Form CMS-10028 Resorurce Report

RESOURCE REPORT

OMB No. 0938-0850

Complete Only One RR Form for the Entire State. Do Not Submit Sponsoring-Agency-Level or Within-State-Regional Resource Reports.
All Person Counts Should Reflect Active Counselors, Coordinators, Other Staff as of the End of Each Grant Year (31 March).
The Unique Count of Counselors Attending Any Update Training During the Grant Year Cannot Exceed the Grand Total Number of Counselors.

12 Month Period for This Report
From: 04/01/
To: 03/01/

State Code

State Grantee Name

Person Completing Report

Title

Telephone Number
(
) ________ - ______________

Section 1
Number of Active Counselors
And Hours As of 31 March
A. Number of Volunteer Counselors
B. Number of SHIP-Paid Counselors
C. Number of In-Kind-Paid Counselors
Total Number of Counselors - A+B+C
D. Volunteer Counselor Hours
E. SHIP-Paid Counselor Hours
F. In-Kind-Paid Counselor Hours
Total Counselor Hours - D+E+F

State
Office

All Other
Local and
Field Sites

Total

Section 2
Number of Local Coordinators / Sponsors and Hours
As of 31 March
A. Number of Volunteer (Unpaid) Coordinators
B. Number of SHIP-Paid Coordinators
C. Number of In-Kind-Paid Coordinators
Total Number of Coordinators - A+B+C
D. Volunteer (Unpaid) Coordinator Hours
E. SHIP-Paid Coordinator Hours
F. In-Kind-Paid Coordinator Hours
Total Coordinator Hours - D+E+F

Section 3
Number of Other Paid and Volunteer
Staff And Hours As of 31 March
A. Number of Volunteer Other Staff
B. Number of SHIP-Paid Other Staff
C. Number of In-Kind-Paid Other Staff
Total Number of Other Staff - A+B+C
D. Volunteer Other Staff Hours
E. SHIP-Paid Other Staff Hours
F. In-Kind-Paid Other Staff Hours
Total Other Staff Hours - D+E+F

State
Office

Total

All Other
Local and
Field Sites

Section 4 - Counselor Trainings
A. Number of Initial Trainings for New SHIP Counselors
B. Number of New SHIP Counselors Attending Initial Trainings
C. Total Number of Counselor Hours in Initial Trainings
D. Number of Update Trainings for SHIP Counselors
E. Number of SHIP Counselors Attending Update Trainings
F. Total Number of Counselor Hours in Update Trainings
Note: Item E should represent the number (unduplicated) of counselors who
attended at least one update training during the full 12 month period.
Please do not count a counselor more than once, even if he/she attended
multiple update trainings. Cannot exceed grand total number of counselors.

Total

Total

Section 5 - - Number of Total Active Counselors (SHIP-Paid, In-Kind-Paid, and Volunteer Counselors) with the Following Characteristics

Years of SHIP Service
1 Less Than 1 Year
2 1 Year Up to 3 Years
3 3 Years Up to 5 Years
4 More Than 5 Years
9 Not Collected

Counselor Age
1 Less Than 65 Years of Age
2 65 Years or Older
9 Not Collected

Counselor Gender
1 Female
2 Male
9 Not Collected

Counselor Race - Ethnicity
1
Hispanic, Latino, or Spanish Origin
2
White, Non-Hispanic
3
Black, African American
4
American Indian or Alaska Native
5
Asian Indian
6
Chinese
7
Filipino
8
Japanese
9
Korean
10 Vietnamese
11 Native Hawaiian
12 Guamanian or Chamorro
13 Samoan
14 Other Asian
15 Other Pacific Islander
16 Some Other Race-Ethnicity
17 More Than One Race-Ethnicity
99 Not Collected

Counselor Disability
1 Disabled
2 Not Disabled

Counselor Speaks Another Language
1 Language Other Than English
2 English Speaker Only
9 Not Collected
Form CMS-10028C (07/13)

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0850. The time
required to complete this information collection is estimated to average 2 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.