MLP Semi-Annual Report Form

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PRA Statement Tab
PAPERWORK REDUCTION ACT (PRA) OF 1995 (Public Law 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to understand performance progress for MLP+ grant recipients.  Public reporting burden for this collection of information is estimated to average 8 hours per grantee and 1 hour for partner organizations, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.
  
OMP Approval Number: 0970-0490
Expiration Date: 04/30/2029

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 PRA of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information, please contact [insert federal contact name and email address].  

Direct Services Tab

Direct Services




 









Report Information




Grant Recipient Name




Start Date for Reporting Period




End Date for Reporting Period









Please report the following information for all individuals referred to or screened by the MLP for legal/social needs. In general, report the minimum number of known counts. Please use the “Notes” columns to document challenges reporting. 





# of unduplicated individuals this reporting period
# of unduplicated individuals since the start of the grant
Notes

Total number of individuals referred for MLP+ services (Enter the total number of individuals who were referred by health care or other partners for MLP services. Include only known information to report a minimum number of known individuals referred. Use the notes column to describe reasons why the referrals count may be incomplete.)




Total number of individuals receiving at least one intake interview for MLP legal or social services (Enter the total number of individuals who met with any MLP staff for an intake interview)




Total number of individuals receiving intake interviews who did not receive MLP services (Enter total number of individuals who did not receive any legal or social services from the MLP after intake; To calculate this total, count the individuals who received intake interview and subtract the individuals receiving legal case services OR social services listed below)


List primary reasons individuals did not receive MLP services:






Individuals Served




 





# of unduplicated individuals this reporting period
# of unduplicated individuals since the start of the grant
Notes

Legal case services (enter each individual only once in row 21)




Total number of individuals receiving case services who received any level of legal services (Enter the total number of low-income individuals for whom the only legal case services during the requested reporting period were brief or extended legal services)




Social services (enter each individual only once in row 23)




Total number of individuals receiving any level of social services including brief (e.g., social service consultation, assistance filling out a form, assistance with a referral for wraparound services etc.) AND intensive services (e.g., case management/service navigation/other services that provide ongoing, individualized assistance to comprehensively address an individual's or family's unique needs) (Enter the number of low-income individuals that received brief or intensive social services during the requested reporting period)






Legal Services Tab 
Direct Services - Legal Cases
 

Case Services
For case services, please track open, ongoing, and closed cases, which represent the provision of MLP+ services to low-income individuals to address a legal problem. A case may be recorded and reported only when the legal services organization has accepted an eligible client for legal assistance on a specific legal issue, or a set of closely related legal issues, and has provided client-specific legal assistance. An individual may have multiple cases open. For example, an individual with legal problems spanning multiple types of legal problems (e.g., individual rights and housing), should have a case recorded for each problem. Closely related legal problems, such as multiple related housing legal issues (e.g., habitability and an eviction issue), should be recorded in a single case. If new legal problems emerge after a case is closed, please report the new legal problems as separate cases, even if the legal problems are closely related to the legal problems addressed in the closed case. For each case that closed this reporting period, please report the type of legal services provided and the type of problem addressed. Additionally, please provide the type of legal problem that is being addressed in each case that remains open at the end of the reporting period.
In column B, please report the following information for services provided by the MLP this reporting period. In column C, please report the following information for the services provided by MLP+ funding this reporting period. Information provided in column C must include services and activities supported only with MLP+ funds either through a direct count for services funded only with MLP+ funds or based on a proportional analysis for services supplemented with MLP+ funds and also funded through other sources. 

Cases
# of cases for the MLP
# of MLP+ funded cases
Notes

Total number of new cases opened this reporting period




Total number of ongoing cases continuing from last reporting period




Total number of cases closed this reporting period









Legal service types for closed cases (report each case only once for highest level of service)
# of closed cases for the MLP
# of closed MLP+ funded cases
Notes

Brief service (cases involving only limited services, e.g., counsel/advice, communicating with third party by phone or letter, simple legal document preparation) (Enter the number of closed cases that only received brief services)




Extended service (cases requiring longer-term/more in-depth services, e.g., negotiated settlements, court appearances, preparation of highly complex documents)  (Enter the number of closed cases that received extended services)









Legal problems for closed cases
Total # of closed cases for MLP
Total # of closed cases with MLP+ funding
Notes

Income maintenance
TANF; Social Security; food stamps; SSDI; SSI, unemployment compensation; veterans’ benefits; state and local income maintenance




Housing
Federally subsidized housing; homeownership/real property; private landlord/tenant; public housing; mobile homes; housing discrimination; mortgage foreclosure; mortgage predatory lending practices




Education 
Discipline; special education/learning disabilities; access; vocational education; student financial aid




Employment
Employment discrimination; wage claims and other FLSA issues; EITC and taxes, employment rights, agricultural worker issues (not wage claims/FLSA issues)




Family and Children
Adoption; custody/visitation; divorce/separation/annulment; adult guardian/conservatorship; parental rights termination; paternity; domestic abuse; support; delinquent juveniles; neglected/abused dependent; emancipation; minor guardianship




Individual rights
Immigration/naturalization; mental health, disability rights, civil rights, human trafficking, criminal record expungement




Consumer/financial 
Bankruptcy/debtor relief; collection; contracts/warranties; collection practices; predatory lending; loans/installment purchase; public utilities; unfair and deceptive sales and practices




Health
Medicaid; Medicare; CHIP; home and community based care; private health insurance; long-term health care facilities; state and local health




Other 
Tribal law; licenses; wills/estates; advance directives/powers of attorney; torts









Legal problems for open cases
Total # of open cases for MLP
Total # of open cases with MLP+ funding
Notes

Income maintenance
TANF; Social Security; food stamps; SSDI; SSI, unemployment compensation; veterans’ benefits; state and local income maintenance




Housing
Federally subsidized housing; homeownership/real property; private landlord/tenant; public housing; mobile homes; housing discrimination; mortgage foreclosure; mortgage predatory lending practices




Education 
Discipline; special education/learning disabilities; access; vocational education; student financial aid




Employment
Employment discrimination; wage claims and other FLSA issues; EITC and taxes, employment rights, agricultural worker issues (not wage claims/FLSA issues)




Family and Children
Adoption; custody/visitation; divorce/separation/annulment; adult guardian/conservatorship; parental rights termination; paternity; domestic abuse; support; delinquent juveniles; neglected/abused dependent; emancipation; minor guardianship




Juvenile
Delinquent, neglected/abused dependent; emancipation; minor guardian/conservatorship




Individual rights
Immigration/naturalization; mental health, disability rights, civil rights, human trafficking, criminal record expungement




Consumer/financial 
Bankruptcy/debtor relief; collection; contracts/warranties; collection practices; predatory lending; loans/installment purchase; public utilities; unfair and deceptive sales and practices




Health
Medicaid; Medicare; CHIP; home and community based care; private health insurance; long-term health care facilities; state and local health




Other 
Tribal law; licenses; wills/estates; advance directives/powers of attorney; torts






Social Service Referrals OPTIONAL TAB
Please complete the table below for referrals made for individuals or families receiving services supported by MLP+ during the reporting period. In column A, list the service type for referrals if counts for each service type are available; in column B, specify the total number of referrals for that service type or category. In column C, select the category for the referral. Provide notes in column D about what kind of services were provided, if needed (for example, if you did not include service types in column A), and also include any notes about reporting for referrals (e.g., if it covers referrals made by social service navigator staff or referrals to non-MLP+-funded services provided by your organization). The first two lines are examples and should be deleted before completion. 

Service type (optional, please provide a count by service type if available)
Number of referrals made this reporting period
Category of Referral (select one:) 
o Employment services
o Education and development services for youth
o Education and development services for adults
o Income and asset building services
o Housing services
o Health services
o Nutrition services
o Transportation services
o Other services (please specify in Notes column)
Notes (e.g., typical service types, information about collection/reporting)
Example: Food pantry
72
Nutrition services
 
Example: Head Start
25
Education and development services for youth
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 












Definitions: 
Employment services: include the provision of skills training and job readiness opportunities for youth and adults (including vocational training, apprenticeships, and self-employment), the distribution of employment supplies (such as uniforms, work boots, and equipment), and services aimed at supporting employment retention and growth (such as referrals, employer interactions, and career pathways). 
Education and development services for youth: include Early Head Start services for individuals aged 0-3, Head Start services for individuals aged 3-5, childcare subsidies or payments, early childhood education for ages 0-5 outside of Head Start, K-12 support services (e.g., English, literacy), young adult literacy classes, and college/post-secondary readiness support (e.g., applications, scholarships). Additionally, they encompass the provision of school supplies, participation in before and after-school activities, summer youth programs, life skills coaching, and home visiting programs, as well as adult education programs such as literacy, English language, high school equivalency, and applied technology classes." 
Education and development services for adults: include adult literacy classes, English language instruction, basic education (e.g., financial literacy), high school equivalency programs, and applied technology courses. These services also include life skills coaching, access to employment readiness support, and participation in social programs such as childcare subsidies, housing assistance, and workforce development initiatives. Additionally, services may provide resources for post-secondary education readiness (e.g., applications, scholarships, and textbooks) and evidence-based home visiting programs to support family stability and growth. 
Income and asset building services: include training and counseling to support income management and asset growth, such as credit repair, financial literacy, budgeting, homebuying, and foreclosure prevention, as well as business and entrepreneurial financial services like micro-loans, business development loans, and entrepreneurial support. Additionally, these services offer benefit coordination and advocacy for programs like child support, health insurance, SSI, Veterans benefits, TANF, and SNAP. Transportation services that facilitate access to income and asset-building opportunities, such as bus vouchers or passes to attend training, are also included. 
Housing services: include rental payment assistance (e.g., emergency rental payments and deposits) and housing payment assistance for down payments or emergency mortgage payments. These services also provide eviction prevention through counseling, landlord/tenant mediation, and utility payment assistance. Housing placement and rapid re-housing services support individuals in securing temporary, transitional, or permanent housing. Additionally, services include housing maintenance and improvements (e.g., structural repairs, accessibility upgrades, emergency home repairs) and weatherization services to enhance energy efficiency and safety in households. 
Health services: include immunizations, health screenings (e.g., physicals and chronic health assessments), and developmental delay screenings. These services also provide healthcare payment assistance for seniors (e.g., prescription and doctor visit payments) and health insurance counseling. Additionally, they cover maternal and child health services (e.g., breastfeeding support and postpartum care), reproductive health services (e.g., family planning and STI prevention), general wellness services (e.g., fitness, mindfulness, and medication management), home visits for older adults, participation in senior centers, mental and behavioral health services (e.g., substance use counseling, mental health support, domestic violence prevention), and dental services for both adults and children (e.g., screenings, exams, and procedures). 
Nutrition services: include food and nutrition skills classes (e.g., cooking and healthy eating), the distribution of prepared meals (e.g., Meals on Wheels, congregate sites), and food distribution services (e.g., groceries and food share programs). These services also support community gardening activities and provide emergency hygiene and clothing assistance, including hygiene kits, diapers, and access to hygiene facilities (e.g., showers and laundry). 
Transportation services:  include public transportation vouchers or passes, gas cards, and non-medical transportation assistance. Additionally, these services offer medical transportation for healthcare-related needs and rideshare or taxi vouchers to ensure access to essential appointments and services. 





































































Partners Tab
Use this form to report information about partners involved in the MLP+ program this reporting period. Partnerships may be formal or informal partnerships that support delivery of services for this grant.

Partner name







Was the partnership established prior to the start of the MLP+ grant project?
Partnership Start Date (MM/YYYY) for new partners (you may enter N/A for partnerships started prior to the start of the grant)
Types of  Services Partner Will Provide to MLP+ Participants [Select all that apply: legal, employment, education and development for youth, education and development for adults, income and asset building, , housing, health, nutrition, transportation,, other (please describe in "Other Notes" section)]
How does the MLP+ project support the activities and objectives of the partner
How does this partnership support the activities and objectives of the MLP+ project?
Other Notes
















Events tab
Events 
Use this form to report information about events your organization has hosted or co-hosted this reporting period with support from the MLP+ grant funding. 

Event Date (MM/DD/YYYY)
Was this event a training? (Y/N)
Title of Event
Description of Event
Purpose (e.g., training, community education, patient outreach, community collaboration)
Target Audience (e.g., medical providers, social service providers, patients, community organizations)
# of Attendees
Is this event part of a series? If yes, please list the series name.
Other Notes




















Outcomes 
Outcomes 
Use this form to report your organization’s administrative data on outcomes for cases closing during the reporting period. Use column B to report outcomes for cases that received extended services and were supported by MLP+ grant funding. If your organization’s administrative data does not support reporting this information, please use the “Notes” columns as needed. Use column C (optional) to report on outcomes for cases that received brief services and were supported by MLP+ grant funding. 

General Outcomes
Outcome
Objective Achieved (Extended Services)
Objective Achieved (Brief Services) OPTIONAL





Notes
Provided knowledge of how to address the legal problem






Assistance provided improved client or household member health






OTHER (Please describe in Notes column)







Income Maintenance
TANF; Social Security; food stamps; SSDI; SSI, unemployment compensation; veterans benefits; state and local income maintenance
Detailed Outcomes
Outcome
Objective Achieved (Extended Services)
Objective Achieved (Brief Services) OPTIONAL





Notes
Obtained, preserved, or increased income benefits (TANF, SSI, SSDI, SNAP, Unemployment, Workers Comp, Veteran, etc.)






Overcame denial of emergency assistance






Obtained assistance with business start/development






Reduced or waived overpayment or debt






Stopped financial exploitation of client by payee or other familiar






Obtained favorable payment schedule






Obtained other monetary relief






OTHER (Please describe in Notes column)







Summary Outcomes
TOTAL cases achieving an objective in this category



TOTAL cases that sought to achieve an objective in this category with a known outcome


Housing
Federally subsidized housing; homeownership/real property; private landlord/tenant; public housing; mobile homes; housing discrimination; mortgage foreclosure; mortgage predatory lending practices
Detailed Outcomes
Outcome
Objective Achieved (Extended Services)
Objective Achieved (Brief Services) OPTIONAL





Notes
Prevented eviction from public housing






Prevented eviction from private housing






Delayed eviction providing time to seek alternative housing






Avoid or delay foreclosure or other loss of home






Obtained access to housing






Obtained or retained participation in subsidized housing






Obtained favorable payment schedule






Obtained modification of a loan






Obtained monetary relief






Avoided, or obtained redress for, charges by landlord






Avoided motion for attorney fees award against client






Improved housing stability






Remedied unsafe housing






Obtained repairs, improved housing conditions, or otherwise enforced rights to decent habitable housing






Preserved or restored access to personal property






Enforced tenant rights






OTHER (Please describe in Notes column)






Summary Outcomes
TOTAL cases achieving an objective in this category



TOTAL cases that sought to achieve an objective in this category with a known outcome




Education Outcomes
Discipline; special education/learning disabilities; access; vocational education; student financial aid
Detailed Outcomes
Outcome
Objective Achieved (Extended Services)
Objective Achieved (Brief Services) OPTIONAL





Notes
Returned or kept student in school






Overcame barrier to enrollment in school






Avoided or delayed or reduced length of suspension






Obtained individualized education program and/or appropriate services






Obtained correction of school records






Avoided inappropriate special education classification






Protected confidential information






Protected student safety






Obtained or increased education programming






Avoided motion for attorney’s fees for client






OTHER (Please describe in Notes column)







Summary Outcomes
TOTAL cases achieving an objective in this category



TOTAL cases that sought to achieve an objective in this category with a known outcome





Employment Outcomes
Employment discrimination; wage claims and other FLSA issues; EITC and taxes, employment rights, agricultural worker issues (not wage claims/FLSA issues)
Detailed Outcomes
Outcome
Objective Achieved (Extended Services)
Objective Achieved (Brief Services) OPTIONAL





Notes
Increased or maintained wages or back pay






Delayed discharge






Overcame, or obtained redress for, job discrimination






Prevented, avoided, or obtained redress for wrongful discharge






Secured damages for illegal job action






Reduced or avoided garnishment or attachment






Obtained or enrolled in training/education 






Resolved on-the-job issues (e.g., safety/grievance)






Avoided motion for attorney’s fees for client






OTHER (Please describe in Notes column)
Summary Outcomes
TOTAL cases achieving an objective in this category




TOTAL cases that sought to achieve an objective in this category with a known outcome




Family and Child Outcomes
Adoption; custody/visitation; divorce/separation/annulment; adult guardian/conservatorship; parental rights termination; paternity; domestic abuse; support; delinquent juvenile, neglected/abused dependent; emancipation; minor guardian/conservatorship

Detailed Outcomes
Outcome
Objective Achieved (Extended Services)
Objective Achieved (Brief Services) OPTIONAL





Notes
Improved client safety or safety of household members






Eliminated or reduced risk to children






Improved family stability






Obtained order of protection






Obtained order for financial responsibilities






Obtained divorce, separation, or annulment






Addressed abuse or neglect an elder	






Prevented guardianship/conservatorship for adult






Obtained guardianship/conservatorship for adult






Obtained/modified parenting plan






Preserved/obtained parental rights






Obtained/preserved right of visitation






Avoided protective order/removal of children






Obtained guardianship or retained guardianship for a child






Prevented or ended guardianship for a child






Obtained adoption






Obtained permanent living situation for a child






Avoided or reversed findings of child abuse/neglect






Obtained foster care services






Improved terms of foster care plan






Obtained emancipation






Avoided motion for attorney’s fees for client






OTHER (Please describe in Notes column)







Summary Outcomes
TOTAL cases achieving an objective in this category



TOTAL cases that sought to achieve an objective in this category with a known outcome





Individual Rights
Immigration/naturalization; mental health, disability rights, civil rights, human trafficking, criminal record expungement
Detailed Outcomes
Outcome
Objective Achieved (Extended Services)
Objective Achieved (Brief Services) OPTIONAL





Notes
Secured safety (e.g., for crime, human trafficking survivor)






Obtained, preserved, or improved rights of disabled persons






Obtained, preserved, or improved rights of institutionalized persons






Improved access for people with disabilities






Obtained tort relief under civil rights claim






Obtained relief, or redress from, constitutional violation






Obtained administrative relief from misconduct






Obtained citizenship






OTHER (Please describe in Notes column)







Summary Outcomes
TOTAL cases achieving an objective in this category



TOTAL cases that sought to achieve an objective in this category with a known outcome




Consumer/Financial
Bankruptcy/debtor relief; collection; contracts/warranties; collection practices; predatory lending; loans/installment purchase; public utilities; unfair and deceptive sales and practices
Detailed Outcomes
Outcome
Objective Achieved (Extended Services)
Objective Achieved (Brief Services) OPTIONAL





Notes







Reduced or avoided debt, dispute, garnishment, attachment, or loss of personal property






Recovered money or item owed to a client






Protected client from illegal creditor harassment






Overcame fraudulent sales practices






Overcame predatory lending practices






Obtained or restored utilities or avoided or delayed termination of utilities






Obtained federal bankruptcy protection






Obtained insurance (other than health or disability)






Obtained positive change to client’s credit report






Obtained favorable payment schedule






Improved client financial stability






Avoided motion for attorney’s fees for client






OTHER (Please describe in Notes column)







Summary Outcomes
TOTAL cases achieving an objective in this category

TOTAL cases achieving a successful or partially successful outcome in this category

TOTAL cases that sought to achieve an outcome in this category that are known to not have achieved a successful or partially successful outcome
TOTAL cases that sought to achieve an objective in this category with a known outcome




Health
Medicaid; Medicare; CHIP; home and community based care; private health insurance; long-term health care facilities; state and local health
Detailed Outcomes
Outcome
Objective Achieved (Extended Services)
Objective Achieved (Brief Services) OPTIONAL





Notes
Obtained, preserved or increased Medicaid, CHIP, or Medicare






Obtained, preserved, or increased other health coverage






Obtained, preserved, or increased individual access to health care






Protected confidential health information






Improved institutional care






Obtained discharge from nursing home, assisted living facility, or mental health treatment






Stopped, or obtained redress for, harmful medical treatment






Obtained order for financial responsibilities






Avoided motion for attorney’s fees for client






OTHER (Please describe in Notes column)







Summary Outcomes
TOTAL cases achieving an objective in this category



TOTAL cases that sought to achieve an objective in this category with a known outcome




Other Outcomes
Tribal law; licenses; wills/estates; advance directives/powers of attorney; torts
Detailed Outcomes
Outcome
Objective Achieved (Extended Services)
Objective Achieved (Brief Services) OPTIONAL





Notes
Obtained a will






Obtained living will and/or health proxy or power of attorney






Settled estate






Obtained other monetary relief






Avoided or reduced tort liability or judgment






Solved a tax problem






Overcame taking of, or restriction of, driver’s license






Corrected criminal history records






OTHER (Please describe in Notes column)







Summary Outcomes
TOTAL cases achieving a successful outcome in this category



TOTAL cases that sought to achieve an objective in this category with a known outcome





Characteristics 
Please use your administrative data to report the following information for focal clients in a case (e.g., a named client for a legal case, benefits applicant, etc.). If your administrative data does not support reporting the requested information, please use the “Unknown” categories and “Notes” columns as needed. For cases involving multiple clients, please choose a focal client considering who will benefit from the case or who your program will work with most frequently. Please report these data for clients involved in MLP+ cases closing during the reporting period.
Individual characteristics
Item
Number
Notes
Total number of focal clients for MLP+ cases closing during the reporting period





Sex


Male


Female


Unknown





Disability status


Disabled


Non-disabled


Unknown





Veteran status


Veteran


Non-veteran


Unknown





Race/ethnicity


Asian


Native Hawaiin or Pacific Islander


Black or African American


Hispanic or Latino


American Indian or Alaska Native


Middle Eastern or North African


White


Another racial/ethnic identity


Unknown



Notes for reporting race/ethnicity
                • For programs that permit participants to select all races/ethnicities that apply using a single question:
                    ◦ If only one race or ethnicity is selected for a participant, report him or her in the corresponding line for the report.
                    ◦ If two or more race or ethnicities are selected for a participant, report him or her in the “Another racial/ethnic identity” line
                • For programs that use a two-question format (e.g., a question for identification as Hispanic/Latino with a separate question for identification as White, Native American, etc.), use the following table adapted from the LSC reporting framework.
                • Use the notes column to indicate any misalignment between your reporting categories and the requested categories. 
Race Recorded with Two Questions
Reporting Race/Ethnicity Category
Hispanic or Latino, any race
Hispanic or Latino
White, not Hispanic Latino
White
American Indian or Alaska Native
American Indian or Alaskan Native
Asian
Asian
Native Hawaiian or Pacific Islander
Native Hawaiin or Pacific Islander
Black or African American
Black or African American
Middle Eastern or North African
Middle Eastern or North African
Some other race
Another racial/ethnic identity
Two or more races
Another racial/ethnic identity
Unknown
Uknown
Household characteristics
Please provide the following household characteristics for MLP+ clients with closed cases during the reporting period. You may use numbers identified at the time of enrollment in services. Provide the information you have if you have cases with incomplete information. Each case should have at least one individual reported for the household.

Item
Number
Notes
Total households


Total number of adults in households


Total number of children in households