Fatherhood Combined

C - Fatherhood Combined OMB.pdf

Performance Measures for Healthy Marriage and Promoting Responsible Fatherhood Grants

Fatherhood Combined

OMB: 0970-0365

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Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
Welcome [
], Grant number: [
Budget period: [XXX]
Report number: [XXX]

REPORTING PERIOD: [

]

] through [

]

1. Across all of your grant’s Authorized Activities, how many people
enrolled and completed during the reporting period? This is an unduplicated
count of people enrolled and completed in any Authorized Activities during the reporting period.

a. Number enrolled

data not collected

b. Number completed

data not collected

2. Of those enrolled during this reporting for all of your grant’s Authorized Activities,
how many people were:
2.a. Sex

Male

2.b. Age

Under 18 years

Female

data not
collected

18 - 24 years
25 – 34 years
35 – 44 years
45 – 54 years
55 – 64 years
65 years or older
data not collected
2.c. Marital Status

Single, Never married
Committed relationship (not married)
Married

Public reporting burden for this collection of information is estimated to average 48 minutes per response including 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, including
suggestions for reducing this burden, to ACF Reports Clearance Officer, Paperwork Reduction Project (OMB# 0970-0365),
Administration for Children and Families, 370 L’Enfant Promenade, S.W., Washington, DC 20447. 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. The OMB number for this project is 0970-0365.

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
Separated
Divorced
Widowed
data not collected

2.d. Ethnicity

Hispanic
Non-Hispanic
data not collected

2.e. Race

American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
data not collected

2.f. Highest Educational
Attainment

No degree or diploma earned
High school diploma/GED
Vocational/Technical Certification
Associate’s degree
Bachelor’s degree
Master’s degree/Advance degree
data not collected

2.g. Employment Status

Full-time employment
Part-time employment
Retired
Student
Disabled
Unemployed

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
data not collected

2.h. Income

Less than $10,000
$10,000 - $19,999
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
More than $80,000
data not collected

In case OFA or its contractors need to follow up on the information provided
in this submission, please provide the name and contact information for the
person who is providing the information.
Grant information provided by:
Name:
Title:
Telephone number: (

)

E-mail address:

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system

Welcome [
], Grant number: [
Budget period: [XXX]
Report number: [XXX]
REPORTING PERIOD: [

]

] through [

]

Authorized Activity 1: Activities to promote marriage or sustain
marriage
1. Of those enrolled during this reporting for Authorized Activity 1, how many people
were:
1.a. Sex

Male

1.b. Age

Under 18 years

Female

data not
collected

18 - 24 years
25 – 34 years
35 – 44 years
45 – 54 years
55 – 64 years
65 years or older
data not collected
1.c. Marital Status

Single, Never married
Committed relationship (not married)
Married
Separated
Divorced
Widowed
data not collected

1.d. Ethnicity

Hispanic
Non-Hispanic
data not collected

OMB Control No: 0970-0365

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
1.e. Race

American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
data not collected

1.f. Educational
Attainment

No degree or diploma earned
High school diploma/GED
Vocational/ Technical Certification
Associate’s degree
Bachelor’s degree
Master’s degree/Advance degree\
data not collected

1.g. Employment Status

Full-time employment
Part-time employment
Retired
Student
Disabled
Unemployed
data not collected

1.h. Income

Less than $10,000
$10,000 - $19,999
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
More than $80,000
data not collected

OMB Control No: 0970-0365

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
2.

During this reporting period for Authorized Activity 1, how many
people:

Enrolled in Authorized Activity 1?

data not collected

Completed Authorized Activity 1?

data not collected

3. During the reporting period, how many people enrolled and completed
each skill area through the following modes of service delivery? Please give
the number that enrolled and completed in each skill area; this may be the same as the reported total
enrolled and total completed.

3. a. Abuse prevention skills
i. Case management

People enrolled
or
data not collected
People completed
or
data not collected
or

ii. Curricula-based training

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

iii. Mentoring/Counseling

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

iv. Peer group meetings

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

OMB Control No: 0970-0365

did not conduct

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
3.b. Budgeting/financial skills
i.

Case management

People enrolled
or
data not collected
People completed
or
data not collected
or

ii.

Curricula-based training

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or
did not conduct

iii.

Mentoring/Counseling

People enrolled
or
data not collected
People completed
or
data not collected
or

iv.

Peer group meetings

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

did not conduct

3.c. Communication skills
i.

Case management

People enrolled
or
data not collected
People completed
or
data not collected
or

ii. Curricula-based training

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected

OMB Control No: 0970-0365

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
or
iii. Mentoring/Counseling

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

iv. Peer group meetings

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

did not conduct

3.d. Conflict resolution skills
i.

Case management

People enrolled
or
data not collected
People completed
or
data not collected
or

ii. Curricula-based training

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

iii. Mentoring/Counseling

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

iv. Peer group meetings

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected

OMB Control No: 0970-0365

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
or

did not conduct

4. Of those who completed each skill area, how many showed improvement
in each of the following?
a. Abuse prevention skills

or
or

a.1 Number completing post-test (or denominator)
applicable

b. Budgeting/financial skills

b.1 Number completing post-test (or denominator)
applicable
or

OMB Control No: 0970-0365

not

data not collected
did not conduct
not

data not collected
or

d.1 Number completing post-test (or denominator)
applicable

did not conduct

c.1 Number completing post-test (or denominator)
applicable

not

data not collected
or

d. Conflict resolution skills

did not conduct
or

c. Communication skills

data not collected

did not conduct
or

not

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
5. Of those who completed, how many showed improvement in each of the
following? Report ‘attitudes towards marriage’ for unmarried participants and ‘commitment to
marriage stability’ for married participants.

Attitudes towards marriage or
Commitment to marriage stability

a.1 Number completing post-test (or denominator)

data not collected
or

Relationship with
spouse/fiancé/partner/co-parent?

data not collected
or

b.1 Number completing post-test (or denominator)

Hopeful about their life improving in the future

or
c.1 Number completing post-test (or denominator)

not applicable

data not collected

did not conduct
or

not applicable

6. How did your program measure improvement in Healthy Marriage skills,
attitudes towards marriage/commitment to marriage stability, and
relationship with the spouse/fiancé/partner/co-parent? Please describe your
methods in the space below.

7. Please attach an example copy of any instruments used to measure
improvement in marriage skills, attitude or commitment improvement,
and relationship improvement.

OMB Control No: 0970-0365

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
In case OFA or its contractors need to follow up on the information provided
in this submission, please provide the name and contact information for the
person who is providing the information.
Grant information provided by:
Name:
Title:
Telephone number: (

)

E-mail address:

Public reporting burden for this collection of information is estimated to average 48 minutes per response including
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, including suggestions for reducing this burden, to ACF Reports Clearance
Officer, Paperwork Reduction Project (OMB# 0970-0365), Administration for Children and Families, 370 L’Enfant
Promenade, S.W., Washington, DC 20447. 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. The OMB number for
this project is 0970-0365.

OMB Control No: 0970-0365

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
Welcome [
], Grant number: [
Budget period: [XXX]
Report number: [XXX]
REPORTING PERIOD: [

]

] through [

]

Authorized Activity 2: Activities to promote responsible parenting
1. Of those enrolled during this reporting for Authorized Activity 2, how many people
were:
1.a. Sex

Male

1.b. Age

Under 18 years

Female

data not
collected

18 - 24 years
25 – 34 years
35 – 44 years
45 – 54 years
55 – 64 years
65 years or older
data not collected
1.c. Marital Status

Single, Never married
Committed relationship (not married)
Married
Separated
Divorced
Widowed
data not collected

1.d. Ethnicity

Hispanic
Non-Hispanic
data not collected

1.e. Race

American Indian/Alaskan Native
Asian

OMB Control No.: 0970-0365

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
Black/African American
Native Hawaiian/Other Pacific Islander
White
data not collected
1.f. Educational
Attainment

No degree or diploma earned
High school diploma/GED
Vocational/Technical Certification
Associate’s degree
Bachelor’s degree
Master’s degree/Advance degree
data not collected

1.g. Employment Status

Full-time employment
Part-time employment
Retired
Student
Disabled
Unemployed
data not collected

1.h. Income

Less than $10,000
$10,000 - $19,999
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
More than $80,000
data not collected

OMB Control No.: 0970-0365

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
2.

During this reporting period for Authorized Activity 2, how many
people:

Enrolled in Authorized Activity 2?

data not collected

Completed Authorized Activity 2?

data not collected

OMB Control No.: 0970-0365

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
3. During the reporting period, how many people enrolled and completed
parenting activities through the following modes of service delivery?
Please give the number that enrolled and completed for each service delivery method; this may be the
same as the reported total enrolled and completed.

a. Case management

People enrolled
or
data not collected
People completed
or
data not collected
or

b. Curricula-based training

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

c. Mediation

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

d. Mentoring/life skills/coaching

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

e. Peer group meeting

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

OMB Control No.: 0970-0365

did not conduct
4

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system

4. Of those who completed, how many showed improvement in each of the
following?
a. Amount of contact with children

data not collected

did not conduct

a.1 Number completing post-test (or denominator)
applicable
b. Commitment to fatherhood

data not collected

did not conduct
or

b.1 Number completing post-test (or denominator)
applicable
c. Hopeful about their life improving in the future

c.1 Number completing post-test (or denominator)
applicable
d. Knowledge of child support enforcement
collected

OMB Control No.: 0970-0365

not

data not collected
did not conduct
or

f.1 Number completing post-test (or denominator)
applicable

data not

d.1 Number completing post-test (or denominator)
applicable

e.1 Number completing post-test (or denominator)
applicable

not

did not conduct

f. Relationship with their child[ren]

data not
or

not

did not conduct

e. Parenting knowledge and skills

not

data not collected
did not conduct
or

not

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system

5. How did your program measure improvement in parenting skills,
commitment to fatherhood, relationship with child[ren], contact with
child[ren] and knowledge of child support enforcement? Please describe your
methods in the space below.

Please attach an example copy of any instruments used to measure
improvement in parenting skills, commitment to fatherhood, relationship,
contact with child[ren]and knowledge of child support enforcement.

OMB Control No.: 0970-0365

)

E-mail address:

Promoting Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system

Public reporting burden for this collection of information is estimated to average 48 minutes per response including
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, including suggestions for reducing this burden, to ACF Reports Clearance
Officer, Paperwork Reduction Project (OMB# 0970-0365), Administration for Children and Families, 370 L’Enfant
Promenade, S.W., Washington, DC 20447. 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. The OMB number for
this project is 0970-0365.

OMB Control No.: 0970-0365

Pathways to Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system

Welcome [
], Grant number: [
Budget period: [XXX]
Report number: [XXX]
REPORTING PERIOD: [

]

] through [

]

Authorized Activity 3: Activities to foster economic stability by helping
fathers improve their economic status
1. Of those enrolled during this reporting for Authorized Activity 3, how many people
were:
1.a. Sex

Male

1.b. Age

Under 18 years

Female

data not
collected

18 - 24 years
25 – 34 years
35 – 44 years
45 – 54 years
55 – 64 years
65 years or older
data not collected
1.c. Marital Status

Single, Never married
Committed relationship (not married)
Married
Separated
Divorced
Widowed
data not collected

1.d. Ethnicity

Hispanic
Non-Hispanic
data not collected

OMB Control No.: 0970-0365

Pathways to Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
1.e. Race

American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
data not collected

1.f. Educational
Attainment

No degree or diploma earned
High school diploma/GED
Vocational/Technical school
Associate’s degree
Bachelor’s degree
Master’s degree/Advance degree
data not collected

1.g. Employment Status

Full-time employment
Part-time employment
Retired
Student
Disabled
Unemployed
data not collected

1.h. Income

Less than $10,000
$10,000 - $19,999
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
More than $80,000
data not collected

OMB Control No.: 0970-0365

Pathways to Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
2.

During this reporting period for Authorized Activity 3, how many
people:

Enrolled in Authorized Activity 3?

data not collected

Completed Authorized Activity 3?

data not collected

3.a. Job Readiness
i.

Case management

People enrolled
or
data not collected
People completed
or
data not collected
or

ii.

Curricula-based training

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or
did not conduct

iii.

Life skills/job coaching

People enrolled
or
data not collected
People completed
or
data not collected
or

iv.

OMB Control No.: 0970-0365

Job readiness assessment
(E.g. Online Work
Readiness Assessment
(OWRA))

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected

Pathways to Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
or
v.

Peer group meetings

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

did not conduct

3.b. Job Search
i.

Case management

People enrolled
or
data not collected
People completed
or
data not collected
or

ii. Curricula-based training

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

iii. Life skills/Job coaching

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

iv. Peer group meetings

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

did not conduct

3.c. Job Training
i.

Case management

OMB Control No.: 0970-0365

People enrolled
or
data not collected

Pathways to Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
People completed
or
data not collected
or
ii. Curricula-based training

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

iii. Life skills/Job coaching

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

iv. Peer group meetings

did not conduct

People enrolled
or
data not collected
People completed
or
data not collected
or

did not conduct

4. Of those that completed Authorized Activity 3 during this reporting
period, how many people:
a. Obtained full-time unsubsidized employment with
wage increase

data not collected

b. Obtained part-time unsubsidized employment with
wage increase

data not collected

c. Obtained new qualifications (e.g. industry specific
certifications, GED)

data not collected

or
or
or

data not collected
data not collected
data not collected

d. With new jobs were still employed:
i. 30 days later
ii. 60 days later
iii. 90 days later

OMB Control No.: 0970-0365

Pathways to Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system
e. Obtained subsidized employment

data not collected

Showed commitment to family financial
responsibility

g. Were hopeful about their life improving in the future

5. How did your program measure improvement in financial /employment
skills, commitment towards financial responsibility, and earnings? Please
describe your methods in the space below.

6. Please attach an example copy of any instruments used to measure
improvement in financial /employment skills, commitment towards
financial responsibility, and earnings.

OMB Control No.: 0970-0365

)

E-mail address:

Pathways to Responsible Fatherhood
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC system

Public reporting burden for this collection of information is estimated to average 48 minutes per response including
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, including suggestions for reducing this burden, to ACF Reports Clearance
Officer, Paperwork Reduction Project (OMB# 0970-0365), Administration for Children and Families, 370 L’Enfant
Promenade, S.W., Washington, DC 20447. 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. The OMB number for
this project is 0970-0365.

OMB Control No.: 0970-0365

File Type	application/pdf
File Title	Questions/information for grantees to enter into system
Author	ICF
File Modified	2012-04-27
File Created	2012-04-27