Sub-Grantees

OMB Control No: XXXX-XXXX
Expiration date: XX/XX/XX

Community Services Block
Grant (CSBG) Annual Report
OMB PRA Clearance
FRN #2

October 2016

CSBG Annual Report Table of Contents
Module 1 - State Administration………………………………………………………………………………………………………………1

Section A: CSBG Lead Agency, CSBG Authorized Official, CSBG Point of Contact////////////.2

Section B: Statewide Goals and Accomplishments...////////////////////////////4

Section C: CSBG Eligible Entity Update..................................................................................................6

Section D: Organizational Standards for Eligible Entities......................................................................7

Section E: State Use of Funds..............................................................................................................10

Section F: State Training and Technical Assistance.............................................................................15

Section G: State Linkages and Communication.....................................................................................17

Section H: Monitoring, Corrective Action, and Fiscal Controls...........................................................20

Section I: Results Oriented Management and Accountability (ROMA) System..................................22

Module 2 – CSBG Eligible Entity Expenditures, Capacity, and Resources...................................................24

Module 2 Instructional Notes////////////////////////////////////////25

Section A: Local Agency CSBG Expenditures.......................................................................................26

Section B: Local Agency Capacity Building..........................................................................................27

Section C: Local Agency Resources Administered by the CSBG Eligible Entity....................................28

Module 3 – Community Level…………………………………………………………………………………………………………………30
Module 3 Instructional Notes////////////////////////////////////////31

Section A: Community Initiative Status Form.....................................................................................33

Section B: Community National Performance Indicators (NPIs)...........................................................34

Section C: Community Strategies////.............................................................................................44

Module 4 - Individual and Family Level…………………………………………………………………………………………………..47

Module 4 Instructional Notes////////////////////////////////////////48

Section A: Individual and Family National Performance Indicators (NPIs)///////////////.50

Section B: Individual and Family Services............................................................................................57

Section C: All Characteristics Report////////////////////////////////////.65

Module 1

State Administration

Page 1 of 66

Community Services Block Grant (CSBG)

Annual Report – State Administration Module

Note: The reporting timeframes for all information in the administrative module is based on the
Federal Fiscal Year, which runs from October 1 of a given calendar year until September 30 of the
following calendar year. When completing the annual report, respondents will first indicate the
Federal Fiscal Year for which the state is submitting data. The Online Data Collection (OLDC) system
will then auto-populate the administrative module with information from the appropriate year (year 1
or year 2) in the accepted CSBG State Plan. States will be able to update information in these sections,
as necessary.

SECTION A

CSBG Lead Agency, CSBG Authorized Official, CSBG Point of Contact

A.1.

Confirm and update the following information in relation to the lead agency designated to
administer the CSBG in the State, as required by Section 676(a) of the CSBG Act.
A.1a. Lead agency
[This section will auto-populate using information provided in the CSBG State Plan. The
State should review all items and may update to note any changes that have taken place
during the year. Any updates or changes will be noted in quality assurance reviews and
may require brief explanation prior to acceptance of the annual report.]
A.1b. Cabinet or administrative department of this lead agency
[Auto-populated from the CSBG State Plan with option to update where applicable]







Community Services Department
Human Services Department
Social Services Department
Governor’s Office
Community Affairs Department
Other, describe:

A.1c. Division, bureau, or office of the CSBG authorized official [Narrative, 2500 Characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.1d. Authorized official of the lead agency [Narrative, 2500 Characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
Instructional note: The authorized official could be the director, secretary,
commissioner etc. as assigned in the designation letter (attached under item 1.3). The
authorized official is the person indicated as authorized representative on the SF424M.

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Module 1, State Administration

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A.1e. Street address [Narrative, 2500 Characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.1f. City [Narrative, 2500 Characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.1g. State [Narrative, 2500 Characters]
[Auto-populated from the CSBG State Plan]
A.1h. Zip code [Narrative 10 Characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.1i. Telephone number and extension [Narrative, 10 – 15 characters including an option for
5 digit extension]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.1j. Fax number [Narrative, 10 characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.1k. Email address [Narrative, 50 characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.1l. Lead agency website [Narrative, 200 characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.2.

Please check additional programs administered by the State CSBG Lead Agency during the
reporting year (FFY).
Weatherization Assistance Program (WAP)
Low Income Home Energy Assistance Program (LIHEAP)
U.S. Department of Agriculture Programs (Specify __________________)
U.S. Department of Housing and Urban Development (HUD) Programs (Specify
_________________)
 Other, describe: If yes, please list below:





October 2016

FRN #2 – CSBG Annual Report
Module 1, State Administration

Page 3 of 66

SECTION B

Statewide Goals and Accomplishments

B.1.

Progress on State Plan Goals: Describe progress in meeting the State’s CSBG-specific goals for
State administration of CSBG as described in the CSBG State Plan.
Goals: [Actual Goals from the CSBG State Plan will be auto-populated from the accepted CSBG
State plan]
 All Goals Accomplished: [Narrative, 2500 characters]
 Goals Partially Accomplished – describe progress: [Narrative, 2500 characters]
 Not Accomplished – explain [Narrative, 2500 characters]
Note: This information is associated with State Accountability Measure 1Sa(i) and will be used
in assessing overall progress in meeting State goals.

B.2.

CSBG Eligible Entity Overall Satisfaction Targets: In the table below, provide the State’s most
recent target for CSBG Eligible Entity Overall Satisfaction during the performance period (FFY).
Prior Year Target
___. [Numerical, 3 digits]
This cell should be left blank in
the first year of submission of
this new annual report format.

Most Recent American
Customer Satisfaction Index
Survey Result
___. [Numerical, 3 digits]
This cell should include the most
recent result of the ACSI survey.
OCS plans to issue ACSI surveys
on a bi-annual basis.

Future Target
___. [Numerical, 3 digits]
Note: OCS issued
Information
Memorandum 150
providing guidance on
establishing targets based
on ACSI results.

Instructional Note: Because the CSBG State Plan may cover two fiscal years, annual updates
related to CSBG Eligible Entity satisfaction should be provided in this annual report. The State’s
target score will indicate improvement or maintenance of the States’ Overall Satisfaction score
from the most recent American Customer Survey Index (ACSI) survey of the State’s CSBG
Eligible Entities. States that did not receive ACSI scores (i.e. States with only a single CSBG
Eligible Entity) should not complete question B.2, but should provide narrative descriptions of
other sources of customer feedback and the State’s response to that feedback in question B.3.
For more information on the ACSI and establishment of targets, see CSBG Information

Memorandum #150 Use of the American Customer Satisfaction Index (ACSI) to Improve Network
Effectiveness.

B.3.

CSBG Eligible Entity Feedback and Involvement: How has the State considered feedback from
CSBG Eligible Entities, OCS, public hearings, and other sources, and/or customer satisfaction
surveys such as the American Customer Satisfaction Index (ACSI)? What actions have been
taken as a result of this feedback?
[Narrative - 2500 Characters]

October 2016

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Module 1, State Administration

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B.4.

State Management Accomplishment: Describe what you consider to be the top management
accomplishment achieved by your State CSBG office during the reporting year (FFY). Provide
examples of how administrative or leadership actions led to improvements in efficiency,
accountability, or quality of services and strategies.
[Narrative – 2500 Characters]

B.5.

CSBG Eligible Entity Management Accomplishments: Describe three notable management
accomplishments achieved by CSBG Eligible Entities in your state during the reporting year
(FFY). Describe how responsible, informed leadership and effective, efficient processes led to
high-quality, accessible, and well-managed services and strategies.
[Narrative – 2500 Characters]

B.6.

Innovative Solutions Highlights: Provide at least three examples of ways in which a CSBG
Eligible Entity addressed a cause or condition of poverty in the community using an innovative
or creative approach. Provide the agency name, local partners involved, outcomes, and specific
information on how CSBG funds were used to support implementation.
[Narrative – 2500 Characters]

October 2016

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Module 1, State Administration

Page 5 of 66

SECTION C

CSBG Eligible Entity Update

C.1.

CSBG Eligible Entities: The table below includes a list of CSBG Eligible Entities in the State as
described in the CSBG State Plan for this reporting year (FFY). Please review and note any
changes or updates in this information. This table should include every CSBG Eligible Entity to
which the State allocated 90 percent of CSBG funds during the reporting period (FFY). The table
should not include entities that only receive remainder/discretionary funds from the State or
tribes/tribal organizations that receive direct funding from OCS under Section 677 of the CSBG
Act.)
1.CSBG Eligible
Entity

2.Public or
Nonprofit

Auto-populated
[Narrative, 2500
characters]

Auto-populated
[Select Public or
Nonprofit]

3.Type of Entity
(choose all that apply)

4.Geographical
Area Served by
county (Provide
all counties)
Auto-populated
[Narrative, 2500
characters]

5.Brief Description
of “Other”

Auto-populated
Auto-populated
[Narrative,
2500
• Community Action
characters]
Agency
• Limited Purpose Agency
If “Other” is
• Local Government
selected in column
Agency
3, provide further
• Migrant or Seasonal
detail here
Farmworker
Organization
• Tribe or Tribal
Organization
• Other (describe in
column 5)
ADD A ROW function Note: rows may be added for each CSBG Eligible Entity funded by the State

C.2.

Total number of CSBG Eligible Entities: __##__ [This will automatically update based on chart
in C.1]

C.3.

Changes to CSBG Eligible Entities List: Did the list of CSBG Eligible Entities under item C.1
change during the reporting period (FFY)? If yes, briefly describe the changes.
 Yes  No
[If yes is selected – Narrative, 2500 characters]
Instructional Note: Limited Purpose Agency refers to a CSBG Eligible Entity that was
designated as a limited purpose agency under Title II of the Economic Opportunity Act of
1964 for the fiscal year 1981, that served the general purposes of a community action agency
under Title II of the Economic Opportunity Act; did not lose its designation as a limited
purpose agency under Title II of the Economic Opportunity Act as a result of failure to comply
with that Act; and has not lost its designation as a CSBG Eligible Entity under the CSBG Act.
Instructional Note: 90 percent funds are the funds a State provides to CSBG Eligible Entities
to carry out the purposes of the CSBG Act, as described under Section 675C of the CSBG
Act. A State must provide “no less than 90 percent” of their CSBG allocation, under Section
675B, to the Eligible Entities.

October 2016

FRN #2 – CSBG Annual Report
Module 1, State Administration

Page 6 of 66

SECTION D
Organizational Standards for CSBG Eligible Entities
Note: Reference CSBG Information Memorandum #138 State Establishment of Organizational
Standards for CSBG Eligible Entities
D.1.

Assessment of Organizational Standards: The CSBG State Plan indicated that the State would
use the following organizational standards for its oversight of the CSBG:
[One of the options below will be auto-populated from the CSBG State Plan based on the
items checked in question 6.1 of the CSBG State Plan]
• CSBG Organizational Standards Center of Excellence (COE) organizational
standards (as described in IM 138) or a modified version of these standards.
• An alternative set of organizational standards as outlined in supporting
documentation to the CSBG State plan.
D.1a.How did the State assess CSBG eligible entities against organizational standards, as
described in IM 138?
[The checkbox below will be auto-populated from the CSBG State Plan with the option for the
State to update information based on its actual implemented assessment process]







Peer-to-peer review (with validation by the State or State-authorized third party)
Self-assessment (with validation by the State or State-authorized third party)
Self-assessment/peer review with State risk analysis
State-authorized third party validation
Regular, on-site CSBG monitoring
Other

D.1b. Describe the assessment process as implemented by the State. Please describe any

changes in the assessment process that occurred since the time of the State plan submission.
Please note that with the exception of regular on-site CSBG monitoring, all assessment options
above may include either on-site or desk review (or a combination). The specific State process
should be described in the narrative. [Narrative, 2500 characters]

October 2016

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Module 1, State Administration

Page 7 of 66

D.2.

Organizational Standards Performance: In the table below, please provide the percentage of
CSBG Eligible Entities that met all State-adopted organizational standards in the reporting
period (FFY). The target set in the CSBG State Plan is provided in the left-hand column. For
more information on the CSBG Organizational Standards, see CSBG Information Memorandum
#138.
Fiscal Year

Autopopulated

Target vs. Actual Performance on the Organizational Standards
State CSBG
Plan Target

Number of
Entities Assessed

[Auto-populated
target from question
6.6. of the State
CSBG plan].

[Insert a number
between 0 – 99]

Number that Met
All (100%) of
State Standards
[Insert a number
between 0 – 99]

Actual Percentage
Meeting All (100%) of
State Standards
[Auto-calculated]

Progress Indicators
Indicate the number of entities that met the following percentages of Organizational Standards.
Number of
Entities Assessed

Note – While the State targets the
percent of CSBG Eligible Entities to
meet 100% of the Organizational
Standards, targets are not set in the
State Plan for 90%, 80%, 70%, and 60%
progress indicators.

[Insert a number
between 0 – 99]
Number of
Entities Assessed
[Insert a number
between 0 – 99]
Number of
Entities Assessed
[Insert a number
between 0 – 99]

Number that Met
between 90% and
99% of State
Standards
[Insert a number
between 0 – 99]
Number that met
between 80% and
89% of State
Standards
[Insert a number
between 0 – 99]

Actual Percentage

Number that met
between 70% and
79% of State
Standards
[Insert a number
between 0 – 99]

Actual Percentage

[Auto-calculated]
Actual Percentage

[Auto-calculated]

[Auto-calculated]

Note: This information is associated with State Accountability Measures 6Sa.
D.2a. In the space below, please identify the challenges and factors contributing to the
difference between the target and actual results provided in the top row of Table D.2 (above).
[Narrative, 2500 characters]

October 2016

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Module 1, State Administration

Page 8 of 66

D.2b. Percentage Meeting Organizational Standards by Category. In the table below, provide
the number of eligible entities that met each category of the Organizational Standards. The
percentage that met all standards in each category will be automatically calculated and totaled
in the bottom row.
Percentage Meeting Organizational Standards by Category
Number that
Number of Entities
Met All
Actual
Category
Standards in
Percentage
Assessed
Category

1. Consumer Input and
Involvement
2. Community Engagement
3. Community Assessment

4. Organizational Leadership
5. Board Governance
6. Strategic Planning
7. Human Resource
Management
8. Financial Operations &
Oversight
9. Data and Analysis

D.3.

[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]

[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]
[Insert a number
between 0 – 99]

[Auto-calculated]
[Auto-calculated]
[Auto-calculated]
[Auto-calculated]
[Auto-calculated]
[Auto-calculated]
[Auto-calculated]
[Auto-calculated]
[Auto-calculated]

Technical Assistance Plans and Quality Improvement Plans: In the table below, please provide
the number of CSBG Eligible Entities with unmet organizational standards with Technical
Assistance Plans (TAPs) or Quality Improvement Plans (QIPs) in place.
Technical Assistance Plans and Quality Improvement Plans
Total Number of CSBG Eligible Entities with unmet organizational
[Insert a number
standards with Technical Assistance Plans (TAPs) in place
between 0 – 99]
Total Number of CSBG Eligible Entities with unmet organizational
standards with Quality Improvement Plans (QIPs) in place

[Insert a number
between 0 – 99]

D.3.a. If the State identified CSBG Eligible Entities with unmet organizational standards for
which it was determined that TAPs or QIPs would not be appropriate, please provide a narrative
explanation below. [If no is selected – Narrative, 2500 characters]
Note: D.3 is associated with State Accountability Measure 6Sb. QIPs are described in Section 678C(a)(4)
of the CSBG Act. For additional information on corrective action and the circumstances under which a
State may establish TAPs and QIPs, see IM-138, Pages 5-6.
October 2016

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Module 1, State Administration

Page 9 of 66

SECTION E

State Use of Funds

Note: The reporting timeframes for expenditure information is based on the Federal Fiscal Year, which
runs from October 1 of a given calendar year until September 30 of the following calendar year. States
that operate according to a different fiscal year should analyze actual quarterly obligation of funds and
report on obligations made during the time period of the Federal Fiscal Year.
CSBG Eligible Entity Allocation (90 Percent Funds) [Section 675C(a) of the CSBG Act]
E.1.

State Distribution Formula: Did the State institute any changes in the distribution formula for
the CSBG Eligible Entities during the reporting period covered by this report?
 Yes  No
E.1a If yes, please describe any specific changes and describe how the State complied with
assurances provided in Question 14 of the CSBG State Plan as required under Section
C76(b)(8) of the State CBSG Act.
[Narrative, 2500 characters]

E.2.

Planned vs. Actual Allocation: Using the table below, specify the actual allocation of 90 percent
of CSBG funds to CSBG Eligible Entities, as described under Section 675C(a) of the CSBG
Act. While the CSBG State Plan allows for either percentages or dollar amounts, this table in
the administrative report must be based on actual dollars allocated to each CSBG Eligible Entity
during the Federal Fiscal Year (FFY). For each CSBG Eligible Entity receiving CSBG funds, provide
the Funding Amount allocated to the CSBG Eligible Entity during the FFY.
Planned vs Actual CSBG 90 Percent Funds
Planned
Actual

CSBG Eligible
Entity
Information in
this cell will be
auto-populated
from the CSBG
State Plan
Section 5, Table
5.1, Column 1

Total

October 2016

Funding Amount ($ or %)
Information in this cell will
be auto-populated from
the CSBG State Plan,
(Section 7, Table 7.2) and
cannot be updated or
changed. Amounts may
have been presented in
either a percentage or
planned dollar amount.
Total will be autocalculated

Allocations
(Based on State Formula)

Obligations

[Numeric response, specify
$ amount]

[Numeric response,
specify $ amount]

Enter the dollar amount
actually allocated to each
CSBG Eligible Entity under
the State formula for the
period covered in the
Federal Fiscal Year.
Total will be autocalculated

FRN #2 – CSBG Annual Report
Module 1, State Administration

Enter the actual dollar
amount obligated to
each CSBG Eligible
Entity through
contracts or
subawards for the
period covered in the
Federal Fiscal Year.
Total will be autocalculated

Page 10 of 66

E.3.

Actual Distribution Timeframe: Did the State make funds available to CSBG Eligible Entities no
later than 30 calendar days after OCS distributed the Federal award?
 Yes  No
E.3a. If no, did the State implement procedures to ensure funds were made available to CSBG
Eligible Entities consistently and without interruption?
 Yes  No
E.3b. If the State was not able to make CSBG funds available within 30 calendar days after
OCS distributed the Federal award and was not able to ensure that funds were made
available consistently and without interruption, provide an explanation of the
circumstances below along with a description of planned corrective actions.
[Narrative, 2500 Characters]
Note: Item E.3 is associated with State Accountability Measure 2Sa.

Administrative Funds [Section 675C(b)(2) of the CSBG Act]
E.4.

What amount of State CSBG funds did the State obligate for administrative activities during the
Federal Fiscal Year? The amount must be based on actual dollars allocated during the Federal
Fiscal Year (FFY). If you provided a percentage in Question 7.6 in the CSBG State Plan, please
convert to dollars.
State Administrative Funds
CSBG State Plan
[Auto-populated target
[If entered in the CSBG State
from the CSBG State Plan Plan as a percentage, convert
Question 7.6]
and insert your number in
dollars here.]

Actual Amount Obligated
[Numeric response, specify $
amount]

[Narrative, 2500 Characters]
E.5.

How many State staff positions were funded in whole or in part with CSBG funds in the
reporting period (FFY)? [Insert a number between 0 – 99]
State Staff Positions Funded
CSBG State Plan
Actual Number
[Auto-populated target from the
[Insert a number between 0 – 99]
CSBG State Plan question 7.7].

October 2016

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Module 1, State Administration

Page 11 of 66

E.6.

How many State Full Time Equivalents (FTEs) were funded with CSBG funds in the reporting
period (FFY)?
State FTEs
CSBG State Plan
[Auto-populated target from the
CSBG State Plan question 7.8].

Actual Number
[Insert a number between 0 – 99]

Remainder/Discretionary Funds [Section 675C(b) of the CSBG Act]
E.7.

Describe how the State used remainder/discretionary funds in the table below.
Instructional Note: While the CSBG State Plan allows for either percentages or dollar
amounts, this table in the administrative report must be based on actual dollars obligated to
each budget category during the Federal Fiscal Year (FFY). States that do not have
remainder/discretionary funds will not complete this item. If a funded activity fits under
more than one category in the table, allocate the funds among the categories. For example, if
the State provides funds under a contract with the State Community Action Association to
provide training and technical assistance to CSBG Eligible Entities and to create a statewide
data system, the funds for that contract should be allocated appropriately between Row a
and Row c. If an allocation is not possible, the State may allocate the funds to the main
category with which the activity is associated.
Note: This information is associated with State Accountability Measures 3Sa.
Remainder/
Discretionary Fund
Uses
(See 675C(b)(1) of the
CSBG Act)
a.

Training/technical
assistance to
CSBG Eligible
Entities

b.

Coordination of
State-operated
programs and/or
local programs
Statewide
coordination and
communication
among CSBG
Eligible Entities

c.

October 2016

Planned vs. Actual Use of Remainder/Discretionary Funds
Planned

Planned $

Obligated

Planned %

Information in these cells will
be auto-populated from the
accepted CSBG State plan and
cannot be updated or
changed.

Actual $

[Enter actual $ for each
item listed for this Federal
Fiscal Year.

Brief description of
services/activities
Narrative 2500
characters – Briefly
describe the actual
services and
activities funded for
each category.
Narrative 2500
characters

Narrative 2500
characters

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Page 12 of 66

Remainder/
Discretionary Fund
Uses
(See 675C(b)(1) of the
CSBG Act)
d. Analysis of
distribution of
CSBG funds to
determine if
targeting greatest
need
e. Asset-building
programs
f. Innovative
programs/
activities by CSBG
Eligible Entities or
other
neighborhood
groups
g. State charity tax
credits
h. Other activities,
specify_________
Totals

E.8.

Planned vs. Actual Use of Remainder/Discretionary Funds
Planned

Planned $

Obligated

Planned %

Actual $

Brief description of
services/activities

[Narrative, 2500
characters]
[Narrative, 2500
characters]

Narrative, 2500
characters]

[Narrative, 2500
characters]
[Narrative, 2500
characters]
Auto-calculated

Auto-calculated

What types of organizations, if any, did the State work with (by grant or contract using
remainder/discretionary funds) to carry out some or all of the activities in table E.7 (above).
[Check all that apply and provide a narrative where applicable]
 CSBG Eligible Entities (if checked, include the expected number of CSBG Eligible Entities to
receive funds) [Narrative, 2500 characters]
 Other community-based organizations
 State Community Action association
 Regional CSBG technical assistance provider(s)
 National technical assistance provider(s)
 Individual consultant(s)
 Tribes and Tribal Organizations
 Other [Narrative, 2500 characters]
 None (the State will carry out activities directly)

October 2016

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Module 1, State Administration

Page 13 of 66

E.9. Total Obligations: Total CSBG funds obligated for the Federal Fiscal Year (Review and confirm
from the chart below).
Category
Obligations to CSBG Eligible Entities (from State CSBG
90% Formula Funds)

Actual Obligations
Auto-populated from Table E.2 (total
actual obligations in contracts and
subawards)

State Administrative Costs

Auto-populated from Table E.4 (total
actual obligations of administrative funds)

Remainder/Discretionary Funds

Auto-populated from Table E.7 (total
actual obligations of State
remainder/discretionary funds).

Total Obligations in FY ___

Total will be auto-calculated from the
three rows above

E.9a. Prior Year Carryover
Of the total amount reported in the row above, the
amount that represents carryover funding from the
prior fiscal year.
E.9b. Carryover for this Fiscal Year
Of the total CSBG amount to the State for this fiscal
year, the amount that was unobligated and will carry
forward to the next fiscal year.

October 2016

[Numeric response, specify $ amount]

[Numeric response, specify $ amount]

FRN #2 – CSBG Annual Report
Module 1, State Administration

Page 14 of 66

SECTION F

State Training and Technical Assistance

F.1.

Describe how the State delivered CSBG-funded training and technical assistance to CSBG
Eligible Entities by completing the table below. Add a row for each activity: indicate the
timeframe; whether it was training, technical assistance or both; and the topic. CSBG funding
used for this activity is referenced under item E.7 (Planned vs. Actual Use of
Remainder/Discretionary Funds.)
Note: F.1 is associated with State Accountability Measure 3Sc.
[This table will be auto-populated with information provided in the State’s accepted CSBG
State plan and should be reviewed and updated based on the actual activities implemented.]
Training and Technical Assistance

Training, Technical
Assistance, or Both
Auto-populated from
Table 8.1 of the CSBG
State Plan
• Training
• Technical
Assistance
• Both

Topic

Actual Dates

Auto-populated from
Table 8.1 of the CSBG
State Plan
• Fiscal
• Governance/Triparti
te Boards
• Organizational
Standards – General
• Organizational
Standards – for
CSBG Eligible Entities
with unmet
standards on
Technical Assistance
Plans (TAPs) or
Quality
Improvement Plans
(QIPs)
• Correcting
Significant
Deficiencies Among
CSBG Eligible Entities
• Reporting
• ROMA
• Community
Assessment
• Strategic Planning
• Monitoring
• Communication
• Technology
• Other

[Enter Date or Range]

Brief Description
[Narrative, 2500 characters]
Provide additional brief
explanation of the technical
assistance activities
implemented. If “Other" was
selected in column 3, describe
in this column.

ADD a ROW function Note: Rows may be added for each additional training

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Module 1, State Administration

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F.2.

Indicate the types of organizations through which the State provided training and/or technical
assistance as described in item F.1, and briefly describe their involvement? (Check all that
apply.) [Check all that applies and narrative where applicable]
 CSBG Eligible Entities (if checked, provide the expected number of CSBG Eligible Entities to
receive funds) [Narrative, 2500 characters]
 Other community-based organizations
 State Community Action association
 Regional CSBG technical assistance provider(s)
 National technical assistance provider(s)
 Individual consultant(s)
 Tribes and Tribal Organizations
 Other [Narrative, 2500 characters]

October 2016

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Module 1, State Administration

Page 16 of 66

SECTION G

State Linkages and Communication

Note: This section describes activities that the State supported with CSBG remainder/discretionary
funds, described under Section 675C(b)(1) of the CSBG Act. Note: This item is associated with State
Accountability Measure 7Sa.
G.1.

State Linkages and Coordination at the State Level: Please review and confirm the areas for
linkages and coordination that were outlined in the CSBG State Plan.
[The items below will be auto-populated based on responses to question 9.1. in the CSBG State
Plan and may be updated.]













State Low Income Home Energy Assistance Program (LIHEAP) office
State Weatherization office
State Temporary Assistance for Needy Families (TANF) office
State Head Start office
State public health office
State education department
State Workforce Innovation and Opportunity Act (WIOA) agency
State budget office
Supplemental Nutrition Assistance Program (SNAP)
State child welfare office
State housing office
Other

G.1a. Describe the linkages and coordination at the State level that the State created or
maintained to ensure increased access to CSBG services by communities and people with lowincomes that avoid duplication of services (as required by the assurance under Section
676(b)(5)) and identified in the CSBG State Plan . Describe or attach additional information as
needed and provide a narrative describing activities including an explanation of any changes
from the original CSBG State Plan.
[Narrative - 2500 Characters]
G.2.

State Linkages and Coordination at the Local Level: Describe the linkages and coordination at
the local level that the State created or maintained with governmental and other social
services, especially antipoverty programs, to assure the effective delivery of and coordination
of CSBG services to people with low-incomes and communities and avoid duplication of services
(as required by assurances under Sections 676(b)(5) and (b)(6)). Review and update the
narrative describing actual activities, including an explanation of any changes from the original
CSBG State Plan. Attach additional information as needed.
[Narrative, 2500 Characters]
[This narrative box will be auto-populated with the actual response to question 9.2.
from CSBG State Plan. The State will review and update the narrative describing actual
activities, including an explanation of any changes from the original CSBG State Plan.]

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Module 1, State Administration

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G.3.

CSBG Eligible Entity Linkages and Coordination
G.3a State Assurance of CSBG Eligible Entity Linkages and Coordination: Describe how the
State assured that the CSBG Eligible Entities coordinated and established linkages to
assure the effective delivery of and coordination of CSBG services to people with lowincomes and communities and avoid duplication of services (as required by the
assurance under Section 676(b)(5)). Attach additional information as needed.
[Narrative, 2500 Characters]
[This narrative box will be auto-populated with the actual response to question 9.3.
from CSBG State Plan. The State will review and update the narrative describing actual
activities, including an explanation of any changes from the CSBG State plan.]
G.3b State Assurance of CSBG Eligible Entity Linkages to Fill Service Gaps: Describe how the
CSBG Eligible Entities developed linkages to fill identified gaps in the services, through
the provision of information, referrals, case management, and follow-up consultations,
according to the assurance under Section 676(b)(3)(B) of the CSBG Act.
[Narrative, 2500 Characters]
[This narrative box will be auto-populated with the actual response to question 9.3b.
from CSBG State Plan. The State will review and update the narrative describing actual
activities, including an explanation of any changes from the original CSBG State Plan.]

G.4.

Workforce Innovation and Opportunity Act (WIOA) Employment and Training Combined Plan
Activities (if applicable): If the State included CSBG employment and training activities as part
of a WIOA Combined State Plan, as allowed under the Workforce Innovation and Opportunity
Act, provide a brief narrative describing the status of WIOA coordination activities, including
web links, if available, to any publicly accessible combined plans and reports.
[Narrative, 2500 Characters]
[Note: This narrative box will only be completed by States in which CSBG employment and
training activities are included as part of a WIOA Combined State Plan. Because the WIOA
Combined State Plan is in a separate system not administered by ACF, information cannot be
auto-populated. The purpose of this section will be to provide an administrative update on Statelevel WIOA plan coordination for States with combined plans, rather than a report on
employment and training outcomes at the CSBG Eligible Entity level. ]

G.5.

Coordination among CSBG Eligible Entities and the State Community Action Association:
Describe State activities that took place to support coordination among the CSBG Eligible
Entities and the State Community Action Association.
[Narrative, 2500 Characters]
[This narrative box will be auto-populated with the actual response to question 9.8. from CSBG
State Plan. The State will review and update the narrative describing actual activities, including
an explanation of any changes from the original CSBG State Plan.]

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Module 1, State Administration

Page 18 of 66

G.6.

Feedback to CSBG Eligible Entities and State Community Action Association: Describe how the
State provided feedback to local entities and the State Community Action Association regarding
its performance on State Accountability Measures.
[Narrative, 2500 Characters]
[This narrative box will be auto-populated with the actual response to question 9.10 from CSBG
State Plan. The State will review and update the narrative describing actual activities, including
an explanation of any changes from the original CSBG State Plan.]
Note: This information is associated with State Accountability Measure 5S(iii). The measure
indicates feedback should be provided within 60 calendar days of the State receiving feedback
from OCS.

October 2016

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Module 1, State Administration

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SECTION H

Monitoring, Corrective Action, and Fiscal Controls

Monitoring of CSBG Eligible Entities (Section 678B(a) of the CSBG Act)
H.1.

Briefly describe the actual monitoring visits conducted during the reporting year including: full
on-site reviews; on-site reviews of newly designated entities; follow-up reviews – including
return visits to entities that failed to meet State goals, standards, and requirements; and other
reviews as appropriate. If a monitoring visit was planned during the year but not implemented,
provide a brief explanation in the far right column of the table below.
Note: This information is associated with State Accountability Measure 4Sa(i).
This table will be auto-populated with information provided in the State’s accepted CSBG
State Plan. The information should be reviewed and updated based on the actual monitoring
visits conducted. Additional rows may be added for monitoring visits that were not included
in the original plan with an explanation of the circumstances in the description. A brief
explanation for any visits that were included in the State plan but not conducted may be
provided in the far right row.
CSBG Eligible Entity

Review Type

Actual Site
Visit Dates

Brief Description of Purpose

Information in these
Dropdown
cells will be autoOptions:
populate with
projected visits in Table • Full onsite
Note: If a monitoring visit was a part of the
10.1 from the CSBG
• Newly
original state monitoring plan, note it as a
State Plan. The State
Designated
scheduled monitoring visit. If the visit was not a
may add rows for
• Follow-up
part of the original monitoring plan, provide a
additional monitoring
• Other
brief explanation for the purpose of the visit (e.g.
visits conducted. The
• No review
Enter dates
a follow-up regarding a special issue). This
State may not delete
section should not be used to outline findings,
visits that were
but should simply note the purpose of the
included in the CSBG
monitoring (e.g. follow-up regarding corrective
State Plan, but may
actions).
provide a brief
[Narrative, 500 characters]
explanation for visits
that were not
conducted in the far
right row.
ADD a ROW function Note: Rows may be added for each additional Monitoring Visit

H.2.

Monitoring Policies: Were any modifications made to the State’s monitoring policies and
procedures during the reporting period (FFY)?
 Yes  No
If changes were made to State monitoring policies and procedures, attach and/or provide a
hyperlink to the modified documents. [Attach a document or add a link]

H.3.

Initial Monitoring Reports: Were all State monitoring reports conducted in manner consistent
with State monitoring policies and procedures and disseminated to CSBG Eligible Entities within
60 calendar days?
 Yes  No

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Module 1, State Administration

Page 20 of 66

If no, provide the actual number of days for initial distribution of all monitoring reports and
provide an explanation for the circumstances that resulted in delayed reports. [Narrative 2500
characters]
Note: This item is associated with State Accountability Measure 4Sa(ii).
Corrective Action, Termination and Reduction of Funding and Assurance Requirements (Section 678C
of the CSBG Act)
H.4.

Quality Improvement Plans (QIPs): Did all CSBG Eligible Entities on Quality Improvement Plans
resolve identified deficiencies within the schedule agreed upon by the State and eligible entity?
 Yes  No
If no, provide an explanation for the circumstances. [Narrative 2500 characters]
Note: The QIP information is associated with State Accountability Measures 4Sc.

H.5.

Reporting QIPs: Did the State report all CSBG Eligible Entities with serious deficiencies from a
monitoring review to the Office of Community Services within 30 calendar days of the State
approving a QIP?
 Yes  No
If no, provide an explanation for the circumstances. A plan to assure timely notification of OCS
must be included in the next CSBG State Plan. [Narrative 2500 characters]
Note: This item is associated with State Accountability Measure 4Sa(iii)).

Fiscal Controls and Audits
H.6.

Single Audit Review: In the table below, provide the dates of any CSBG Eligible Entity Single
Audits in the Federal Audit Clearinghouse that were received and reviewed during the Federal
Fiscal Year as required by the CSBG regulations applicable to 45 CFR 75.521. If the audit
contained findings requiring a management decision by the State, provide the date the decision
was issued.
Employer
Identification
Number (EIN) of
Agency

Date Audit Was
Accepted by
Federal Audit
Clearinghouse

State
Management
Decision
Required?

[Numeric]

[Date]

[Y/N]

State
Management
Decision
Issued within
Six Months?
[Y/N/Pending]

Date
Management
Decision Issued
(if applicable)
[Date]

Add a ROW function Note: Rows may be added for each additional Single Audit accepted by the Federal Audit
Clearinghouse during the fiscal year.

H.7. Single Audit Management Decisions: Briefly describe any management decisions issued
according to State procedures of CSBG Eligible Entity single audit. Provide the audit finding
reference number from the Federal Audit Clearinghouse and describe any required actions and
timelines for correction. [Narrative, 2500 Characters]
Note: This information is associated with State Accountability Measure 4Sd.
October 2016

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Module 1, State Administration

Page 21 of 66

SECTION I

Results Oriented Management and Accountability (ROMA) System

I.1.

ROMA Participation: In which performance measurement system did the State and CSBG
Eligible Entities participate, as required by Section 678E(a) of the CSBG Act and the assurance
under Section 676(b)(12) of the CSBG Act?
Auto-populated from the CSBG State Plan. State will review and confirm
 The Results Oriented Management and Accountability (ROMA) System
 Another performance management system that meets the requirements of section 678E(b)
of the CSBG Act
 An alternative system for measuring performance and results
I.1a. If ROMA was selected in item I.1, provide an update on any changes in procedures or to
data collection systems that were initiated or completed in the reporting period.
[Attachment and Narrative, 2500 characters]
I.1b. If ROMA was not selected in item I.1, describe the system the State used for
performance measurement. Provide an update on any changes in procedures or to data
collection systems that were initiated or completed in the reporting period.
[Narrative, 2500 characters]

I.2.

State ROMA Support: How did the State support the CSBG Eligible Entities in using the ROMA
system or alternative performance measurement system in promoting continuous
improvement? For example, describe any data systems improvements, support for community
needs assessment, support for strategic planning, data analysis etc.
[Narrative, 2500 characters or attach a document]

I.3.

State Review of CSBG Eligible Entity Data: Describe the procedures and activities the State
used to review the ROMA data (i.e. all data from elements of the ROMA cycle) from CSBG
Eligible Entities for completion and accuracy (e.g. methodology used for validating the data
submitted annually by the local agencies).
[Narrative, 2500 characters or attach a document]

I.4

State Feedback on Data Collection, Analysis, and Reporting: State Accountability Measure
5S(ii) requires states to submit written feedback to each CSBG Eligible Entity regarding the
entity’s performance in meeting ROMA goals, as measured through National Performance
Indicator (NPI) data, within 60 calendar days of submitting the State’s Annual Report. Has the
state provided each CSBG Eligible Entity written, timely (at a minimum within 60 days of the
submission) feedback regarding the entity’s performance in meeting ROMA goals as
measured through national performance data?
 Yes  No

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Module 1, State Administration

Page 22 of 66

If no, describe the plan to assure timely notification of the CSBG Eligible Entities within
60 calendar days of submitting the State’s CSBG Annual Report. [Narrative 2500
characters]
If yes, please describe.
Note: This information is associated with State Accountability Measure 5S(ii).
I.5.

State and CSBG Eligible Entity Continuous Improvement. Provide 2-3 examples of changes
made by CSBG Eligible Entities to improve service delivery and enhance impact for individuals,
families, and communities with low-incomes based on their in-depth analysis of performance
data.
[Narrative, 2500 characters or attach a document]

October 2016

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Module 1, State Administration

Page 23 of 66

Module 2

CSBG Eligible Entity Expenditures,

Capacity, and Resources

Page 24 of 66

Instructional Notes

Module 2 - CSBG Eligible Entity Expenditures, Capacity, and

Resources

Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity - Data Entry Form
Section A: CSBG Expenditures by CSBG Eligible Entity Data Entry Form meets the Congressional requirement
for an explanation of the total amount of CSBG funding expended during the reporting period (identified below)
based on categories referenced in the CSBG Act.
CSBG funding expended during the reporting period should be identified in the domain that best reflects
the services delivered and strategies implemented, as well as the administrative costs associated with the
domains. Further instructions will be provided, but please keep the following in mind, per domain:
Services Supporting Multiple Domains: Expenditures reported under Services Supporting Multiple Domains
are those that span or support outcomes achieved across multiple domains for families and individuals,
such as case management, transportation, and childcare.
Linkages: Many of the activities that were associated with Linkages are now captured in Domain 9: Agency
Capacity Building. This narrows the definition of Linkages, but continues to include community initiatives
and information and referral calls.
Agency Capacity Building: Expenditures for Agency Capacity Building are detailed in Table B on this form.
Reporting on Administration: Administrative costs for CSBG reporting are defined by the Office of
Community Services as “equivalent to typical indirect costs or overhead." As distinguished from program
administration or management expenditures that qualify as direct costs, administrative costs refer to
central executive functions that do not directly support a specific project or service.
Module 2, Section B: CSBG Eligible Entity Capacity Building - Data Entry Form
Section B: CSBG Eligible Entity Capacity Building Data Entry Form provides detail on agency capacity building
funded by CSBG and other funding sources.
Module 2, Section C: Allocated Resources per CSBG Eligible Entity - Data Entry Form
Section C: Allocated Resources per CSBG Eligible Entity data entry form provides data on resources allocated
to, administered through, and generated by the CSBG Eligible Entity. This report provides valuable information
on how CSBG leverages funds from multiple federal, state, local, and private sources as required in the CSBG
Act.

October 2016

FRN #2 –CSBG Annual Report
Module 2, Instructional Notes

Page 25 of 66

Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity - Data Entry Form
Name of CSBG Eligible Entity Reporting: ___________________________________________
A. CSBG Eligible Entity Reporting Period
1. July 1 - June 30
2. October 1 - September 30
3. January 1 - December 31

"X"

B. CSBG Expenditures Domains
1. Employment
2. Education and Cognitive Development
3. Income, Infrastructure, and Asset Building
4. Housing
5. Health and Social/Behavioral Development (includes nutrition)
6. Civic Engagement and Community Involvement
7. Services Supporting Multiple Domains
8. Linkages (e.g. partnerships that support multiple domains)
9. Agency Capacity Building (detailed below in Table C)
10. Other (e.g. emergency management/disaster relief)

CSBG Funds

Total CSBG Expenditures (auto calculated)
Of the CSBG funds reported above, report the total amount used for Administration. For more information on
what qualifies as Administration, refer to IM37.

C. Details on Agency Capacity Building Activities Funded by CSBG:
1. Please identify which activities were funded by CSBG under Agency Capacity in Table B. Please check all that apply.
Community Needs Assessment

Data Management & Reporting

Strategic Planning

Training & Technical Assistance

Other*

*Below please specify Other Activities funded by CSBG under Agency Capacity:

October 2016

FRN #2 – CSBG Annual Report
Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity

Page 26 of 66

$0

Module 2, Section B: CSBG Eligible Entity Capacity Building - Data Entry Form
Name of CSBG Eligible Entity: _________________________________________________________
"X"

A. CSBG Eligible Entity Reporting Period
1. July 1 - June 30

auto-populated from Module
2, Section A

2. October 1 - September 30
3. January 1 - December 31
B. Hours of Agency Capacity Building (e.g. training, planning, assessment):

Hours

1. Hours of Board Members in capacity building activities
2. Hours of Agency Staff in capacity building activities
C. Volunteer Hours of Agency Capacity Building (e.g. program support, service delivery, fundraising):
1. Total number of volunteer hours donated to the agency
a. Of the above, the total number of volunteer hours donated by individuals with low-incomes
D. The number of staff who hold certifications that increase agency capacity to achieve family and community
outcomes, as measured by one or more of the following:
1. Number of Nationally Certified ROMA Trainers
2. Number of Nationally Certified ROMA Implementers
3. Number of Certified Community Action Professionals (CCAP)
4. Number of Staff with a child development certification
5. Number of Staff with a family development certification
6. Number of Pathways Reviewers
7. Number of Staff with Home Energy Professional Certifications
a. Number of Energy Auditors
b. Number of Retrofit Installer Technicians
c. Number of Crew Leaders
d. Number of Quality Control Inspectors (QCI)
8. Number of LEED Risk Certified assessors
9. Number of Building Performance Institute (BPI) certified professionals
10. Number of Classroom Assessment Scoring System (CLASS) certified professionals
11. Number of Certified Housing Quality Standards (HQS) Inspectors
12. Number of American Institute of Certified Planners (AICP)
13. Other (Please specify others below):

E. Number of organizations, both public and private, that the CSBG Eligible Entity actively works with to expand
resources and opportunities in order to achieve family and community outcomes:
1. Non-Profit
2. Faith Based
3. Local Government
4. State Government
5. Federal Government
6. For-Profit Business or Corporation
7. Consortiums/Collaborations
8. School Districts
9. Institutions of Post-Secondary Education/Training
10. Financial/Banking Institutions
11. Health Service Organizations
12. Statewide Associations or Collaborations

October 2016

FRN #2 – CSBG Annual Report
Module 2, Section B: CSBG Eligible Entity Capacity Building

Hours

Number

Unduplicated Number of
Organizations

Page 27 of 66

Module 2, Section C: Allocated Resources per CSBG Eligible Entity Data Entry Form

Name of CSBG Eligible Entity: _____________________________________
A. CSBG Eligible Entity Reporting Period

"X"

1. July 1 - June 30
2. October 1 - September 30
3. January 1 - December 31

auto-populated from Module 2, Section A

B. Amount of FY 20XX CSBG allocated to reporting entity

C. Federal Resources Allocated (Other than CSBG)
1. Weatherization (DOE) (include oil overcharge $$ )

1.

2. Health and Human Services (HHS)
a.

LIHEAP - Fuel Assistance (include oil overcharge $$ )

b.

LIHEAP - Weatherization (include oil overcharge $$ )

2b.

c.

Head Start

2c.

2a.

d.

Early Head Start

2d.

e.

Older Americans Act

2e.

f.

Social Services Block Grant (SSBG)

2f.

g.

Medicare/Medicaid

2g.

h.

Assets for Independence (AFI)

2h.

i.

Temporary Assistance for Needy Families (TANF)

2i.

j.

Child Care Development Block Grant (CCDBG)

2j.

k.

Community Economic Development (CED)

2k.

Other HHS Resources

l.
i.
ii.
iii.
iv.

CFDA #:
CFDA #:
CFDA #:
CFDA #:

2l. Total Other HHS Resources (autocalculated)
3. Department of Agriculture (USDA)

2l.i
2l.ii
2l.iii
2l.iv
$

2l.

a.

Special Supplemental Nutrition for Women, Infants, and Children (WIC)

3a.

b.

All USDA Non-Food programs (e.g. rural development)

3b.

c.

All other USDA Food programs

3c.

-

4. Department of Housing and Urban Development (HUD)
a.

Community Development Block Grant (CDBG) - Federal, State, and Local

4a.

b.

Section 8

4b.

c.

Section 202

4c.

d.

Home Tenant-Based Rental Assistance (HOME TBRA)

4d.

e.

HOPE for Homeowners Program (H4H)

4e.

f.

Emergency Solutions Grant (ESG)

4f.

g.

Continuum of Care (CoC)

4g.

h.

All other HUD programs, including homeless programs

4h.

5. Department of Labor (DOL)
a.

Workforce Innovation and Opportunity Act (WIOA) *previously WIA

5a.

b.

Other DOL Employment and Training programs

5b.

c.

All other DOL programs

5c.

6. Corporation for National and Community Service (CNCS) programs
7. Federal Emergency Management Agency (FEMA)
8. Department of Transportation
9. Department of Education
10. Department of Justice
11. Department of Treasury
12. Other Federal Resources

7.
8.
9.
10.
11.

i.

CFDA #:

12.i

ii.

CFDA #:

12.ii

iii.

CFDA #:

12.iii

iv.

CFDA #:

13. Total Other Federal Resources (autocalculated)
14. Total: Non-CSBG Federal Resources Allocated (autocalculated)

October 2016

6.

FRN #2 – CSBG Annual Report
Module 2, Section C: Allocated Resources per CSBG Eligible Entity

12.iv
13.

$
14 $

-

-

Page 28 of 66

D. State Resources Allocated
1.

a.

State appropriated funds used for the same purpose as Federal CSBG funds

b.

State Housing and Homeless programs (include housing tax credits )

1b.

c.

State Nutrition programs

1c.

d.

State Early Childhood Programs (e.g. Head Start, Day Care )

1d.

e.

State Energy programs

1e.

f.

State Health programs

1f.

g.

State Youth Development programs

1g.

h.

State Employment and Training programs

1h.

i.

State Senior programs

1i.

j.

State Transportation programs

1j.

k.

State Education programs

1k.

l.

State Community, Rural and Economic Development programs

1l.

m.

State Family Development programs

1m.

n.

Other State Resources

i.

1n.i

ii.

1n.ii

iii.

1n.iii

iv.

1n.iv

1n. Total Other State Resources (autocalculated)

1n.

$

-

2.

$

-

$

-

$

-

$
$

-

2. Total: State Resources Allocated (autocalculated)
3.

1a.

If any of these resources were also reported under Item 15 (Federal Resources), please estimate the
amount.

3.

E. Local Resources Allocated
1.

a.

Amount of unrestricted funds appropriated by local government

1a.

b.

Amount of restricted funds appropriated by local government

1b.

c.

Value of Contract Services

1c.

d.

Value of in-kind goods/services received from local government

1d.

2. Total: Local Resources Allocated (autocalculated)
3.

If any of these resources were also reported under Item 15 or 17 (Federal or State Resources), please
estimate the amount.

2.
3.

F. Private Sector Resources Allocated
1.

a.

Funds from foundations, corporations, United Way, other nonprofits

1a.

b.

Other donated funds

1b.

c.

Value of other donated items, food, clothing, furniture, etc.

1c.

d.

Value of in-kind services received from businesses

1d.

e.

Payments by clients for services

1e.

f.

Payments by private entities for goods or services for low income

clients or communities

1f.

2. Total: Private Sector Resources Allocated (autocalculated)
3.

If any of these resources were also reported under Item 15, 17, or 20 (Federal, State or Local Resources),
please estimate the amount.

G. Total Non-CSBG Resources Allocated: (Federal, State, Local & Private) (autocalculated)
H. Total Resources in CSBG Eligible Entity (including CSBG) (autocalculated)
Note : * All totals are autocalculated

October 2016

FRN #2 – CSBG Annual Report
Module 2, Section C: Allocated Resources per CSBG Eligible Entity

2.
3.

G.
H.

Page 29 of 66

Module 3

Community Level

Page 30 of 66

Instructional Notes
Module 3 - Community Level
Module 3, Section A: Community Initiative Status Form
CSBG Eligible Entities will complete the Community Initiative Status Form for the CSBG Eligible Entity identified
initiatives intended to achieve community level outcomes. This form provides a central place to report valuable
information about a single community initiative that started, continued, or ended during the current reporting
period. The information reported on the status form will be selected via a dropdown menu or written as a
narrative. In future reporting periods, CSBG Eligible Entities will update the status form based on the initiative's
progress. Please see additional notes below:
Problem Identification: CSBG Eligible Entities will provide information on how the problem was identified in

the Community Needs Assessment. This will include any data collected.

Issue/CSBG Community Domains: Select the domain(s) category(ies) that best describe the issue addressed

by the initiative. A full list is provided in the Status Form.

Ultimate Expected Outcomes: Select the indicator(s) from the Community Level NPIs (full list is found in

Section B) that measures the ultimate expected outcome of the initiative OR enter an "Other Outcome

Indicator".

Partnership Type: Select the partnership type from the choices provided. For example, a multi-partner

initiative includes the CSBG Eligible Entity and one or more partners.

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form

To facilitate the reporting, use, and learning from Community NPIs the Annual Report provides two types of
indicators (Counts of Change and Rates of Change). Based on the community-level work in which the CSBG
Eligible Entity is engaged, select the appropriate NPIs in either section. All the NPIs are optional and a category of
“other” exists for a CSBG Eligible Entity to create its own indicator if none of those provided captures what the
CSBG Eligible Entity is trying to achieve.
The first way to report impact is the Counts of Change indicators. These are basic measures that provide the
number of units being measured, e.g. jobs, houses, resources, etc. that have been added (created) or subtracted
(eliminated), and in some cases maintained, in the community the CSBG Eligible Entity has targeted.
The second way to report impact is the Rates of Change indicators. While requiring a bit more information, these
indicators tell the full story of the magnitude of the impact a community initiative (usually involving multiple
organizations) has had in a community.

October 2016

FRN #2 –CSBG Annual Report
Module 3, Instructional Notes

Page 31 of 66

Instructional Notes
Module 3 - Community Level
In the Rates of Change section, the measures call for reporting the “percent change”—the increase or decrease of
something from one year to the next. Please see the examples below.
Example 1: If you are measuring a percent increase in shelter beds, you would provide the following
information:
II.) Baseline existing starting point used for comparisons (#): Total Number of shelter beds (last year)
III.) Target (#): Targeted Number of shelter beds
V.) Actual Results (#): Actual number of shelter beds for the year

Example 2: If you are measuring a percent increase in the high school graduation rate in the identified

community (in this case one school district), you would provide the following information:

II.) Baseline existing starting point used for comparisons (#): High School Graduation Rate (last year)

III.) Target (#): Targeted High School Graduation Rate

V.) Actual Results (#): Actual High School Graduation Rate (at the end of the initiative)

The calculation for a percent increase or decrease for the community NPI rates of change is auto calculated in
column VI (actual percent change from baseline). The same logic applies when reporting a percent decrease.
Note, outcomes will only be reported once a community initiative has been reached or when progress has been
made toward the ultimate expected outcome. If progress has not been made, there is a place to identify this in
the Community Initiative Status Form.
Assistance with these types of calculations can either be obtained locally or from the national partners.
Module 3, Section C: Community Strategies List
CSBG Eligible Entities will use the Community Strategies field provided in the Community Initiative Status form to
identify relevant strategies community level initiative. A complete listing of the Community Strategies is found in
Section C. The Community Strategies List provides a basic identification of strategies, arranged by Domain and by
topic area. The list cannot be all-inclusive, as such an “other” category is included. This standardized list will aid
in local and state analysis of the relationship between community-level strategies and outcomes.

October 2016

FRN #2 –CSBG Annual Report
Module 3, Instructional Notes

Page 32 of 66

Module 3, Section A: Community Initiative Status Form
Name of CSBG Eligible Entity Reporting:
Use the dropdown menu to select the response where appropriate.

1. Initiative Name
2. Initiative Year
3. Problem Identification
4. Goal/Agenda
5. Issue/CSBG Community
Domains
6. Ultimate Expected Outcome
7. Identified Community
8. Expected Duration
9. Partnership Type
10. Partners
11. Strategy(ies)
12. Progress on
Outcomes/Indicators

1-7+ years
Narrative
(Provide a narrative on the scope of the problem)
Narrative
(Provide a narrative on the goal/agenda)
Employment; Education and Cognitive Development; Income, Infrastructure,
and Asset Building; Housing; Health and Social/Behavioral Development; or Civic
Engagement and Community Involvement
Community Level National Performance Indicators (NPIs)
(Reference the Community NPIs listed in Section B)
Neighborhood, City, School District, County, Service Area, State, Region, or Other
Narrative
(Provide the range in years, e.g. 1-3 years)
Independent CAA Initiative, CAA is the core organizer of multi-partner Initiative,
or CAA is one of multiple active investors and partners
Narrative
(Provide a narrative on the key 1-3 partners)
Select from the Community Level Strategies listed in Section C
No Outcomes to Report, Interim Outcomes, Final Outcomes

13. Impact of Outcomes

Narrative
(Provide additional information on the scope of the impact of these outcomes.
e.g. If an initiative created a health clinic, please describe how many individuals
and families are expected to be impacted.)

14. Outcomes/Indicators to
Report
15. Final Status

Community Level National Performance Indicators (NPIs)
(Reference the Community NPIs listed in Section B)
Initiative Active, Initiative Ended Early, Initiative Ended as Planned, Completed
Still Delivering Value

16. Lessons Learned

October 2016

Narrative

Module 3, Section A: Community Initiative Status Form

Page 33 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form

Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.

Employment Indicators

Name of CSBG Eligible Entity Reporting:
I.) Identified
Community
(auto-populated)

Counts of Change for Employment Indicators

II.) Target
(#)

III.) Actual
Results
(#)

IV.) Performance
target accuracy
(% auto calculated)

Counts
1. Number of jobs created to increase opportunities for people with low incomes in the identified community.
of
Change 2. Number of job opportunities maintained in the identified community.
3. Number of “living wage ” jobs created in the identified community*.
4. Number of “living wage” jobs maintained in the identified community*.
5. Number of jobs created in the identified community with a benefit package.
*When reporting on indicators related to living wage, agencies can provide their own definition or select from national or locally-defined models. Please indicate the living wage definition used in the General Comment box.

I.) Identified
Community

Other Other Counts of Change for Employment Indicators - Please specify below.
Counts of
Change

I.) Identified
Community

Rates of Change for Employment Indicators
Rates of
Change

Other
Rates of
Change

(auto-populated)

(auto-populated)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

IV.) Expected %
change from
baseline
(Target % auto
calculated)

II.) Target
(#)

III.) Actual
Results

IV.) Performance
target accuracy

(#)

(% auto calculated)

V.) Actual Results VI.) Actual %
(#)
change from
baseline

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

1. Percent decrease of the unemployment rate.
2. Percent decrease of the youth unemployment rate.
3. Percent decrease of the underemployment rate.

Other Rates of Change for Employment Indicators
- Please specify below.

I.) Identified
Community
(auto-populated)

IV.) Expected %
change from
baseline
(Target % auto
calculated)

V.) Actual Results VI.) Actual %
(#)
change from
baseline

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

General comments:

October 2016

FRN #2 –CSBG Annual Report
Module 3, Section B: Community NPIs - Employment

Page 34 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form

Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.

Education and Cognitive Development Indicators

Name of CSBG Eligible Entity Reporting:
Counts of Change for Education and Cognitive Development Indicators

I.) Identified
Community

II.) Target
(#)

(auto-populated)

III.) Actual
Results

IV.) Performance
target accuracy

(#)

(% auto calculated)

III.) Actual
Results

IV.) Performance
target accuracy

(#)

(% auto calculated)

1. Number of accessible and affordable early childhood or pre-school education assets or resources added to the
identified community.
2. Number of accredited or licensed affordable child care facilities added in the identified community.
3. Number of new Early Childhood Screenings offered to children (ages 0-5) of families with low-incomes in the
Counts
identified community.
of
Change 4. Number of accessible and affordable education assets or resources added for school age children in the
identified community. (e.g., academic, enrichment activities, before/after school care, summer programs)
5. Number of accessible and affordable post secondary education assets or resources added for newly graduating
youth in the identified community. (e.g. college tuition, scholarships, vocational training, etc.)
6. Number of accessible and affordable basic or secondary education assets or resources added for adults in the
identified community. (e.g. literacy, ESL, ABE/GED, etc.)

Other Other Counts of Change for Education and Cognitive Development Indicators - Please specify below.
Counts of
Change

October 2016

I.) Identified
Community
(auto-populated)

FRN #2 –CSBG Annual Report
Module 3, Section B: Community NPIs - Education and Cognitive Development

II.) Target
(#)

Page 35 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form

Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.

Education and Cognitive Development Indicators

Rates of Change for Education and Cognitive Development
Indicators

I.) Identified
Community
(auto-populated)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

IV.) Expected %
change from
baseline
(Target % auto
calculated)

V.) Actual Results VI.) Actual %
(#)
change from
baseline

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

1. Percent increase of children in the identified community who
are kindergarten ready.
2. Percent increase of children in the identified community at (or
above) the basic reading level.
3. Percent increase of children in the identified community at (or
above) the basic math level.

Rates of
4. Percent increase in high school (or high school equivalency)
Change
graduation rate in the identified community.
5. Percent increase of the rate of youth in the identified
community who attend post-secondary education.
6. Percent increase of the rate of youth in the identified
community who graduate from post-secondary education.
7. Percent increase of adults in the identified community who
attend post-secondary education.
8. Percent increase of adults in the identified community who
graduate from post-secondary education.
9. Percent increase in the adult literacy rate in the identified
community .

Other
Rates of
Change

Other Rates of Change for Education and Cognitive
Development Indicators
- Please specify below.

I.) Identified
Community
(auto populated)

IV.) Expected %
change from
baseline
(Target % auto
calculated)

V.) Actual Results VI.) Actual %
(#)
change from
baseline

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

General comments:

October 2016

FRN #2 –CSBG Annual Report
Module 3, Section B: Community NPIs - Education and Cognitive Development

Page 36 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form

Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.

Infrastructure and Asset Building Indicators

Name of CSBG Eligible Entity Reporting:
Counts of Change for Infrastructure and Asset
Building Indicators

I.) Identified
Community

II.) Target
(#)

(auto-populated)

III.) Actual
Results

IV.) Performance
target accuracy

(#)

(% auto calculated)

III.) Actual
Results

IV.) Performance
target accuracy

(#)

(% auto calculated)

1. Number of new accessible assets/resources created in the identified community:
a. Commercial
b. Financial
c. Technological/ Communications (e.g.
broadband)
d. Transportation
Counts
e. Recreational (e.g. parks, gardens, libraries)
of
f. Other Public Assets/Physical Improvements
Change
2. Number of existing assets/resources made accessible to the identified community:
a. Commercial
b. Financial
c. Technological/ Communications (e.g.
broadband)
d. Transportation
e. Recreational (e.g. parks, gardens, libraries)
f. Other Public Assets/Physical Improvements
Other
Counts of
Change

October 2016

Other Counts of Change for Infrastructure and Asset
Building Indicators - Please specify below.

I.) Identified
Community
(auto populated)

II.) Target
(#)

FRN #2 –CSBG Annual Report
Module 3, Section B: Community NPIs - Infrastructure and Asset Building

Page 37 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form

Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.

Infrastructure and Asset Building Indicators

Rates of Change for Infrastructure and Asset Building
Indicators

I.) Identified
Community
(auto-populated)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

IV.) Expected %
change from
baseline

V.) Actual
Results
(#)

VI.) Actual %
change from
baseline
(% auto calculated)

(Target % auto
calculated)

VII.)
Performance
target
accuracy
(% auto
calculated)

1. Percent decrease of abandoned or neglected
buildings in the identified community.
2. Percent decrease in emergency response time
Rates of measured in minutes in the identified community.
Change (EMT, Police, Fire, etc.).
3. Percent decrease of predatory lenders and/or
lending practices in the identified community.
4. Percent decrease of environmental threats to
households (toxic soil, radon, lead, air quality, quality
of drinking water, etc.) in the identified community.
5. Percent increase of transportation services in the
identified community.

Other
Rates of
Change

Other Rates of Change for Infrastructure and Asset
Building Indicators
- Please specify below.

I.) Identified
Community
(auto-populated)

IV.) Expected %
change from
baseline
(Target % auto
calculated)

V.) Actual
Results
(#)

VI.) Actual %
change from
baseline
(% auto calculated)

VII.)
Performance
target
accuracy
(% auto
calculated)

General comments:

October 2016

FRN #2 –CSBG Annual Report
Module 3, Section B: Community NPIs - Infrastructure and Asset Building

Page 38 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form

Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.

Housing Indicators

Name of CSBG Eligible Entity Reporting:
I.) Identified
Community

Counts of Change for Housing Indicators

II.) Target
(#)

(auto-populated)

III.) Actual
Results

IV.) Performance
target accuracy

(#)

(% auto calculated)

III.) Actual
Results

IV.) Performance
target accuracy

(#)

(% auto calculated)

1. Number of safe and affordable housing units developed in the identified community (e.g. built or set aside units
Counts for people with low incomes).
2. Number of safe and affordable housing units maintained and/or improved through WAP or other rehabilitation
of
Change efforts in the identified community.
3. Number of shelter beds created in the identified community.
4. Number of shelter beds maintained in the identified community.
Other
Counts of
Change

I.) Identified
Community

Other Counts of Change for Housing Indicators- Please specify below.

(auto-populated)

I.) Identified
Community
(auto-populated)

Rates of Change for Housing Indicators

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

II.) Target
(#)

IV.) Expected % V.) Actual Results VI.) Actual %
(#)
change from
change from
baseline
baseline
(Target % auto
calculated)

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

1. Percent decrease in the rate of homelessness in the identified
Rates of community.
Change 2. Percent decrease in the foreclosure rate in the identified
community.
3. Percent increase in the rate of home ownership of people with
low incomes in the identified community.
4. Percent increase of affordable housing in the identified
community.
5. Percent increase of shelter beds in the identified community.

Other
Rates of
Change

Other Rates of Change for Housing Indicators
- Please specify below.

I.) Identified
Community
(auto populated)

IV.) Expected % V.) Actual Results VI.) Actual %
(#)
change from
change from
baseline
baseline
(Target % auto
calculated)

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

General comments:

October 2016

FRN #2 –CSBG Annual Report
Module 3, Section B: Community NPIs - Housing

Page 39 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form

Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.

Health and Social/Behavioral Indicators

Name of CSBG Eligible Entity Reporting:
I.) Identified
Community

Counts of Change for Health and Social/Behavioral Indicators

II.) Target
(#)

(auto-populated)

III.) Actual
Results

IV.) Performance
target accuracy

(#)

(% auto calculated)

III.) Actual
Results

IV.) Performance
target accuracy

(#)

(% auto calculated)

1. Number of accessible and affordable physical health assets or resources created in the identified community.

Counts
of
2. Number of accessible and affordable behavioral and mental health assets or resources created in the identified community.
Change
3. Number of public safety assets and resources created in the identified community.
4. Number of accessible and affordable healthy food resources created in the identified community.
5. Number of activities designed to improve police and community relations within the identified community.

Other
Counts of
Change

I.) Identified
Community

Other Counts of Change for Health and Social/Behavioral Indicators- Please specify below.

Rates of Change for Physical Health, Wellbeing, and
Development Indicators

I.) Identified
Community
(auto-populated)

(auto-populated)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

IV.) Expected %
change from
baseline
(Target % auto
calculated)

II.) Target
(#)

V.) Actual Results VI.) Actual %
(#)
change from
baseline

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

1. Percent decrease in infant mortality rate in the identified community.

Rates of
Change 2. Percent decrease in childhood obesity rate in the identified
community.

3. Percent decrease in adult obesity rate in the identified community.
4. Percent increase in child immunization rate in the identified
community.
5. Percent decrease in uninsured families in the identified community.

October 2016

FRN #2 –CSBG Annual Report
Module 3, Section B: Community NPIs - Health and Social/Behavioral

Page 40 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form

Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.

Health and Social/Behavioral Indicators

Rates of Change for Behavioral and Mental health, Emotional
Wellbeing, and Development Indicators

I.) Identified
Community
(auto-populated)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

IV.) Expected %
change from
baseline
(Target % auto
calculated)

V.) Actual Results VI.) Actual %
(#)
change from
baseline

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

1. Percent decrease in the teen pregnancy rate in the identified
community.
2. Percent decrease in unplanned pregnancies in the identified
community.
Rates of 3. Percent decrease in substance abuse rate in the identified
Change community.(e.g. cigarettes, prescription drugs, narcotics, alcohol).
4. Percent decrease in domestic violence rate in the identified
community.
5. Percent decrease in the child abuse rate in the identified community.
6. Percent decrease in the child neglect rate in the identified community.
7. Percent decrease in the elder abuse rate in the identified community.
8. Percent decrease in the elder neglect rate in the identified
community.
I.) Identified
Community

Rates of Change for Public Safety Indicators

(auto populated)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

IV.) Expected %
change from
baseline
(Target % auto
calculated)

V.) Actual Results VI.) Actual %
(#)
change from
baseline

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

Rates of 1. Percent decrease in recidivism rate in the identified community.
Change 2. Percent decrease in non-violent crime rate in the identified
community.
3. Percent decrease in violent crime rate in the identified community.
4. Percent decrease in teens involved with the juvenile court system in
the identified community.

Other
Rates of
Change

Other Rates of Change for Health and Social/Behavioral
Indicators
- Please specify below.

I.) Identified
Community
(auto populated)

IV.) Expected %
change from
baseline
(Target % auto
calculated)

V.) Actual Results VI.) Actual %
(#)
change from
baseline

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

General comments:

October 2016

FRN #2 –CSBG Annual Report
Module 3, Section B: Community NPIs - Health and Social/Behavioral

Page 41 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form

Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.

Civic Engagement and Community Involvement Indicators

Name of CSBG Eligible Entity Reporting:

Rates of Change for Civic Engagement and Community
Involvement Indicators

I.) Identified
Community
(auto-populated)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

IV.) Expected % V.) Actual Results VI.) Actual %
(#)
change from
change from
baseline
baseline
(Target % auto
calculated)

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

1. Percent increase of donated time to support the CSBG Eligible Entity's
delivery of services and/or implementation of strategies to address
Rates of conditions of poverty in the identified community.

Change 2. Percent increase of donated resources to support the CSBG Eligible
Entity's delivery of services and/or implementation of strategies to
address conditions of poverty in the identified community.
3. Percent increase of people participating in public hearings, policy
forums, community planning, or other advisory boards related to the
CSBG Eligible Entity's delivery of service and/or implementation of
strategies to address conditions of poverty in the identified community.

Other
Rates of
Change

Other Rates of Change for Civic Engagement and Community
Involvement Indicators
- Please specify below.

I.) Identified
Community
(auto-populated)

IV.) Expected % V.) Actual Results VI.) Actual %
(#)
change from
change from
baseline
baseline
(Target % auto
calculated)

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

General comments:

October 2016

FRN #2 –CSBG Annual Report
Module 3, Section B: Goal 2 Community NPIs - Civic Engagement Community Involvement

Page 42 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form

Goal 3: People with low-incomes are engaged and active in building opportunities in communities.

Civic Engagement and Community Involvement Indicators

Name of CSBG Eligible Entity Reporting:

Rates of Change for Civic Engagement and Community
Involvement Indicators

I.) Identified
Community
(auto-populated)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

II.) Baseline

III.) Target

existing starting
point used for
comparisons
(#)

(#)

IV.) Expected % V.) Actual Results VI.) Actual %
(#)
change from
change from
baseline
baseline
(Target % auto
calculated)

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

Rates of
Change 1. Percent increase of people with low incomes who support the CSBG

Eligible Entity's delivery of service and/or implementation of strategies
to address conditions of poverty in the identified community.
2. Percent increase of people with low incomes who acquire and
maintain leadership roles with the CSBG Eligible Entity or other
organizations within the identified community.

Other
Rates of
Change

Other Rates of Change for Civic Engagement and Community
Involvement Indicators
- Please specify below.

I.) Identified
Community
(auto-populated)

IV.) Expected % V.) Actual Results VI.) Actual %
(#)
change from
change from
baseline
baseline
(Target % auto
calculated)

VII.) Performance
target accuracy
(% auto calculated)

(% auto
calculated)

General comments:

October 2016

FRN #2 –CSBG Annual Report
Module 3, Section B: Goal 3 Community NPIs - Civic Engagement Community Involvement

Page 43 of 66

Module 3, Section C: Community Strategies List
Employment Strategies
Minimum/Living Wage Campaign
Job Creation/Employment Generation
Job Fairs
Earned Income Tax Credit (EITC) Promotion
Commercial Space Development
Employer Education
Employment Policy Changes
Employment Legislative Changes
Other Employment Strategy: (please specify)
Education and Cognitive Development Strategies
Preschool for All Campaign
Charter School Development
After School Enrichment Activities Promotion
Pre K-College/Community College Support
Children’s Trust Fund Creation
Scholarship Creation
Child Tax Credit (CTC) Promotion
Adoption Child Care Quality Rating
Adult Education Establishment
Education and Cognitive Development Policy Changes
Education and Cognitive Development Legislative Changes
Other Education and Cognitive Development Strategy: (please specify)
Infrastructure and Asset Building Strategies
Cultural Asset Creation
Police/Community Relations Campaign
Neighborhood Safety Watch Programs
Anti-Predatory Lending Campaign
Asset Building and Savings Promotion
Develop/Build/Rehab Spaces
Maintain or Host Income Tax Preparation Sites
Community-Wide Data Collection Systems Development
Local 211 or Resource/Referral System Development
Water/Sewer System Development
Community Financial Institution Creation
Infrastructure Planning Coalition
Park or Recreation Creation and Maintenance
Rehabilitation/Weatherization of Housing Stock
Community Center/Community Facility Establishment
Asset Limit Barriers for Benefits Policy Changes
Infrastructure and Asset Building Policy Changes
Infrastructure and Asset Building Legislative Changes
Other Infrastructure and Asset Building Strategy: (please specify)

October 2016

FRN #2 – CSBG Annual Report
Module 3, Section C: Community Strategies List

Page 44 of 66

Module 3, Section C: Community Strategies List
Housing Strategies
End Chronic Homelessness Campaign
New Affordable Single Unit Housing Creation
New Affordable Multi- Unit Housing Creation (Single Resident Occupancy (SRO), temporary housing, transitional housing)
Tenants’ Rights Campaign
New Shelters Creation (including day shelters and domestic violence shelters)
Housing or Land Trust Creation
Building Codes Campaign
Housing Policy Changes
Housing Legislative Changes
Other Housing Strategy: (please specify)
Health and Social/Behavioral Development Strategies
Health Specific Campaign
Farmers Market or Community Garden Development
Grocery Store Development
Gun Safety/Control Campaign
Healthy Food Campaign
Nutrition Education Collaborative
Food Bank Development
Domestic Violence Court Development
Drug Court Development
Alternative Energy Source Development
Develop or Maintain a Health Clinic
Health and Social/Behavioral Development Policy Changes
Health and Social/Behavioral Development Legislative Changes
Other Health and Social/Behavioral Development Strategy: (please specify)
Community Support Strategies
Off-Hours (Non-Traditional Hours) Child Care Development
Transportation System Development
Transportation Services Coordination and Support
Community Support Policy Changes
Community Support Legislative Changes
Other Community Support Strategy: (please specify)
Emergency Management Strategies
State or Local Emergency Management Board Enhancement
Community wide Emergency Disaster Relief Service Creation
Disaster Preparation Planning
Emergency Management Policy Changes
Emergency Management Legislative Changes
Other Emergency Management Strategy: (please specify)

October 2016

FRN #2 – CSBG Annual Report
Module 3, Section C: Community Strategies List

Page 45 of 66

Module 3, Section C: Community Strategies List
Civic Engagement and Community Involvement Strategies- Goal 2
Development of Health and Social Service Provider Partnerships
Recruiting and Coordinating Community Volunteers
Poverty Simulations
Attract Capital Investments
Build/Support Increased Equity
Equity Awareness Campaign
Coordinated Community-wide Needs Assessment
Civic Engagement and Community Involvement in Advocacy Efforts
Civic Engagement Policy Changes
Civic Engagement Legislative Changes
Other Civic Engagement and Community Involvement Strategy: (please specify)
Civic Engagement and Community Involvement Strategies — Goal 3
Empowerment of Individuals/Families with Low-Incomes
Campaign to Ensure Individuals with Low-Incomes are Represented on Local Governing Bodies
Social Capital Building Campaign for Individuals/Families with Low-Incomes
Campaign for Volunteer Placement and Coordination
Civic Engagement Policy Changes
Civic Engagement Legislative Changes
Other Civic Engagement and Community Involvement Strategy: (please specify)

October 2016

FRN #2 – CSBG Annual Report
Module 3, Section C: Community Strategies List

Page 46 of 66

Module 4

Individual and Family Level

Page 47 of 66

Instructional Notes
Module 4 - Individual and Family Level
Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
All Individual and Family NPIs are optional there is a category for "Other Outcome Indicator". CSBG Eligible
Entities will only report an "Other Outcome Indicator" if the current NPIs do not capture the outcomes the CSBG
Eligible Entity is trying to achieve. Sample language is provided in the “Other Outcome Indicator” data entry
section and will be modified by the CSBG Eligible Entity as necessary.
Please see additional notes below:
For All Individual and Family Domains:
Targeting: Targets are set in the Community Action Plan and are identified through the planning phase of the
CAA’s ROMA (Results Oriented Management and Accountability) cycle. The following will be repotred for every
indicator:
Column I: Number of Participants Served

Column II: Target (number planned to achieve an outcome in the reporting period)

Column III: Actual Results (actual number of participants who achieved the outcome)

Please note, it is rare that 100% of the people served will achieve the proposed outcome.
Domain Specific Instructions:
Employment, Income and Asset Building, and Housing Domains
Indicators tracking outcomes for 90 or 180 days: CSBG Eligible Entities are only expected to report on
indicators with retention time frames for programs that specifically include follow up. If the CSBG Eligible
Entity does not conduct follow up activities as a part of their programs, outcomes for indicators with retention
time frames will not be reported.
Employment Domain
NPI 5-7: When reporting on indicators related to living wage, CSBG Eligible Entities can provide their own
definition or select from national or locally-defined models. Please idenitfy the living wage definition used in
the General Comments Section.
Income and Asset Building Domain
NPI 1 and 2: CSBG Eligible Entities are only expected to report on basic needs indicators as applicable to the
CSBG Eligible Entity's programs. When reporting on indicators related to basics needs, CSBG Eligible Entities
can provide their own definition or select from national or locally-defined models. Please idenitfy the basic
needs definition used in the General Comments Section.
NPI 8: This indicator requires agencies to keep an unduplicated count of people who report improved financial
well-being based on responses to the CFPB Financial Well Being Scale (found in the link below)
http://www.consumerfinance.gov/reports/financial-well-being-scale/

October 2016

FRN #2 –CSBG Annual Report
Module 4, Instructional Notes

Page 48 of 66

Instructional Notes
Module 4 - Individual and Family Level
Outcomes Across Multiple Domains:
The data from this indicator will help tell the story of how many lives were improved because of the CSBG
Network. Reporting on this indicator requires CSBG Eligible Entities to keep an unduplicated count of
individuals who achieved one or more outcomes reported in the NPIs.
Module 4, Section B: Individual and Family Services - Data Entry Form

CSBG Eligible Entities will report unduplicated counts of individuals receiving any of the services listed on the
Individual and Family Services form. This standardized Individual and Family Services list will aid in analysis of the
relationship between people, services, and outcomes.

Module 4, Section C: All Characteristics Report - Data Entry Form
The All Characteristics Report collects data on all individuals and households, whether or not funded directly
by CSBG. This demographic information will strengthen the CSBG Annual Report by demonstrating who is
being served by CSBG Eligible Entities.
To obtain unduplicated counts, a CSBG Eligible Entity will need to have a system that distinguishes the
characteristics for each individual/household. While some individuals and households may be served by
several programs within a reporting year and entered into multiple data systems (e.g. LIHEAP, WIC, etc.), they
must be reported as unduplicated individuals (in row A) and unduplicated households (in row B) in this report.
Please note, a single person is reported as an unduplicated individual and an unduplicated household.
We recognize that CSBG Eligible Entities have multiple data systems and may not be able to have an
unduplicated count across several systems. If you are unable to collect any characteristics on unduplicated
individuals or households due to data systems issues, include those individuals in row E and households in row
F at the end of this report. Additionally, please indicate the programs in which these individuals and
households were enrolled. The system will allow mutliple programs to be added.

October 2016

FRN #2 –CSBG Annual Report
Module 4, Instructional Notes

Page 49 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Employment Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of
Participants
Served

Employment

II.) Target (#)

III.) Actual
Results (#)

in program(s) (#)

1. The number of unemployed youth who obtained
employment to gain skills or income.
2. The number of unemployed adults who obtained
employment (up to a living wage).
3. The number of unemployed adults who obtained and
maintained employment for at least 90 days
(up to a living wage).
4. The number of unemployed adults who obtained and
maintained employment for at least 180 days
(up to a living wage).
5. The number of unemployed adults who obtained
employment (with a living wage or higher).
6. The number of unemployed adults who obtained and
maintained employment for at least 90 days
(with a living wage or higher).
7. The number of unemployed adults who obtained and
maintained employment for at least 180 days
(with a living wage or higher).
I.) Number of
Participants
Served

Employment

II.) Target (#)

III.) Actual
Results (#)

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (% auto
calculated)

calculated)

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (% auto
calculated)

calculated)

#DIV/0!

#DIV/0!

a. Of the above, the number of employed participants
who Increased income from employment through
wage or salary amount increase.

#DIV/0!

#DIV/0!

b. Of the above, the number of employed participants
who increased income from employment through
hours worked increase.

#VALUE!

#DIV/0!

c. Of the above, the number of employed participants
who increased benefits related to employment.

#DIV/0!

#DIV/0!

in program(s) (#)

8. The number of employed participants in a careeradvancement related program who entered or
transitioned into a position that provided increased
income and/or benefits.

Other Employment Outcome Indicator

I.) Number of
Participants
Served

II.) Target (#)

III.) Actual
Results (#)

in program(s) (#)

9. The number of individuals or households
______________.

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (% auto
calculated)

calculated)

#DIV/0!

#DIV/0!

Comments:

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section A: Individual and Family NPIs - Employment

Page 50 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Education and Cognitive Development Indicators
Name of CSBG Eligible Entity Reporting:

Education and Cognitive Development

I.) Number of
Participants
Served

II.) Target (#)

III.) Actual
Results (#)

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (%
auto calculated)

calculated)

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

7. The number of individuals who obtained a high school diploma
and/or obtained an equivalency certificate or diploma.

#DIV/0!

#DIV/0!

8. The number of individuals who obtained a recognized credential,
certificate, or degree relating to the achievement of educational or
vocational skills.

#DIV/0!

#DIV/0!

9. The number of individuals who obtained an Associate’s degree.

#DIV/0!

#DIV/0!

10. The number of individuals who obtained a Bachelor’s degree.

#DIV/0!

#DIV/0!

in program(s) (#)

1. The number of children (0 to 5) who demonstrated improved
emergent literacy skills.
2. The number of children (0 to 5) who demonstrated skills for
school readiness.
3. The number of children and youth who demonstrated improved
positive approaches toward learning, including improved attention
skills. (auto total).
a. Early Childhood Education (ages 0-5)
b. 1st grade-8th grade
c. 9th grade-12th grade
4. The number of children and youth who are achieving at basic
grade level (academic, social, and other school success skills). (auto
total)
a. Early Childhood Education (ages 0-5)
b. 1st grade-8th grade
c. 9th grade-12th grade
5. The number of parents/caregivers who improved their home
environments.
6. The number of adults who demonstrated improved basic
education.

Other Education and Cognitive Development Outcome
Indicator

0

0

I.) Number of
Participants
Served

0

0

0

II.) Target (#)

0

III.) Actual
Results (#)

in program(s) (#)

11. The number of individuals or households ______________.

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (%
auto calculated)

calculated)

#DIV/0!

#DIV/0!

Comments:

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section A: Individual and Family NPIs - Education

Page 51 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Income and Asset Building Indicators
Name of CSBG Eligible Entity Reporting:

Income and Asset Building

I.) Number of
Participants
Served

II.) Target (#)

III.) Actual
Results (#)

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (% auto
calculated)

calculated)

1. The number of individuals who achieved and maintained
capacity to meet basic needs for 90 days.

#DIV/0!

#DIV/0!

2. The number of individuals who achieved and maintained
capacity to meet basic needs for 180 days.

#DIV/0!

#DIV/0!

3. The number of individuals who opened a savings
account or IDA.

#DIV/0!

#DIV/0!

4. The number of individuals who increased their savings.

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

in program(s) (#)

5. The number of individuals who used their savings to
purchase an asset.
a. Of the above, the number of individuals who
purchased a home.
6. The number of individuals who improved their credit
scores.
7. The number of individuals who increased their net
worth.
8. The number of individuals engaged with the Community
Action Agency who report improved financial well-being.

Other Income and Asset Building Outcome Indicator

I.) Number of
Participants
Served

II.) Target (#)

III.) Actual
Results (#)

in program(s) (#)

9. The number of individuals or households
______________.

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (% auto
calculated)

calculated)

#DIV/0!

#DIV/0!

Comments:

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section A: Individual and Family NPIs - Income and Assets

Page 52 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Housing Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of
Participants
Served

Housing

II.) Target (#)

III.) Actual
Results (#)

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (% auto
calculated)

calculated)

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

5. The number of households who avoided eviction.

#DIV/0!

#DIV/0!

6. The number of households who avoided foreclosure.

#DIV/0!

#DIV/0!

7. The number of households who experienced improved
health and safety due to improvements within their home
(e.g. reduction or elimination of lead, radon, carbon
dioxide and/or fire hazards or electrical issues, etc).

#DIV/0!

#DIV/0!

8. The number of households with improved energy
efficiency and/or energy burden reduction in their homes.

#DIV/0!

#DIV/0!

in program(s) (#)

1. The number of households experiencing homelessness
who obtained safe temporary shelter.
2. The number of households who obtained safe and
affordable housing.
3. The number of households who maintained safe and
affordable housing for 90 days.
4. The number of households who maintained safe and
affordable housing for 180 days.

Other Housing Outcome Indicator

I.) Number of
Participants
Served

II.) Target (#)

III.) Actual
Results (#)

in program(s) (#)

9. The number of individuals or households
______________.

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (% auto
calculated)

calculated)

#DIV/0!

#DIV/0!

Comments:

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section A: Individual and Family NPIs - Housing

Page 53 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Health and Social/Behavioral Development Indicators
Name of CSBG Eligible Entity Reporting:

Health and Social/Behavioral Development

I.) Number of
Participants
Served

II.) Target (#)

III.) Actual
Results (#)

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (% auto
calculated)

calculated)

1. The number of individuals who demonstrated increased
nutrition skills (e.g. cooking, shopping, and growing food).

#DIV/0!

#DIV/0!

2. The number of individuals who demonstrated improved
physical health and well-being.

#DIV/0!

#DIV/0!

3. The number of individuals who demonstrated improved
mental and behavioral health and well-being.

#DIV/0!

#DIV/0!

4. The number of individuals who improved skills related
to the adult role of parents/ caregivers.

#DIV/0!

#DIV/0!

5. The number of parents/caregivers who demonstrated
increased sensitivity and responsiveness in their
interactions with their children.

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!
#DIV/0!

#DIV/0!
#DIV/0!

6. The number of seniors (65+) who maintained an
independent living situation.
7. The number of individuals with disabilities who
maintained an independent living situation.
8. The number of individuals with chronic illness who
maintained an independent living situation.
9. The number of individuals with no recidivating event for
six months.
a. Youth (ages 14-17)
b. Adults (ages 18+)

Other Health and Social/Behavioral Development
Outcome Indicator

in program(s) (#)

0

I.) Number of
Participants
Served
in program(s) (#)

0

II.) Target (#)

0

III.) Actual
Results (#)

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (% auto
calculated)

calculated)

#DIV/0!

#DIV/0!

10. The number of individuals or households
______________.
Comments:

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section A: Individual and Family NPIs - Health and Social/Behavioral

Page 54 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Civic Engagement and Community Involvement Indicators
Name of CSBG Eligible Entity Reporting:

Civic Engagement and Community Involvement

I.) Number of
Participants
Served

II.) Target (#)

III.) Actual
Results (#)

in program(s) (#)

1. The number of Community Action program participants
who increased skills, knowledge, and abilities to enable
them to work with Community Action to improve
conditions in the community.
a. Of the above, the number of Community Action
program participants who improved their leadership
skills.
b. Of the above, the number of Community Action
program participants who improved their social
networks.
c. Of the above, the number of Community Action
program participants who gained other skills,
knowledge and abilities to enhance their ability to
engage.

Other Civic Engagement and Community Involvement
Outcome Indicator

I.) Number of
Participants
Served

II.) Target (#)

III.) Actual
Results (#)

in program(s) (#)

2. The number of individuals or households
______________.

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (% auto
calculated)

calculated)

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (% auto
calculated)

calculated)

#DIV/0!

#DIV/0!

Comments:

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section A: Individual and Family NPIs - Civic and Community

Page 55 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Outcomes Across Multiple Domains
Name of CSBG Eligible Entity Reporting:

Outcomes Across Multiple Domains

I.) Number of
Participants
Served

II.) Target (#)

III.) Actual
Results (#)

in program(s) (#)

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (% auto
calculated)

calculated)

#DIV/0!

#DIV/0!

1. The number of individuals who achieved one or more
outcomes as identified by the National Performance
Indicators in various domains.
I.) Number of
Participants
Served

Other Outcome Indicator

in program(s) (#)

II.) Target (#)

III.) Actual
Results (#)

IV.) Percentage V.) Performance
Target Accuracy
Achieving
(III/II = V] (% auto
Outcome
[III/ I = IV ] (% auto
calculated)

calculated)

#DIV/0!

#DIV/0!

2. The number of individuals or households
______________.
Comments:

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section A: Individual and Family NPIs - Outcomes Across Multiple Domains

Page 56 of 66

Module 4, Section B: Individual and Family Services Data Entry Form

Goal 1: Individuals and Families with low-incomes are stable

and achieve economic security.

Employment Services

Name of CSBG Eligible Entity Reporting:
Employment Services

Unduplicated Number of
Individuals Served

Skills Training and Opportunities for Experience
Vocational Training
On-the-Job and other Work Experience
Youth Summer Work Placements
Apprenticeship/Internship
Self-Employment Skills Training
Job Readiness Training

Career Counseling
Workshops
Coaching

Job Search
Coaching
Resume Development
Interview Skills Training
Job Referrals
Job Placements
Pre-employment physicals, background checks, etc.

Post Employment Supports
Coaching
Interactions with employers

Employment Supplies
Employment Supplies

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section B: Employment Services

Page 57 of 66

Module 4, Section B: Individual and Family Services Data Entry Form

Goal 1: Individuals and Families with low-incomes are stable

and achieve economic security.

Education and Cognitive Development Services

Name of CSBG Eligible Entity Reporting:
Education and Cognitive Development Services

Unduplicated Number of
Individuals Served

Child/Young Adult Education Programs
Early Head Start
Head Start
Other Early-Childhood (0-5 yr. old) Education
K-12 Education
K-12 Support Services
Financial Literacy Education
Literacy/English Language Education
College-Readiness Preparation/Support
Other Post Secondary Preparation
Other Post Secondary Support
School Supplies
School Supplies
Extra-curricular Programs
Before and After School Activities
Summer Youth Recreational Activities
Summer Education Programs
Behavior Improvement Programs (attitude, selfesteem, Dress-for-Success, etc.)
Mentoring
Leadership Training
Adult Education Programs
Adult Literacy Classes
English Language Classes
Basic Education Classes
High School Equivalency Classes
Leadership Training
Parenting Supports (may be a part of the early
childhood programs identified above)
Applied Technology Classes
Post-Secondary Education Preparation
Financial Literacy Education
Post-Secondary Education Supports
College applications, text books, computers, etc.
Financial Aid Assistance
Scholarships
Home Visits
Home Visits

October 2016

FRN #2 – CSBG Annual Report
Module 4, Module 4, Section B: Education and Cognitive Development Services

Page 58 of 66

Module 4, Section B: Individual and Family Services Data Entry Form

Goal 1: Individuals and Families with low incomes are stable and

achieve economic security.

Income and Asset Building Services

Name of CSBG Eligible Entity Reporting:
Income and Asset Building Services

Unduplicated Number of
Individuals Served

Training and Counseling Services
Financial Capability Skills Training
Financial Coaching/Counseling
Financial Management Programs (including budgeting, credit
management, credit repair, credit counseling, etc.)
First-time Homebuyer Counseling
Foreclosure Prevention Counseling
Small Business Start-Up and Development Counseling
Sessions/Classes
Benefit Coordination and Advocacy
Child Support Payments
Health Insurance
Social Security/SSI Payments
Veteran's Benefits
TANF Benefits
SNAP Benefits
Asset Building
Saving Accounts/IDAs and other asset building accounts
Other financial products (IRA accounts, MyRA, other
retirement accounts, etc.)
VITA, EITC, or Other Tax Preparation programs
Loans And Grants
Micro-loans
Business incubator/business development loans

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section B: Income and Asset Building Services

Page 59 of 66

Module 4, Section B: Individual and Family Services - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve
economic security.
Housing Services
Name of CSBG Eligible Entity Reporting:
Housing Services

Unduplicated Number of
Individuals Served

Housing Payment Assistance
Financial Capability Skill Training
Financial Coaching/Counseling
Rent Payments (includes Emergency Rent Payments)
Deposit Payments
Mortgage Payments (includes Emergency Mortgage Payments)
Eviction Prevention Services
Eviction Counseling
Landlord/Tenant Mediations
Landlord/Tenant Rights Education
Utility Payment Assistance
Utility Payments (LIHEAP-includes Emergency Utility Payments)
Utility Deposits
Utility Arrears Payments
Level Billing Assistance
Housing Placement/Rapid Re-housing
Temporary Housing Placement (includes Emergency Shelters)
Transitional Housing Placements
Permanent Housing Placements
Rental Counseling
Housing Maintenance & Improvements
Home Repairs (e.g. structural, appliance, heating systems. etc.)
(Including Emergency Home Repairs)
Weatherization Services
Independent-living Home Improvements (e.g. ramps, tub and
shower grab bars, handicap accessible modifications, etc.)
Healthy Homes Services(e.g. reduction or elimination of lead,
radon, carbon dioxide and/or fire hazards or electrical issues,
etc.)
Energy Efficiency Improvements (e.g. insulation, air sealing,
furnace repair, etc.)

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section B: Housing Services

Page 60 of 66

Module 4, Section B: Individual and Family Services Data Entry Form

Goal 1: Individuals and Families with low incomes are stable and

achieve economic security.

Health and Social/Behavioral Development

Name of CSBG Eligible Entity Reporting:
Health and Social/Behavioral Development Services

Unduplicated Number of
Individuals Served

Health Services, Screening and Assessments
Immunizations
Physicals
Developmental Delay Screening
Vision Screening
Prescription Payments
Doctor Visit Payments
Maternal/Child Health
Nursing Care Sessions
In-Home Affordable Seniors/Disabled Care Sessions
(Nursing, Chores, Personal Care Services)
Health Insurance Options Counseling
Reproductive Health Services
Coaching Sessions
Family Planning Classes
Contraceptives
STI/HIV Prevention Counseling Sessions
STI/HIV Screenings
Wellness Education
Wellness Classes (stress reduction, medication management,
mindfulness, etc.)
Exercise/Fitness
Mental/Behavioral Health
Detoxification Sessions
Substance Abuse Screenings
Substance Abuse Counseling
Mental Health Assessments
Mental Health Counseling
Crisis Response/Call-In Responses
Domestic Violence Programs
Support Groups
Substance Abuse Support Group Meetings
Domestic Violence Support Group Meetings
Mental Health Support Group Meeting

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section B: Health and Social/Behavioral Development Services

Page 61 of 66

Module 4, Section B: Individual and Family Services Data Entry Form

Goal 1: Individuals and Families with low incomes are stable and

achieve economic security.

Health and Social/Behavioral Development

Name of CSBG Eligible Entity Reporting:
Health and Social/Behavioral Development Services (Cont'd.)

Unduplicated Number of
Individuals Served

Dental Services, Screenings and Exams
Adult Dental Screening/Exams
Adult Dental Services (including Emergency Dental Procedures)
Child Dental Screenings/Exams
Child Dental Services (including Emergency Dental Procedures)
Nutrition and Food/Meals
Skills Classes (Gardening, Cooking, Nutrition)
Community Gardening Activities
Incentives (e.g. gift card for food preparation, rewards for
participation, etc.)
Prepared Meals
Food Distribution (Food Bags/Boxes, Food Share Program, Bags of
Groceries)
Family Skills Development
Family Mentoring Sessions
Life Skills Coaching Sessions
Parenting Classes
Emergency Hygiene Assistance
Kits/boxes
Hygiene Facility Utilizations (e.g. showers, toilets, sinks)

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section B: Health and Social/Behavioral Development Services

Page 62 of 66

Module 4, Section B: Individual and Family Services - Data Entry

Form

Goal 1: Individuals and Families with low-incomes are stable and

achieve economic security.

Services Supporting Multiple Domains

Name of CSBG Eligible Entity Reporting:
Services Supporting Multiple Domains
Unduplicated Number of
Individuals Served
Case Management
Case Management

Eligibility Determinations
Eligibility Determinations

Referrals
Referrals

Transportation Services
Transportation Services (e.g. bus passes, bus transport, support for auto
purchase or repair; including emergency services)

Childcare
Child Care subsidies
Child Care payments

Eldercare
Day Centers

Identification Documents
Birth Certificate
Social Security Card
Driver's License

Re-Entry Services
Criminal Record Expungements

Immigration Support Services
Immigration Support Services (relocation, food, clothing)

Legal Assistance (includes emergency legal assistance)
Legal Assistance

Emergency Clothing Assistance
Emergency Clothing Assistance

Mediation/Customer Advocacy Interventions (debt forgiveness, negotiations or issues with
landlords, coordinating with other services or government)
Mediation/Customer Advocacy Interventions

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section B: Services Supporting Multiple Domains

Page 63 of 66

Module 4, Section B: Individual and Family Services - Data Entry

Form

Goal 1: Individuals and Families with low-incomes are stable and

achieve economic security.

Civic Engagement and Community Involvement

Name of CSBG Eligible Entity Reporting:
Civic Engagement and Community Involvement Services

Unduplicated Number of
Individuals Served

Voter Education and Access
Leadership Training
Tri-partite Board Membership
Citizenship Classes
Getting Ahead Classes
Volunteer Training

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section B: Civic Engagement and Community Involvement Services

Page 64 of 66

Module 4, Section C: All Characteristics Report - Data Entry Form

Goal 1: Individuals and Families with low-incomes are stable and achieve economic security.

Name of CSBG Eligible Entity Reporting:
A. Total unduplicated number of all INDIVIDUALS about whom one or more characteristics were obtained:
B. Total unduplicated number of all HOUSEHOLDS about whom one or more characteristics were obtained:

C. INDIVIDUAL LEVEL CHARACTERISTICS
1. Gender
a. Male
b. Female
c. Other
d. Unknown/not reported
TOTAL (auto calculated)

Number of Individuals

2. Age
a. 0-5
b. 6-13
c. 14-17
d. 18-24
e. 25-44
f. 45-54
g. 55-59
h. 60-64
i. 65-74

j. 75+
k. Unknown/not reported
TOTAL (auto calculated)

Number of Individuals

0

0

3. Education Levels

Number of Individuals
[ages 14-24]

a.
b.
c.
d.
e.

[ages 25+]

Grades 0-8
Grades 9-12/Non-Graduate
High School Graduate/ Equivalency Diploma
12 grade + Some Post-Secondary
2 or 4 years College Graduate

0

0

a. Youth ages 14-24 who are neither working or in school

a. Disabling Condition

0

II. Race
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian and Other Pacific Islander
e. White
f. Other
g. Multi-race (two or more of the above)
h. Unknown/not reported

TOTAL (auto calculated)

0

7. Military Status
a. Veteran
b. Active Military
c. Unknown/not reported
TOTAL (auto calculated)

Number of Individuals

0

8. Work Status (Individuals 18+)

Number of Individuals

c. Migrant Seasonal Farm Worker
d. Unemployed (Short-Term, 6 months or less)
e. Unemployed (Long-Term, more than 6 months)

Number of Individuals

5. Health

Number of Individuals

a. Employed Full-Time
b. Employed Part-Time

f. Graduate of other post-secondary school
g. Unknown/not reported
TOTAL (auto calculated)
4. Disconnected Youth

6. Ethnicity/Race
I. Ethnicity
a. Hispanic, Latino or Spanish Origins
b. Not Hispanic, Latino or Spanish Origins
c. Unknown/not reported
TOTAL (auto calculated)

f. Unemployed (Not in Labor Force)
g. Retired
h. Unknown/not reported
TOTAL (auto calculated)

0

Number of Individuals
Yes

No

Unknown

Yes

No

Unknown

b. Health Insurance*
*If an individual reported that they had Health Insurance please identify the source of health
insurance below.

Health Insurance Sources
i. Medicaid
ii. Medicare
iii. State Children’s Health Insurance Program
iv. State Health Insurance for Adults
v. Military Health Care
vi. Direct-Purchase
vii. Employment Based
viii. Unknown/not reported
TOTAL (auto calculated)

October 2016

0

FRN #2 – CSBG Annual Report
Module 4, Section C: All Characteristics Report

Page 65 of 66

Module 4, Section C: All Characteristics Report - Data Entry Form

Goal 1: Individuals and Families with low-incomes are stable and achieve economic security.
Name of CSBG Eligible Entity Reporting:

D. HOUSEHOLD LEVEL CHARACTERISTICS
9. Household Type

Number of Households

a. Single Person
b. Two Adults NO Children
c. Single Parent Female
d. Single Parent Male
e. Two Parent Household
f. Non-related Adults with Children
g. Multigenerational Household
h. Other
i. Unknown/not reported
TOTAL (auto calculated)

0

13. Sources of Household Income

Number of Households

a. Income from Employment Only
b. Income from Employment and Other Income Source
c. Income from Employment, Other Income Source,
and Non-Cash Benefits
d. Income from Employment and Non-Cash Benefits
e. Other Income Source Only
f. Other Income Source and Non-Cash Benefits
g. No Income
h. Non-Cash Benefits Only
i. Unknown/not reported
TOTAL (auto calculated)

10. Household Size
a. Single Person

Number of Households

0

Below, please report the types of Other income and/or non-cash benefits received by
the households who reported sources other than employment

14. Other Income Source
Number of Households
a. TANF
b. Supplemental Security Income (SSI)
c. Social Security Disability Income (SSDI)
d. VA Service-Connected Disability Compensation
e. VA Non-Service Connected Disability Pension

b. Two
c. Three
d. Four
e. Five
f. Six or more
g. Unknown/not reported
TOTAL (auto calculated)

0

f. Private Disability Insurance
g. Worker’s Compensation

11. Housing
a. Own
b. Rent
c. Other permanent housing
d. Homeless
e. Other
f. Unknown/not reported

Number of Households

TOTAL (auto calculated)
12. Level of Household Income
(% of HHS Guideline)

0
Number of Households

a. Up to 50%
b. 51% to 75%
c. 76% to 100%
d. 101% to 125%
e. 126% to 150%
f. 151% to 175%
g. 176% to 200%
h. 201% to 250%
i. 250% and over
j. Unknown/not reported
TOTAL (auto calculated)

h. Retirement Income from Social Security
i. Pension
j. Child Support
k. Alimony or other Spousal Support
l. Unemployment Insurance
m. EITC
n. Other
o. Unknown/not reported
15. Non-Cash Benefits
a. SNAP
b. WIC
c. LIHEAP
d. Housing Choice Voucher
e. Public Housing
f. Permanent Supportive Housing
g. HUD-VASH
h. Childcare Voucher
i. Affordable Care Act Subsidy
j. Other

Number of Households

k. Unknown/not reported
0

E. Number of Individuals Not Included in the Totals Above
(due to data collection system integration barriers)
1. Please list the unduplicated number of INDIVIDUALS served in each program*:

Program Name

Number of Individuals

F. Number of Households Not Included in the Totals Above
(due to data collection system integration barriers)
1. Please list the unduplicated number of HOUSEHOLDS served in each program*:

Program Name

Number of Households

*The system will add rows to allow reporting on multiple programs.

October 2016

FRN #2 – CSBG Annual Report
Module 4, Section C: All Characteristics Report

Page 66 of 66

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average 203 hours per response for State
CSBG Lead Agencies and 756 hours per response for eligible entities, 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. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please send to: [email protected]