DCS-3: Service Receipt in MIS

Service Receipt Wireframes
Office of Family Assistance
Healthy Marriage and Responsible Fatherhood Grant Program
TEMPLATE TO COLLECT INFORMATION ON SERVICES PROVIDED TO PARTICIPANTS

OMB Control No.: xxxx-xxxx
Expiration Date: xx/xx/xxxx

This template will be used by grantees to enter information on services received by a
participant on at least a weekly basis. Staff should only complete the forms which are
relevant for specific services received by the participant, for example, workshop
attendance, participation in an individual service contact, or receipt of a referral. Grantees
should enter information that applies to more than one participant (such as adding or
revising a workshop) only as needed.
Information on service receipt will be used by the Office of Family Assistance to meet
grants management requirements and by grantees themselves to self-monitor progress
and challenges (continuous quality improvement).

THE PAPERWORK REDUCTION ACT OF 1995
Public reporting burden for this collection of information is estimated to average 2 minutes 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. The information requested in this template
will be used to document how programs receiving HMRF grant funding operate. The data gathered will allow ACF
to better monitor grantee progress and performance.

OMB Control No.:xxxx-xxxx
Expiration Date: xx/xx/xxxx