Grantee Information Collection

Appendix P

GRANTEE INFORMATION FORM

Public reporting burden for this collection of information is estimated to average 60 minutes per respondent, including the time for reviewing instructions, 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 to Eileen Pederson, U.S. Department of Labor, Employment and Training Administration, Office of Policy Development and Evaluation, Room N-5641, 200 Constitution Avenue, NW, Washington, DC 20210. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this information collection is xxxx-xxxx. Expiration Date xx/xx/20xx.

XV. Grantee Information Form

Name of site:

Site code:

Name of site visitor:

Date of site visit:

Grant Information

1. Is this your first DOL Grant?

2. If no, in what grant cycles have you received a DOL grant?

3. How many youth are you contracted to serve under the current grant cycle?

Budget

4. What is the FY 2011-2012 total budget?

	What is the total sponsoring agency budget for FY 2011-2012?
	What is the total YouthBuild program budget for FY 2011-2012?

5. List all YouthBuild program funding sources for this grant period:

Name	Description	Amount	Total length of grant (years)
DOL

Program Staff

6. Describe staffing for the program.

Name	Title	Description of role	Background (education, job history, other relevant experience working with at-risk youth)	FTE1	Years1

1 In your YouthBuild program