Partnerships and Sustainability

OMB# 0990-XXXX

Expiration Date: XX/XX/XXXX

Candidate Pregnancy Assistance Fund Performance Measures

FY2017-2019 Cohort

Partnerships and Sustainability Form

1. How many program partners from each sector listed below were actively engaged in the PAF project of the federal grant year? [Actively engaged partners should include both state-level and local/community partner organizations who either serve as a PAF program implementation site, provide core services to the expectant and parenting PAF participants, serve on the advisory group for a PAF project, and/or provide technical assistance, or advice related to the PAF program such as to a PAF grantee or sub-grantee]

Education (K-12, Institutions of Higher Education) ____

Labor/Workforce Development Agencies ____

Health Care and Public Health (Hospitals, providers, public health departments) ____

Mental & Behavioral Health Care Providers (including substance abuse prevention and treatment) ____

Housing Agencies ____

Child Care/Early Education (including Child Care Resource & Referrals, Day Care centers, Head Start, etc.) ____

Faith-Based Organizations ____

Social Services or Human Services Agencies ____

Adoption or Foster Care Agencies ____

Juvenile Justice ____

Other Agencies _________

Total Number of Partners (unduplicated): ______________

2. How many program implementation sites (subawardees) were funded by the PAF grant during the grant year (July 1-June 30), by type:

High Schools (high school, charter school, any secondary school) ____

Institutes of Higher Education (2 yr. colleges, community colleges) ____

Institutes of Higher Education (4 yr. colleges/universities, public or private) ____

Community Service Organizations ____

Other (specify) ____

Total ____

3. How many program implementation sites (sub-recipients) were funded by the PAF grant in each of the following categories of urbanicity. [Specific definitions will be provided to grantees based on the 2013 National Center for Health Statistics Urban–Rural Classification Scheme for Counties]:

Urban ____

Rural ____

Suburban ____

(Question 5 will be asked only in the final data collection, at the end of grant year )

4. How many of the program sites (subawardees) report having plans to continue implementation of the core services for the expectant and parenting population after the end of OAH funding? (Firm plans includes having a work plan to continue implementation of services at the site, formal agreements with program providers to continue core program services at the site) ____

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-XXXX. The time required to complete this information collection is estimated to average 144/60 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.