Form 1 ACF-ANA-Project-Impact-Assessment SF-PPR

PERFORMANCE PROGRESS REPORT

SF-PPR

Administration for Native Americans

Administration for Children and Families

U.S. Department of Health and Human Services

Project Impact Assessment

					Page 1	of 24 Pages
1. Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency			3a. DUNS Number
					3b. EIN
4. Recipient Organization (Name and Complete Address Including Zip Code)					5. Recipient Identifying Number or Account Number
6. Project Reporting Period			7. Reporting Period End Date		8. Final Report? Yes No
Start Date: (Month, Day, Year)	(Month, Day, Year)		(Month, Day, Year)		9. Report Frequency
					annual semi-annual quarterly other (If other, describe: End of Project)
10. Performance Narrative (performance narrative is covered in the attached PPR forms)
11. Other Attachments
12. Certification: I certify to the best of my knowledge and belief that this report is correct and complete for performance of activities for the purposes set forth in the award documents.
12a. Typed or Printed Name and Title of Authorized Certifying Official				12c. Telephone (area code, number and extension)
				12d. Email Address
12b. Signature of Authorized Certifying Official				12e. Date Report Submitted (Month, Day, Year)
				10. Agency Use Only

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden for this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

SF-PPR (Supplemental Continuation of Cover Page)

						Page 2	of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency	3a. DUNS		4. Reporting Period End Date (Month, Day, Year)
IDENTIFYING INFORMATION: To be completed by the Evaluator prior to the site visit
(1) Label	(2) Additional Information on Grantee			(3) Provide Information Requested:
PIA-A101	Evaluator’s Name:
PIA-A102	Other ANA Staff/Contractors Present at Site Visit:
PIA-A103	Date of Evaluation:
GRANTEE INFORMATION:
PIA-A201	Geographic Designation: http://www.ers.usda.gov/Data/RuralurbanContinuumCodes/2003/
PIA-A202	Office Phone:
PIA-A203	Grantee Fax Number:
PIA-A204	Contact’s Name (if different from Authorized Grant Representative)
PIA-A205	Contact’s Title:
PIA-A206	Contact’s Phone #:
PIA-A207	Contact’s Fax #:
PIA-A208	Contact’s Email:
PIA-A209	Grantee Type			Tribe
ANA CONTACTS:
PIA-A301	ANA Program Specialist
PIA-A302	Grants Management Specialist

SF-PPR (Supplemental Continuation of Cover Page)

					Page 3	of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency	3a. DUNS		4. Reporting Period End Date (Month, Day, Year)
IDENTIFYING INFORMATION: To be completed by the Evaluator prior to the site visit
(1) Label	(2) Additional Information on Grant Project			(3) Provide Information Requested:
GRANT INFORMATION:
PIA-A401	Project Title:
PIA-A402	All proposed staff positions filled?			Yes No
PIA-A403	List positions vacant and reasons for hiring delays:
PIA-A404	Project Period:			12 mos. 24 mos. 36 mos. Other (Specify:_____________)
PIA-A405	Original Project Start Date (mm/dd/yyyy)
PIA-A406	Original Project End Date (mm/dd/yyyy)
PIA-A407	Amended Start Date (mm/dd/yyyy)
PIA-A408	Amended End Date (w/NCEs)
PIA-A409	Project Status at Time of Visit			Project ended Final 3 months Other (Specify:_____________)
PIA-A410	Total Grant Amount			$
PIA-A411	Total for Year 1:			$
PIA-A412	Total for Year 2:			$
PIA-A413	Total for Year 3:			$
PIA-A414	Total for Year 4:			$
PIA-A415	Total for Year 5:			$
PIA-A416	Any supplements?			Yes Amount $___________ No Date _______________
PIA-A417	Any carryovers?			Yes Amount $___________ No Date _______________
PIA-A418	Did the project receive an LCE (low cost extension)?			Yes Amount $___________ No Date _______________
PIA-A419	Did the project receive TA during implementation?			Yes No If Yes, what type? (Check multiple if applicable.) Electronic On-Site PIP

SF-PPR-B

Page 4

of 24 Pages

1.Federal Agency and Organization Element to Which Report is Submitted

HHS/ACF/ANA

2. Federal Grant or Other Identifying Number Assigned by Federal Agency

3a. DUNS

4. Reporting Period End Date

(Month, Day, Year)

GRANT INFORMATION (Continued): To be completed by Evaluator prior to site visit

PIA-A420

Grant Type

Social Development

Youth Development	Cultural Preservation Activities
Supporting Elders	Education Development
Supporting People with Disabilities

Economic Development

Business Development	Transportation for Elders and Disabled
Community Strategic Planning	Transportation for Workforce Development
Organizational Capacity Building	International Tourism and Trade
Subsistence Project	Job Training
Emergency Response Activities

Governance

Tribal Governance & Program Enhancement	Constitutional Reform
Management and Leadership Development	Operational Planning
Information Management Systems	Tribal Court Systems
Codes and Ordinances	Leadership Development/ Management

Family Preservation I - Planning

Curriculum Development	Community Assessment
Develop Family Preservation Strategic Plan

Family Preservation II – Implementation

Relationship and Marriage Education	Responsible Fatherhood or Parenting
Foster Care	Grandparents Raising Grandchildren
Foster Parent Training	Research

Environmental Regulatory Enhancement

Environmental Assessment	Enforcement
Infrastructure Improvement	Energy Assessment
Develop Regulations, Ordinances or Laws	Energy Projects for Export
Develop a Technical Program	Renewable Energy Resources
Training

Language Preservation

Assessment	Implementation
Planning	Immersion

PIA-A421

Background Information:

Table of Activity Results SF-PPR-D

Page 5

of 24 Pages

1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA

2. Federal Grant or Other Identifying Number Assigned by Federal Agency

3a. DUNS

4. Reporting Period End Date (Month, Day, Year)

PRE-VISIT INFORMATION Baseline Data:

(1) Label

(2) Subject

(3.1) Status Prior to Project

(3.2) Change after Project

(3.3) Comments

PIA-B101

PIA-B102

PIA-B103

PIA-B104

PIA-B105

PIA-B106

PIA-B107

PIA-B108

PIA-B109

PIA-B110

POST-VISIT CHECKLIST (To be completed by Evaluator during the site visit) Please list all documents to be sent to the Evaluator by the grantee following the site visit.

(1) Label

(2) Document

(3.1) Due Date

(3.2) Comments

PIA-B201

PIA-B202

PIA-B203

PIA-B204

PIA-B205

1. OBJECTIVE WORK PLAN

(1) Label

(2) Question

(3.1) Response

(3.2) Comments

PIA-B301

Was the OWP a useful guide for your project’s implementation?

Yes No

PIA- B302

Was the OPR a useful to monitor your project?

Yes No

PIA- B303

What changes would you make to the OPR?

Table of Activity Results SF-PPR-D

										Page 6		of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA					2. Federal Grant or Other Identifying Number Assigned by Federal Agency		3a. DUNS			4. Reporting Period End Date (Month, Day, Year)
1. OBJECTIVE WORK PLAN 1.1 Evaluator: Using the OWP, list the grantee’s objectives, the results and benefits, the criteria for evaluating the results and benefits and the deliverables for each objective below. This should be done in advance of the site visit. During the visit, confirm the status of these objectives with the grantee and note any comments below. Include the status of incomplete objectives with their projected completion date. (Pre-populate shaded areas.)
(1) Label	(2) Year	(3.1) Objective	(3.2) Results and Benefits Expected	(3.3) Criteria for Evaluating Results and Benefits Expected		(3.4) Deliverables		(3.5) Product	(3.6) Documentation Reviewed		(3.7) Comments
PIA-1.001	1	1
PIA-1.002	1	2
PIA-1.003	1	3
PIA-1.004	2	1
PIA-1.005	2	2
PIA-1.006	2	3
PIA-1.007	3	1
PIA-1.008	3	2
PIA-1.009	3	3
PIA-1.010	4	1
PIA-1.011	4	2
PIA-1.012	4	3
PIA-1.013	5	1
PIA-1.014	5	2
PIA-1.015	5	3

Note: This page can be duplicated

SF-PPR-B

						Page 7	of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency		3a. DUNS		4. Reporting Period End Date (Month, Day, Year)
2. PROJECT IMPACT 2.1 Impact Indicators
2.1.1 Partnerships:
(1) Label	(2) Partner’s Name				(3) Pre-existing or New?			(4)
PIA-2.1.101					Pre-existing New
PIA-2.1.102					Pre-existing New
PIA-2.1.103					Pre-existing New
PIA-2.1.104					Pre-existing New
PIA-2.1.105					Pre-existing New
PIA-2.1.106					Pre-existing New
PIA-2.1.107					Pre-existing New
PIA-2.1.108					Pre-existing New
PIA-2.1.109					Pre-existing New
PIA-2.1.110					Pre-existing New
PIA-2.1.111					Pre-existing New
PIA-2.1.112					Pre-existing New
PIA-2.1.113					Pre-existing New
PIA-2.1.114					Pre-existing New
PIA-2.1.115					Pre-existing New
PIA-2.1.116					Pre-existing New
PIA-2.1.117					Pre-existing New
PIA-2.1.118					Pre-existing New
PIA-2.1.119					Pre-existing New
PIA-2.1.120					Pre-existing New
2.1.2 Consider the three partnerships that were most important to your project’s implementation. What made them crucial to your project?
(1) Label	(2) Partner’s Name		(3) Type of Partnership		(4) Description
PIA-2.1.101
PIA-2.1.102
PIA-2.1.103

SF-PPR-D

									Page 8		of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA			2. Federal Grant or Other Identifying Number Assigned by Federal Agency			3a. DUNS			4. Reporting Period End Date (Month, Day, Year)
2.1.3 Leveraged Resources: What resources other than the 20% non-federal match have you been able to attract as a result of this project?
PIA-2.1.300	Check here if grantee was unable to leverage resources.				Unable to leverage resources
(1) Label	(2) Source (Pre-populate from OPR)	(3.1) Documentation Reviewed			(3.2) Amount of Federal $		(3.3) Amount of Non-Federal $			(3.4) Brief description of how the resource leveraged contributed to meeting the project goal and objectives
PIA-2.1.301
PIA-2.1.302
PIA-2.1.303
PIA-2.1.304
PIA-2.1.305
PIA-2.1.306
PIA-2.1.307
PIA-2.1.308
PIA-2.1.309	Total Leveraged Resources:
2.1.2 Impact Indicator Targets
(1) Label	(2) Impact/Performance Indicator			(3) Original Target				(4) Actual Achieved
PIA-2.1.401	Partnerships
PIA-2.1.402	Resources Leveraged
PIA-2.1.403
PIA-2.1.404
2.2 Statement of Need/Problem Statement
(1) Label	(2) Statement of Need/Problem Statement (Pre-populate)			(3) You stated this Statement of Need/Problem as your identified needs and problems in your community. To what extent do you feel this project addressed these problems and needs?
PIA-2.1.201

SF-PPR-B

						Page 9	of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA			2. Federal Grant or Other Identifying Number Assigned by Federal Agency		3a. DUNS	4. Reporting Period End Date (Month, Day, Year)
2.3 Impact Summary: (Evalulator: Have the grantee identify the beneficiaries of this project. Then ask the grantee to discuss the impact this project has had on each identified beneficiary.)
(1) Label	(2) Beneficiary			(3.1) Realized Impact
PIA-2.3.001
PIA-2.3.002
PIA-2.3.003
PIA-2.3.004
PIA-2.3.005
PIA-2.3.006
3. Community Involvement and Outreach 3.1 Who developed the project proposal?
(1) Label	(2) Name and Title			(3) Relationship to Community
PIA-3.101				Native (but not from community Tribal Member Consultant Program Staff Other (_______________)
PIA-3.102				Native (but not from community Tribal Member Consultant Program Staff Other (_______________)
PIA-3.103				Native (but not from community Tribal Member Consultant Program Staff Other (_______________)
PIA-3.104				Native (but not from community Tribal Member Consultant Program Staff Other (_______________)
PIA-3.201	How was the project developed?

SF-PPR-B

						Page 10	of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency	3a. DUNS			4. Reporting Period End Date (Month, Day, Year)
3. Community Involvement and Outreach (continued)
(1) Label	(2) Name and Title			(3) Relationship to Community				(4)
PIA-3.301	Please rank the extent of community involvement During the project planning phase:			Not Involved Involved Very Involved N/A
PIA-3.302	Please rank the extent of community involvement During project implementation			Not Involved Involved Very Involved N/A
PIA-3.401	Were elders involved during Project Planning:			Yes No
PIA-3.402	Were elders involved during Project Implementation:			Yes No If yes, how many?______
PIA-3.501	Were youth involved during Project Planning:			Yes No
PIA-3.502	Were youth involved during Project Implementation:			Yes No If yes, how many?______
PIA-3.601	Did this project promote intergenerational exchanges?			Yes No Specify: Elders/Youth Grandparents/Grandchildren
PIA-3.700	What marketing materials/outreach activities worked best for you to bring attention to this project? List the top three:			_________________________________ _________________________________ _________________________________
PIA-3.800	Did any members of the community and/or general public express doubts or misgivings about this project?			Yes No	If yes, please elaborate:
PIA-3.900	Did you face any opposition from the community/general public while implementing your project?			Yes No	If yes, please elaborate:

SF-PPR-D

								Page 11		of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency				3a. DUNS		4. Reporting Period End Date (Month, Day, Year)
4.1 Challenges Please tell us about the major challenges you encountered on this project, whether you anticipated them, and how you were able to overcome them. (Evaluator: Allow the grantee to answer this open-ended question before following up with the specific challenges below. Place answers in the table provided below. Add additional comments on the following page)
(1) Label	(2) Challenge		(3.1) Rank	(3.2) Encountered Challenge?	(3.3) Expected/ Anticipated Challenge?		(3.4) Able to Overcome Challenge?		(3.5) If Applicable, How Challenge was Overcome
PIA-4.1.01	Staff turnover			Yes No	Yes No		Yes No
PIA-4.1.02	Late start: If late start, specify reason:      			Yes No	Yes No		Yes No
PIA-4.1.03	Scope too ambitious			Yes No	Yes No		Yes No
PIA-4.1.04	Geographic isolation / travel issues			Yes No	Yes No		Yes No
PIA-4.1.05	Lack of expertise			Yes No	Yes No		Yes No
PIA-4.1.06	Challenges with ANA processes			Yes No	Yes No		Yes No
PIA-4.1.07	Underestimated project cost			Yes No	Yes No		Yes No
PIA-4.1.08	Underestimated personnel needs			Yes No	Yes No		Yes No
PIA-4.1.09	Partnership fell through			Yes No	Yes No		Yes No
PIA-4.1.10	Lack of community support (implementation)			Yes No	Yes No		Yes No
PIA-4.1.11	Lack of community support (planning)			Yes No	Yes No		Yes No
PIA-4.1.12	Hiring delays			Yes No	Yes No		Yes No
PIA-4.1.13				Yes No	Yes No		Yes No
PIA-4.1.14				Yes No	Yes No		Yes No
PIA-4.1.15				Yes No	Yes No		Yes No
PIA-4.1.16				Yes No	Yes No		Yes No
PIA-4.1.17				Yes No	Yes No		Yes No
PIA-4.1.18				Yes No	Yes No		Yes No
PIA-4.200	Additional comments on project challenges
PIA-4.300	Is there anything you would have done differently in implementing your project?		Yes No		Comments:

SF-PPR-D

								Page 12		of Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency			3a. DUNS			4. Reporting Period End Date (Month, Day, Year)
5. STAFFING 5.1 PERSONNEL
5.1.1 Project Director:
(1) Label	(2) Question		(3.1) Answer	(3.2)		(3.3)	(3.4)		(3.5) Explanation
PIA-5.1.1.01	Are you the original project director?		Yes No
PIA-5.1.1.02	Did you attend an ANA Post-Award Training?		Yes No						If not, why?

Please list all project directors of this grant (past and present) along with their start and end dates.
(1) Label	(2) Name	(3.1) Start Date	(3.2) End Date	(3.3)	(3.4)	(3.5)

PIA-5.1.1.03
PIA-5.1.1.04
PIA-5.1.1.05

5.1.2 Consultants hired

PIA-5.1.2.01	Did you hire any consultants for this project?	Yes No
PIA-5.1.2.02	If yes, how many?
PIA-5.1.2.03	How many are Native Americans?

SF-PPR-D

* For recording ‘Total Jobs Created’, see DPPE Impact Visit Manual			Page 13	of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA	2. Federal Grant or Other Identifying Number Assigned by Federal Agency	3a. DUNS	4. Reporting Period End Date (Month, Day, Year)

5.2 Full-time Job Equivalents Created Please provide details of all positions that were funded by the project

5.1.1 Project Director:

(1) Label

(2) Position Title

(3.1) # of Positions

(3.2) # of People Who Filled Position

(3.3) # Native?

(3.4) Estimated Hours per Week

(3.5) Estimated # of Weeks

(3.6) Estimated Total (hours per week x # of weeks

(3.7) ANA Grant Funding

(3.8) Project-Generated Funding

(3.9) Lev. Funds

(3.10) NFS

(3.11) Job to continue after project?

Existed Prior

PIA-5.2.01

PIA-5.2.02

PIA-5.2.03

PIA-5.2.04

PIA-5.2.05

PIA-5.2.06	Total People Employed
PIA-5.2.07	Total Positions Created
PIA-5.2.08	Total FTEs Created
Created During / For Project

PIA-5.2.11

PIA-5.2.12

PIA-5.2.13

PIA-5.2.14

PIA-5.2.15

PIA-5.2.16	Total People Employed
PIA-5.2.17	Total Positions Created
PIA-5.2.18	Total FTEs Created

Fulltime Equivalents created for post-project (Anticipated)

PIA-5.2.21

PIA-5.2.22

PIA-5.2.23

PIA-5.2.24

PIA-5.2.25

PIA-5.2.26	Total People Employed
PIA-5.2.27	Total Positions Created
PIA-5.2.28	Total FTEs Created

SF-PPR-D

Page 14

of 24 Pages

1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA

2. Federal Grant or Other Identifying Number Assigned by Federal Agency

3a. DUNS

4. Reporting Period End Date (Month, Day, Year)

6. PROJECT RESULTS AND BENEFITS 6.1 Income Generated

PIA-6.1.100

Did the project generate income?.

Yes No

(1) Label

(2) Activity that Generated Income

(3.1) Documentation Reviewed

(3.2) $ Amount Generated to Date

(3.3)

(3.4)

PIA-6.1.201

PIA-6.1.202

PIA-6.1.203

PIA-6.1.204

PIA-6.1.205

Total Income Generated by this Project:

PIA-6.1.206

:

Comments:

PIA-6.1.300

If income will be generated after the project’s completion, will it be used to sustain the work of the project?

Yes No N/A

Please explain:

PIA-6.2.100

Were any businesses created as a result of this project (i.e. through direct grant funding, income generated or resources leveraged by the grant)? If yes, please provide details below:

Yes No

(1) Label

(2) Business Name

(3.1) Purpose of Business

(3.2) Source of Funding (e.g., ANA Funds, Leveraged Funds)

(3.3)

(3.4)

PIA-6.2.101

PIA-6.2.102

PIA-6.2.103

PIA-6.3.100

Did this project support native-owned businesses (e.g., purchased goods from Native-owned businesses)?

Yes No

6.4 Training

PIA-6.4.100

Did anyone receive training as a result of this project?

Yes No

(Evaluator: : Please discuss total # of people who successfully completed training with the grantee to ensure that the final total does not double-Count those who may have taken more than one training course/workshop.)

(1) Label

(2) Course/Workshop Name or Primary Objective of Course/Workshop

(3) # of people who successfully completed training

(4) # of new (unduplicated) people

(5) For Family Preservation Only: # hours needed to complete training

PIA-6.4.101

PIA-6.4.102

PIA-6.4.103

PIA-6.4.104

PIA-6.4.105

PIA-6.4.106

Totals:

SF-PPR-B

Page 15

of 24 Pages

1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA

2. Federal Grant or Other Identifying Number Assigned by Federal Agency

3a. DUNS

4. Reporting Period End Date (Month, Day, Year)

6.5 Project Sustainability

(1) Label

(2) Question

(3) Response

(4) Explanation

PIA-6.5.100

Did you develop a formal sustainability plan for your project?

Yes No

Provide a brief synopsis of how the project results/benefit/services will be sustained.

PIA-6.5.200

Please elaborate on any steps taken to finance this project’s sustainability

Other federal funds Tribal funds Private foundations State funds Non-Tribal Funds Colleges/universities Program income Additional funds not required Other: (_______)

PIA-6.5.300

What level of future project funding do you currently have in place? (Evaluator please only check one.)

Desired funding levels for sustainability in place Some funding already secured to sustain project Still seeking funding, none currently in place No continuation funding secured and no plan in place through which to obtain funds Do not need additional funding to sustain project benefits (stated by grantee)

PIA-6.5.400

If you could share some best practices from your project with other ANA grantees, what would they be?

7. FINANCIAL

PIA-7.1.100

(Evaluator: Write in the applicant’s required NFS total here:)

(Pre-populate with applicant’s required NFS total here)

PIA-7.1.101

How did you track the non-federal contribution to the project?

PIA-7.1.102

Documentation Reviewed:

PIA-7.2.001

Did you make any changes to your budget?

Yes No

If yes, what changes:

PIA-7.2.002

(Evaluator: If you feel the budget changes are significant, ask the following question:) Did you ask for ANA approval:

Yes No

Explanation:

PIA-7.3.000

Were there, or do you expect there to be, any ANA funds left over at the end of the ANA project period?

Yes No If yes, how much? $_______________

Please explain why there were unspent funds

PIA-7.4.000

Did a financial staff member attend the ANA Post Award Training?

Yes No Title: ___________

PIA-7.5.000

How often does someone from your staff meet with program staff with regard to this project?

PIA-7.6.000

Audit: When was your most recent audit, compilation or review?

7.7 Financial Procedures:

PIA-7.7.100

How often is your financial procedures manual updated?

PIA-7.7.200

How frequently are actual expenditures compared to budgeted amounts?

PIA-7.7.300

Who within your tribe/organization is responsible for the following actions? Please list the position title

PIA-7.7.301

Authorizing cash disbursements:

PIA-7.7.302

Drawing down cash?

PIA-7.7.303

Conducting bank reconciliations?

7.7.4. Verification of Financial Procedures: (Evaluator: Review the budget and ask for documentation for the 3 most expensive line items. Ask for a few sample timesheets) On timesheets, verify signatures from employee and supervisor (for hourly positions); compare the salary to the approved budget; and verify the salary amount with the personnel file. For invoices, verify purchases with the approved budget; check which vendor/consultant was paid; verify authorization signature; and check bank reconciliation (unreconciled difference should be $0).

PIA-7.7.400

Comments/Findings:

SF-PPR-B

Page 16

of 24 Pages

1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA

2. Federal Grant or Other Identifying Number Assigned by Federal Agency

3a. DUNS

4. Reporting Period End Date (Month, Day, Year)

8. COMPETITIVE AREA-SPECIFIC QUESTIONS Evaluator: Ask the grantee only those questions associated with their competitive area

SEDS Projects

PIA-8.100

Were any codes or ordinances developed as a result of this project?

Yes No If yes, please list each below.

(1) Label

(2) Type of code/ordinance: Environmental, Energy, Governmental Procedure, Financial, Business, Industry, Other (specify)

(3) Adopted/Implemented?

(4) Explanation

PIA-8.101

Was this code or ordinance adopted, enacted or passed? Yes No Was this code or ordinance implemented? Yes No

If implemented, please explain how: If not implemented, please explain why not:

PIA-8.102

Was this code or ordinance adopted, enacted or passed? Yes No Was this code or ordinance implemented? Yes No

If implemented, please explain how: If not implemented, please explain why not:

PIA-8.103

Was this code or ordinance adopted, enacted or passed? Yes No Was this code or ordinance implemented? Yes No

If implemented, please explain how: If not implemented, please explain why not:

PIA-8.104

Was this code or ordinance adopted, enacted or passed? Yes No Was this code or ordinance implemented? Yes No

If implemented, please explain how: If not implemented, please explain why not:

Family Preservation Projects

PIA-8.200

What curriculum was used to implement the activities of your project?

PIA-8.300

Did you adapt an existing curriculum to be culturally appropriate?

Yes

If yes, please describe how you adapted the curriculum.

No If no, did you develop your own curriculum? Yes No

Comments:

8.4 Project Participants

PIA-8.401

How many participants were served by the project?

PIA-8.402

Of those served how many completed an educational training?

PIA-8.403

How many couples (wed/unwed) were involved in the project?

Wed _____ Unwed _____

PIA-8.404

How many single parents were involved in the project?

Yes No

PIA-8.500

Did you capture any baseline data before your project began?

Yes No

If yes, please describe the data you collected and any changes.

PIA-8.600

Did your project conduct pre-post assessment surveys?

Yes No If yes, how many surveys were collected? ____________

Please summarize the findings

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Page 17

of 24 Pages

1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA

2. Federal Grant or Other Identifying Number Assigned by Federal Agency

3a. DUNS

4. Reporting Period End Date (Month, Day, Year)

Language Projects

8.8 Language Surveys

PIA-8.8.100

How many language surveys were developed as a result of this project?

PIA-8.8.200

If language surveys were developed, how many surveys were distributed and how many returned?

Distributed:________ Returned: ________

PIA-8.8.300

What strategies were used to encourage people to return the surveys?

8.9 Language Classes (If immersion project, skip to Question 8.10)

8.9.1 Complete the following:

(1) Label

(2) Level

(3.1) # of classes

(3.2) # of class hours

(3.3) # of students

PIA-8.9.101

PIA-8.9.102

PIA-8.9.103

8.9.3 What were the top 3 activities/methods that most effectively engaged students and facilitated learning? (Structure, skill based, active language methods, games, etc)

(1) Label

(2) Activities/Methods

PIA-8.9.201

PIA-8.9.202

PIA-8.9.203

PIA-8.9.300

How was improvement measured?

8.10 Language Immersion Classes

8.10.1 Complete the following:

(1) Label

(2) Level

(3.1) # of classes

(3.2) # of class hours

(3.3) # of students

PIA-8.10.101

PIA-8.10.102

PIA-8.10.103

8.10.2 What were the top 3 activities/methods that most effectively engaged students and facilitated learning? (Structure, skill based, active language methods, games, etc)

(1) Label

(2) Activities/Methods

PIA-8.10.201

PIA-8.10.202

PIA-8.10.203

PIA-8.9.300

How was improvement measured?

8.11 Language Immersion Classes

PIA-8.11.100

How many language teachers were trained as a result of this project?

PIA-8.11.200

Was this a certification program?

Yes No

PIA-8.11.300

If yes, what body issued the certification?

PIA-8.11.400

How many teachers were certified?

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						Page 18	of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency		3a. DUNS		4. Reporting Period End Date (Month, Day, Year)
8.12 Number of people increasing ability to speak a native language:
(1) Label	(2) Question		(3) Response			(4) Explanation
PIA-8.12.100	How many individuals have increased their ability to speak the native language as a result of this project?		Youth (0-18 years) ______ Adults (18+ years) ______			Please explain how you arrived at this figure:
PIA-8.12.200	Has anyone achieved fluency in the native language as a result of this project?		Yes No			If yes, how many achieved fluency? Youth (0-18 years) ______ Adults (18+ years) ______
PIA-8.12.300	How do you measure fluency?		Do you use an established language assessment tool? Yes No			If no, have you created your own tool? Yes No
Environmental Projects
PIA-8.13.000	What was the main focus of your project? If applicable, ask questions associated with project focus identified:		Data Collection Staff Training Develop Regulations Environmental Education Develop/implement Management Systems (GiS, Enforcement) Develop a Tribal Environmental Protection Act (TEPA) Develop management plan(s) for specific resources Other (Specify:_____________)
8.14 Data Collection (to identify pollution sources or determine impact on environmental quality)
PIA-8.14.100	What was data was collected for?		Establish Baseline Monitor condition/trend
PIA-8.14.200	Has anyone achieved fluency in the native language as a result of this project?		Yes No
PIA-8.14.300	How is this data going to be used?
PIA-8.14.400	Was what you learned different from your original hypothesis?		Yes No		Comments:
8.14. Sustainability
PIA-8.14.501	How will future data collection be carried out?
PIA-8.14.502	Is staff able to continue data collection efforts?
PIA-8.14.601	Challenges – Did you experience any challenges specifically related to checkerboard reservation access?		Yes No		Comments:

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							Page 19	of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency			3a. DUNS		4. Reporting Period End Date (Month, Day, Year)
8.15 Staff Training (to develop capacity to monitor or enforce regulatory programs)
(1) Label	(2) Question			(3) Response					(4)
PIA-8.15.100	Sustainability – how will future staff be trained in case of turnover or changes in the program?
8.16 Staff Training (to develop capacity to monitor or enforce regulatory programs)
PIA-8.16.100	Were any environmental regulations, codes or ordinances created as a result of this project?			Yes No If yes, please include details in the table below.
(1) Label	(2) Type of Regulation, Code or Ordinance		(3.1) Was this regulation code or ordinance adopted enacted or passed?	(3.2) Was this regulation code or ordinance adopted implemented?		(3.3) If yes, please explain how. If no, please explain why not.
PIA-8.16.101			Yes No	Yes No
PIA-8.16.101			Yes No	Yes No
PIA-8.16.101			Yes No	Yes No
PIA-8.16.101			Yes No	Yes No
PIA-8.16.101			Yes No	Yes No
PIA-8.16.200	Sustainability – How will policies & procedures and enforcement plans be developed and carried out Sustainability – how will future staff be trained in case of turnover or changes in the program?
PIA-8.16.300	Do you have TAS from EPA and/or is it needed for this (these) regulation(s)?
8.17 Develop/Implement Management Systems (GIS, Enforcement)
PIA-8.17.100	GIS – Is the system up and running and do you have all types of data that you need?
PIA-8.17.201	Sustainability – How are you going to keep your database updated?
PIA-8.17.202	Sustainability – Do you have staff with time and resources to maintain it?
PIA-8.17.300	Challenges – Did you have or do you foresee challenges getting data from partnering agencies or organizations?

SF-PPR-B

					Page 20	of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency		3a. DUNS	4. Reporting Period End Date (Month, Day, Year)
ADDENDUM Evaluator: Include any project-specific questions for the grantee and community members here. These should be developed before the site visit based on your review of the grant file.
Questions for the grantee:
(1) Label	(2) Question		(3) Answer:				(4)
PIA-E01
PIA-E02
PIA-E03
PIA-E04
PIA-E05
Questions for community members:
PIA-E06
PIA-E07
PIA-E08
PIA-E09
PIA-E10

SF-PPR-D

						Page 21		of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency		3a. DUNS		4. Reporting Period End Date (Month, Day, Year)
LIST OF INTERVIEWEES
(1) Label	(2) Interviewee’s Name		(3.1) Title/Relationship to Project		(3.2) Phone		(3.3) Email		(3.4)
PIA-D01
PIA-D02
PIA-D03
PIA-D04
PIA-D05
PIA-D06
PIA-D07
PIA-D08
PIA-D09
PIA-D10
PIA-D11
PIA-D12
PIA-D13
PIA-D14
PIA-D15
PIA-D16
PIA-D17
PIA-D18
PIA-D19
PIA-D20

Note: This page can be duplicated

SF-PPR-B

						Page 22	of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency		3a. DUNS		4. Reporting Period End Date (Month, Day, Year)
ANA SERVICES
(1) Label	(2) Question				(3) Answer:				(4)
PIA-E100	Are you aware that ANA offers pre-application training and technical assistance (T/TA)?				Yes No
PIA-E101	If yes, how did you hear about it?				ANA Program Specialist TA Provider’s website Phone call from TA Provider ANA website Letter from TA Provider Word of mouth Other: (Specify     )
PIA-E200	Have you taken advantage of any technical assistance during your project not including any ANA trainings you attended?				Yes No
PIA-E201	If yes, please provide the name of the T/A Provide
PIA-E202	What type of T/A did you receive?				Electronic On-site
On a scale of 1 to 5, with 1 being poor and 5 being excellent, how would you rate the Program specialists you listed above?
PIA-E300	Quality (e.g., ability to answer your questions, ability to assist you in overcoming challenges):		Poor Average Excellent 1 2 3 4 5					Comments:
Please provide the names of the Program specialists you had during your project
(1) Label	(2)		(3) Name					(4)
PIA-E301	Specialist 1
PIA-E302	Specialist 2
PIA-E303	Specialist 3
PIA-E304	Specialist 4
On a scale of 1 to 5, with 1 being poor and 5 being excellent, how would you rate the Program specialists you listed above?
PIA-E305	Responsiveness (e.g., responding to your phone calls/e-mails/other communication in a timely manner:		Poor Average Excellent 1 2 3 4 5 Specialist 1 Specialist 2 Specialist 3 Specialist 4					Comments:
PIA-E306	Ability to answer your questions		Poor Average Excellent 1 2 3 4 5 Specialist 1 Specialist 2 Specialist 3 Specialist 4					Comments:
PIA-E307	Ability to assist you in overcoming project challenges:		Poor Average Excellent 1 2 3 4 5 Specialist 1 Specialist 2 Specialist 3 Specialist 4					Comments:

SF-PPR-B

								Page 23	of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency			3a. DUNS			4. Reporting Period End Date (Month, Day, Year)
Program specialists rating (continued)
(1) Label	(2) Instructions		(3) Rating						(4)
PIA-E400	Please insert the name of the ANA staff member conducting the impact visit:		Matthew Gallagher Jeff Weiser Amanda Day Christopher Watson Richard Glass Courtney Roy Other (Specify:_____________)
On a scale of 1 to 5, with 1 being poor and 5 being excellent, how would you rate this person?
PIA-E401	Communication prior to Impact Visit (e.g., providing you with information, responding to your phone calls/e-mails/other communication in a timely manner):		Poor Average Excellent 1 2 3 4 5 Specialist 1 Specialist 2 Specialist 3 Specialist 4						Comments:
PIA-E402	Impact Evaluator’s Familiarity with Project:		Poor Average Excellent 1 2 3 4 5 Specialist 1 Specialist 2 Specialist 3 Specialist 4						Comments:
PIA-E500	Please insert the name of the T/TA provider conducting the impact vitas:
PIA-E501	Familiarity with Project:		Poor Average Excellent 1 2 3 4 5 Specialist 1 Specialist 2 Specialist 3 Specialist 4						Comments:
PIA-E502	Ability to answer any technical assistance questions/provide suggestions and feedback to grantee:		Poor Average Excellent 1 2 3 4 5 Specialist 1 Specialist 2 Specialist 3 Specialist 4						Comments:
PIA-E600	Please share any recommendations or comments you may have for improving ANA’s Impact Evaluation process (e.g. initial contact, timing of visit, questions asked, and length of visit).
PIA-E700	Do you read the monthly listserv sent by your ANA Program Specialist?			Yes No		Comments/Suggestions:
PIA-E800	Do you visit the ANA website?			Yes No		Comments/Suggestions:
PIA-E900	Please comment if you have any suggestions on how ANA can better serve you.

SF-PPR-B

						Page 24	of 24 Pages
1.Federal Agency and Organization Element to Which Report is Submitted HHS/ACF/ANA		2. Federal Grant or Other Identifying Number Assigned by Federal Agency		3a. DUNS		4. Reporting Period End Date (Month, Day, Year)
Photo Release
(1) Label	(2) Description:		(3) Response:					(4)
I give authorization to the Administration for Native Americans (ANA) to use my project-related photo(s) in support of the mission of ANA to help promote the self-sufficiency of Native Americans. I understand the photo(s) may or may not be used in PowerPoint presentations, the ANA website, ANA marketing materials, and Congressional Impact Reports.
PIA-F100	Typed or Printed Name
PIA-F200	Tribe/Organization affiliation
PIA-F300	Description of Photos:
PIA-F400	Location:
PIA-F501 Signature					PIA-F502 Date Signed (Month, Day, Year)
PIA-F601 For Minors – (Signature of Guardian)					PIA-F602 Date Signed (Month, Day, Year)
Contact information Release
I give authorization to the Administration for Native Americans (ANA) to use my contact information to support the mission of ANA to help promote the self-sufficiency of Native Americans. I understand my contact information may or may not be used on the ANA website to promote collaboration among ANA grantees implementing projects of similar themes and goals.
PIA-G100	Typed or Printed Name
PIA-G200	Title
PIA-G501 Signature					PIA-G502 Date Signed (Month, Day, Year)

Note: These sections can be duplicated

OMB Approval Number: XXXX-XXXX

Expiration Date: mm/dd/yy