4 - B3-specific eligibility data (Applicant)

                                                                                                                                                         OMB #: XXXX-XXXX

                                                                                                                                             EXPIRATION: XX/XX/201X

4 - B3-specific eligibility data

[The nFORM MIS is being developed by the Fatherhood and Marriage Local Evaluation and Cross-site (FaMLE Cross-site) Project for federal Responsible Fatherhood Grantees. This MIS has already been approved by the OMB (0970-0460). Staff members at the Grantees will enter information into nFORM about fathers and their program participation. This instrument describes additional information that will be collected in nFORM for sites in the B3 study.]

[The following information will be collected at the top of the Application Form screen in nFORM for applicants in sites testing the employment intervention:]

Is a father □ Yes □ No

Over 18 years of age □ Yes □ No

Prior criminal justice involvement □ Yes □ No

Moderate or high risk □ Yes □ No

Risk score: _________

[The following information will be collected at the top of the Application Form screen in nFORM for applicants in sites testing the parenting intervention:]

Has child between 2 months old and 2 years and 11 months old □ Yes □ No

Has seen this child in person in the past 30 days □ Yes □ No

Ineligible for another reason _________ □ Yes □ No

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 2 minutes per response for weekly service data entry for the FaMLE Cross-site data collection, 1 minute per response for eligibility data entry for the B3 study, 9 minutes per response for entry of B3 enrollment data, and 1 minute per response for weekly service data entry for the B3 study. These averages include 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. The data will also be used to learn about the effects of parenting and employment services for fathers.

[This box will appear on the client profile page in nFORM. The text is slightly modified from the text that was approved as part of the FaMLE Cross-site OMB package (0970-0460). The modifications include adding detail about the additional burden required for the B3 study and adding a sentence at the end to indicate the additional way that the nFORM data will be used for the B3 study.]