ECSH Reporting Form

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Ethnic Commnity Self-Help (ECSH) Program Data Indicators
1. Recipient Name:
2. Grant Number:
3. Reporting Period End Date:

DIRECT SERVICES
Program Activities

First Reporting
Period

Second Reporting
Period

First Reporting
Period

Second Reporting
Period

4. Number of New Enrollments
5. Number of Clients Served
6. Number of Clients Served According to Sex
6a. Female
6b. Male
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
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

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
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
Identify progress towards each Output
Model in the following spaces. Add more spaces as
for Months 1-6
necessary.

14. Logic Model Outcomes Progress
Please list all planned Outcomes from the Logic
Model in the following spaces. Add more spaces as
necessary.

Identify progress towards each
Output for Months 7-12.

Semi-Annual Results
First Reporting Period
Second Reporting Period
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 03/31/2026. If you have any comments on this collection of
information, please contact Zahra Cheema, ACF/ORR, by email at [email protected].

OMB Control Number: 09700490
Expiration Date: 3/31/2026