Form 1 Annual Data Report

OMB Control No: XXXX-XXXX
Expiration date: XX/XX/XXXX

Administration for Native Americans
Annual Data Report (ADR)
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to
average 1 hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number.
Please Note: Many of the questions in this form ask for a “total number” of people as well as a “new number." The total number refers to all of the
people that participated in a particular activity, whereas the new number refers to the individuals that were participating in the project for the first
time and had not been counted before. For example, if a total of six individuals completed training X, but two of those individuals had already
completed previous training(s) during the project, then the number of new people that completed training X would be four.
A. IMPACT INDICATOR(S)
Your approved project impact indicator or indicators are identified below, as well as your pre-grant status (baseline measure), end-of-project target,
three year target, and means of measurement.
Impact Indicator

Pre-Grant
Status

End-of-Project
Target

Three Year PostProject Target

Means of Measurement

[this whole table pre-filled, not editable by
grantee]

1. For each impact indicator, please report on the actual change that has occurred so far. For example, if your impact indicator is the unemployment
rate, list the actual unemployment rate at the end of the reporting period.
Impact Indicator

Actual Change During Reporting Period

These fields pre-filled
and not editable

These fields to be filled by the grantee

B. NATIVE YOUTH AND ELDER ENGAGEMENT
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Expiration date: XX/XX/XXXX
For each reporting period, please update the table below if any project activities occurred in which Native youth or Elders participated. This table
should reflect only those activities occurring within the reporting period so that, by project’s end, all activities that took place are reflected.
1. During this reporting period, did this project provide any opportunities or activities for Native youth or Elders?
Yes

No

Not Applicable

1a. If yes, please complete the following table:
Total # of
youth
participating

Title/Description of Activity

# of New
youth
participating

Total # of
Elders
participating

# of New
Elders
participating

2. During this reporting period, did any of the above activities involving Elders and/or youth promote cultural preservation?

Yes

No

2a. If yes, please describe:
3. During this reporting period, has the project engaged youth in leadership development activities?

Yes

No

3a. If yes, please describe:
C. PARTNERSHIPS
1. For each reporting period, please update the table below. The table should reflect only those partnerships relevant to the reporting period so that by
project’s end all partnerships are reflected.
Name of Partner

New = Partnership Formed
During the Project
Pre-existing = Partnership
Existed Prior to the Project
New
New

Pre-existing
Pre-existing

Cumulative Total Since Beginning of Project:
2

Type of Partner (drop-down Resources Contributed to the Project by the
menu*)
Partner

(This field auto-populated by the number of entries in ‘Name of Partner’ column)

OMB Control No: XXXX-XXXX
Expiration date: XX/XX/XXXX
*Options : Federal Govt./Agency, Tribal Govt./Agency, State Govt./Agency, Nonprofit, Private Business, Individual/Volunteer, Volunteer Association/Civic Organization,
School/University, CDFI, Philanthropic, Other.

2. If there are any potential organizations or individuals that your project would like to partner with, but have not yet been able to, please indicate
below:

Name of Potential Partner

Potential Role in Support of the Project

D. COMMUNITY INVOLVEMENT AND PARTICIPATION IN THE PROJECT
1. During this reporting period, have any volunteers (unpaid individuals providing service or resources to the project) been utilized in the
implementation of your project?
Yes
No
1a. How many individual (unduplicated) volunteers?
1b. What contribution(s) did volunteers make to the project?
1c. How many total hours did volunteers work during this reporting period?
2. During this reporting period, if community participation is intended as part of your project, what is your estimate of the level of actual community
participation compared with desired participation? This may include, but is not limited to, the intended beneficiaries of the project.
No community
participation

50% or less community
participation than desired

More than 50%
community participation

Desired community
participation achieved

Not applicable

E. USE OF ON-GOING PROJECT DATA
1. During the reporting period, how did your project use project information (data) to improve implementation of the project?
2. During the reporting period, how did you measure results or benefits occurring as a result of the project?
3. During the reporting period, did you obtain feedback from community members to get their viewpoints on project progress?
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Yes

No

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3a. If yes, how did you use such feedback?

F. PROJECT BENEFITS
1. During the reporting period, what changed in your community as a result of the project? These may include expected and unexpected and intended
and unintended changes as well as positive and negative changes.
2. During this reporting period, were any businesses created due to the project?

Yes

No

2a. If yes, how many businesses?
2b. If applicable, please identify what type(s) of businesses were created (e.g. suppliers of materials, food processing firms, etc.):
3. During this reporting period, did any members of your community, including project staff, complete training sponsored or arranged by the project
in order to learn a new skill, gain knowledge, develop expertise, earn a credential, or otherwise obtain beneficial experience during this reporting
period?
Yes
No
3a. If yes, please update the following table during each reporting period, as applicable. The table should reflect only those trainings occurring in
the reporting period.
Name of
Training or
Workshop

Description of Skills or
Knowledge Developed

Total # of People who
Completed the
Training

# of People who were
Project staff

# of New People who
Completed the Training

4. Were any ordinances, codes, regulations, or other governmental documents developed during this reporting period?
Applicable

Yes

Total # of Hours to
Complete Training

No

4a. If yes, please update the following table, reflecting just this reporting period, as applicable.
Type of ordinance,
code, or regulation
(drop-down menu*)
4

Brief description of the
ordinance, code, or
regulation

Was the ordinance,
code, or regulation
adopted/passed?

Was the ordinance,
code, or regulation
implemented?

If implemented, please explain
how. If not, please explain why.

Not

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Yes
Yes

No
No

Yes
Yes

No
No

*Options: Environmental, Energy, Govt. Procedure, Financial, Business, Industry, Other .
5. During the reporting period, did the project create any materials or resources (e.g., curricula, training materials, translated written materials,
resource guides, financial literacy guides, etc.)?
Yes
No
5a. If yes, please update this table, reflecting just the current reporting period , as applicable. Once a particular resource is entered, it should
not be entered again in subsequent reporting periods unless a new resource was created.
Material or resource
created due to the
project

How does this material or resource support the project’s goals?

Type of resource
(drop-down
menu*)

Electronic/Technology Based?
(Check ‘Yes’ if this is a technology
based resource, such as an app for a
phone or tablet, a podcast, etc.)
Yes
No
Yes
No
*Options: curricula, training materials, translations, resource guides, other.

6. Does your project currently have a plan in place to secure post-project funding to continue or extend project benefits?
6a. If no, would you like ANA’s help with establishing such a plan?

Yes

Yes

No

No

7. Please describe any collaboration with partners, including federal, tribal, or state partnership to continue or extend project outcomes, services, and
activities in order to achieve your community’s desired long-term goals after this ANA project ends.
Not applicable

G. LESSONS LEARNED AND ADDITIONAL SUPPORT
1. Please describe any lessons learned, promising practices, innovations, etc. you think could help similar projects overcome or resolve obstacles you
have encountered in the reporting period related to the success of the project.
2. Please identify support or resources that ANA could provide or arrange to help your project overcome or resolve obstacles you have encountered
in the reporting period.
Not applicable
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Expiration date: XX/XX/XXXX
H. SUSTAINABLE EMPLOYMENT AND ECONOMIC DEVELOPMENT (SEEDS) PROJECTS ONLY
1. Please attach a completed copy of your most current SEEDS Data Collection Sheet with each ADC submission.
2. Please describe any added benefits that have been realized due to participants’ new employment or business growth.

I. LANGUAGE PROJECTS ONLY
1. Please identify the language or language family addressed by your project
2. Please complete the following sentence by checking all that apply from the following list:

“My language project uses ANA grant funds to _______________: [Select all that apply and only update if there are any changes from the previous
reporting period]

Assess or measure language fluency/proficiency
Provide classroom language instruction
Provide language instruction via language immersion classes
Provide language instruction in the home
Train language instructors
Develop language materials
Compile, transcribe, or analyze oral testimony or records
Other. Please describe
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OMB Control No: XXXX-XXXX
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3. During this reporting period, were any language surveys or assessments developed

Yes

No

If yes, please include blank copies with the ADC submission.
3a. If yes to Question 3, how many different surveys or assessments were developed?
3b. If yes to Question 3, how many total surveys or assessments were distributed, and how many were returned?
Distributed:

Returned:

3c. If yes to Question 3, please describe the overall purpose of any surveys or assessments that were developed (for example, to assess the
current number of proficient speakers, to gauge community members’ interest in taking language classes, to measure progress, etc.):
4. Were language classes conducted during this reporting period?

Yes

No

4a. If yes, please complete the following reflecting classes conducted during this reporting period:
Proficiency Level
Total # of Classes
[drop-down menu]*
[drop-down menu]*
*Options: novice, beginner, intermediate, advanced

Total # of Class Hours

Total # of Students

Immersion?
Yes
No
Yes
No

Average Age of Students

4b. If the average age of language learners was between 0-6, does the project have an on-going relationship with one or more Head Start or
Early Head Start programs?
Yes
No
Not applicable
5. If instruction is part of your language project, please describe, in as much detail as possible, methods, materials, and strategies used, during the
reporting period, to measure progress in language proficiency or fluency,
6. If applicable to your project, how many new youth increased their ability to speak a Native language (language proficiency) during this reporting
period?
7. If applicable to your project, how many new adults increased their ability to speak a Native language (language proficiency) during this reporting
period?

8. If applicable to your project, did any youth achieve fluency in a Native language?
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Yes

No

If yes, how many (new)?

9. If applicable to your project, did any adults achieve fluency in a Native language?

Yes

No

OMB Control No: XXXX-XXXX
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If yes, how many (new)?

10. If applicable to your project, during the reporting period, have any language teachers been trained?

Yes

No

If yes, please complete the following:
10a. How many of these teachers received training in language instruction?
10b. Please check the type of training that these teachers received related to language instruction (check both if applicable):
Teacher training/professional development for language instruction
Language acquisition for teachers
10c. How many of these teachers received training in an area other than instruction
Please describe
10d. Did any of these language teachers receive a certification or credential as a result of training?

Yes

No

10e. If yes, what organization issued the certification or credential?
10f. How many language teachers received certification or a credential?

K. Esther Martinez Immersion (EMI) Projects Only
1. Please identify which type of EMI project this is [Note – whichever option is checked, the requirements for that particular type of EMI project will
automatically pop up so that grantees have a frame of reference for question 2]: [Only update if there are any changes from the previous reporting
period]
Language Nest
Language Survival School
Language Restoration Program
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2. Please describe in detail any obstacles or delays in meeting the requirements for the EMI language project option (language nest, language
survival school, or language restoration):
Not Applicable

L. ENVIRONMENTAL REGULATORY ENHANCEMENT (ERE) PROJECTS ONLY
1. During the reporting period did this project collect environmental baseline data?

Yes

No

1a. If yes, please describe what was learned from the data and how it will be used:
2. During the reporting period, did this project collect data to monitor environmental conditions?

Yes

No

2a. If yes, please describe what was learned from the data and how it will be used:
3. If applicable, during the reporting period how did the project result in increased capacity for the Tribe to manage its physical resources and/or the
environmental quality on tribal lands?:
4. Has there been any improvement in the environmental quality on tribal lands as a result of this project?
Yes

No

Not Applicable

To Be Determined

4a. If yes, please describe:

End-of-Project Addendum –BENEFITS, RESULTS, AND OUTCOMES
PLEASE NOTE: This section should be completed only in the final reporting period of the project and reflect the entire project period.
A. BENEFICIARIES
In the table below, please describe positive changes that have occurred in people’s lives as a result of this project. In the ‘Beneficiaries’ column,
identify whose lives have changed. These can be individuals (e.g. Jane Doe) or groups of people (e.g. tribal youth), as appropriate. If one or more of
the beneficiaries listed is an individual person, please feel free to safeguard that person’s identity by not listing his or her full name. In the ‘Realized
Benefit’ column, please describe, in as much detail as possible, the positive changes that have occurred for the identified individual or group.
Beneficiary
Beneficiary type
Realized benefit(s)
[drop-down menu]*

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Expiration date: XX/XX/XXXX
* Options: Individuals, community groups, governmental agencies, organizations, other
B. OBJECTIVE WORK PLAN – FINAL SUMMARY
Objective 1 – [pre-loaded from OWP]:
1. Please describe the overall progress and results and benefits that were accomplished by the end of the project.
Objective 2 – [pre-loaded from OWP, if applicable]:
2. If applicable, Please describe the overall progress and results and benefits that were accomplished by the end of the project.
Objective 3 – [pre-loaded from OWP, if applicable]:
3. If applicable, Please describe the overall progress and results and benefits that were accomplished by the end of the project.
C. PROBLEM STATEMENT AND PROJECT GOAL
The overall goal of this project was stated as: [pre-loaded from OWP]. Additionally, the problem statement in the ‘Objectives and Need for
Assistance’ section of the grant application was identified as follows: [pre-loaded from application].
1. Please describe the extent to which the overall goal of the project was achieved:
2. Please describe the extent to which the condition identified or environment described in the problem statement was addressed:
.

D. PROJECT DEVELOPMENT
Please identify who wrote the grant application in the table below:
Name

Title

Program Staff
Yes
No
Yes
No

Consultant
Yes
No
Yes
No

E. COMMUNITY AND EXTERNAL DATA
1. What has changed in your organization and community as a result of this project?
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Native
Yes
Yes

No
No

Tribal Member
Yes
No
Yes
No

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2. What information, feedback, observation(s), input, or other data from your community was most valuable to realizing project benefits, results, and
outcomes?
3. If applicable, what information, feedback, observation(s), input, or other data from ANA, other federal agencies, or others influenced project
benefits, results, and outcomes?
F. CONTINUATION/SUSTAINABILITY OF PROJECT GOALS, RESULTS, AND EFFORTS
1. If you could share any promising practices from your project with other ANA grantees, what would they be?
2. If you could do this project over again, what would you do differently? Please describe in as much detail as possible.
3. Has your project disseminated your project’s accomplishments and successes, internally and externally?

Yes

No

3a. If yes, please describe how.
4. How have you publicized your project (e.g. community meetings, web site updates, email/listserv, etc.)?
5. Please provide a detailed description of what outcomes, services, and activities you want to continue or extend after the project has ended,
including any new activities intended to achieve your community’s desired long-term goals.

6. How do you intend to financially continue or extend desired project outcomes, services, and activities after this ANA-funded project ends? Please
check all that apply.
N/A (additional funds not required)
State/Territory funds
Other grant federal funds
Private foundation grants
Corporate Donations

Program income
Tribal funds
Fundraising campaigns
Colleges/Universities
Other:

7. If applicable, what level of funding do you currently have in place to continue or extend project benefits?
Desired funding levels sufficient to continue or extend project benefits are in place
Some, but not all needed funding has been secured to continue or extend project benefits
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Please describe any plans or efforts being made to secure additional resources to sustain desired project outcomes, services, and
activities:
Still seeking needed funding, none currently in place
Please describe any plans or efforts being made to secure additional resources to sustain desired project outcomes, services, and
activities:
No funding secured to continue or extend project benefits and no plan in place through which to obtain funds
Not applicable because there are no current plans to continue or extend project benefits
8. Is your organization interested in:
ANA’s project planning and development training?
If yes, please describe topics of interest:
ANA’s pre-application training?
Yes
If yes, please describe topics of interest:

Yes

No

No

Facilitated roundtables with organizations with similar projects for the purpose of sharing resources and continuing or extending project benefits?
Yes
No
If yes, please describe topics of interest:
Other meetings? Please describe :

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