Statistical Report and Instructions

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Overview

PL477 Stat Form (DOI)
PL477 Stat Instructions (DOI)

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Sheet 1: PL477 Stat Form (DOI)

OMB 1076-0135
Expiration Date: XX/XX/XXXX
PL 477  Statistical Report
Tribal Nation Name:				Original
Report Period: (From/To)				Revision
	Current Participants			Participants Terminated
	Adults	Youth		Adults	Youth
I. Total Participants
II. Participant Characteristics
A. Education Level
1. Nongraduate
2. Current Student Pre-K-12
3. High School Diploma/High School Equivalency
4. Postsecondary - no degree
5. Postsecondary Degree/Certificate
B. Veterans
C. Participants with a Disability
D. Participants with Justice Involvement
III. Participant Activities/Services
A. Employment
1. Entered Unsubsidized Employment
2. In Unsubsidized Employment 2nd Quarter After Exit
3. Average Earnings Gain
4. Other Employment Outcomes
5. Employment Objective Not Achieved
B. Education/Training
1. Degree/Certificate Attained
2. Other Education Outcomes
3. Education Objective Not Achieved
C. Related Services (Supportive)
1. Cash Assistance		Individuals
2. General Assistance		Individuals
3. Child Assistance		Individuals
4. Adult Care Assistance		Individuals
5. Burial Assistance		Individuals
6. Emergency Assistance		Individuals
7. Cash Assistance for Families	Average Monthly Numbers
7a. Families with one or two parents receiving cash assistance from the Tribe where the parents are participating in a work activity approved in the PL477 plan for at least the minimum number of hours approved in the PL477 plan.		Families
7b. Families with one or two parents receiving cash assistance (not including disregarded cases).		Families
7c. Adult and child recipients.		Individual, both Adult and Children
7d. Families receiving cash assistance.
7d(i).One-parent families		Families
7d(ii).Two-parent families		Families
7d(iii). No-parent families/ “child-only” cases		Families
7e. Families by number of child recipients
7e(i). One child		Families
7e(ii). Two children		Families
7e(iii). Three children		Families
7e(iv). Four or more children		Families
7f. Child recipients by age
7f(i). Age 0-1		Children
7f(ii). Age 2-5		Children
7f(iii). Age 6-11		Children
7f(iv). Age 12-15		Children
7f(iv). Age 16-19		Children
7g. Cash assistance amount		Dollar Amount
7h. Work Participation Status (average monthly number of adults)
7h(i). Work Requirement Met		Families
7h(ii). Work Requirement Not Met		Families
7h(iii). Deemed Hours		Families
7h(iv). Exempt, Other		Families
7h(v). Exempt, Disabled		Families
7h(vi). Exempt, Tribal TANF Plan Reason		Families
7h(vii). Disregarded, Other Reason		Families
7h(viii). Disregarded, Child under 1		Families
7i. Adults in work activities (average monthly)		Families
8. Utility Assistance
8a. Heating		Households			Households
8b. Cooling		Households			Households
8c. Crisis		Households			Households
8d. Weatherization		Households			Households
9. Services to Victims of Crimes
9a. Victims of domestic violence, sexual assault, dating violence, stalking, or sex trafficking served.
9b. Victims of domestic violence, sexual assault, dating violence, stalking, or sex trafficking who could not be served
9c. Victims of other crimes served.
10. Cultural and Language Activities
11. Nutrition Services
12. Child Care and Development Activities	Children
12a. Children Receiving Child Care
12a(i). Birth to Five
12a(ii). School Age
12b. Care Received – Type of Provider
12b(i). Center-Based
12b(ii). Family Child Care Home
12b(iii). In-Home (Child’s Home)
IV. Jobs Creation/Economic Development
A. Jobs Created
B. AI/AN Employed
C. Businesses Assisted
[Threaded comment] Your version of Excel allows you to read this threaded comment; however, any edits to it will get removed if the file is opened in a newer version of Excel. Learn more: https://go.microsoft.com/fwlink/?linkid=870924 Comment: Do we want this reported on a separate page to reflect PII Reply: Doedu. Do we want this reported on a separate page to reflect PII Reply: HHS Comments Lisa Zingman The name of the person preparing PII is not generally considered protected PII that cannot be shared with other Federal agencies. It is also subject to FOIA. In our opinion there are no privacy concerns here V. Report Prepared By
Print Name:	Sign:
Phone Number:	Date:
Privacy Act Statement
Paperwork Reduction Act Statement

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Sheet 2: PL477 Stat Instructions (DOI)

OMB 1076-0135
Expiration Date XX/XX/XXXX
Public Law 102-477 Program Statistical Report	Line description (comprehensive for plan)	Statutory Citation
[Threaded comment] Your version of Excel allows you to read this threaded comment; however, any edits to it will get removed if the file is opened in a newer version of Excel. Learn more: https://go.microsoft.com/fwlink/?linkid=870924 Comment: Cross check language on narrative report regarding statistical report instructions Instructions	Purpose: The attached Program Statistical Report is one of three parts of the statutorily integrated annual report for Public Law 102-477, as amended (PL477). The report provides statistical summary data of participants receiving any of the services available under the initiative. The data includes current participants and those terminated from the program identifying outcomes, characteristics, activities, goals and objectives. At the time of enrollment, participants are categorized as adult (age 24 and above), youth (age 23 and under). The report collects summary data sufficient to demonstrate compliance with all non-waived federal requirements identified in the PL477 Plan. If a Tribe is not required by the terms of its PL477 Plan to report on any data point listed in the Program Statistical Report, it should write “N/A” in the response field. Finally, the report provides economic development data including number of jobs created and businesses assisted. Responses to the report will be provided in a uniform format. Statistics listed are reported by program services and activities, in accordance with the PL477 plan, not by fund source.	25 U.S.C. § 3410(b)(2)
Indentification Section:	Provide the name of the Tribe or Tribe organization along with the report period (To/From). Annual reports are required, unless a formal written request has been requested and approved in advance. Indicate if this report in an original submission or a revision.	25 U.S.C. § 3410(b)(2)
I. Total Participants:	Report the total number of Adults and Youth Participants Served and Terminated
II. Participant Characteristics	greyed out
A.Education Level	greyed out
1. Nongraduate:	At the time of enrollment into the program, report participants who had not attained a high school diploma or or General Education Diploma (GED) / High School Equivalency Diploma (HiSET) and were not attending school.	ANEP: Section 6304 of the Elementary and Secondary Education Act, (20 U.S.C. 7544 (a)(2)(B)) – Mandatory Activities; ANEP: Section 6303 of the ESEA (20 U.S.C. 7543); performance measures published under 34 CFR 75.110 for the ANEP program
2. Current Student Pre-K-12	At the time of enrollment into the program, report participants who were enrolled in any level of pre-K to grade 12 education. [Note - post-secondary students are counted in B(5).]	ANEP: Section 6304 of the Elementary and Secondary Education Act, (20 U.S.C. 7544 (a)(2)(B)) – Mandatory Activities; ANEP: Section 6303 of the ESEA (20 U.S.C. 7543); performance measures published under 34 CFR 75.110 for the ANEP program
3. High School Diploma/High School Equivalancy	At the time of enrollment into the program, report participants whose highest level of educational attainment a high school diploma.
4. Postsecondary Education - no degree	At the time of enrollment into the program, report participants whose highest level of educational attainment in the program was greater than a high school diploma or GED /HiSET.
5. Postsecondary Degree / Certificate	At the time of enrollment into the program, report participants who have attained a postscondary degree or certificate. Options may include, but are not limited to, two-year college, four-year college or university, independant private career schools, the military, or apprenticeships, or (on-the-job training (OJT).
B. Veterans	At the time of enrollment into the program, report participants that have served in the military and are considered veterans.
C.Participants with a Disability	At the time of enrollment into the program, report participants who have self-reported as having a physical or mental impairment that substantially limits one or more major life activities.	Section 13 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 710(b)) – Reports; Section 121(a) of the Rehabilitation Act, as amended (29 U.S.C. 741(a)); performance measures published under 34 CFR 75.110 for the AIVRS program
D. Participants with Justice Involvement	At the time of enrollment into the program, report participants with justice system involvement; impacted by the justice system; or affected by the justice system.	DOJ citation for OVW is 34 U.S.C. 20110(g), which requires the OVC Director to report "on the effectiveness of the activiities supported under [VOCA, which appropriateds the funding allocated by the CJS Act to TVSSA]."
III. Participation Activities/Services	greyed out
A. Employment	Total with Employment Objective: Count all terminees who included an employment objective in their individualized service plan when they were participants.
1. Entered Unsubsidized Employment	Entered Unsubsidized Employment: Include the number of terminees who have entered employment and do not receive a subsidy. Include self-employment in this count.	25 U.S.C. 3410(b)(2)(A)
2. Continued In Unsubsidized Employment 2nd Quarter After Exit	For those terminees who have entered unsubsidized employment, include the number who have continued in unsubsidized employment during the 2nd quarter after exiting the program.	25 U.S.C. 3410(b)(2)(A)
3. Average Adult Earnings Gain	For those adult terminees who have entered unsubsidized employment, calculate the hourly wage at the last job held within the measurement period prior to PL477 enrollment and compare that rate with the hourly wage earned at time of termination from this program. Terminees unemployed for the entire six months prior to entering the program should be considered to have $0 per hour rate at entry. To illustrate, if at termination, such a person entered unsubsidized employment earning $6.50 per hour, the gain would be $6.50 per hour. Add all gains and subtract any losses. Divide this number by the number of adult terminees who entered unsubsidized employment. The result will be the average gain.
4. Other Employment Outcomes	Other Employment Outcomes: Include the number of terminees who met an employment objective other than entered unsubsidized employment. This includes participants who have been successfully assisted in retaining an existing job with supportive services or successfully completed an (OJT) assignment but were not retained in employment.
5. Employment Objective Not Acheived	Include the number of terminees who had an employment objective but did not meet any of their employment goals.
B. Education / Training	Count all terminees who included an education/training objective in their individualized service plan when they were participants. Include terminees gaining knowledge such as completing a semester or more of classes, or long or short-term classroom training.
1. Degree / Certificate Attained	Include the number of participants who attained a degree or certificate. Examples of programs resulting in degrees and certificates are provided in the instructions for II.B(5).	Section 114(a) of the Strengthening Career and Technical Education for the 21st Century Act (“Perkins V”) (20 U.S.C. 2324(a)(1)) – Program Performance Information; Section 116(b) (1), (c)(1) of Perkins V (20 U.S.C. 2326(b)(1), (c)(1)); performance measures published under 34 CFR 75.110 for the NACTEP program
2. Other Education Outcomes	Report the number of terminees who met an educational goal other than attainment of a certificate or degree.
3. Education Objective Not Acheived	Report the number of terminees who had educational goals but did not meet any of them.
C. Related Services (Supportive)	Count all terminees who included a related (supportive) service objective in their individualized service plan when they were participants.
1. Cash Assistance	Cash Assistance: “Cash assistance” means any financial assistance provided to individuals or families in accordance with the terms of the PL477 Plan. Count the total individuals receiving cash assistance at any time during enrollment in a PL477 service, or within 6 months prior to enrollment, should be included in this section. For example, if a participant receives cash assistance at the time of enrollment, entered unsubsidized employment and continues with supportive services for 90 days, the individual should be counted as a cash assistance recipient here because cash assistance was received during enrollment, and also counted in the employment and supportive services sections.	Items A, B, H, I: Required under 42 U.S.C. 611(b)(1)(A) and 42 U.S.C. 612(c) as part of reporting on the work participation rate.
2. General Assistance	Count the total number of individuals receiving general assistance.
3. Child Assistance	Count the total number individual youth receiving child assistance.
4. Adult Care Assistance	Count the total number of individual adults receiving adult care assistance.
5. Burial Assistance	Count the total number of individuals receiving burial assistance. Burial assistance means a financial assistance payment made on behalf of an indigent American Indian/Alaska Native person who meets the eligibility criteria to provide minimum burial expenses according to Bureau of Indian Affairs payment standards established by the Assistant Secretary – Indian Affairs.
6. Emergency Assistance	Count the total number of individuals receiving emergency assistance.
7. Cash Assistance for Families	Cash Assistance for Families: "Cash Assistance for Families" means any financial assistance provided to families in accordance with the terms of the PL477 Plan. Families (as defined in the PL477 Plan) receiving cash assistance at any time during enrollment in a PL477 project, or within the measurement period prior to enrollment, should be included in this section. For example, if a participant's family receives cash assistance at the time of enrollment, is placed in a job, and continues with supportive services for 90 days, the individual's family should be counted as a cash assistance recipient because cash assistance was received during enrollment. Only complete this section of the report if you (1) have agreed in your PL477 Plan to be bound by the reporting requirements at 42 U.S.C. §§ 611(b)(1)(A), 611(b)(2), and 612(c); and (2) you have elected in your plan to provide the required data annually by completing this section. Tribes that are subject to the reporting requirements at 42 U.S.C. §§ 611(b)(1)(A), 611(b)(2), and 612(c) may elect in their plan to submit individual-level data directly to the TANF Data Portal (https://tanfdata.acf.hhs.gov/). For the purpose of this section, a child is an individual who has not attained 18 years of age, or is 18 or 19 years of age and is a full time student in secondary school.	Only complete this section of the report if you (1) have agreed in your PL477 Plan to be bound by the reporting requirements at 42 U.S.C. §§ 611(b)(1)(A), 611(b)(2), and 612(c); and (2) you have elected in your plan to provide the required data annually by completing this section. Tribes that are subject to the reporting requirements at 42 U.S.C. §§ 611(b)(1)(A), 611(b)(2), and 612(c) may elect in their plan to submit individual-level data directly to the TANF Data Portal (https://tanfdata.acf.hhs.gov/).
7a. Families with one or two parents receiving cash assistance from the Tribe where the parents are participating in a work activity approved in the PL477 plan for at least the minimum number of hours approved in the PL477 plan.	The average monthly number of families with one or two parents receiving hold receiving cash assistance from the Tribe who where the parents are participating in a work activity approved in the PL477 Plan for at least the minimum number of hours approved in the PL477 Plan.	Items A, B, H, I: Required under 42 U.S.C. 611(b)(1)(A) and 42 U.S.C. 612(c) as part of reporting on the work participation rate.
7b. Families with an adult or minor head-of-household receiving cash assistance (not including disregarded cases).	The average monthly number of families with one or two parents receiving cash assistance (not including disregarded cases).	Items A, B, H, I: Required under 42 U.S.C. 611(b)(1)(A) and 42 U.S.C. 612(c) as part of reporting on the work participation rate.
7c. Adult and child receipients.	This section covers the average monthly number of families receiving cash assistance (by number of parents).	Items C-G: Required under 42 U.S.C. 611(b)(2) as part of reporting to Congress on the demographic and financial characteristics of families receiving assistance.
7d. Families receiving cash assistance.	Enter the average monthly number of one-parent families receiving family cash assistance.	Items C-G: Required under 42 U.S.C. 611(b)(2) as part of reporting to Congress on the demographic and financial characteristics of families receiving assistance.
7d(i).One-parent families	Enter the average monthly number of one-parent families receiving family cash assistance.
7d(ii).Two-parent families	Enter the average monthly number of two-parent familes receivng family cash assistance.
7d(iii). No-parent families/ “child-only” cases	Enter the average monthly number of families in which only the child receives family cash assistance.
7e. Families by number of child recipients	This section covers the average monthly number of families by number of child recipients.	Items C-G: Required under 42 U.S.C. 611(b)(2) as part of reporting to Congress on the demographic and financial characteristics of families receiving assistance.
7e(i).One child	Enter the average monthly number of families in which one child receives cash assistance.
7e(ii).Two children	Enter the average monthly number of families in which two children receive cash assistance
7e(iii).Three children	Enter the average monthly number of families in which three children receive cash assistance
7e(iv). Four or more children	Enter the average monthly number of families in which four or more children receive cash assistance.
7f. Child recipients by age	This section covers the average monthly number of child recipients by age.	Items C-G: Required under 42 U.S.C. 611(b)(2) as part of reporting to Congress on the demographic and financial characteristics of families receiving assistance.
7f(i). Age 0-1	Enter the average monthly number of children between ages 0-1 receiving family cash assistance.
7f(ii). Age 2-5	Enter the average monthly number of children between ages 2-5 receiving family cash assistance.
7f(iii). Age 6-11	Enter the average monthly number of childrne between ages 6-11 receiving family cash assistance
7f(iv). Age 12-15	Enter the average monthly number of children between ages 12-15 receiving family cash assistance
7f(v). Age 16-19	Enter the average monthly number of children between ages 16-19 receiving family cash assistance
7g. Cash assistance amount	Enter the average monthly dollar amount of cash assistance that the family received or that was paid on behalf of the family. See item #20 starting on page 7 of the Tribal TANF Data Coding Instructions for a full definition of “assistance”, available at https://www.acf.hhs.gov/ofa/policy-guidance/tribal-tanf-data-coding-instructions.	Items C-G: Required under 42 U.S.C. 611(b)(2) as part of reporting to Congress on the demographic and financial characteristics of families receiving assistance.
7h. Work Participation Status (average monthly number of adults)	See item #48 starting on page 21 of the Tribal TANF Data Coding Instructions to complete these data elements 1-8 below, available at https://www.acf.hhs.gov/ofa/policy-guidance/tribal-tanf-data-coding-instructions.	Items A, B, H, I: Required under 42 U.S.C. 611(b)(1)(A) and 42 U.S.C. 612(c) as part of reporting on the work participation rate.
7h(i).Work Requirement Met	Enter the average monthly number of families required to participate in work activitiies and meeting minimum participation requirements.
7h(ii). Work Requirement Not Met	Enter the average monthly number of families required to participate in work activities but not meeting minimum participation requirements.
7h(iii). Deemed Hours	Enter the average monthly number of families deemed engaged in work.
7h(iv). Exempt, Other	Enter the average monthly number of families exempt for a reason other than a disabled parent or a reason specified in the PL477 plan. "Exempt" means that the individual will not be penalized for failure to engage in a work activitiey, however, the family receiving cash assistance is included in the calculation of the work participation rate.
7h(v). Exempt, Disabled	Enter the average monthly number of families exempt because of a disabled parent.
7h(vi). Exempt, Tribal TANF Plan Reason	Enter the average monthly number of families exempt for reasons specified in the negotiated PL477 plan.
7h(vii). Disregarded, Other Reason	Enter the average monthly number of families disregarded for a reason other than having a child under 12 months. "Disregarded" from the participation rate means the family is not included in the participation rate.
7h(viii). Disregarded, Child under 1	Enter the average monthly number of families disregarded with a child under 12 months.
7i. Adults in work participation activities (average monthly)	Enter the average monthly number of adults in work participation activities. See item #48 starting on page 23 of the Tribal TANF Data Coding Instructions for work participation activities , available at https://www.acf.hhs.gov/ofa/policy-guidance/tribal-tanf-data-coding-instructions.	Item I: Required under 42 U.S.C. 611(b)(4) as part of reporting to Congress on trends in employment.
8. Utility Assistance	Count the total number of households receiving utility assistance.
8a. Heating	Count the total number of households receiving heating assistance: assistance with home heating bills, preventing energy shutoffs, reconnecting services, and repairing or replacing heating equipment.	42 U.S.C. 8629 Section 2610, 42 U.S.C. 8629(b
8b. Cooling	Count the total number of households receiving cooling assistance: assistance with home cooling bills, preventing energy shutoffs, reconnecting services, and repairing or replacing cooling equipment.	42 U.S.C. 8629 Section 2610, 42 U.S.C. 8629(b
8c. Crisis	Count the total number of households receiving services in response to a crisis, as determined by the Tribe.	42 U.S.C. 8629 Section 2610, 42 U.S.C. 8629(b
8d. Weatherization	Count the total number of households receiving weatherization or energy efficiency improvements.
9. Services to Victims of Crimes	Count all participants and terminees who received services due to being a victim of crime.	FVPSA  42 U.S.C. 10406(d) as made applicable to tribes to 42 U.S.C.10409(c). 42 U.S.C. 10401, 10404(a)(4) & (c), 10407(b)(4), 10408(b), and 10409(c) & (e).
9a. Victims of domestic violence, sexual assault, dating violence, stalking, or sex trafficking served.	Count the number of persons provided services under the PL477 Plan due to being a victim of domestic violence, sexual assault, dating violence, stalking, or sex trafficking.
9b. Victims of domestic violence, sexual assault, dating violence, stalking, or sex trafficking who could not be served	Count the number of persons who sought services under the PL477 Plan due to being a victim of domestic violence, sexual assault, dating violence, stalking, or sex trafficking but could not be served.
9c. Victims of other crimes served.	Count the number of persons provided services under the PL477 Plan due to being a victim of a crime other than domestic violence, sexual assault, dating violence, stalking, or sex trafficking.
10. Cultural and Language Activities	Count the total number of adults or youth receiving cultural or language services or participating in cultural or language activities.
11. Nutritional Services	Count the total number of adults or youth receiving nutritional services.
12. Child Care and Development Activities - Children	Count of total number of such children served. The two age categories will add up to the total number of children shown receiving child care. These child care services include any such services provided through the program, regardless of whether the program's PL477 budget includes funds from formal child care programs, such as the Child Care and Development Fund program.
12a. Children Receiving Child Care	Greyed out
12a(i). Birth to Five	Count the unduplicated total number of children birth to age five.
12a(ii). School Age	Count the unduplicated total number of children age five to thirteen, as well as any qualifying children (physically and/or mentally incapable of self-care, or under court supervision) over the age of thirteen up to and including age nineteen.
12b. Care Received - Type of Provider	Count children using each type of provider. A child may be counted in more than one provider line (Lines 1 – 3) if the child receives care from more than one provider type for different portions of the typical day, week, or month.
12b (i). Center Based	Count the children being provided group care in a facility outside of the child’s or provider’s home.
12b(ii). Family Child Care Home	Count the children being provided care in a private residence other than the child’s residence.
12b(iii). In-Home (Child's Home)	Count the children being provided care in the child’s home.
IV. Jobs Creation/Economic Development	greyed out
A. Jobs Created	Count the number of new jobs (not participants) which were created as a result of your PL477 program. Only count those jobs that did not exist before the PL477 program helped create them. The count includes jobs created at a new or expanding business that received on the job training support.
B. American Indians/Alaska Natives Employed	Count the number of additional American Indians/Alaska Natives who were employed as a result of the jobs created (and reported in the previous line item).
C. Businesses Assisted	Provide the number of businesses that the PL477 program assisted. This may include businesses assisted through supportive services such as counseling services for existing employees, training for employees of businesses, on-the-job placements, recruitment and advertisement of positions, and related support. Count all businesses assisted. Do not limit the count to tribal businesses or individual tribal members’ businesses.
V. Report Prepared By
Print Name:	Sign:
Phone Number:	Date:
Paperwork Reduction Act Statement: The information being collected meets the requirements of PL477 and is composed of a single report consisting of an annual narrative, statistical, and financial report. A response is required to obtain and retain benefits of the program. The report is used to monitor the progress of the grantees in delivering services, to identify unmet needs, to identify any other problems, and to provide information to justify budget submissions by the twelve Federal agencies involved. The report is shared with all participating Federal agencies providing funds to a Tribe through an approved 477 Plan. Only Tribes who have an approved 477 Plan are required to submit the annual report. The reporting system takes about 14.5 hours to complete. Some Tribes have automated the data collection and thus may require less time. In compliance with the Paperwork Reduction Act of 1995, as amended, this collection has been reviewed by the Office of Management and Budget and assigned a number and expiration date. The OMB control number for this collection is 1076-0135 with an expiration date of XX/XX/XXXX. The number and expiration date are also displayed on top of this page. Please note that an agency may not conduct or sponsor, and you are not required to respond to, any information collection that does not display a currently valid OMB Control Number. Comments concerning this information collection, including suggestions for reducing the burden, can be sent to: Information Collection Clearance Officer, Office of Regulatory Affairs – 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 us to withhold this information, you must state that prominently at the beginning of your comment. We will honor your request to the extent allowable by law.
Privacy Act Statement: The information being collected for the Act’s single reporting system is covered by INTERIOR/BIA-8 (76 FR 56787) and INTERIOR/BIA-23 (55 FR 34087). The single reporting system contains information used to monitor the progress of the grantees in delivering services to Tribal members, to identify unmet needs, to identify any other problems, and to provide information to justify budget submissions by the twelve Federal agencies involved.