2 LASSIE Survey for Higher Education

2007-2008 Program and Performance Measurement Report

Higher Education

Please fill out this form completely.

The Program and Performance Measurement Report Registration Information (pages 2-3 of this form) should be completed by any organization receiving Learn and Serve funds (CNCS grantees, subgrantees, organizations receiving grants from subgrantees).

This Program Reporting Form (beginning on page 4) should be completed by:

(1) LSA grantees (such as direct higher education grantees) directly operating LSA funded service-learning programs;

(2) Any organization receiving a subgrant under the Learn and Serve America (LSA) program (i.e. a Learn and Serve grant awarded by a State Education Agency, Grantmaking Entity, or Higher Education Consortium);

(3) By institutions receiving program grants from subgrantee organizations.

The questions on this form refer to the July 1, 2007 – June 30, 2008 program year.

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Corporation for National and Community Service, 1201 New York Avenue, NW, Washington, D.C. 20525; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

Registration Form

Subgrantee ID number: (from grantee):
Organization/School Name:
School District (if applicable):
Program Name (if any):
Contact Person – First Name:			Last Name:
Contact Title:
Street Address:
City:	State:		Zip+4:
Email:
Telephone:
Fax:
Website (if any):
Additional Contact Persons:
First Name:		Last Name:
Title:		Email:
Telephone:		Fax:

1. Please choose one of the descriptions below. Only fill out the ethnic description if you are a higher education organization and one applies.

K-12	Higher Education	Community-Based Organization
	 2 Year Public College	 National Not-for-profit Organization
 School District	 2 Year Private College	 State or Regional Not-for-Profit
 Regional Education Agency	 4 Year Public College or University	 Local Not-for-Profit
 State Education Agency	 4 Year Private College or University	 State service commission
	 Graduate/Professional Program
	 Higher Education Association/ Consortia
 Public School	If checked above, secondary window asks for the following: “Is your college or university a:”
 Private School	 Historically Black College/University
 Public Charter School	 Hispanic Serving Institution
 Indian/Tribal School	 Tribal College/University

2. Is your institution religious or faith-based?

 Yes  No  Don’t Know

3. Please indicate which of the following activities you performed during the 2007-2008 program year using Learn and Serve grant funds:

My institution or organization used Learn and Serve funds to provide training and technical assistance and/or curriculum development for service-learning activities	 Yes	 No
My institution or organization subgranted Learn and Serve funds to other institutions or organizations	 Yes	 No
My institution or organization ran Learn and Serve funded service-learning activities (Note: answering yes to this question indicates that you will report on participants and service-learning activities for this program year)	 Yes	 No

4. Please list all of the institutions or organizations to which you make grants of Learn and Serve America funds. For each, please provide the name of the organization, the size of the grant, and contact information for the lead contact person for the programs. Please note, do not include mini-grants or grants to individuals within your institution, or small grants to individuals (for example, training stipends) in other institutions.

Institution/ Organization	Grant Size (Dollars)	Contact Person	Address	Telephone/ Fax	Email

End of Website Registration Questions

Program Reporting Form

I. Institutional Questions

1. Institution size: provide the total number of students in your institution as a whole

Total Number of Students

2. What best describes the scope of service-learning activities at your institution during the 2007-2008 program year? Check all that apply.

 Entire institution	 Individual classrooms/faculty
 College or school within the institution (for example, School of Education)	 Extracurricular programs/activities
 Multiple departments	 One or more institutes or centers
 Single department	 Other (specify)
	 Don’t know

3. Does your institution have service-learning requirements for any of your students?

 Yes, for all students

 Yes, for some students

 No (skip to question 5)

 Don’t Know (skip to question 5)

4. If your institution has a service-learning requirement for students, what type(s) of service-learning requirement(s) does your institution have?

Required courses that incorporate service-learning	 Yes	 No
Specific number of hours of service outside the classroom	 Yes	 No
Some other requirement (specify__________________)	 Yes	 No

II. Funding Sources

5. 2007-2008 Learn and Serve Grant Amount (from grantee file link/lookup): $ __________

6. Is the current grant the first Learn and Serve America grant that your institution has received?

 Yes, this is the first grant

 No, we have received prior grants

 Don’t know

7. What are the other (non-Learn and Serve) sources of funding for your service-learning initiatives or programs this year? (check all that apply)

 State service-learning funds (non LSA)	 Endowments for service-learning
 Other state grant or program funds	 Federal Work-Study funds
 General college/university operating funds	 Other Corporation for National and Community Service Grants
 Foundation grants	 Other federal funds (e.g. Title III)
 Corporate grants	 Other
 Community/private contributions (e.g., private donors)	 Don’t Know

III. Service-Learning Participants

In this section we are interested in the individuals who participate in your LSA service-learning programs and activities.

8. Please provide demographic information on the service-learning participants who were engaged in Learn and Serve-supported activities from July 1, 2007 to June 30, 2008. If you have no students in a given category, enter “0” in the relevant box.

LSA Funded Service-Learning Participants		Estimated Number of Service-Learning Participants
Total number of higher education student service-learners in LSA supported activities/programs at your institution
	Undergraduate student service-learners
	Graduate student service-learners
	Unknown
Total number of non-higher education student service-learners in LSA supported activities/programs at your institution
	K – 5th grade
	6th grade – 8th grade
	9th grade – 12th grade
	School dropouts
	Grade unknown
Total number of faculty involved in teaching LSA supported service-learning courses
Total number of faculty participating in LSA supported curriculum development projects, workshops, or other non-teaching/course specific service-learning activities.
Total number of staff involved in LSA supported service-learning activities
Total number of adult community members participating in LSA supported service-learning activities
	Community members between 18 and 39 years of age (born between 1988 and 1966)
	Community members between 40 and 60 years of age (born between 1945 and 1965)
	Community members age 61 or older (born before 1945)
	Age Unknown

Ethnic background of LSA Higher Education Students	Estimated Number
Hispanic
Non-Hispanic
Ethnicity Unknown

Racial background of LSA Higher Education Students	Estimated Number
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
Race Unknown

Gender of LSA Higher Education Students	Estimated Number
Male
Female
Gender Unknown

Other Categories of LSA Higher Education Students	Estimated Number
Higher education student service-learners who are Federal Work-Study students
Higher education student service-learners with disabilities

Additional Volunteers

9. Approximately how many youth volunteers (defined as youth 5-17 years old) were involved in LSA supported service activities (one-time volunteers). Do not include regular program participants reported above.

________ Estimated number of youth volunteers  Don’t Know

10. Approximately how many adult volunteers (defined as 18 or older) were involved in LSA supported service-related activities (one-time volunteers). Do not include program staff/faculty.

________ Estimated number of adult volunteers  Don’t Know

10a. Approximately how many of these adult volunteers are Baby Boomers (defined as individuals born between 1946 and 1964, or between the ages of 41 and 61).

________ Estimated number of Baby Boomer volunteers  Don’t Know

Youth Participants from Disadvantaged Circumstances

11. Approximately how many youth (between the ages of 5 – 17) who are from disadvantaged circumstances provided community service through your LSA supported service activities during the 2007-2008 program year?

______ Estimated Number  Don’t Know

IV. Beneficiaries

12. Did any of your LSA supported activities provide services to youth from disadvantaged circumstances during the 2007-2008 program year? (NOTE: youth included here may have also been reported in question 13 if they provided community service as part of their activities.)

 Yes  No  Don’t Know

(If Yes, proceed to 12a. If No or Don’t Know, proceed to 13)

12a. Approximately how many of the youth beneficiaries of your LSA supported activities belong to the following populations (categories are not exclusive):

Disadvantaged Youth Beneficiaries	Estimated Number	Don’t Know
Economically disadvantaged youth		
Foster children		
Adjudicated youth		
Children of incarcerated parents		
Students who are disabled/ in special education		

13. Approximately how many K-12 youth were mentored through your LSA supported service-learning activities?

_______ Estimated Number  Don’t Know  Do not have mentoring activities (skip to question 14)

13a. Approximately how many of those mentored are from disadvantaged circumstances?

_______ Estimated Number  Don’t Know

14. Approximately how many K-12 youth were tutored through your LSA supported service-learning activities?

_______ Estimated Number  Don’t Know  Do not have tutoring activities (skip to question 15)

14a. Approximately how many of those tutored are from disadvantaged circumstances?

_______ Estimated Number  Don’t Know

15. Approximately how many individuals received independent living services, including respite care, to help them live independently in their homes in community-based settings?

_______ Estimated Number  Don’t Know  Do not have independent living service activities

V. Service-Learning/Participant Experience

Program Hours and Duration

16. In this question we are trying to get information about the duration of the LSA programs and activities in your institution and the amount of time service-learners are engaged in preparation, reflection, and service. Please fill in the table below with the numbers of program participants and average hours of preparation and service. If you do not run projects for any of the three durations, check “Do Not Run.” If you don’t know the number of participants and average hours for any of the three durations, check “Don’t Know.”

Instructions for completing table on service hours

1. First, estimate the number of service-learning participants who were in service-learning programs of the durations listed in the table below from July 1, 2007 to June 30, 2008. If you have more than one activity or program, please combine them in reporting participant numbers and hours. The total number of participants for all durations should equal the total number of participants reported in question 11.

2. Next, for each of the project durations, calculate the average hours of preparation for the service and formal reflection per participant during or after the service and enter that figure in column 3. 3. Finally, enter the average number of hours of service for a participant. Enter that figure in column 4.

• Preparation activities might include conducting background research, collecting data, attending trainings, assembling materials, rehearsing parts, and meeting to plan project activities during and after class.

• Formal reflection activities might include classroom discussions, keeping a journal, writing an essay or a poem, and making a class presentation.

• Service might include a variety of activities, including the following: providing direct service to individuals (tutoring, assisting at a human services agency, working in a classroom, etc.); service projects addressing a community need (for example, cleaning a park, raising money for a local program, monitoring local water quality), or education and advocacy efforts such as presenting a play on a community issue, organizing or testifying at a public hearing, or preparing educational materials (brochures, posters, etc.) on a local issue.

Example 1. The “Plant a Tree Project” lasted 2 months and involved 60 students (see ‘a’ in the table below). The average student in this project spent 8 hours engaged in preparation for the service and in formal reflection activities during and after the service (see ‘b’). The service activity itself took approximately 2 hours per student (see ‘c’).

Example 2: The senior Civics Class is organized around a core service-learning program. It meets one hour, two days a week for one semester, and has 25 students (see ‘d’). Each student in this class spent 63 hours engaged in service-learning preparation for the service and formal reflection during and after the service (see ‘e’). The service activity itself was 10 hours (see ‘f’). (Calculation: 2 hours of class + 1 hour of preparation + .5 hours of formal reflection x 18 weeks = 63 hours per student; 10 hours of service per student).

EXAMPLES

Duration	Do Not Run this Type of Program	Number of Participants	Average Hours of Preparation and/or Formal Reflection per Participant	Average Hours of Service per Participant	Don’t Know
Programs and activities that last 2 months or less		a. 60 participants	b. 8 hours each	c. 2 hours each
Programs and activities that last for most or all of one semester/term		d. 25 students	e. 63 hours each	f. 10 hours each
Programs and activities that last for most or all of the whole academic year

[End of pop-up instruction page]

PLEASE FILL IN

Duration	Do Not Run this Type of Program	Number of Participants	Average Hours of Preparation and/or Formal Reflection per Participant	Average Hours of Service per Participant	Don’t Know
Programs and activities that last 2 months or less
Programs and activities that last for most or all of one semester/term
Programs and activities that last for most or all of the whole academic year

If DO NOT KNOW – instruction will pop up: “If you do not know, please estimate the number of hours you expect someone to spend.”

Project Characteristics

17. To what extent are the following characteristics present in the Learn and Serve-funded service-learning programs in your institution?

	Never	Rarely	Occasionally	Frequently	Always
Service activities are of sustained or significant duration (e.g. more than 40 hours per participant per year).					
Service projects have clear and specific learning objectives.					
Program staff (teachers, faculty, program coordinators, etc.) work with participants to draw the connections between the service that participants are providing and what they should be learning.					
The service that students perform has a strong connection to the curriculum they are studying.					
The relationship between service and civic participation, responsibility, skills and concepts are made explicit.					
Project participants are given organized time to reflect on their service.					
Participants have a leadership role in all phases of a project, including making decisions about the development of the project as well as its execution.					
Projects are based in strong partnerships with community groups that include mutually agreed upon goals, roles and responsibilities.					
Both learning and service are emphasized in all projects.					

VI. LSA Service –Learning Activities

Service Categories

18. For each of the following service categories, fill in the percentage of your LSA-supported service-learning activities and/or programs that fall into the category. If you do not have any service activities in a given category, leave the % blank; do not enter “0.” For each category where activities take place, please check up to three of the most common types of service being conducted.

Community and Economic Development ____ % of service activities/programs

 Civic/Community Organizing	 Food Production	 Thrift Store
 Community Clean-up	 Housing Referrals/Relocation	 Transportation Services
 Consumer Education	 Housing Rehabilitation/Construction	 Volunteer Recruitment
 Economic Revitalization/Improvement	 Small Business Development	 Workforce Development, including Adult Mentoring
 Financial Asset Development	 Technology Access and Training	 Other Economic and Community Development (specify)

Disaster Recovery/Relief* ____ % of service activities/programs

 Disaster Mitigation	 Disaster Recovery	 Other Disaster (specify)
 Disaster Preparedness	 Disaster Response

*If you have activities under Disaster Recovery/Relief, please answer questions 23 and 24 below

Education ____ % of service activities/programs

 Adult Literacy	 ESL	 Service-Learning
 After School Programs	 GED	 Special Education
 Classroom Education - Elementary	 Job Preparedness	 Tutoring - Elementary
 Classroom Education – Middle School	 Library Services	 Tutoring – Middle School
 Classroom Education – High School	 Pre-Elementary Day Care	 Tutoring – High School
 Cultural Heritage	 School Preparedness including Head Start	 Other Education (specify)

Environment ____ % of service activities/programs

 Clean Air	 Environmental Protection	 Waste Reduction, Management, Recycling
 Clean Water	 Environmental Restoration	 Other Environment (specify)
 Energy Conservation	 Indoor Environment
 Environmental Awareness	 Toxic Waste Management

Health/Nutrition _____ % of service activities/programs

 Boarder Babies	 Health Screening	 Mental Health
 CHIOS/CHIPS	 HIV/AIDS	 Developmental Disabilities
 Congregate Meals	 Hospice/Terminally Ill	 Physical Disabilities Programs
 Delivery of Health Services	 Immunization	 Public Health
 Food Distribution/Collection	 In-Home Care	 Substance Abuse
 Health Education	 Maternal/Child Health Services	 Other Health/Nutrition (specify)

Human Needs ____ % of service activities/programs

 Adoption	 Safe Havens	 Transitional Housing
 Crisis Intervention	 Social Services Planning and Delivery	 Other Human Needs (specify)
 Homeless Assistance	 Social Services Community Coordination(specify)

Independent Living ____ % of service activities/programs

 Adult Day Care/Senior Center	 Respite	 Senior Companionship
 Independent Living – Disabled	 Senior Center Program (Non-Residential)	 Other Independent Living (specify)
 Independent Living - Seniors	 Senior Citizen Assistance

Public Safety ____ % of service activities/programs

 Accident Prevention	 Community Policing/Community Patrol	 Household Security
 Adult Abuse/Neglect	 Conflict Resolution/Mediation	 Legal Assistance
 Adult Offender/Ex-Offender Services/Rehabilitation	 Crime Awareness/Crime Avoidance	 Sexual Abuse/Rape
 Adult Safety Programs	 Family Violence	 Victim/Witness Assistance
 Animal Care/Humane Society	 Fire Prevention	 Other Public Safety (specify)

Youth Development ____ % of service activities/programs

 Child Abuse	 Gangs	 Teen Pregnancy/ Abstinence/Parent Support
 Children and Youth Safety	 Juvenile Justice	 Youth Leadership Development
 Delinquency	 Mentoring	 Other Youth Development (specify)

Disaster Preparedness and Response Programs (please answer questions 19 and 20 if you had service-activities in disaster preparedness and response)

19. How many service-learning participants have been certified in disaster training during the 2007-2008 program year?

_______________ Number  Don’t Know

20. How many local disasters did service-learning participants respond to during the 2007-2008 program year?

_______________ Number  Don’t Know

VII. Community Partners

Approximately how many community partners (community agencies, local government, businesses, etc.) were formally involved in managing and/or planning LSA supported service-learning activities with your college/university during this year – for example, serving on advisory boards or planning projects.

If you do not know the number of community partners, please check here and skip to question 22: 

		Number of Organizations
Total number of partner agencies/organizations
Of the total number of partners, how many were: (NOTE: the following categories are mutually exclusive; the sum of the numbers reported for 21a – 21d should equal the total number provided above.)
21a.	Regularly and actively involved in planning and managing LSA funded service-learning?
21b.	Periodically involved in planning and/or managing LSA funded service-learning?
21c.	Advised on LSA funded service-learning but were not directly involved planning or managing LSA funded service-learning?
21d.	Served as only a service site?

21e. How many of the total number of partner agencies/organizations are faith based? _____  Don’t Know

22. Does your service-learning program have an advisory board?  Yes  No  Don’t Know

If YES, then: How many partner organizations are represented on the advisory board? ____

23. How many new community partnerships were formed as a result of your current LSA funding? _______

Collaboration with Other Federal Programs

24. With which of the following Corporation for National and Community Service or U.S. Department of Education sponsored programs does your LSA program collaborate? (Check all that apply)

 AmeriCorps	 Upward Bound
 AmeriCorps*VISTA	 GEAR-UP
 Senior Corps (Foster Grandparents, Senior Companions, RSVP)	 None
 Federal Work-Study	 Don’t Know

25. How many of the following types of program volunteers were involved in coordinating service-learning programs and activities on a regular or on-going basis at your institution? (NOTE: this include members and volunteers who are involved in your school/district even if your school/district is not the host organization.)

____ AmeriCorps	 None
____ AmeriCorps*VISTA	 Don’t Know
____ Senior Corps SaYes volunteer

VIII. Institutional Supports for Service-Learning

These questions are about all service-learning in your institution.

26. How long have there been organized service-learning activities at your institution (e.g. regular, ongoing service-learning)?

 One year or less

 Two to five years

 Six years or more

 Don’t know

27. Please indicate which policies listed below are in place in your institution? For each type of policy, please indicate Yes, No, or Don’t Know.

	Yes	No	Don’t Know
Service-learning is included in the campus strategic plan.			
Service-learning is part of the official core curriculum in at least one discipline or major at the institution *(If yes, answer question 28)			
Service-learning is part of the official core curriculum in at least one course that is required for graduation.			
Public or institution-wide recognition is given to students receiving the President’s Volunteer Service Award			
Information about the President’s Volunteer Service Award and other CNCS national service programs is provided to students			

28. *If service-learning is part of the official core curriculum in at least one discipline or major, please indicate the subject(s). Check all that apply.

 Social Sciences (e.g. Political Science, History)	 Arts (incl. Music/theater)	 Social work
 Humanities (English, classics, etc.)	 Medicine/Nursing	 Allied Health
 Sciences	 Law/Criminal Justice	 Computer Science
 Math	 Education	 Vocational/Technical
 Foreign Languages	 Engineering	 Other
 Public Policy/Public Administration

29. During the past year, how many courses with service-learning activities were created at your institution as result of the Learn and Serve funds?

__________ Estimated number of courses Don’t Know

30. During the past year, how many courses with service-learning activities were provided by your institution overall?

__________ Estimated number of courses Don’t Know

31. Indicate the extent to which the following policies/practices were present at your institution over the past year:

	Never	Rarely	Occasionally	Frequently	Always
Service-learning is included in the institution’s current professional development plans					
The institution has adopted and/or disseminated quality standards for service-learning (for example, the Essential Elements of Service-Learning)					
Service-learning is included in the orientation for new faculty					
Service-learning is considered as one of the criteria in faculty promotion and/or tenure.					
Students are involved in decision-making about the service-learning activities in the institution, for example, through an advisory council or other formal planning or decision-making body					

32. During the past year, to what extent were the following available at your institution? Please indicate how regularly or widely each type of support is available.

	Never	Rarely	Occasionally	Frequently	Always
Financial support for planning, training, and implementation of service-learning projects or programs					
Reduction in course load to allow time for service-learning program development or supervision					
Technical assistance on planning or implementation of service-learning activities					
Recognition or rewards for faculty/staff for quality service-learning practice					

IX. Service-Learning Coordinator

33. The college/university has a full or part-time service-learning coordinator or staff person with responsibility for service-learning

 Yes  No (skip to question 39)

34. If there is a service-learning coordinator for the college/university, how many years of professional experience has the coordinator had with service-learning (for example, as a coordinator, faculty member, etc.)? If more than one coordinator, please provide information on the primary coordinator.

 Less than 1 year  1-4 years  5 years or more

35. Is the service learning coordinator a full time or part-time employee of the college/university?

 Full-time

 Part-time

36. Approximately what percentage of the coordinator’s total job responsibilities is service-learning?

 100 %  50%  Less than 25%

 75 %  25%

37. Please select the answer that best describes the extent of training/professional development the service-learning coordinator has received:

 No formal education/training/professional development related to service-learning

 One workshop, conference, or training session

 Multiple workshops/conferences/training sessions, OR one or more semesters of formal education
(pre-service or in-service) focused on service-learning

 A combination of a semester or more of formal education and multiple workshops/training sessions.

38. What percentage of the service-learning coordinator’s salary is from grants and institutional funds in 2007-2008 (including LSA funds):

Grants _____%

Institutional funds _____%

X. Program Description

39. Please provide a brief (100-150) word description of one service-learning project or activity funded by the current LSA subgrant. In doing so, please make sure you answer the following questions: What is the purpose of the project? What are the academic or educational goals? Where and when does it take place? Who are the participants? Who are the beneficiaries of the service? What are the intended results?

XI. Training and Technical Assistance and Curriculum Development (Only for those who indicated that they provided training and technical assistance and/or curriculum development under question 3 of the Registration Form)

Please provide information on any training, technical assistance or curriculum development that your organization conducted during the 2007-2008 program year that was supported by Learn and Serve funds.

40. How many faculty, teachers, staff and/or students received technical assistance through your LSA-funded technical assistance programs during the 2008 program year?

_______________ Number  Don’t Know

41. How many faculty, teachers, staff and/or students have attended the LSA-supported trainings that you provided during the 2008 program year? (NOTE: trainings can be in-person, via telephone, or web-based)

_______________ Number  Don’t Know

42. How many training and technical assistance and/or curriculum products (e.g. training manuals, lesson plans, assessment tools) were created?

_______________ Number  Don’t Know

43. Please provide a brief description (100-150 words) of the training and technical assistance and/or curriculum development activities that were supported by Learn and Serve funds. The description may include any special initiatives that you introduced, areas covered by training and technical assistance, and subject or service areas for curricula developed, as well as the number and type of school, teachers, staff, and students involved in these activities.

XII. Technical Assistance Strengths and Needs (Optional)

44. In which of the following areas do you believe your institution/program is particularly strong and capable of providing technical assistance to other Learn and Serve programs? Please check all that apply.

Program Management

Program Content

 Program Design  Strategic Planning  Developing Community Partnerships  Assessing community impact  Building Community/Institutional Support  Service Site Recruitment  Volunteer/service site training  Staff development/teacher education  Managing/Overseeing Service Sites  Program evaluation strategies/Performance measurement  Financial/grant management  Marketing  Other (specify) ________________________  None

 Curriculum/program design (specify subject area)  Development/Leadership  Orientation  Reflection techniques  Youth voice/youth governance  Individual assessment strategies (portfolios, etc.)  Promotion & tenure  Other (specify) _____________________  None

45. In which of the following areas do you feel your institution/program is most in need of technical assistance or training? Please check the three highest priority areas for assistance.

Program Management

Program Content

 Program Design  Strategic Planning  Developing Community Partnerships  Assessing community impact  Building Community/Institutional Support  Service Site Recruitment  Volunteer/service site training  Staff development/teacher education  Managing/Overseeing Service Sites  Program evaluation strategies/Performance measurement  Financial/grant management  Marketing  Other (specify) ________________________

 Curriculum/program design (specify subject area)  Development/Leadership  Orientation  Reflection techniques  Youth voice/youth governance  Individual assessment strategies (portfolios, etc.)  Promotion & tenure  Other (specify) _____________________  None

OMB Control Number 3045-0089