CSBG Disaster Supplemental Annual Report Module 2

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OMB No. 0970-0492
Expiration Date: 02/28/2023

Instructional Notes
Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity
Section A: CSBG Expenditures by CSBG Eligible Entity Data Entry Form meets the Congressional requirement
for an explanation of the total amount of CSBG funding expended during the reporting period (identified below)
based on categories referenced in the CSBG Act.
CSBG funding expended during the reporting period should be identified in the domain that best reflects the
services delivered and strategies implemented, as well as the administrative costs associated with the
domains.
Module 2, Section B: CSBG Eligible Entity Capacity Building
Section B: CSBG Eligible Entity Capacity Building Data Entry Form provides detail on agency capacity building
funded by CSBG and other funding sources.
Module 2, Section C: Allocated Resources per CSBG Eligible Entity
Section C: Allocated Resources per CSBG Eligible Entity data entry form provides data on resources allocated
to, administered through, and generated by the CSBG Eligible Entity. This report provides valuable information
on how CSBG leverages funds from multiple federal, state, local, and private sources as required in the CSBG
Act.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this
collection is to meet the requirement of the Community Services Block Grant (CSBG) Act (42 U.S.C. § 9901, et seq) that
all states that receive CSBG funding participate in a performance management system (Section 678E(a)(1)(A))) and
submit a report to the Secretary on an annual basis (Section 678E(a)(2)). Public reporting burden for this collection of
information is estimated to average 198 hours per grantee and 697 hours per sub-grantee, including the time for reviewing
instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory
collection of information per the Community Services Block Grant (CSBG) Act (42 U.S.C. § 9901, et seq) Section
678E(a)(1)(A)) and Section 678E(a)(2). An agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a
currently valid OMB control number. If you have any comments on this collection of information, please contact
[email protected].

CSBG Annual Report V2

Module 2, Instructional Notes

Module 2, Section A: CSBG Disaster Supplemental Expenditures by CSBG Eligible Entity
Name of CSBG Eligible Entity Reporting:
State:
A.1. CSBG Eligible Entity Reporting Period
A.1a. July 1 - June 30
A.1b. October 1 - September 30
A.1c. January 1 - December 31

DUNS:
"X"

A.2. Amount of FY 20XX CSBG Disaster Supplemental allocated to reporting entity
CSBG Disaster
Supplemental
Funds

A.3. CSBG Disaster Supplemental Expenditures Domains
A.3a. Employment
A.3b. Education and Cognitive Development
A.3c. Income, Infrastructure, and Asset Building
A.3d. Housing
A.3e. Health and Social/Behavioral Development (includes nutrition)
A.3f. Civic Engagement and Community Involvement
A.3g. Services Supporting Multiple Domains
A.3h. Linkages (e.g. partnerships that support multiple domains)
A.3i. Agency Disaster Recovery Capacity Building (detailed below in Table A.4)
A.3j. Other (Home Repairs)
A.3k. Total CSBG Disaster Supplemental Expenditures (auto calculated)

$0

A.4. Of the CSBG Disaster Supplemental funds reported above, report the total amount used for Administration. For more information on w
A.5. Details on Agency Disaster Recovery Capacity Building Activities Funded by CSBG Disaster:
1. Please identify which activities were funded by CSBG Disaster under Agency Capacity in Table A.3. Please check all that
apply.
Community Disaster Needs As...

Disaster Data Management & ...

Strategic Disaster Recovery
Planning

Training & Technical Assistance

Other*

*Below please specify Other Activities funded by CSBG under Agency Capacity:

Module 2, Section B: CSBG Eligible Entity Capacity Building
Name of CSBG Eligible Entity Reporting:
State:
B.1. CSBG Eligible Entity Reporting Period
B.1a. July 1 - June 30
B.1b. October 1 - September 30
B.1c. January 1 - December 31

B.2. Hours of Agency Capacity Building (e.g. training, planning, assessment):

DUNS:
"X"
auto-populated from Module 2,
Section A

Hours

B.2a. Hours of Board Members in capacity building activities
B.2b. Hours of Agency Staff in capacity building activities
B.3. Volunteer Hours of Agency Capacity Building (e.g. program support, service delivery, fundraising):
B.3a. Total number of volunteer hours donated to the agency
B.3a.1. Of the above, the total number of volunteer hours donated by individuals with low-incomes
B.4. The number of staff who hold certifications that increase agency capacity to achieve family and community
outcomes, as measured by one or more of the following:
B.4a. Number of Nationally Certified ROMA Trainers
B.4b. Number of Nationally Certified ROMA Implementers
B.4c. Number of Certified Community Action Professionals (CCAP)
B.4d. Number of Staff with a child development certification
B.4e. Number of Staff with a family development certification
B.4f. Number of Pathways Reviewers
B.4g. Number of Staff with Home Energy Professional Certifications
B.4g.1. Number of Energy Auditors
B.4g.2. Number of Retrofit Installer Technicians
B.4g.3. Number of Crew Leaders
B.4g.4. Number of Quality Control Inspectors (QCI)
B.4h. Number of LEED Risk Certified assessors
B.4i. Number of Building Performance Institute (BPI) certified professionals
B.4j. Number of Classroom Assessment Scoring System (CLASS) certified professionals
B.4k. Number of Certified Housing Quality Standards (HQS) Inspectors
B.4l. Number of American Institute of Certified Planners (AICP)
B.4m. Other (Please specify others below):

B.5. Number of organizations, both public and private, that the CSBG Eligible Entity actively works with to expand
resources and opportunities in order to achieve family and community outcomes:
B.5a. Non-Profit
B.5b. Faith Based
B.5c. Local Government
B.5d. State Government
B.5e. Federal Government
B.5f. For-Profit Business or Corporation
B.5g. Consortiums/Collaborations
B.5h. School Districts
B.5i. Institutions of Post-Secondary Education/Training
B.5j. Financial/Banking Institutions
B.5k. Health Service Organizations
B.5l. Statewide Associations or Collaborations

Hours

Number

Unduplicated Number of
Organizations

Name of CSBG Eligible Entity Reporting:
State:

DUNS:

C.1. CSBG Eligible Entity Reporting Period
C.1a. July 1 - June 30

"X"

C.1b. October 1 - September 30

auto-populated from Module 2, Section A

C.1c. January 1 - December 31
C.2. Amount of FY 20XX CSBG Disaster Supplemental provided to reporting entity

$

4,000

$

-

C.3. Federal Resources Allocated (Other than CSBG)
C.3a. Weatherization (DOE) (include oil overcharge $$)
C.3b. Health and Human Services (HHS)

C.3a.

C.3b.1.

LIHEAP - Fuel Assistance (include oil overcharge $$)

C.3b.1.

C.3b.2.

LIHEAP - Weatherization (include oil overcharge $$)

C.3b.2.

C.3b.3.

Head Start

C.3b.3.

C.3b.4.

Early Head Start

C.3b.4.

C.3b.5.

Older Americans Act

C.3b.5.

C.3b.6.

Social Services Block Grant (SSBG)

C.3b.6.

C.3b.7.

Medicare/Medicaid

C.3b.7.

C.3b.8.

Assets for Independence (AFI)

C.3b.8.

C.3b.9.

Temporary Assistance for Needy Families (TANF)

C.3b.9.

C.3b.10.

Child Care Development Block Grant (CCDBG)

C.3b.10.

C.3b.11.

Community Economic Development (CED)

C.3b.11.

C.3b.12.

Other HHS Resources

C.3b.12.i.
C.3b.12.ii.
C.3b.12.iii.
C.3b.12.iv.
C.3b.12.v.
C.3b.12.vi.
C.3b.12.vii.
C.3b.12.viii.
C.3b.12.ix.
C.3b.12.x.

CFDA #:
CFDA #:
CFDA #:
CFDA #:
CFDA #:
CFDA #:
CFDA #:
CFDA #:
CFDA #:
CFDA #:

C.3b.13. Total Other HHS Resources (autocalculated)

C.3b.12.i.
C.3b.12.ii.
C.3b.12.iii.
C.3b.12.iv.
C.3b.12.v.
C.3b.12.vi.
C.3b.12.vii.
C.3b.12.viii.
C.3b.12.ix.
C.3b.12.x.
C.3b.13.

C.3c. Department of Agriculture (USDA)
C.3c.1.

Special Supplemental Nutrition for Women, Infants, and Children (WIC)

C.3c.1.

C.3c.2.

All USDA Non-Food programs (e.g. rural development)

C.3c.2.

C.3c.3.

All other USDA Food programs

C.3c.3.

C.3d. Department of Housing and Urban Development (HUD)
C.3d.1.

Community Development Block Grant (CDBG) - Federal, State, and Local

C.3d.1.

C.3d.2.

Section 8

C.3d.2.

C.3d.3.

Section 202

C.3d.3.

C.3d.4.

Home Tenant-Based Rental Assistance (HOME TBRA)

C.3d.4.

C.3d.5.

HOPE for Homeowners Program (H4H)

C.3d.5.

C.3d.6.

Emergency Solutions Grant (ESG)

C.3d.6.

C.3d.7.

Continuum of Care (CoC)

C.3d.7.

C.3d.8.

All other HUD programs, including homeless programs

C.3d.8.

C.3e. Department of Labor (DOL)
C.3e.1.

Workforce Innovation and Opportunity Act (WIOA) *previously WIA

C.3e.1.

C.3e.2.

Other DOL Employment and Training programs

C.3e.2.

C.3e.3.

All other DOL programs

C.3e.3.

C.3f. Corporation for National and Community Service (CNCS) programs
C.3g. Federal Emergency Management Agency (FEMA)
C.3h. Department of Transportation
C.3i. Department of Education
C.3j. Department of Justice
C.3k. Department of Treasury
C.3l. Other Federal Resources

C.3f.
C.3g.
C.3h.
C.3i.
C.3j.
C.3k.

C.3l.i.

CFDA #:

C.3l.i.

C.3l.ii.

CFDA #:

C.3l.ii.

C.3l.iii.

CFDA #:

C.3l.iii.

C.3l.iv.

CFDA #:

C.3l.iv.

C.3l.v.

CFDA #:

C.3l.v.

C.3l.vi.

CFDA #:

C.3l.vi.

C.3l.vii.

CFDA #:

C.3l.vii.

C.3l.viii.

CFDA #:

C.3l.viii.

C.3l.ix.

CFDA #:

C.3l.ix.

C.3l.x.

CFDA #:

C.3l.x.

C.3m. Total Other Federal Resources (autocalculated)
C.3n. Total: Non-CSBG Federal Resources Allocated (autocalculated)

C.3m.

$

-

C.3.n.

$

-

C.4. State Resources Allocated
C.4a.

State appropriated funds used for the same purpose as Federal CSBG funds

C.4a.

C.4b.

State Housing and Homeless programs (include housing tax credits)

C.4b.

C.4c.

State Nutrition programs

C.4c.

C.4d.

State Early Childhood Programs (e.g. Head Start, Day Care)

C.4d.

C.4e.

State Energy programs

C.4e.

C.4f.

State Health programs

C.4f.

C.4g.

State Youth Development programs

C.4g.

C.4h.

State Employment and Training programs

C.4h.

C.4i.

State Senior programs

C.4i.

C.4j.

State Transportation programs

C.4j.

C.4k.

State Education programs

C.4k.

C.4l.

State Community, Rural and Economic Development programs

C.4l.

C.4m.

State Family Development programs

C.4m.

C.4n.

Other State Resources
C.4n.i.

C.4n.i.

C.4n.ii.

C.4n.ii.

C.4n.iii.

C.4n.iii.

C.4n.iv.

C.4n.iv.

C.4n.v.

C.4n.v.

C.4n.vi.

C.4n.vi.

C.4n.vii.

C.4n.vii.

C.4n.viii.

C.4n.viii.

C.4n.ix.

C.4n.ix.

C.4n.x.

C.4n.x.

C.4o. Total Other State Resources (autocalculated)

C.4o.

$

-

C.4p. Total: State Resources Allocated (autocalculated)

C.4p.

$

-

C.4q. If any of these resources were also reported under Item C.3n. (Federal Resources),

C.4q.

$

-

$

-

$
$

4,000

please estimate the amount.
C.5. Local Resources Allocated
C.5a.

Amount of unrestricted funds appropriated by local government

C.5a.

C.5b.

Amount of restricted funds appropriated by local government

C.5b.

C.5c.

Value of Contract Services

C.5c.

C.5d.

Value of in-kind goods/services received from local government

C.5d.

C.5e. Total: Local Resources Allocated (autocalculated)

C.5e.

If any of these resources were also reported under Item C.3n. or C.4p. (Federal or State
C.5f. Resources), please estimate the amount.

C.5f.

C.6. Private Sector Resources Allocated
C.6a.

Funds from foundations, corporations, United Way, other nonprofits

C.6a.

C.6b.

Other donated funds

C.6b.

C.6c.

Value of other donated items, food, clothing, furniture, etc.

C.6c.

C.6d.

Value of in-kind services received from businesses

C.6d.

C.6e.

Payments by clients for services

C.6e.

C.6f.

Payments by private entities for goods or services for low income
clients or communities

C.6f.

C.6g. Total: Private Sector Resources Allocated (autocalculated)

C.6g.

C.6h. If any of these resources were also reported under Item C.3n., C.4p. or C.5e. (Federal, State
or Local Resources), please estimate the amount.

C.6h.

C.7. Total Non-CSBG Resources Allocated: (Federal, State, Local & Private) (autocalculated)
C.8. Total Resources in CSBG Eligible Entity (including CSBG) (autocalculated)
Note : * All totals are autocalculated

C.7.
C.8.