2024 Version – Semi-Annual Quantitative Report MANDATORY

---

Overview

PRA Statement
Instructions
Services and Referrals
Housing Community
Partners
Characteristics

---

Sheet 1: PRA Statement

PAPERWORK REDUCTION ACT OF 1995 (Public Law 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF 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 3 hours per grant recipient, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. 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 0970-0628 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact [email protected].

---

Sheet 2: Instructions

Instructions for Completing the Mandatory Form of the Semi-Annual Report

Services and Referrals Tab

Use this form to report the number of individuals* eligible for any AHSSD services who have received wraparound supportive services since the start of the project period.

• Use column B to report the number of individuals receiving services directly funded by AHSSD either through a direct count for services funded only with AHSSD funds or based on a proportional analysis for services supplemented with AHSSD funds.

• Use column C to report the number of individuals receiving a service that is directly funded by your organization through AHSSD funds or other funding your organization receives.

• Use column D to report the number of individuals who were referred by your organization to a service provided by an external organization.

• Use column E to report the number of individuals for whom your organization tracked access to that service type.

• Use column F to report the number of individuals for whom your organization has confirmed access to that service type.

• Use column G to report the number of individuals who have received the service from your organization or have accessed the service from an external organization (i.e., the number of unduplicated individuals represented in columns C and G).

For example, if an individual attends an afterschool program provided through AHSSD funds in your community and also attends a before-school program that you referred them to, then that person would be included in the row for "Before and afterschool activities" in multiple columns. The individual would be included in column B because they participated in an AHSSD-funded activity; in column C because AHSSD-funded activities should also be included in your organization's total; in column D because you referred them to an external service of this type; in column E because you tracked their access to this type of service; and column F because your organization confirmed the individual accessed that type of service from an external provider. They would also be counted once (as an unduplicated individual) in column G for accessing this type of service from your organization or from another organization based on a referral your organization made.

*Note, when services address the needs of the entire household, please include all household members affected in columns B, C, D, E, and F. Examples of services that might impact multiple household members include family coaching, coordination for some types of benefits, housing services, and lactation services for mothers and nursing babies.

Housing Community Tab 

Use this form to report the number of individuals eligible for AHSSD services who have received wraparound supportive services since the start of the project period. For example, if you are serving a residential community with 100 affordable units (“affordable” defined as occupant paying no more than 30 percent of gross monthly income for housing costs, including utilities), then please fill out the section for all 100 units. If only 75 of the units are affordable, then only include the information about those 75 units. If all 100 are affordable but you are limiting access to services to only half of those units, then complete the section about the 50 units who are eligible to receive services from you.

Partners Tab

Use this form to report information about partnerships supporting services to residents in AHSSD communities. For the first reporting period, please list all partners that will support the grant activities and list if the partnership is new or pre-existing. For subsequent reports, please list only new partnerships that will support the grant activities. For the purposes of this grant, please provide a full list of organizations that you work with, regardless of whether or not you have a formal partnership agreement in place. In addition, if you are part of an organization with many parts, you can list those other branches as partners. For example, if you are part of a tribal government, you may list the tribal health department as a partner. Similarly, if your organization also has a Head Start program that you are referring families to, you can include the Head Start program as a partner.

Characteristics Tab

Use the characteristics tab to report the characteristics of the individuals who received services as reported in the services and referrals tab. This tab should not include information about individuals who reside in eligible households that have not received services.

This tab requests individual-level characteristics in two columns:

• Column D (“Number of Individuals”): requests counts of individuals who have received any services (both intensive and light-touch). For services targeted at the household level (e.g., family coaching, housing assistance, family benefit coordination), include all individuals in the household that received that service.

• Column F (“Number Receiving Intensive Services”): requests counts of only individuals who have received intensive services, which are defined as individualized, ongoing services to address the distinct needs of a person or family. For services that comprehensively address the needs of the household, include all individuals in the household that benefited from intensive services.

In other words, you will include individuals who received intensive services in both columns D and F, but you will only include individuals who received lighter touch services in column D. “Intensive Services” are defined as individualized, ongoing services to address the distinct needs of an individual or family, e.g., case management, service coordination, coaching).

The household-level characteristics columns requests household-level characteristics of the individuals who received services in the same format. Please note, households should only be counted one time. If multiple individuals in the household receive services, please count the household only once.

• Column N (“Number of Households”): requests counts of unduplicated households with at least one individual who received any service.

• Column Q (“Number Receiving Intensive Services”): requests counts of unduplicated households with at least one individual who received intensive services.

---

Sheet 3: Services and Referrals

Grant recipient name:
Grant Number:
Reporting period end date:
Employment and training services
Service Type	# unduplicated residents receiving service directly funded by AHSSD	# of unduplicated residents receiving service provided directly by your organization	# of unduplicated residents referred to service provided by external organization	# of unduplicated residents tracked for accessing external service	# of unduplicated residents accessing service provided by external organization	Total unduplicated # of residents receiving service from grant recipient or accessing external service	Notes
Skills training and opportunities for job readiness (e.g., vocational training, apprenticeship, self-employment) for youth
Skills training and opportunities for job readiness (e.g., vocational training, apprenticeship, self-employment) for adults
Supplies for employment readiness/sustainment (e.g., uniforms, work boots, equipment)
Services for employment retention and growth (e.g., referrals, employer interaction, career pathways)
Employment counseling or coaching
Other (Please specify in “Notes” (column H))
Total unduplicated receiving any employment and training service:
Childcare Services
Service Type	# unduplicated residents receiving service directly funded by AHSSD	# of unduplicated residents receiving service provided directly by your organization	# of unduplicated residents referred to service provided by external organization	# of unduplicated residents tracked for accessing external service	# of unduplicated residents accessing service provided by external organization	Total unduplicated # of residents receiving service from grant recipient or accessing external service	Notes
Early Head Start services (ages 0 - 3)
Head Start services (ages 3 - 5)
Childcare subsidies or payments
Early childhood education (ages 0-5), outside of Early Head Start and Head Start.
Drop-in childcare services
Counseling or consultation for childcare services
Other (Please specify in “Notes” (column H))
Total unduplicated receiving any childcare service:
Youth Supports and Programs
Service Type	# unduplicated residents receiving service directly funded by AHSSD	# of unduplicated residents receiving service provided directly by your organization	# of unduplicated residents referred to service provided by external organization	# of unduplicated residents tracked for accessing external service	# of unduplicated residents accessing service provided by external organization	Total unduplicated # of residents receiving service from grant recipient or accessing external service	Notes
K-12 Support Services (e.g.: English, literacy, etc.)
Youth (age 14 – 24) literacy classes
College/post-secondary readiness support (e.g.: applications, scholarships, textbooks, computers)
School supplies and equipment
Before and after school activities for youth
Summer youth programs (e.g.: recreational and educational)
Life skills and coaching services for youth
Other (Please specify in “Notes” (column H)
Total unduplicated receiving any youth supports or programs:
Adult Education and Skills Development Programs
Service Type	# unduplicated residents receiving service directly funded by AHSSD	# of unduplicated residents receiving service provided directly by your organization	# of unduplicated residents referred to service provided by external organization	# of unduplicated residents tracked for accessing external service	# of unduplicated residents accessing service provided by external organization	Total unduplicated # of residents receiving service from grant recipient or accessing external service	Notes
Adult literacy classes
English language classes
High school equivalency classes
Applied technology classes
Life skills and coaching services
Tuition assistance
Other (Please specify in “Notes” (column H))
Total unduplicated receiving any adult education and skills development programs:
Income and Asset Building Services
Service Type	# unduplicated residents receiving service directly funded by AHSSD	# of unduplicated residents receiving service provided directly by your organization	# of unduplicated residents referred to service provided by external organization	# of unduplicated residents tracked for accessing external service	# of unduplicated residents accessing service provided by external organization	Total unduplicated # of residents receiving service from grant recipient or accessing external service	Notes
Training and counseling services for income management and asset building (e.g.: credit repair, financial literacy, financial management, budgeting, homebuying, foreclosure avoidance)
Business and entrepreneurial financial services (e.g.: micro-loans, business development loans, business development, entrepreneurial support)
Benefit coordination services (e.g.: child support, health insurance, SSI, Veterans, TANF, SNAP)
Other (Please specify in “Notes” (column H))
Total unduplicated receiving income and asset building services:
Housing Services
Service Type	# unduplicated residents receiving service directly funded by AHSSD	# of unduplicated residents receiving service provided directly by your organization	# of unduplicated residents referred to service provided by external organization	# of unduplicated residents tracked for accessing external service	# of unduplicated residents accessing service provided by external organization	Total unduplicated # of residents receiving service from grant recipient or accessing external service	Notes
Rental payment assistance (e.g.: emergency rental payments and deposits)
Housing payment assistance (e.g.: down payments and emergency mortgage payments)
Eviction prevention services (e.g.: eviction counseling, landlord/tenant mediations and rights)
Utility payment assistance (to include deposits, arrears, and assistance)
Rapid re-housing and housing placement services (e.g.: temporary, transitional, and permanent housing placements)
Housing maintenance and improvement services (e.g.: structural, accessibility improvements, emergency home repairs, water safety, healthy home)
Weatherization and energy efficiency services
Other (Please specify in “Notes” (column H))
Total unduplicated receiving any housing services:
Health and Nutrition Services
Service Type	# unduplicated residents receiving service directly funded by AHSSD	# of unduplicated residents receiving service provided directly by your organization	# of unduplicated residents referred to service provided by external organization	# of unduplicated residents tracked for accessing external service	# of unduplicated residents accessing service provided by external organization	Total unduplicated # of residents receiving service from grant recipient or accessing external service	Notes
Immunizations
Health screenings (e.g., physicals, chronic health screenings)
Developmental delay screening
Healthcare payment assistance (prescription payments, doctor visit payments)
Health insurance options counseling (i.e., include the number of individuals for whom insurance information was provided)
Reproductive health services (e.g., family planning, contraceptives, STI or HIV prevention)
Maternal or child health services (e.g., breastfeeding support, safe sleeping, postpartum support) (for services involving mother and child, like breastfeeding support, please include both in reported numbers)
General wellness services (e.g., medication management, mindfulness, exercise, fitness)
Older adult care home visits (e.g., nursing, chores, personal care services)
Elder day centers or senior centers
Disability services
Substance use or misuse services (e.g., intake, screening, counseling, support groups, and hotline)
Mental health services (e.g., intake, screening, counseling, support group, hotline)
Domestic violence prevention or support services (e.g., support groups and hotline)
Dental services for adults (e.g., screenings, exams, procedures)
Dental services for children (e.g., screenings, exams, procedures)
Food/nutrition skills classes (cooking, nutrition)
Prepared meals (e.g., through a congregate nutrition site, Meals on Wheels, a prepared food delivery or pickup program)
Food distribution services (bags, boxes, food share, groceries)
Community gardening activities
Hygiene kits/supplies
Diapers/diapering supplies (number of children receiving supplies)
Hygiene utilization services (e.g., showers, toilets, sinks, laundry facilities)
Clothing assistance
Other (Please specify in “Notes” (column H))
Total unduplicated receiving any health or nutrition services:
Civic Engagement and Involvement
Service Type	# unduplicated residents receiving service directly funded by AHSSD	# of unduplicated residents receiving service provided directly by your organization	# of unduplicated residents referred to service provided by external organization	# of unduplicated residents tracked for accessing external service	# of unduplicated residents accessing service provided by external organization	Total unduplicated # of residents receiving service from grant recipient or accessing external service	Notes
Voter education and access services
Tri-partite board participation
Volunteer opportunities
Community engagement events
Tenant councils
Community needs assessments (e.g., completed surveys or participated in focus groups for the community)
Other (Please specify in “Notes” (column H))
Total unduplicated receiving any civic engagement and involvement services:
Transportation Services
Service Type	# unduplicated residents receiving service directly funded by AHSSD	# of unduplicated residents receiving service provided directly by your organization	# of unduplicated residents referred to service provided by external organization	# of unduplicated residents tracked for accessing external service	# of unduplicated residents accessing service provided by external organization	Total unduplicated # of residents receiving service from grant recipient or accessing external service	Notes
Public transportation voucher/pass
Gas card
Non-medical transportation
Medical transportation
Rideshare/taxi vouchers
Transportation Education/ Consultation
Other (Please specify in “Notes” (column H))
Total unduplicated receiving any transportation services:
Legal, Tax, and Immigration Support
Service Type	# unduplicated residents receiving service directly funded by AHSSD	# of unduplicated residents receiving service provided directly by your organization	# of unduplicated residents referred to service provided by external organization	# of unduplicated residents tracked for accessing external service	# of unduplicated residents accessing service provided by external organization	Total unduplicated # of residents receiving service from grant recipient or accessing external service	Notes
Legal advice, record expungement
VITA and other tax advice or assistance
Immigration assistance
Other (Please specify in “Notes” (column H))
Total unduplicated receiving any legal, tax, or immigration support
Family Relationships Services
Service Type	# unduplicated families receiving service directly funded by AHSSD	# of unduplicated families receiving service provided directly by your organization	# of unduplicated families referred to service provided by external organization	# of unduplicated families tracked for accessing external service	# of unduplicated families accessing service provided by external organization	Total unduplicated # of families receiving service from grant recipient or accessing external service	Notes
Home visiting program
Parenting and family skills education
Family coaching
Other (Please specify in “Notes” (column H))
Total unduplicated receiving any family relationships services:
Intensive Services
	# unduplicated residents receiving service directly funded by AHSSD	# of unduplicated residents receiving service provided directly by your organization	# of unduplicated residents referred to service provided by external organization	# of unduplicated residents tracked for accessing external service	# of unduplicated residents accessing service provided by external organization	Total unduplicated # of residents receiving service from grant recipient or accessing external service	Notes (please describe the primary focus of the services, typical frequency and duration of interactions)
Intensive services (individualized, ongoing services to address the distinct needs of an individual or family, e.g., case management, service coordination, coaching); you may include individuals who have received services through one of the service areas above (e.g., family coaching), so long as the services are intensive in nature (i.e., long-term, ongoing services to address distinct needs);
TOTAL
	# unduplicated residents receiving service directly funded by AHSSD	# of unduplicated residents receiving service provided directly by your organization	# of unduplicated residents referred to service provided by external organization	# of unduplicated residents tracked for accessing external service	# of unduplicated residents accessing service provided by external organization	Total unduplicated # of residents receiving service from grant recipient or accessing external service	Notes
Total INDIVIDUAL residents receiving any services:
Total resident HOUSEHOLDS receiving any services:

---

Sheet 4: Housing Community

	Reporting Period: First Quarter of 6-Month Reporting Cycle	Reporting Period: Second Quarter of 6-Month Reporting Cycle	Reporting Period: Full Project Period -- Start of Program Through End of 6-Month Reporting Cycle
Indicator	[enter start date and end date here]	[enter start date and end date here]	[enter start date and end date here]
Total # of units occupied for some portion of time during the reporting period
Total unduplicated # of individuals residing in housing community for some portion of time during the reporting period
Total unduplicated # of households residing in housing community for some portion of time during the reporting period
# of units current on paying rent for all months during the reporting period (if applicable)
# of households moving into the community during the reporting period
# of household moving out of the community during the reporting period
# of household move-outs that were community initiated during the reporting period
# of households evicted during the reporting period

---

Sheet 5: Partners

Partner name

Is this a pre-existing partnership (Y/N)  If no, then please enter the partnership start date for new partnerships in column C. If Yes, please describe any changes to the partnership due to the AHSSD grant in column H.

Partnership start date for new partnerships (MM/YYYY)

Types of Services Partner Will Provide to AHSSD Residents [Select all that apply: employment and training; childcare; youth supports; adult education and skills development; income and asset building; housing; health and nutrition; civic engagement and involvement; transportation; legal, tax, and immigration support; family relationships; other (please describe in "Other Notes" section)]

Description of Services Partner Will Provide to AHSSD Participants

Is partner a subgrant recipient or contractor (i.e., will partner receive AHSSD funding for provision of these services) [Select: subgrant recipient, contractor, does not receive AHSSD funding, other]

Location of Service Delivery for AHSSD Residents [select all that apply: in their homes, in the housing community, in the surrounding community, virtual, other]

Other Notes

---

Sheet 6: Characteristics

Total unduplicated number of INDIVIDUALS who received services through the AHSSD grant this reporting period:								0
Total unduplicated number of all HOUSEHOLDS who received services from the AHSSD grant this reporting period:								0
INDIVIDUAL-LEVEL CHARACTERISTICS							HOUSEHOLD-LEVEL CHARACTERISTICS
1. Gender Identity		Number of Individuals		Number Receiving Intensive Services			5. Households with Children		Number of Households		Number Receiving Intensive Services
a.	Male						a.	No children in household
b.	Female						b.	Children reside in household
c.	Transgender, non-binary or another gender						c.	Unknown
d.	Unknown or not reported						d.	TOTAL	0		0
e.	TOTAL	0		0
2. Age		Number of Individuals		Number Receiving Intensive Services			6. Households Size		Number of Households		Number Receiving Intensive Services
a.	0-4						a.	Single Person
b.	5-17						b.	Two
c.	18-24						c.	Three
d.	25-34						d.	Four
e.	35-44						e.	Five
f.	45-64						f.	Six or more
g.	65-84						g.	Unknown
h.	85+						h.	TOTAL	0		0
i.	Unknown or not reported
j.	TOTAL	0		0
3. Education Levels		Number of Individuals		Number Receiving Intensive Services			7. Level of Household Income		Number of Households		Number Receiving Intensive Services
a.	Grades 0-8						(% of HHS Guideline)
b.	Grades 9-12 or non-graduate						a.	Up to 50%
c.	High school graduate, GED, or equivalency diploma						b.	51% to 75%
d.	Some college						c.	76% to 100%
e.	2 or 4 years college graduate						d.	101% to 125%
f.	Graduate of other post-secondary school						e.	126% to 150%
g.	Unknown						f.	151% to 175%
h.	TOTAL	0		0			g.	176% to 200%
							h.	201% to 250%
4. Race/Ethnicity		Number of Individuals		Number Receiving Intensive Services			i.	251% and over
a. Ethnicity							j.	Unknown
	a.1. Hispanic, Latino or Spanish Origins						k.	TOTAL	0		0
	a.2. Not Hispanic, Latino or Spanish Origins
	a.3. Unknown
	a.4. TOTAL	0		0
b. Race	b.1. American Indian or Alaska Native
	b.2. Asian
	b.3. Black or African American
	b.4. Native Hawaiian and Other Pacific Islander
	b.5. White
	b.6. Other
	b.7. Multi-race (two or more of the above)
	b.8. Unknown
	b.9. TOTAL	0		0