Form 1 Grantee Characteristics Form

Formative Data Collections for ACF Program Support

Grantee Characteristics Form

OFA Training and Technical Assistance (TTA)

OMB: 0970-0531

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GRANT INFORMATION

Grant Snapshot

  • Grant #

  • Grant Type

    • FatherhoodFIRE

    • FRAMEWorks

    • READY4Life

  • Funded Organization Name

  • Annual Funding Level

    • $350,000-$699,999

    • $700,000-$999,999

    • $1,00,000-$2,000,000

  • Annual Funding Amount

  • Funded Evaluation Type

    • Local Impact (LI)

    • Local Descriptive (LD)

    • Focus on Performance (FP)

    • Strengthening the Implementation of Marriage and Relationship Programs (SIMR)

    • Strengthening the Implementation of Responsible Fatherhood Programs (SIRF)

  • ACF Region

    • Region 1 (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont)

    • Region 2 (New Jersey, New York, Puerto Rico and the U.S. Virgin Islands)

    • Region 3 (Delaware, the District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia)

    • Region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee)

    • Region 5 (Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin)

    • Region 6 (Arkansas, Louisiana, New Mexico, Oklahoma, and Texas)

    • Region 7 (Iowa, Kansas, Missouri, and Nebraska)

    • Region 8 (Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming)

    • Region 9 (Arizona, California, Hawaii, Nevada, American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Republic of Palau, and Commonwealth of the Northern Mariana Islands)

    • Region 10 (Alaska, Idaho, Oregon, and Washington)

  • HMRF Funding History: First time OFA HMRF Grantee

    • Yes

    • No

  • Prior HMRF OFA Cohort and Grant Type

    • Cohort One - HMRE

    • Cohort One - HMRE Resource Center Cooperative Agreement

    • Cohort One - RF

    • Cohort One - RF Cooperative Agreement

    • Cohort Two - HMRE

    • Cohort Two - RF

    • Cohort Three - HMRE

    • Cohort Three - Fatherhood

    • Cohort Three – ReFORM

  • Prior Funding Level

    • $350,000-$699,999

    • $700,000-$999,999

    • $1,00,000-$2,000,000

  • Other Federal Funding Source(s)

    • CDC - HHS

    • Child Support - ACF

    • Children's Bureau - ACF

    • Department of Labor - Re-Entry

    • Department of Labor - Youth

    • Department of Labor - Other

    • Department of Labor - Adults

    • Family and Youth Services Bureau - ACF/FYSB

    • Office of Adolescent Health (OAH) - HHS/OAH

    • Office of Family Assistance (non-HMRF) - ACF

    • Office of Juvenile Justice - Justice

    • Other

Leadership Team

  • Active Program Director Name

    • Organization Title

    • Start Date

    • % of Time Allocated to HMRF Grant

      • 51% or more

      • 50% or less

    • Actual Time Allocated to the HMRF Grant

    • # Years HMRF Experience Prior to this Grant

    • Program Director Phone

    • Program Director Email

    • Program Director Status

      • Permanent Program Director

      • Interim Program Director

  • Authorizing Official Name

    • Phone

    • Email

  • Active Program Manager

    • Organization Title

    • Program Title

    • Start Date

    • % of Time Allocated to HMRF Grant

    • Phone Email

  • Data Manager Name

    • Organization Title

    • Phone

    • Email

  • Financial Officer Name

    • Organization Title

    • Phone

    • Email

  • Other Key Decision Maker Name

    • Title

    • Phone

    • Email

Organization Information

  • Organization Type

    • Public Institutions of Higher Education - Non-Profit

    • Private Institutions of Higher Education - Non-Profit

    • Public Non-Profit Community Entity

    • Private Non-Profit Community Entity

    • University

    • Cooperative Extension

    • Government Entity (State, County, Municipality)

    • Tribal Organization

    • Religious Organization

    • Other

  • Organization Focus

    • Positive Youth Development

    • HMRF

    • Child Support

    • Mental Health

    • Education

    • Child Welfare

    • ReEntry

    • Pregnancy Prevention

    • Social Services

    • Workforce

    • Family Resource Center

    • Home Visitation Program

    • Prison

    • Jail

    • Community Action Council

    • Other

  • Organization Size

    • 0-10

    • 11--50

    • 51-100

    • 101-200

    • >200

  • Is the HMRF grant program operating within a department or division of a broader organization?

    • Yes

    • No

    • If yes, what is the department/division?

  • Approximately how many staff are working on the HMRF grant program?

  • Affiliated with National or Regional Organization

    • Yes

    • No

    • If yes, National or Regional Organization Name

  • Funding Sources for the Organization – check all that apply

    • Federal Funding

    • State Funding

    • Local Government Funding

    • Private Donations

    • Private Grants

    • Contracts

    • Fees/Fees for Service

    • Earned Revenue

    • Other

  • Organization Address

    • Address Line 2

    • City

    • State

    • Zip

  • Organization Facebook

  • Organization Twitter

  • Organization Phone

  • Organization Website/Other Info

  • Program Address

    • Address Line 2

    • City

    • State

    • Zip

  • Program Main Phone

  • Program Facebook

  • Program Twitter

  • Program Website/Other info

  • Requested Number of nFORM Accounts

Evaluation

  • Previous Federal Research

    • Building Strong Families (BSF)

    • Community Healthy Marriages (CHMI)

    • Hispanic Healthy Marriage Initiative (HHMI)

    • Parents & Children Together (PACT)

    • Supporting Healthy Marriages (SHM)

    • Youth Education & Relationship Status (YEARS)

    • Other

    • N/A

  • Applied for Local Evaluation but Not Approved (checkbox)

  • Local Impact Design (if eval type = LI)

    • Total Sample Size

    • Program Sample

    • Control Sample

    • % Ratio

    • Additional Local Evaluation Information

      • Efficacy Study

      • Implementation Study

      • No Treatment Control Group

    • Lead Local Evaluator Name

      • Phone

      • Email

      • Organization Name

    • Research Questions

  • Local Descriptive Design (if eval type = LD)

    • Total Sample Size

    • Lead Local Evaluator Name

      • Phone

      • Email

      • Organization Name

    • Research Questions

  • Focus on Performance (if eval type = FP)

    • Started as Focus on Performance

      • Yes

      • No

PROGRAM STRUCTURE

Target Population

  • Populations Served

    • Adult Couples

    • Adult Individuals

    • Youth in High School (grades 9-12)

    • High-School Aged Youth (14-17)

    • Youth in Late Adolescence to Early Adulthood (18-24)

    • Community Fathers

    • Incarcerated Fathers

  • Proposed Service Numbers

  • Additional Details of Adults (over 18)

    • N/A (Youth Only)

    • Active-duty military and veteran fathers

    • Active-duty military and veteran individuals and couples

    • Any Adult

    • Couples - Expectant/Pregnant

    • Couples-Adoptive/Foster Parents

    • Couples-General

    • Expectant Mothers

    • Father Figures With Children 24 & Under

    • Fathers (expectant, adoptive, stepfathers) With Children 24 & Under

    • Fathers participating in Head Start or Healthy Start programs

    • Fathers receiving TANF assistance, as well as those who have previously received or are eligible to receive TANF assistance;

    • Homeless

    • Immigrants/Refugees

    • Individuals- Disabilities

    • Individuals-Incarcerated/ReEntry

    • Individuals-TANF Eligible/Recipients

    • Low-income fathers

    • Low-income, at-risk individuals

    • Non-custodial and custodial single fathers

    • Non-custodial and custodial single parents

    • Unserved/Underserved Population

    • Young adults (18-24)

    • Other

  • Additional Details of Youth (ages 14-18) - check all that apply

    • N/A (Adult Only)

    • Any Youth

    • At-Risk and Low-Income Youth

    • Criminal Justice Involved

    • Homeless/Runaway Youth

    • In Alternative School (Title I or Traditional)

    • In High School

    • In or Aging Out of Foster Care

    • Pregnant/Parenting Teens

    • Other

Service Overview

  • Service Delivery Settings (check all that apply)

    • In-house only

    • In Community

    • Virtual/Online

  • Delivery Setting(s) Details (check all that apply)

    • College/University

    • Combination of Service Delivery Settings

    • Community

    • Cooperative Extension

    • Faith Based Facility

    • Family Resource Centers

    • Government Offices

    • Grantee Organization

    • Health/Mental Health Facility

    • High School or Other Schools

    • Military Base

    • Prison/Jails/Detention

    • Shelter/Residential Facility

    • Workforce Center

    • Other

  • Youth Service Setting(s)

    • In-school

    • Out of school

    • Combination of both

  • High School involvement

    • N/A

    • Schools as Referral Partners Only

    • Services Delivered in Alternative Schools

    • Services Delivered in High School as Ancillary Activity (lunch hour, before or after school)

    • Services Delivered in High School Classrooms by HMRF Educators (guest educators)

    • Services Delivered in High School Classrooms by Teachers (integrated into classroom curriculum)

  • # of School Partners

  • Service Components

    • HMRE/RF Workshops

    • Case Management

    • Parenting

    • Employment Services

    • Financial Education

    • Intake

    • IPV

    • Other

  • Language for Service Delivery

    • English

    • Spanish

    • Other

  • Primary Workshop Hours

  • Curriculum(a) [dropdown] (if grant type = HM or youth)

  • Critical Components of the Curriculum (first four are required) (if grant type = HM or youth)

    • Communication skills (including expression, discussion, and negotiation skills)

    • Conflict resolution, management, and problem-solving skills

    • Knowledge of the benefits of marriage

    • Stress and anger management

    • Affection and intimacy

    • Expression and discussion of negotiation skills

    • Financial literacy, such as budgeting, financial planning, and management

    • Parenting skills (as applicable)

    • Trauma and its effects on forming healthy relationships (as applicable)

  • Grantee is doing the following to meet TRI-service requirements: (if grant type = RF)

    • Responsible Parenting

      • Curriculum(a) [dropdown]

      • Approach

        • Full workshop

        • Integrated workshop content

        • Other approach

    • Economic Stability

      • Curriculum(a) [dropdown]

      • Approach

        • Full workshop

        • Integrated workshop content

        • Other approach

    • Promote or Sustain Healthy Marriage

      • Curriculum(a) [dropdown]

      • Approach

        • Full workshop

        • Integrated workshop content

        • Other approach

Partners

  • Responsible for Delivering HMRF Workshops

    • Grantee

    • Partner/Subawardee

    • Both Partner and Grantee Organization

  • Partner Service Responsibilities

    • All Aspects of Program Delivery

    • Intake

    • Financial Education

    • HMRF Workshops

    • Employment

    • Case Management

    • Parenting

    • Unknown

    • Other

  • Location of Partner-Led Services

    • At Partner Facility

    • At Grantee Facility

    • In Community

    • Other

  • Grantee has MOU Agreements/Contracts with Service Delivery Partners

    • Yes

    • No

  • Key Service Delivery Partners

  • Key Strategic Partner Type(s) - check all that apply

    • American Job Centers, WIBs, and other Workforce Innovation and Opportunity Act funded employment training programs

    • Child welfare agencies and organizations

    • Criminal justice agencies (including prisons, jails, pre-release centers, courts, probation, parole)

    • Domestic violence organizations

    • Head Start programs

    • Healthy Start programs

    • High school systems

    • Housing

    • Legal aid and community action agencies

    • Local child support agency

    • Local substance and mental health agencies

    • Public health services, including health insurance navigators and enrollment specialists.

    • State, local, and tribal child support agencies

    • State, local, and tribal Temporary Assistance for Needy Families (TANF) agencies

    • Other

Employment

  • Types of services

    • No Employment Services

    • Coaching

    • Job Readiness - Integrated Service

    • Job Readiness - Stand-Alone Service

    • Job Search

    • One-Stop Partnership

    • Resource Room

    • Full-scale EWD Program with Certificate Trainings

    • Subsidized Employment

    • Apprenticeships

  • Employment Provider

    • Grantee

    • Partner Organization - employment services are an integrated component of the program - typically through contract or MOU

    • Both Partner and Grantee Organization

    • Referral Only - participants are referred to organizations in the community with expertise in employment

  • Grantee has MOU Agreements/Contracts with Employment Provider

    • Yes

    • No

  • Key Employment Providers

Incentive Structure

  • Incentive Use by Purpose (check all that apply)

    • Recruitment

    • Intake

    • Participation

    • Research

  • Total Amount(s) of Incentives Per Person

  • Incentive Structure Approved by OFA (checkbox)

Case Management

  • Cast Management Structure includes at least 8 individual service contacts per client throughout the course of the program? (checkbox)

  • Types of Case Management

    • Intensive

    • Moderate

    • Light-Touch

    • Other

  • Case Management Recipients

    • All Participants

    • All Participants but at Varied Levels Based on Need and Interest

    • Some Participants Based on Assessment of Needs

    • Some Participants Based on Request

    • None

    • Other

  • Foundations of Case Management

    • Barrier Removal (Workshop)

    • Barrier Removal (Life Challenge)

    • Curriculum Reinforcement

    • Life Coaching

    • Employment Coaching

    • Other

  • Format of Case Management

    • One-on-One Sessions

    • Group Format

    • Phone Coaching

    • Other

  • Duration

    • None

    • 1 session

    • 1 month

    • 1-3 months

    • 3-6 months

    • 6-9 months

    • 1 year

    • At Participants Request

  • Frequency

    • 1x

    • 1x per week

    • 1x per month

    • 1x per quarter

    • Leveling system with decreasing contact over time (for grantees with services longer than 3 months)

    • At Participants Request

    • Other

  • Case Management Structure Approved by OFA (checkbox)

DV/IPV

  • DV/IPV Approach

    • Screening for Services

    • Screening Out of the Program

    • No Screening

    • Assessment for IPV

    • Uncertain of Practice

  • Does the grantee have a DV/IPV Protocol

    • Yes

    • No

    • Uncertain

  • DV Partners

  • DV Training (include information by who, frequency, curriculum if any)

CQI PROCESS

Implementation Team

  • Team Members

  • Meeting Frequency

  • Grantee has a written CQI plan in place

    • Yes

    • No

  • Grantee is receiving/has received CQI TTA from MPR?

    • Yes

    • No

  • Responsible party for CQI

    • Program Director

    • Program CQI Lead

    • Organizational CQI

    • Outside Contractor



















File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorChelsea Yamamoto
File Modified0000-00-00
File Created2021-01-11

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