Form 1 ECSH Program Data Indicators

Ethnic Commnity Self-Help (ECSH) Program Data Indicators					OMB Control Number: 0970-0490 Expiration Date: 1/31/2023
1. Recipient Name:
2. Grant Number:
3. Reporting Period End Date:
DIRECT SERVICES
Program Activities	First Reporting Period	Second Reporting Period
4. Number of New Enrollments
5. Number of Clients Served
6. Number of Clients Served According to Gender
6a. Women
6b. Men
6c. Other/Unspecified
7. Number of Clients Served According to Status
7a. Refugee
7b. Asylee
7c. Cuban/Haitian Entrants
7d. Special Immigrants Visa Holders
7e. Afghan Humanitarian Parolees
7f. Amerasians
7g. Victims of Human Trafficking
7h. Ukraine Humanitarian Parolees
8. Types of Services Provided	First Reporting Period	Second Reporting Period
8a. Navigation Services
8b. Cultural/community orientation
8c. Health-related services
8d. Home management services
8e. Transportation
8f. Translation and interpretation services
8g. Case management services
8h. English language training
8i. Employability services
8j. Academic enrichment/college preparation
8k. Emotional wellness services
8l. Referral services
8m. Citizenship preparation/civic engagement
8n. Other (list):
ORGANIZATIONAL DEVELOPMENT
Program Activities	First Reporting Period	Second Reporting Period
9. Number of New Partnerships Developed
10. Type of New Partnerships Developed
10a. Educational organization
10b. Local/state government entity
10c. Medical service provider
10d. Legal service provider
10e. Faith-based group
10f. Other (list)
11. Types of Training Provided to Staff	First Reporting Period	Second Reporting Period
11a. Case management
11b. Case documentation
11c. Interpretation
11d. Cultural sensitivity and awareness
11e. Self-care
11f. Cultural orientation provision
11g. Public benefits
11h. Health services and systems
11i. Non-profit management
11j. Other (list)
CIVIC ENGAGEMENT
12. Types of Community Engagement Activities Conducted (list)	First Reporting Period		Second Reporting Period
LOGIC MODEL OUTPUTS & OUTCOMES
13. Logic Model Outputs Progress	Semi-Annual Results
	First Reporting Period		Second Reporting Period
Please list all planned Outputs from the Logic Model in the following spaces. Add more spaces as necessary.	Identify progress towards each Output for Months 1-6		Identify progress towards each Output for Months 7-12.
14. Logic Model Outcomes Progress	Semi-Annual Results
	First Reporting Period		Second Reporting Period
Please list all planned Outcomes from the Logic Model in the following spaces. Add more spaces as necessary.	Identify progress towards each Outcomes for Months 1-6		Identify progress towards each Outcomes for Months 7-12.
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, the Office of Refugee Resettlement (ORR) is gathering data on your grant program to understand the design and effectiveness of the program and to inform technical assistance needs. Public reporting burden for this collection of information is estimated to average 2 hours per recipient, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required to retain a benefit (Pub. L. 105-285, section 680(b) as amended). 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. The OMB# is 0970-0490 and the expiration date is 01/31/2023. If you have any comments on this collection of information, please contact Zahra Cheema, ACF/ORR, by email at [email protected].