OMB# 0990-XXXX
Expiration Date: XX/XX/XXXX
Candidate Pregnancy Assistance Fund Performance Measures
FY2017-2019 Cohort
Participant Reach and Demographics
During the federal grant year (July 1-June 30), how many expectant and/or parenting participants did the PAF program serve within each of the following settings? Include the total number for each category:
Expectant or parenting mothers at high schools ____
Expectant or parenting fathers at high schools ____
Expectant or parenting mothers at Institutions of Higher Education ____
Expectant or parenting fathers at Institutions of Higher Education ____
Expectant or parenting mothers at community service organizations ____
Expectant or parenting fathers at community service organizations ____
Expectant or parenting mothers at other settings ____
Expectant or parenting fathers at other settings ____
Total number of expectant and parenting participants (all Settings): ____
During the federal grant year (July 1-June 30), how many dependent children of expectant or parenting teens, students, or young adults were served by the PAF program?
Dependent Children of an expectant or parenting student, teen, or young adult ____
During the federal grant year (July 1-June 30), how many extended family members of expectant and parenting participants were served by the PAF program? ____
[Extended family members are defined as other partners, spouses, Parents or guardians of expectant and parenting students, teens, youth, and young adults who were not covered in questions 1-3]
Indicate the number of expectant and parenting teens, students, and young adults served by the PAF program during the federal grant year (July 1-June 30) by their racial category:
White __________
African American or Black __________
American Indian or Alaska Native __________
Asian __________
Native Hawaiian/Pacific Islander __________
More than 1 Race __________
Other Race __________
Race Unknown/Not Reported __________
Indicate the number of expectant and parenting teens, students, and young adults served by the PAF program during the federal grant year (July 1-June 30) by their ethnicity:
Hispanic/Latino __________
Non-Hispanic/Latino __________
Ethnicity Unknown/Not-Reported __________
Indicate the number of expectant and parenting teens, students, and young adults served by the PAF program during the federal grant year (July 1-June 30) by their age (as of [Insert Date]):
<14 _______
15 _______
16 _______
17 _______
18 _______
19 _______
20-24 _______
25+ _______
Unknown/not reported _____
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 583/60 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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Tara Rice |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |