1076-0143 Form

OMB Control # 1076-0143 Expires: XX/XX/XXXX

SELF-GOVERNANCE MINIMUM DATA COLLECTION REQUESTED BY OCTOBER 1, 20XX

Tribe/Consortium: ___________________ ___________ Reporting Period: ________________

GENERAL TRIBAL DATA INFORMATION

TRIBAL DEMOGRAPHICS & ENROLLMENT*(1)(2):

Requested Data	Tribal Response
Total Tribal enrollment
Total Tribal Resident Indian Population (TRIP)
TRIP under age 16 years old (by gender)
TRIP between 16 - 64 years old (by gender)
TRIP over 64 years old (by gender)
TRIP between 16 - 64 years old not available for work
TRIP employed in PUBLIC sector
TRIP employed in PRIVATE sector
Total TRIP employed, but below poverty level
Total # Trust/Restricted Acres

*(1) List and describe sources used.

*(2) Provide an explanation where TRIP has changed over or under 10%.

FINANCIAL INFORMATION:

Requested Data	Tribal Response
Total Self-Governance direct funding received
Total Contract Support Cost (CSC) request for BIA-funded programs
Total CSC funded under Self-Governance for BIA-funded programs
Total CSC un-funded (shortfall)

FTE=s (STAFFING):

Requested Data	Tribal Response
Total Tribal FTE=s funded under S/G BIA-funded programs (direct funding)

Budget Category	Tribal BIA/AFA Self-Governance Expenditures	Tribal Goals	Quantitative Outcome Measures (Relate to Tribal Goals)
Tribal Government			Tribal Government No Minimum Data Required
Human Services			Welfare Assistance (breakdown by General Assistance, Child Welfare & Disaster Assistance):  Total # of cases during the report year.  Total $ for these cases
			Indian Child Welfare Act  # of Indian children placed in Indian homes  # of Indian children placed in non-Indian homes  # of family reunifications  # of parental rights terminations  # of Indian children who received services from ICWA during report period  # of Indian children removed # of cases involving siblings
			Child Abuse & Neglect # of child abuse/neglect cases (include all referrals)  # of cases involving alcohol & substance abuse
Education			Johnson O’Malley  Total # of Students Define range by grade  # students in remedial education/tutoring
			Scholarships/Higher Ed.  # of graduates  # of students served + associated $ (total cost)
			AVT/Adult Education # of adults receiving GED or High School Diploma  Total # of Adults receiving training # of job placements resulting from training
Public Safety and Justice			Tribal Courts  # of active cases during report year  # of appeals (include Tribal and federal appeals)
			Law Enforcement Total # of Part I Actual Offenses:  Homicide  Forcible Rape  Robbery  Aggravated Assault  Burglary  Larceny - Theft  Motor Vehicle Theft  Arson Total # of Offenses (other than Part I):  Assaults (no weapons)  Forgery/Counterfeiting  Embezzlement  Stolen property  Vandalism  Weapons (carrying, possessing, etc.) Prostitution Sex Offenses  Drug Abuse Violations (sell, manufacture, possess)  Gambling DWI Liquor Laws Drunkenness  Drug Abuse Violations (sell, manufacture, possess)  Gambling
			Law Enforcement (cont.) Disorderly Conduct ARPA Violations All other offenses Curfews & loitering (persons under 18)  Runaways (under 18) Thefts Other: # of Domestic Violence Incidents
			Community Fire Protection No minimum data required (Tribal specific information only)
Community Development			HIP  # of eligible applicants served.  # of new home construction  # of repaired homes
			Economic Development Loans (Credit and Finance) No minimum data required. (Tribal specific information only.)
			Roads  # of miles of Indian Roads  $ expended for new construction of roads  $ expended for maintenance/repair of roads
Resource Management			Forestry  Total # of Forest acres  Reforestation Planted Acres Need Acres  Stand Improvement Thinned Acres Need Acres  Timber Volume Offered Sold  Timber Harvested Volume Value $ (Note: This information is also collected on the Position and Funding Analysis Report (PFAR). Therefore, it is a tribal option to also report here. Tribes are asked to also send a copy of the (PFAR) report to the OSG). # of timber sales permits $ amount of timber sales (Tribal option to report sales)
			Fisheries No minimum data required. (Tribal specific information only.)
			Water Resources/Rights No minimum data required. (Tribal specific information only.)
			Irrigation # of acres irrigated # of individual water users operation and maintenance cost per acre
Trust Services			Realty/Appraisals  # of Appraisals (during Report Year) Submitted Approved Pending Approval  # of Acquisitions Approved (acres) Pending (acres)  # of acres disposed (taken out of trust) # of requests for probate  # of leases Approved Pending  # of Rights of Way Approved Pending # of Environmental assessments (EA), Environmental Impact Statements (EIS) Finding Of No Significant Impact (Fonsi) Approved Pending
			Cadastral Survey # of miles surveyed and monuments sets
			Agriculture Minerals & Grazing:  # of surface leases Approved Pending # of mineral leases/permits (specify transaction & specify resource) Approved Pending  # of Rights of Way Approved Pending  # of all other Transactions (ie, oil & gas, specify transaction & specify resource) Approved Pending # of grazing permits Approved Pending # of farming acres # of grazing units # and kinds of livestock
			Other: Using the Approved and Pending Format, report on any of the following which are relevant to your tribe: Individual requests for mortgages Tribal requests for mortgages Individual and tribal requests for exchange applications; Gift and conveyance applications; Negotiated sales applications; Supervised sales applications Involuntary conveyances; Petitions for partition Applications for fee patents, certificates of competency, and removals of restrictions
.			Unresolved Rights Protection # of cases resolved
			Land, Titles & Records No minimum data identified at this time.
General Administration			Tribal Annual Audits
Economic Development			Economic Development No minimum data required. (Tribal specific)
Other Tribal Initiatives: Examples include Inland hunting/fishing Cultural programs			Other Tribal Initiatives: Include other data elements the Tribe wishes to report regarding:  Redesigned programs  New programs  Non-BIA programs within the DOI i.e., OST, BLM, NPS, etc. (Include programs operated, funding amount and funding agency.)

Paperwork Reduction Act Statement

This information is collected to meet the reporting requirements of the Tribal Self-Governance Act. The information is supplied by a respondent to retain a benefit, that is, participation in the Self-Governance program. It is estimated that this form will take an average of 64 hours to complete. This includes the amount of time it takes to gather the information and fill out the form. 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. Comments concerning clarity, utility or information or burden reduction may be sent to Attn: Information Collection Clearance Officer – Indian Affairs, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104. Please note: comments, names, and addresses of commentators are available for public review during regular business hours. If you wish to withhold this information you must state this prominently at the beginning of your comment. We will honor your request to the extent allowable by law.