Student Support Services Annual Performance Report

OMB Approval No: 1840-XXXX

Expiration Date: MM/DD/CCYY

Student Support Services Program

2010-11 Annual Performance Report

Section I, Part 1—Project Identification/Characteristics

Certification and Warning Statements

A. Project Identification

1 PR/Award Number: [pre-populated] P042A ___ ____ _______

2. Type of Institution [pre-populated]________________________

3. Project Type: [pre-populated] ___________________________

4. Reporting Period: [pre-populated] _______________________

5. GPA Scale: [dropdown] _______________________________

6. Name of Grantee Institution: [pre-populated]

_________________________________________________

7. Address:__________________________________________

_________________________________________________

_____________________________ _____ ___________

City State Zip + 4

B. Project Director and Data Entry Person Information

8. Project Director Information [pre-populated]

8a. Name of Project Director:

______________________ ___ __________________

First Name MI Last Name

8b. Telephone #: (______) ________________________

Area Code Number Ext.

8c. Fax #: (______) ________________________

Area Code Number

8d. Email Address:_____________________________

D. Certification: We certify that the performance report information reported and submitted electronically on ____/____/______ is readily verifiable. The information reported is accurate and complete to the best of our knowledge.

________________________________________________ ______________________________________________

Name of Project Director (Print) Name of Certifying Official (Print)

________________________________ ____/____/______ ________________________________ ____/____/____ Signature Date Signature Date

E. Warnings: Any person who knowingly makes a false statement or misrepresentation on this report is subject to penalties which may include fines, imprisonment, or both, under the United States Criminal Code and 20 U.S.C. 1097. Further Federal funds or other benefits may be withheld under this program unless this report is completed and filed as required by existing law (20 U.S.C.) 1231a) and regulations (34 CFR 75.590 and 75.720).

Authority: Public Law 104-13, as amended.

Paperwork Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1840-xxxx. The time required to complete this information collection is estimated to average 15 hours per response, including the time to review instructions, search existing data resources, gather required data, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4536. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Federal TRIO Programs, U.S. Department of Education, 1990 K Street, N.W., Suite 7000, Washington, D.C. 20006-8510.

9. Data Entry Person Information

9a. Name of Data Entry Person:

____________________ ____ _________________

First Name MI Last Name

9b. Telephone #: (______) _______________________

Area Code Number Ext.

9c. Email Address:_____________________________

C. Project Characteristics

10a. Has a Summer Bridge Program? 10e. If yes in field #10d, please enter the dollar amount for

 Yes  No

10b. If yes in field #10a, number of summer bridge participants served: ________________ 10f. Received institutional or other non-federal funds?

10c. Used Federal grant funds to provide Grant Aid? 10g. If yes in field #10f, please enter the dollar amount for the

 Yes  No reporting period: $______________

10d. Required to provide matching funds for Grant Aid?

 Yes  No

10e. If yes in field #10d, please enter the dollar amount for the reporting period: $_____________.00.

10f. Received institutional or other non-federal funds?

 Yes  No

10g. If yes in field #10f, please enter the dollar amount for the reporting period: $_____________.00.

Section I, Part 2—Project Required Services

Required Service	Number of participants receiving service that was provided by project	Number of participants referred to another service provider
Academic Tutoring	______	______
Advice and assistance in postsecondary course selection	______	______
Education/counseling to improve financial and economic literacy	______	______
Information in applying for Federal Student Aid	______	______
Assistance in completing and applying for Federal Student Aid	______	______
Assistance in applying for admission to Graduate School and obtaining Federal student aid (not applicable to 2-year institutions)	______	______
Assisting in applying for admission to 4-Year Institution and obtaining Federal student aid (not applicable to 4-year institutions)	______	______

Definitions:

The “Number of participants receiving service that was provided by project” is defined as those participants that were offered services by the project and subsequently received services from the project. This figure does not include participants that were offered services by the project but declined them (e.g., due to lack of need, participant refused the service, etc.).

The “Number of participants referred to another service provider” is defined as those participants that were offered services by the project but were subsequently referred to another service provider. Note that the Department is not asking projects to report on whether participants actually received services from the service provider or for projects to follow-up with these participants to ensure services were rendered. The Department is only requesting that the projects report on the number of participants that were referred to another service provider.

The Department is asking projects to report on the number of participants, not the number of contacts. For instance, if a participant received a service that was provided by a project multiple times, he/she should only be counted once for the purposes of this report. However, it is possible for a participant to be counted once in each of the two columns for a given service; that is, a participant received a service that was provided by the project and was also referred to another service provider. For example, a participant might have received math tutoring that was provided by the project but was also referred to another service provider for language arts tutoring.