| Johnson O'Malley Program Contact Information and Number of Eligible Indian Students Served |
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| Name of JOM Contractor: |
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| Contractor Type: |
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| Address: |
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| Name of Point of Contact for JOM Program |
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| Email: |
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| Phone Number: |
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| Number of Schools: |
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| School Names: |
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| Number of JOM Students by School: |
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| Number of JOM Students by School, by Grade Level: |
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| TERMS |
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| Name of JOM Contractor - Example: "X" Tribe or "X" School |
| Contractor Type - 638/Tribal Priority Allocation (TPA) Tribe, 477/Tribal Priority Allocation, Office of Self-Governance (OSG) Tribe, Public School, Previously Private Schools, or State Department of Education (if known) |
| Address - Contractor's Address (City, State, Zip Code) |
| Name of Point of Contact for JOM Program - Name of person who is the point of contact for the JOM Program |
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| Email - Email Address of the point of contact for JOM Program |
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| Phone Number - Phone Number of the point of contact for the JOM Program |
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| Number of Schools - Number of schools with eligible JOM students |
| School Names - List the names of schools JOM funds are distributed to by JOM Contractor |
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| Number of JOM Students by School - Number of eligible JOM students served in School Year 2018-19 |
| Number of JOM Students by School, by Grade Level - Number of students listed by grade level. For example School X: Grade 1 = 10; Grade 2 = 13, etc. |
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| Please submit the above information to [email protected] |
| For questions, please contact Angela Barnett, [email protected], (405) 605-6051, ext. 302 (office), or (703) 817-5879 (mobile) |
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| Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to identify the number of eligible Indian students served or potentially served by each eligible entity. Your response is voluntary and we will not share the results publicly. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey and assigned OMB Control Number 1090-0011, which expires ##/##/####. |
Estimated Burden Statement: We estimate the survey will take you ## minutes to complete, including time to read instructions, gather information, and complete and submit the survey. You may submit comments on any aspect of this information collection to the Information Collection Clearance Officer, [Insert Bureau], [Insert mailing address].” |