Form 3.0 - Tribal Short 3.0 - Tribal Short CSBG Annual Report 3.0 Tribal Annual Report Short Form

Annual Report 3.0

Tribal Annual Report

OMB No.: 0970-0492

Expires: December 31, 2027

PUBLIC BURDEN STATEMENT

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) The purpose of this collection is to meet the requirement of the Community Services Block Grant (CSBG) Act (42 U.S.C. § 9901, et seq) that all states that receive CSBG funding participate in a performance management system (Section 678E(a)(1)(A))) and submit a report to the Secretary on an annual basis (Section 678E(a)(2)). Public reporting burden for this collection of information is estimated to average 1,800 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 mandatory collection of information per the Community Services Block Grant (CSBG) Act (42 U.S.C. § 9901, et seq) Section 678E(a)(1)(A)) and Section 678E(a)(2). 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. If you have any comments on this collection of information, please contact [email protected].

CSBG Tribal Annual Report Table of Contents

Module 1: Tribal Administration 3

Instructional Note 4

Tribal Administration 5

Section A: CSBG Lead Tribal Agency, CSBG Authorized Official, CSBG Point of Contact 5

Module 2: Tribal CSBG Expenditures 6

Instructional Note 7

Tribal CSBG Expenditures 8

Section A: Tribal CSBG Expenditures 8

Module 3: Individual and Family 9

Instructional Note 10

Section A: Individual and Family Level 11

Employment Services 11

Childcare, Early Childhood, Youth Development, and Adult Education Services 12

Income and Asset Building Services 13

Housing Services 14

Health and Nutrition Services 15

Civic Engagement and Community Involvement Services 16

Transportation Services 17

Partnerships, Linkages, and Coordination Services 18

Section B: All Characteristics Report 19

Module 1: Tribal Administration

Instructional Note

Module 1, Section A: Tribal Administration

The reporting timeframes for all information in the tribe or tribal organization’s administration module is based on the FEDERAL FISCAL YEAR, which runs from October 1 of a given calendar year until September 30 of the following calendar year.

Tribal Administration

Section A: CSBG Lead Tribal Agency, CSBG Authorized Official, CSBG Point of Contact

A.1. Provide the following information in relation to the tribe or tribal organization designated to administer CSBG as required in Sections 676 and 677 of the CSBG Act, the Human Services Reauthorization Act of 1998 (P.L.105-285), and relevant federal policy guidance. The following information should mirror the information provided on the Application for Federal Assistance, SF-424M.

A.1a. Name of Tribe or Tribal Organization

A.1b. CSBG Program Contact Person Name

Title

A.1c. Work Telephone number and Extension (if applicable)

A.1d. Email Address

A.1e. Fax

Module 2: Tribal CSBG Expenditures

Instructional Note

Module 2, Section A: Tribal Expenditures

Section A: CSBG Tribal Expenditures Form meets the Congressional requirement for an explanation of the total amount of CSBG funding expended during the reporting period (identified below) based on categories referenced in the CSBG Act.

CSBG funding expended during federal fiscal year should be identified in the domain that best reflects the services delivered and strategies implemented, as well as the administrative costs associated with the domains.

Note: The reporting timeframes for all information in the tribal expenditures module is based on the FEDERAL FISCAL YEAR, which runs from October 1 of a given calendar year until September 30 of the following calendar year

Tribal CSBG Expenditures

Section A: Tribal CSBG Expenditures

A.2. CSBG Expenditures Domains	CSBG Funds
A.2a. Employment
A.2b. Childcare, Early Childhood, Youth Development, and Adult Education
A.2c. Income and Asset Building
A.2d. Housing
A.2e. Health and Nutrition
A.2f. Civic Engagement and Community Involvement
A.2g. Transportation
A.2h. Partnerships, Linkages, and Coordination
A.2i. Other
A.2j. Total CSBG Expenditures (auto calculated)	0

Module 3: Individual and Family

Instructional Note

Module 3, Section A: Individual and Family

Section A: Individual and Family Services Data Entry Form provides information on the work CSBG Tribal Agencies did to serve individuals and families. This standardized Individual and Family Services list will aid in analysis of the relationship between people, services, and outcomes.

Module 3, Section B: All Characteristics Report

Section B: The All Characteristics Report Data Entry Form collects data on all individuals and households, whether or not funded directly by CSBG. This demographic information strengthens the CSBG Annual Report by demonstrating those served by CSBG Tribal Agencies.

Note: The reporting timeframes for all information in this module is based on the FEDERAL FISCAL YEAR, which runs from October 1 of a given calendar year until September 30 of the following calendar year. The data collected in this module relates to Goal 1: Individuals and families with low incomes are stable and achieve economic security.

Section A: Individual and Family Level Employment Services

SRV 1. Describe all employment related services, such as support for job placement, vocational and skills training, job development, and eliminating barriers to work. (If you did not provide this service, indicate “N/A” for not applicable.)

Childcare, Early Childhood, Youth Development, and Adult Education Services

SRV 2. Describe all education related services, such as adult education, literacy programs, scholarships, Head Start enhancement, child development programs, and anti-drug education. Additionally, describe all youth development related activities, such as activities that address the needs of youth in communities with low income to include establishment of violence-free zones, intervention, and mediation programs, mentoring and life skills training, job creation, entrepreneurship programs, and after-school childcare programs. (If you did not provide this service, indicate “N/A” for not applicable.)

Income and Asset Building Services

SRV 3. Describe all income management and asset building related services, such as budgeting assistance, tax preparation, tax credit education, medical benefits, claims assistance, and savings programs. (If you did not provide this service, indicate “N/A” for not applicable.)

Housing Services

SRV 4. Describe all housing related services, such as homeownership counseling and loan assistance, landlord-tenant relations, housing assistance, homeless services, and home repair and rehabilitation. (If you did not provide this service, indicate “N/A” for not applicable.)

Health and Nutrition Services

SRV 5. Describe all health and nutrition related services, such as food banks, public education, health counseling, transportation to health services, community garden programs, and production and delivery programs. (If you did not provide this service, indicate “N/A” for not applicable.)

Civic Engagement and Community Involvement Services

SRV 6. Describe all partnerships and community engagement related services, such as activities designed to help families and individuals with low incomes achieve greater participation in the affairs of their communities, including partnerships with local law enforcement agencies, housing authorities, private foundations, and other public and private partners. CSBG funding also supports interagency partnerships and Tribal-State partnerships as well. (If you did not provide this service, indicate “N/A” for not applicable.)

Transportation Services

SRV 7. Describe all transportation related activities such as transportation vouchers, public transit fare assistance, medical transportation services, community shuttle services, rideshare programs, volunteer driver programs, and child and youth transportation. (If you did not provide this service, indicate “N/A” for not applicable.)

Partnerships, Linkages, and Coordination Services

SRV 8. Describe all linkages and coordination between anti-poverty programs, such as eligibility coordination to make more effective use of related programs, including other public and private sources. Fill identified gaps in the services through the provision of information, referrals, eligibility coordination, case management, and follow-up consultations.

Section B: All Characteristics Report

1. Total unduplicated number of all INDIVIDUALS about whom one or more characteristics were obtained:

2. INDIVIDUAL LEVEL CHARACTERISTICS

1. Sex	Number of Individuals
Male Female TOTAL (auto calculated)
	0

2. Military Status	Number of Individuals
a. Veteran
b. Active Military
c. Never Served in the Military
d. Unknown/not reported
e. TOTAL (auto calculated)	0
3. Work Status (Individuals 18+)	Number of Individuals
a. Employed Full-Time
b. Employed Part-Time
c. Seasonal Farm Worker
d. Unemployed (Short-Term, 6 months or less)
e. Unemployed (Long-Term, more than 6 months)
f. Unemployed (Not in Labor Force)
g. Retired
h. Unknown or not reported
i. Total (auto calculated)	0