Form 1 HM Combined

Performance Measures for Healthy Marriage and Promoting Responsible Fatherhood Grants

B - HM Combined OMB

Public Sector

OMB: 0970-0365

Document [pdf]

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Healthy Marriage
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 Allowable Activities, how many people
enrolled during the reporting period? This is an unduplicated count of people
enrolled in any Allowable Activities during the reporting period.

a. Number enrolled

data not collected

2. Across all of your grant’s Allowable Activities, how many people
completed during the reporting period? This is an unduplicated count of people
completing any Allowable Activities during the reporting period.

a. Number completed

data not collected

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

Male

3.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
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.

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System

3.c. Marital Status

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

3.d. Ethnicity

Hispanic
Non-Hispanic
data not collected

3.e. Race

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

3.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

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.

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
3.g. Employment Status

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

3.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

Healthy Marriage
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:

Healthy Marriage
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 [

]

Allowable Activity 2: Education in high schools on the value of
marriage, relationship skills, and budgeting

1. During this reporting period for the high school program (Allowable

Activity 2), how many students:
Enrolled in the program?

data not collected

Completed the program?

data not collected

OMB Control No.: 0970-0365

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
2. Of those enrolled during this reporting for Allowable Activity 2, how many people
were:
2.a. Sex

Male

2.b. Age

Under 15 years

Female

data not
collected

15 -16 years
17-18 years
Older than 18 years
data not collected
2.c. Grade

Below 9th grade
9th grade
10th grade
11th grade
12th grade
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

OMB Control No.: 0970-0365

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
3. Of those enrolled and completed in this Activity, how many people

enrolled and completed each skill area through the following modes of
service delivery?

a. Abuse prevention skills

Students enrolled
or
data not collected
Students completed
or
data not collected
or

b. Budgeting/financial skills

activity not conducted

Students enrolled
or
data not collected
Students completed
or
data not collected
or

c. Communication skills

activity not conducted
Students enrolled
or
data not collected
Students completed
or
data not collected

d. Conflict resolution skills

activity not conducted

Students enrolled
or
data not collected
Students completed
or
data not collected
or

OMB Control No.: 0970-0365

activity not conducted

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System

4. Of those completed in each skill area, how many showed

improvement in each of the following?
a. Abuse prevention

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

data not collected
activity not conducted
or
not applicable

b. Budgeting/financial

or
data not collected
or
activity not conducted
or
not applicable
b.1 Number completing post-test (or denominator)
c. Communication

or
data not collected
or
activity not conducted
c.1 Number completing post-test (or denominator)
or
not applicable
d. Conflict resolution

or
data not collected
or
activity not conducted
d.1 Number completing post-test (or denominator)
or
not applicable

5. Of those completed, how many showed improvement in the

following?
a. Attitudes towards marriage

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

OMB Control No.: 0970-0365

data not collected
or

not

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
6. How did your program measure improvement in Healthy Marriage
skills and attitudes towards marriage? Please describe your methods in the
space below.

7. Please attach an example copy of any instruments used to measure
improvement in marriage skills and attitudes towards marriage.

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:

OMB Control No.: 0970-0365

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
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

Healthy Marriage
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 [

]

Allowable Activity 3: Marriage education, marriage skills, and
relationship skills programs that may include parenting skills, financial
management, conflict resolution and job and career advancement
1. Of those enrolled during this reporting for Allowable 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

Healthy Marriage
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

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
During this reporting period for Allowable Activity 3, how many
people:

Enrolled in Allowable Activity 3?

data not collected

Completed Allowable Activity 3?

data not collected

3. Of those who enrolled and completed this Activity, how many received

each service?
a. Abuse prevention

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

b. Budgeting/financial

activity not conducted

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

c. Communication

activity not conducted

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

OMB Control No.: 0970-0365

activity not conducted

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
d. Conflict resolution

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

e. Job & career advancement

activity not conducted

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

f. Parenting

activity not conducted

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

OMB Control No.: 0970-0365

activity not conducted

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System

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

or
or

data not collected
activity not conducted

a.1 Number completing post-test (or denominator)
applicable
b. Budgeting/financial
or

or
data not collected
activity not conducted

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

not

or
data not collected
activity not conducted

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

not

or
data not collected
activity not conducted

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

e. Job & career advancement
i. Obtained full-time unsubsidized
employment with wage increase

data not collected

ii. Obtained part-time unsubsidized
employment with wage increase

data not collected

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

data not collected

or
or
or

data not collected
data not collected
data not collected

iv. With new jobs were still employed:
a. 30 days later
b. 60 days later
c. 90 days later

OMB Control No.: 0970-0365

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System

v. Obtained subsidized employment

data not collected

vi.

data not collected

Showed commitment to family financial
responsibility

Parenting
or

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

or
data not collected
activity not conducted

not applicable

Of those who completed, how many showed improvement in each of
the following?
a. Attitudes towards marriage

a.1 Number completing post-test (or denominator)
applicable
b. Relationship with their co-parent

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

data not collected
or

not

data not collected
or

not

6. How did your program measure improvement in Healthy

Marriage skills, attitudes towards marriage, and relationship
with their co-parent? Please describe your methods in the space below.

OMB Control No.: 0970-0365

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
7.

Please attach an example copy of any instruments used to
measure improvement in marriage skills, attitudes towards
marriage, and relationship with their co-parent.

)

E-mail address:

OMB Control No.: 0970-0365

Healthy Marriage
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 [

]

Allowable Activity 4: Pre-marital education and marriage skills
training for engaged couples and for couples or individuals interested in
marriage
1. Of those enrolled during this reporting for Allowable Activity 4, 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

Healthy Marriage
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

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System

2. During this reporting period for the marriage skills training program

for engaged or individuals interested in marriage (Allowable Activity
4), how many people: Count each member of a couple as one person.
Enrolled in the program?

data not collected

Completed the program?

data not collected

3. Of those enrolled and completed, how many received content in

each skill area?
a. Abuse prevention skills

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

b. Budgeting/financial skills

activity not conducted

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

c. Communication skills

activity not conducted

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

d. Conflict resolution skills

OMB Control No.: 0970-0365

activity not conducted

People enrolled

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
or

data not collected

People completed
or
data not collected
or

activity not conducted

4. Of those completed in each skill area, how many showed

improvement in each of the following?
a. Abuse prevention

or
or

data not collected
activity not conducted

a.1 Number completing post-test (or denominator)
applicable
b. Budgeting/financial

or
or

not

data not collected
activity not conducted

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

OMB Control No.: 0970-0365

data not collected
activity not conducted

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

not

data not collected
activity not conducted

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

not

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System

5. Of those completed, how many showed improvement in each of the
following?
a. Attitudes towards marriage

a.1 Number completing post-test (or denominator)
applicable
b. Relationship with their fiancé/partner
b.1 Number completing post-test (or denominator)
applicable

data not collected
or

not

data not collected
or

not

6. How did your program measure improvement in Healthy Marriage skills,
attitudes towards marriage, and relationship with their fiancé/partner?
Please describe your methods in the space below.

Please attach an example copy of any instruments used to measure
improvement in marriage skills, attitudes towards marriage, and
relationship with their fiancé/partner.

OMB Control No.: 0970-0365

)

E-mail address:

OMB Control No.: 0970-0365

Healthy Marriage
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 [

]

Allowable Activity 5: Marriage enhancement or marriage skills training
programs for married couples
1. Of those enrolled during this reporting for Allowable Activity 5, 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

Healthy Marriage
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

2. During this reporting period for the marriage enhancement program or

OMB Control No.: 0970-0365

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
marriage skills training programs for married couples (Allowable
Activity 5), how many married people: Count each member of a couple as one person.
Enrolled in the program?

data not collected

Completed the program?

data not collected

3. Of those enrolled and completed in this Activity, how many received

content in each skill area?

a. Abuse prevention skills

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

b. Budgeting/financial skills

activity not conducted

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

c. Communication skills

activity not conducted

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

OMB Control No.: 0970-0365

activity not conducted

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
d. Conflict resolution skills

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

activity not conducted

4. Of those completed in each skill area, how many showed

improvement in each of the following?
a. Abuse prevention

or
or

data not collected
activity not conducted

a.1 Number completing post-test (or denominator)
applicable
b. Budgeting/financial

or
or

not

data not collected
activity not conducted

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

not

data not collected
activity not conducted

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

not

data not collected
activity not conducted

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

not

5. Of those completed, how many showed improvement in each of

the following?

OMB Control No.: 0970-0365

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
a. Commitment to marriage stability

a.1 Number completing post-test (or denominator)
applicable
b. Relationship with their spouse

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

data not collected
or

not

data not collected
or

not

6. How did your program measure improvement in Healthy

Marriage skills, commitment to marriage stability, and
relationship with their spouse? Please describe your methods in the space
below.

7. Please attach an example copy of any instruments used to

measure improvement in marriage skills, commitment to
marriage stability, and relationship with spouse.

OMB Control No.: 0970-0365

)

E-mail address:

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System

OMB Control No.: 0970-0365

Healthy Marriage
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 [

]

Allowable Activity 6: Divorce reduction programs that teach
relationship skills
1. Of those enrolled during this reporting for Allowable Activity 6, 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

Healthy Marriage
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

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
2. During this reporting period for the divorce reduction program
(Allowable Activity 6), how many people: Count each member of a couple as one
person.

Enrolled in the program?

data not collected

Completed the program?

data not collected

3. Of those enrolled and completed in this Activity, how many received
content in each skill area?
a. Communication skills

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

b. Conflict resolution skills

activity not conducted

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

c. Abuse prevention skills

activity not conducted

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

OMB Control No.: 0970-0365

activity not conducted

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System

d. Budgeting/financial skills

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

activity not conducted

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

or
or

data not collected
activity not conducted

a.1 Number completing post-test (or denominator)
applicable
b. Budgeting/financial

or
or

not

data not collected
activity not conducted

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

not

data not collected
activity not conducted

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

not

data not collected
activity not conducted

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

not

5. Of those completed, how many showed improvement in each of

the following?
OMB Control No.: 0970-0365

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
a. Commitment to marriage stability

a.1 Number completing post-test (or denominator)
applicable
b. Relationship with their spouse

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

data not collected
or

not

data not collected
or

not

6. How did your program measure improvement in Healthy

Marriage skills, commitment to marriage stability, and
relationship with their spouse? Please describe your methods in the space
below.

Please attach an example copy of any instruments used to
measure improvement in marriage skills, commitment to
marriage stability, and relationship with spouse.

OMB Control No.: 0970-0365

)

E-mail address:

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System

OMB Control No.: 0970-0365

Healthy Marriage
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 [

]

Allowable Activity 7: Marriage mentoring programs which use
married couples as role models and mentors in at-risk communities.
1. Of those enrolled during this reporting for Allowable Activity 7, 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

Healthy Marriage
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

OMB Control No.: 0970-0365

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
data not collected

2. During this reporting period for the marriage mentoring program

(Allowable Activity 7), how many people:

Count only those being mentored

and count each member of a couple as one person.
Enrolled in the program?

data not collected

Completed the program?

data not collected

3. Of those enrolled and completed in this Activity, how many received

content in each skill area?
a. Abuse prevention skills

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

b. Budgeting/financial skills

activity not conducted

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

c. Communication skills

activity not conducted
People enrolled
or
data not collected
People completed
or
data not collected

OMB Control No.: 0970-0365

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System
activity not conducted

d. Conflict resolution skills

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

⁯ activity not conducted

3. Of those completed in each skill area, how many showed

improvement in each of the following?
a. Abuse prevention

or
or

data not collected
activity not conducted

a.1 Number completing post-test (or denominator)
applicable
b. Budgeting/financial

or
or

not

data not collected
activity not conducted

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

OMB Control No.: 0970-0365

data not collected
activity not conducted

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

not

data not collected
activity not conducted

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

not

Healthy Marriage
OLDC Report Questions/Information for OFA HMRF Grantees to Enter into
OLDC System

4. Of those completed, how many showed improvement in each of
the following?
a. Commitment to marriage stability

a.1 Number completing post-test (or denominator)
applicable
b. Relationship with their spouse

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

data not collected
or

not

data not collected
or

not

5. How did your program measure improvement in Healthy
Marriage skills, commitment to marriage stability, and
relationship with their spouse. Please describe your methods in the space
below.

Please attach an example copy of any instruments used to
measure improvement in marriage skills, commitment to
marriage stability, and relationship with their spouse.

OMB Control No.: 0970-0365

)

E-mail address:

OMB Control No.: 0970-0365

File Type	application/pdf
File Title	Allowable Activity 1: Public advertising campaigns on the value of marriage and skills to increase marital stability and health
Author	Diana Davis
File Modified	2012-04-27
File Created	2012-04-27