FS-1500-23 Cooperator Performance Report (Optional Template)

FS-1500-23 (VER. XX/XX) OMB No. 0596-0217

Optional Project Performance Report*
1. Recipient/Cooperator Name:
2. Agreement Number:		3. Project Title:
4. Reporting Period End Date:		5. Report Type:	Interim		Final

For each program/project in the agreement narrative, please provide brief information on the following:

6. Status Summary:

6. What has been accomplished to date? Please provide a comparison of actual accomplishments to the objectives established in the agreement narrative (quantify where possible):

6. Any problems encountered? Explain delays or changed costs or conditions that significantly impair the ability to meet agreement objectives and timelines. If necessary, please work with the F.S. program manager for an extension of the agreement period.

6. Any changes that you plan to propose? Please work with F.S. program manager to determine if a modification is needed (e.g., a change is needed to the objectives or financial plan).

6. Briefly describe work to be performed during the next reporting period.

6. Any other comments considered of importance but not discussed above?

6. Signatures of Authorized Representative: by signature below, the signing parties certify that they are the official representatives of their respective parties and authorized to act in their respective areas for matters related to the above-referenced grant/agreement.

Submitted: Cooperator Program Mgr	Signature:		Date:
	Name/Title:		Phone:

*Note to Cooperator Project Lead: This optional form helps respond to the performance reporting required by the agreement.

Reviewed: FS Program Mgr	Signature:		Date:
	Name/Title:		Phone:

*Note to F. S. Program Manager: Please document this and any other monitoring activity in NRM or send to G&A Personnel.

Burden Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct, or sponsor and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0217 Response to this collection of information is Optional (Title VIII of IIJA). The time required to complete this information collection is estimated to average 2 hours per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s Target Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, DC 20250-9410, or call toll free at (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.

The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 522) govern the confidentiality to be provided for information received by the Forest Service

INSTRUCTIONS FOR FORM FS-1500-23

1. Enter the recipient’s or cooperator’s name.

2. Enter the orginal U.S. Forest Service agreement number.

3. Enter the project’s title.

4. Enter the type of report.

6-8. Provide information related to each program/project in the agreement narrative.

11. Self explanatory.

Revised 11-25-13