Form 3.0 - Tribal Short 3.0 - Tribal Short CSBG Annual Report 3.0 Tribal Annual Report Short Form

OMB No.: 0970-0492

Expires: Month DD, YYYY

Annual Report 3.0

Tribal Short Form

PUBLIC BURDEN STATEMENT

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) 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 1,800 hours per grant recipient, 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 CSBGData@acf.hhs.gov.

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CSBG Tribal Short Form Table of Contents

Module 1: Tribal Administration 1

Community Services Block Grant (CSBG) Annual Report 2

Tribal Administration Module 1 2

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

Module 2: Tribal CSBG Expenditures 3

Community Services Block Grant (CSBG) Annual Report 4

Tribal CSBG Expenditures Module 2 4

Section A: Tribal CSBG Expenditures 4

Module 3: Individual and Family Level 5

Individual and Family Level – Module 3 6

Employment Services 6

Childcare, Early Childhood, Youth Development, and Adult Education Services 7

Income and Asset Building Services 8

Housing Services 9

Health and Nutrition Services 10

Civic Engagement and Community Involvement Services 11

Transportation Services 12

Partnerships, Linkages, and Coordination Services 13

Module 1: Tribal Administration

Module 1, Section A: Tribal Administration

Instructional Note

The reporting timeframes for all information in the tribe or tribal organization’s 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.

Tribal Administration

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

1. Provide the following information in relation to the tribe or tribal organization designated to administer CSBG as required in Sections 676 and 677 of the CSBG Act, the Human Services Reauthorization Act of 1998 (P.L.105-285), and relevant federal policy guidance. The following information should mirror the information provided on the Application for Federal Assistance, SF-424M.

A.1a. Name of Tribe or Tribal Organization

A.1b. CSBG Program Contact Person

Name Title

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

A.1d. Email Address

Module 2: Tribal CSBG Expenditures

Module 2, Section A: Tribal Expenditures

Instructional Note

Section A: CSBG Tribal Expenditures 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 federal fiscal year 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.

Note: The reporting timeframes for all information in the tribal expenditures 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

Tribal CSBG Expenditures

Section A: Tribal CSBG Expenditures

Name of CSBG Tribal Agency:

A.2. CSBG Expenditures Domains	CSBG Funds
A.2a. Employment
A.2b. Childcare, Early Childhood, Youth Development, and Adult Education
A.2c. Income and Asset Building
A.2d. Housing
A.2e. Health and Nutrition
A.2f. Civic Engagement and Community Involvement
A.2g. Transportation
A.2h. Partnerships, Linkages, and Coordination
A.2i. Total Expenditures
A.2j. Total CSBG Expenditures (auto calculated)	$0

A.3. Report the total amount used for Administration. For more information on what qualifies as Administration, refer to IM37.

Module 3: Individual and Family

Module 3, Section A: Individual and Family

Instructional Note

Section A: Individual and Family Services Data Entry Form provides information on the work CSBG Tribal Agencies did to serve individuals and families. This standardized Individual and Family Services list will aid in analysis of the relationship between people, services, and outcomes.

Individual and Family Level

Employment Services

Name of CSBG Tribal Agency:

SRV 1. Describe all employment related services, such as support for job placement, vocational and skills training, job development, and eliminating barriers to work. (If you did not provide this service, indicate “N/A” for not applicable.)

Childcare, Early Childhood, Youth Development, and Adult Education Services

Name of CSBG Tribal Agency:

SRV 2. Describe all education related services, such as adult education, literacy programs, scholarships, Head Start enhancement, child development programs, and anti-drug education. Additionally, describe all youth development related activities, such as activities that address the needs of youth in communities with low income to include establishment of violence-free zones, intervention and mediation programs, mentoring and life skills training, job creation, entrepreneurship programs, and after-school childcare programs. (If you did not provide this service, indicate “N/A” for not applicable.)

Income and Asset Building Services

Name of CSBG Tribal Agency:

SRV 3. Describe all income management and asset building related services, such as budgeting assistance, tax preparation, tax credit education, medical benefits claims assistance, and savings programs. (If you did not provide this service, indicate “N/A” for not applicable.)

Housing Services

Name of CSBG Tribal Agency:

SRV 4. Describe all housing related services, such as homeownership counseling and loan assistance, landlord-tenant relations, housing assistance, homeless services, and home repair and rehabilitation. (If you did not provide this service, indicate “N/A” for not applicable.)

Health and Nutrition Services

Name of CSBG Tribal Agency:

SRV 5. Describe all health and nutrition related services, such as food banks, public education, health counseling, transportation to health services, community garden programs, and production and delivery programs. (If you did not provide this service, indicate “N/A” for not applicable.)

Civic Engagement and Community Involvement Services

Name of CSBG Tribal Agency:

SRV 6. Describe all partnerships and community engagement related services, such as activities designed to help families and individuals with low incomes achieve greater participation in the affairs of their communities, including partnerships with local law enforcement agencies, housing authorities, private foundations, and other public and private partners. CSBG funding also supports interagency partnerships and Tribal-State partnerships as well. (If you did not provide this service, indicate “N/A” for not applicable.)

Transportation Services

Name of CSBG Tribal Agency:

SRV 7. Describe all transportation related activities such as transportation vouchers, public transit fare assistance, medical transportation services, community shuttle services, rideshare programs, volunteer driver programs, and child and youth transportation. (If you did not provide this service, indicate “N/A” for not applicable.)

Partnerships, Linkages, and Coordination Services

Name of CSBG Tribal Agency:

SRV 8. Describe all linkages and coordination between anti-poverty programs, such as eligibility coordination to make more effective use of related programs, including other public and private sources. Fill identified gaps in the services through the provision of information, referrals, eligibility coordination, case management, and follow-up consultations.