%

d. Housing Choice Voucher

d. 101% to 125%

e. Public Housing

e. 126% to 150%

f. Permanent Supportive Housing

f. 151% to 175%

g. HUD-VASH

g. 176% to 200%

h. Childcare Voucher

h. 201% to 250%

i. Affordable Care Act Subsidy

i. 251% and over

j. Other

j. Unknown/not reported

k. Unknown/not reported

k. TOTAL (auto calculated)

0

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

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*:

Program Name

Number of Households

*The system will add rows to allow reporting on multiple programs.