OMB #: 0990-0416
Exp. Date: xx/xx/xxxx
Attachment B Forms:
PAF Performance Measures: Grantee Organization Level Measures
(Performance Questions for All Grantees)
How many eligible participants received at least one activity? Indicate the total number in each category below.
a) Expectant female teens (19 years and younger)
b) Expectant male teens (19 years and younger)
c) Parenting teen mothers (19 years and younger )
d) Parenting teen fathers (19 years and younger )
e) Expectant women (20 years and older)
f) Expectant men (20 years and older )
g) Parenting women (20 years and older)
h) Parenting men (20 years and older )
i) Children (of expectant or parenting participants [reported in a to h] above)
How many non-participants (extended family members) received at least one activity?
Indicate the number served in each category.
a) Parent or Guardian of the expectant or parenting participant
b) Grandparent of the expectant or parenting participant
c) Spouse of the expectant or parenting participant
d) Partner of the expectant or parenting participant
e) Other
What is the age of expectant and parenting participants?
Indicate the total number in each category below.
a) 12 years and younger
b) 13 years old
c) 14 years old
d) 15 years old
e) 16 years old
f) 17 years old
g) 18 years old
h) 19 years old
i) 20-24 years old
j) Over 24 years old
What is the ethnicity of expectant and parenting participants?
Indicate the total number in each category below.
a) Hispanic or Latino
b) Not Hispanic or Latino
c) Unknown or not reported
What is the race of expectant and parenting participants?
Indicate the total number in each category below. (Grantees are instructed to allow participants to specify which race(s) they identify with; grantees would report more than one race to OAH).
a) Asian
b) Black or African American
c) American Indian or Alaska Native
d) Native Hawaiian or Other Pacific Islander
e) White
f) More than one race
g) Unknown or not reported
What is the current relationship status of expectant and parenting participants?
a) Married
b) Not married (never married, divorced, separated, or widowed) but living with a boyfriend/girlfriend/partner (cohabiting)
c) Neither married nor cohabiting
d) Missing/unknown/not reported
What is the current living arrangement of expectant and parenting participant?
Indicate the total number in each category below.
a) Lives alone or with child/children
b) Lives with spouse/partner
c) Lives with parent(s)
d) Lives with spouse’s/partner’s parent(s) or other related adult(s)
e) Lives with other unrelated adult(s)
f) Lives in foster or group home
g) Homeless/no permanent residence
h) Other
i) Missing, Unknown or not reported
How many expectant or parenting female participants received any financial or social support for themselves or their (youngest) child from the child’s father in the last 4 weeks?
Indicate the total number in each category below.
a) Financial support (examples include giving the teen or woman money, child support payments, buying clothes, diapers or other supplies for the baby, paying for doctors’ visits?)
b) Social support (examples include assisting with child care, going to doctor’s visits, helping with chores, assisting with transportation)
How many expectant and parenting male participants provided financial or social support for their (youngest) child or the child’s mother in the last 4 weeks?
Indicate the total number in each category below.
a) Financial support (examples include giving the teen or woman money, child support payments, buying clothes, diapers or other supplies for the baby, paying for doctors’ visits?)
b) Social support (examples include assisting with child care, going to doctor’s visits, helping with chores, assisting with transportation)
How many expectant and parenting participants received any of the following services directly from program staff?
Indicate the total number in each category below.
a) Health care services (including prenatal care, postpartum care, reproductive health, pediatric care, and primary care)
b) Education support services (including tutoring services, credit recovery, individualized graduation plans, flexible scheduling, homebound instruction for extended absences, GED registration and enrollment, school re-enrollment assistance, college application assistance, financial aid resources or application assistance, dropout prevention services)
c) Child care services
d) Transportation Services
e) Parenting skills information
f) Healthy relationships information
g) Concrete supports (such as food, housing, clothing, furniture)
h) Case management services
i) Home visitation services
j) Vocational Services (including job training, career counseling, resume writing assistance)
k) Other
How many expectant and parenting participants (and/or dependent children) were referred to any of the following services by program staff?
Indicate the total number in each category below.
a) Health care services (including prenatal, post-partum care, reproductive health, pediatric care, and primary care)
b) Education support services (including tutoring services, credit recovery, individualized graduation plans, flexible scheduling, homebound instruction for extended absences, GED registration and enrollment, school re-enrollment assistance, college application assistance, financial aid resources or application assistance, dropout prevention services)
c) Child care services
d) Parenting skills information
e) Transportation Services
f) Healthy relationships information
g) Concrete supports (such as food, housing, clothing, furniture)
h) Case management services
i) Home visitation services
j) Vocational Services (including job training, career counseling, resume writing assistance)
k) Intimate Partner Violence Prevention
l) Other
How many extended family members of the expectant and parenting participants were referred by program staff at least once for any services?
Indicate the total number referred. (Extended family members may include any family member who is not eligible for services, such as the participants’ parents, legal guardians, grandparents)
a) Health care services (including prenatal, post-partum care, reproductive health, pediatric care, and primary care)
b) Education support services (including tutoring services, credit recovery, individualized graduation plans, flexible scheduling, homebound instruction for extended absences, GED registration and enrollment, school re-enrollment assistance, college application assistance, financial aid resources or application assistance, dropout prevention services)
c) Child care services
d) Parenting skills information
e) Transportation Services
f) Healthy relationships information
g) Concrete supports (such as food, housing, clothing, furniture)
h) Case management services
i) Home visitation services
j) Vocational Services (including job training, career counseling, resume writing assistance)
k) Intimate Partner Violence Prevention
l) Other
How many new staff (including teachers, facilitators, and human service professionals) has received initial training from the grantee or project partners? Please include only training provided to new staff.
How many existing staff (including teachers, facilitators, and human service professionals) has received supplemental or follow-up training from the grantee or project partners? Please include only training provided to existing staff.
How many formal and informal implementation partners currently involved in project planning, coordination, or implementation?
Indicate the number in each category below.
a) Formal (grantee has an MOU/written agreement with an entity to help implement the program)
b) Informal (Entity that assists with program outreach or planning but no formal agreement is in place)
Of the formal and informal implementation partners that were engaged at the beginning of the program year, how many were new to the project this year?
Indicate the number in each category below.
a) Number of formal partners
b) Number of informal partners
How many implementation partners were lost during the program year?
Indicate the number in each category below.
a) Number of formal partners
b) Number of informal partners
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0416. The time required to complete this information collection is estimated to average 19 hours per respondent, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Tara Rice |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |