Form TAB B TAB B TAB B - CMC Baseline Report

Connecting Minority Communities Pilot Program (CMC) Reporting Requirements

Connecting Minority Communities Pilot Program Report Forms (FINAL).xlsx

CMC Baseline Report Form

OMB: 0660-0048

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Overview

CMC Data Report Form Cover
Baseline Report
Performance (Technical) Report
Annual Report

Sheet 1: CMC Data Report Form Cover

Connecting Minority Communities Pilot Program (CMC)
Data Report Form
This Connecting Minority Communities Pilot Program (CMC) report form will serve as a tool to capture indicators highlighting broadband infrastructure, and adoption and use activities from the award's inception to the award's closeout. The form contains three separate reports: Baseline Report, Performance (Technical) Report, and Annual Report.
Baseline Report:
The Baseline Report is submitted once at the beginning of your project and is based on anticipated figures and schedules. You will use the Baseline Report to provide your projected goals and planned activities from the award start date to closeout. Some metrics will also ask you to provide data on the current state of your program before expending CMC grant funds. The Baseline Report is due 45 calendar days after NEPA approval.
Performance (Technical) Report:
The Performance (Technical) Report is submitted semi-annually for periods ending March 31 and September 30 and captures project performance and outcomes. You will use the Performance (Technical) Report to provide your actual completed goals and planned activities from award inception to the current reporting period. You will submit the semi-annual report twice a year until you expend all CMC grant funds, as well as upon closeout of the award. The Performance Report is due 30 calendar days after the closing period. The final closeout report is due 120 calendar days after the last Performance Technical Report.
Annual Report:
The Annual Report captures narrative data on your project. You will use the Annual Report to provide necessary information on CMC grant-funded project activities from award inception to the current reporting period. You will submit the annual report once a year until you expend all CMC grant funds. The Annual Report is due 30 calendar days after the closing period.
Click on the links below to view the report forms. Fill in NA for any indicators for which you do not collect data.
Baseline Report
Performance (Technical) Report
Annual Report

Sheet 2: Baseline Report
OMB Control No. XXX-XXXX Expiration Date:
TRIBAL BROADBAND CONNECTIVITY PROGRAM BASELINE REPORT
GENERAL INFORMATION
GENERAL Recipient Organization:
Award Identification Number:
Recipient Street Address
City, State, Zip Code
DUNS/UEI Number:
Award Start Date (MM/DD/YYYY):
Report Submission Date (MM/DD/YYYY):
Award End Date (MM/DD/YYYY):






MILESTONES/KEY INDICATORS
PROJECT MILESTONE CATEGORIES
1
Please use the following table to project project element completion as a percentage of funds spent on project elements over the projected number of six year periods that the project element will take to complete. For project elements which fall into a project milestone category which is not listed on this table, please list this project element in row 1j. Other.
MILESTONE CATEGORIES Year 1 Year 2 Year 3 Year 4
Period 1 - Projected Period 2 - Projected Period 1 - Projected Period 2 - Projected Period 1 - Projected Period 2 - Projected Period 1 - Projected Period 2 - Projected
1a. Overall Project







1b. Network Design







1c. Equipment Procurement







1d. Network Build (all components - owned, leased, Indefeasible Rights of Use, etc.)







1e. Broadband Deployment







1f. Equipment Deployment







1g. Remote Learning







1h. Anchor Community Adoption







1i. Digital Skills/Workforce Development Training







1j. Other (please specify):







Organizational Partners
2a Please use the following table to list your organizational partners, the type of organization, the organization's role in completion of project activities, and whether or not the partner has changed their involvement or role in the project within the past six months.
PARTNER NAME Partner Type Partner Role Change in Past Six Months?








































2b If you selected "Community Anchor Institution" or "Community-Based Organization" for any of the listed partner organizations, please specify.

REMOTE LEARNING INFRASTRUCTURE
3a What types of technology (hardware, software, online platforms) will be deployed to facilitate and improve remote learning infrastructure?
TECHNOLOGY NAME Technology Type Technology Description Total Cost








































3b What types of professional development training will be implemented to facilitate and improve remote learning infrastructure and IT management?
Professional Development Training Type Number of Participants Professional Development Training Description





















ANCHOR COMMUNITY ADOPTION
4a List the anchor community activities your project will carry out over the course of the grant period of performance
Anchor Community Activity Census Tract Target Beneficiary Target Output for the Grant Period of Performance




























BROADBAND INTERNET AND DEVICES
5a Describe the Internet Devices which will be acquired with CMC-provided funds.
Number of Devices Purchased Loan or Donation? Device Type Total Cost Recipient



































5b If you defined any Device Types as "Other," please explain.

5c Describe the Broadband Subscriptions which will be acquired with CMC-provided funds.
Number of Subscriptions Provider Type Average Cost to Recipient Total Cost to Institution (If Applicable) Recipient Speed










































5d Describe the Broadband Deployments which will be undertaken with CMC-provided funds.
Location Location Type Network Type Deployment Cost Ongoing Cost Description










































DIGITAL SKILLS AND WORKFORCE DEVELOPMENT
6a What types of digital skills or workforce development will be offered?
Type of Training Number of Participants Participants Who Completed Training Participant Type Training Objectives Training Objectives Met? College Credit Awarded?

















































6b Will participants be awarded a certification upon completion of training? If so, describe the certification.

MEASUREMENT AND EVALUATION
7a Describe performance measurements which will be utilized to evaluate the project’s effectiveness or the benefits delivered to project beneficiaries
Project Purpose Benefit Beneficiary How Will This Be Measured?




























7b Describe performance measurements which will be utilized to evaluate the project's impact on digital equity
Project Purpose Benefit Beneficiary How Will This Be Measured?





























CERTIFICATION I certify to the best of knowledge and belief that this report is correct and complete for performance of activities for the purposes set forth in the award documents.
Typed or printed name and title of Authorized Certifying Official: Telephone (area code, number and extension):

Signature of Certifying Official: Email Address:

Date:

Sheet 3: Performance (Technical) Report
OMB Control No. XXX-XXXX Expiration Date:
CONNECTING MINORITY COMMUNITIES PILOT PROGRAM (TECHNICAL) REPORT
GENERAL INFORMATION
GENERAL Recipient Organization:
Award Identification Number:
Recipient Street Address
City, State, Zip Code
DUNS/UEI Number:
Award Start Date (MM/DD/YYYY):
Report Submission Date (MM/DD/YYYY):
Award End Date (MM/DD/YYYY):
Reporting Period Start Date (MM/DD/YYYY):
Final Report Yes
Reporting Period End Date (MM/DD/YYYY):
No
GENERAL PROJECT INFORMATION
1a What key milestones have been achieved in the past six months?

1b What barriers or challenges have you encountered in the course of achieving your project milestones?

1c Please describe any issues anticipated during the next reporting period that may impact planned progress against the project milestones. In particular, please identify any areas or issues where technical assistance from NTIA may be useful

1d What notable successes have been achieved in the project, thus far?

1e Please describe significant project milestones planned for completion during the next reporting period

1f Is this project a consortium project?
ORGANIZATIONAL PARTNERS
2a Please use the following table to list your organizational partners, the type of organization, the organization's role in completion of project activities, and whether or not the partner has changed their involvement or role in the project within the past six months.
PARTNER NAME Partner Type Partner Role Change in Past Six Months?








































2b If you selected "Community Anchor Institution" or "Community-Based Organization" for any of the listed partner organizations, please specify.

2c What barriers or challenges have you encountered in the course of working with any of these project partners that may impact the goals or outcomes of the project?

REMOTE LEARNING INFRASTRUCTURE
3a What types of technology (hardware, software, online platforms) have you deployed to facilitate and improve remote learning infrastructure?
TECHNOLOGY NAME Technology Type Technology Description Total Cost








































3b What types of professional development training have you implemented to facilitate and improve remote learning infrastructure and IT management?
Professional Development Training Type Number of Participants Professional Development Training Description





















3c What percentage of classes are currently offered remotely?
3d What percentage of classes are currently offered using a hybrid model?
ANCHOR COMMUNITY ADOPTION
4a List the anchor community activities your project will carry out in the next six months, and the results of those activities.
Anchor Community Activity Census Tract Target Beneficiary Target Output for Next Six Months




























4b Please use the following table to record the requested values for indicators of community broadband adoption. The field "Other outcome not listed here:" may be edited to record an indicator of community adoption you wish to provide to NTIA that may not have been specifically requested.
Community Adoption Indicator Baseline Current
Number of participants enrolled in community-based

Number of participants who have completed community-based programs

If applicable, number of participants who have obtained jobs following completion of a community-based program

Number of anchor community members with a broadband subscription

Other outcome not listed here:

4c Did the 15-mile radius present any barriers or challenges in the delivery of services, scope of the project, project outcomes, etc.?

How were these barriers or challenges resolved to meet the project's expected goals?

BROADBAND INTERNET AND DEVICES
5a Describe the Internet Devices which will be acquired with CMC-provided funds.
Number of Devices Purchased Loaned or Donated? Device Type Total Cost Recipient



































5b If you defined any Device Types as "Other," please explain.

5c Describe the Broadband Subscriptions which will be acquired with CMC-provided funds.
Number of Subscriptions Provider Type Average Cost to Recipient Total Cost to Institution (If Applicable) Recipient Speed










































5d Describe the Broadband Deployments which will be undertaken with CMC-provided funds.
Location Location Type Network Type Deployment Cost Ongoing Cost Description










































5e What barriers or challenges have you encountered in the course of implementing project elements associated with the purchase and distribution of Internet Devices?

5f What barriers or challenges have you encountered in the course of implementing project elements associated with the purchase and distribution of broadband subscriptions?

5g What barriers or challenges have you encountered in the course of implementing project elements associated with the purchase and deployment of broadband networks?

DIGITAL SKILLS AND WORKFORCE DEVELOPMENT
6a What types of digital skills or workforce development were offered?
Type of Training Number of Participants Participants Who Completed Training Participant Type Training Objectives Training Objectives Met? College Credit Awarded?

















































6b Were participants awarded a certification upon completion of training? If so, describe the certification and the number of recipients?

6c What barriers or challenges have you encountered in the course of implementing project elements associated with digital skills training?

MEASUREMENT AND EVALUATION
7a Describe performance measurements utilized to evaluate the project’s effectiveness or the benefits delivered to project beneficiaries
Project Purpose Benefit Beneficiary How Was This Measured?




























7b Describe performance measurements utilized to evaluate the project's impact on digital equity
Project Purpose Benefit Beneficiary How Was This Measured?




























7c How did these activities align with your CMC project narrative goals?

7d Are these activities on track to meet these goals within the timeline? If not, what is the plan to meet these activities' goals within the timeline?

7e If not, what steps will be implemented to meet those goals and outcomes over the next 6 months and/or by the end of the period of performance?

7f Describe any best practices or lessons-learned obtained at this point in the period of performance of the project.


CERTIFICATION I certify to the best of knowledge and belief that this report is correct and complete for performance of activities for the purposes set forth in the award documents.
Typed or printed name and title of Authorized Certifying Official: Telephone (area code, number and extension):

Signature of Certifying Official: Email Address:

Date:

Sheet 4: Annual Report
OMB Control No. XXX-XXXX Expiration Date:
CONNECTING MINORITY COMMUNITIES PILOT PROGRAM ANNUAL REPORT
GENERAL INFORMATION
GENERAL Recipient Organization:
Award Identification Number:
Recipient Street Address
City, State, Zip Code
DUNS/UEI Number:
Project Period Start Date (MM/DD/YYYY):
Report Submission Date (MM/DD/YYYY):
Project Period End Date (MM/DD/YYYY):
Award Start Date (MM/DD/YYYY):
Award End Date (MM/DD/YYYY):
1 Please describe each service provided with grant funds (600 words or less)

2 If applicable, please list subcontractors and describe how they expended funds (600 words or less)

3 Please describe how the recipient and subrecipient (if applicable) expended the funds (600 words or less)

4 If applicable, please list each subrecipient that received a subgrant through funding (600 words or less)


CERTIFICATION I certify to the best of knowledge and belief that this report is correct and complete for performance of activities for the purposes set forth in the award documents.
Typed or printed name and title of Authorized Certifying Official: Telephone (area code, number and extension):

Signature of Certifying Official: Email Address:

Date:
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File Modified0000-00-00
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