Project Impact Survey

OMB #: 0970-0379

EXPIRATION: 08/31/2016

Project Outcome Assessment Survey Instructions

Identifying information [To be filled out by Federal Staff or its Contractor Designee (ANA Staff)]

Evaluator’s Name: ANA staff enter their full name.

Other ANA Staff/Contractors Present at the Site Visit: List any other ANA staff present at the visit.

Evaluation Region: Select the ANA region the grantee is located.

State: Select the state/territory the grantee is located.

Date of Evaluation: Enter the date the on-site evaluation occurs.

Grantee Information [To be filled out by Federal Staff or its Contractor Designee (ANA Staff)]

Grantee Name: Enter the grantee name as listed on the Notice of Grant Award.

Grant Number: Enter the grantee number as listed on the Notice of Grant Award.

Updated Grantee Contact Info: Update Grantee Contact Info if it is not correct in GrantSolutions.

Geo Designation: Enter the geographic designation using information found at United States Department of Agriculture’s Economic Research Service http://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx

Number of Program Specialists during Project Period: Enter the number of ANA Program Specialists the grant had throughout the project period.

Grant Category: Select the grant category from the drop down menu.

Grant Sub-Category: Select the grant sub-category from the drop down menu.

Original Project Duration: Enter the number of years the project was originally awarded.

Total Federal Funding Amount: Enter the total amount of federal funding including supplements, or de-obligations.

Grant History [To be filled out by Federal Staff or its Contractor Designee (ANA Staff)]

Received TA: Indicate whether the grantee received Technical Assistance at any time through the project period. Indicate what the issue was and if there was a resolution.

Received Supplements: Indicate whether the grantee received supplements at any time through the project period and the circumstance.

Received Carryover: Indicate whether the grantee received a budget carry-over at any time through the project period and the circumstance.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

Received an LCE: Indicate whether the grantee received a low-cost extension at the end of the project period and the circumstance.

Received an NCE: Indicate whether the grantee received a no-cost extension at the end of the project period and the circumstance.

Pre-Visit Information [To be filled out by Federal Staff or its Contractor Designee (ANA Staff)]

Background Information/General Comments: Use this space to note any background information or concerns with the grantee prior to the visit.

1. Objective Work Plan [To be filled out by Federal Staff or its Contractor Designee (ANA Staff)]

1.1 Objective: Enter the Objectives from the approved Objective Work Plan from the original application, application revisions or GrantSolutions.

Relevant Years: Check the number of years in the original project period.

Results (Outputs)/Benefits (Outcomes) Expected: Enter the results or benefits from the approved Objective Work Plan from the original application, application revisions or GrantSolutions.

Criteria for Evaluating Results and Benefits Expected: Enter the criteria for evaluating the results or benefits from the approved Objective Work Plan from the original application, application revisions or GrantSolutions.

Deliverables (Product): Enter any deliverable or product the grant might intend to produce through the project period.

The remainder of the Project Outcome Assessment Survey Instructions will be completed on-site with the grantee as a guided conversation. No further instructions are necessary.