OMB# 0990-XXXX
Expiration Date: XX/XX/XXXX
Candidate Pregnancy Assistance Fund Performance Measures
FY2017-2019 Cohort
Core Services and Evidence-based Programs Provided to PAF Program Participants
The Services and Referrals questions align with the five core services described in the PAF FOA in Appendix A. Grantees will be expected to report on the total number of the priority population receiving services through the PAF program (either provided directly by the PAF program staff or through referrals made by PAF program staff) during the grant year within each of the 5 domains. Grantees should collect these numbers from all program sites; the grantee will report aggregate numbers to OAH annually.
How many expectant and parenting participants received any of the following health care services through the PAF program either through direct service or referrals provided by PAF program staff during the federal grant year (July 1-June 30):
Obstetric Care (Prenatal care Childbirth Classes, Delivery care, and postnatal care) ____
Reproductive Health Care (family planning, STI screening) ____
Breastfeeding skills and resources ____
Health Insurance (enrollment and other supports) ____
Primary health care ____
Mental and behavioral health services (including suicide prevention) ____
Violence prevention and intervention services (domestic violence, sexual violence, sexual assault, stalking, dating violence) ____
Substance abuse prevention and counseling (tobacco, alcohol, and drug cessation) ____
Dental hygiene/oral health ____
Other health services ____
How many dependent children of the expectant and parenting participants received any of the following services through the PAF program either through direct service or referrals provided by PAF program staff during the federal grant year (July 1-June 30):
Well child/Primary Care visits ____
Nutritional counseling and services ____
Health insurance (enrollment and other supports) _______
Child Care Resources, Referrals, and Placement ____
Early childhood education (such as early Head Start, Head Start, other pre-school) ____
Dental hygiene ____
Other: ____
How many expectant and parenting PAF Participants received any of the following Self-Sufficiency, Education or Employment Services either through direct service or referrals provided by PAF program staff during the federal grant year (July 1-June 30)
Mentorship ____
Academic or educational supports (tutoring, credit recovery, advising) ____
Workforce development (Job Readiness, vocational training, job placement) ____
Life Skills (financial literacy and budgeting, home economics) ____
College planning and readiness ____
Other ____
How many expectant and parenting participants received any of the following concrete supports through the PAF program either through direct service or referrals provided by PAF program staff during the federal grant year (July 1-June 30):
Housing assistance ____
Food ____
Clothing ____
Transportation ____
Child needs (Diapers, Formula, Bottles, Car seats, Cribs, etc.) ____
Child Support ____
Benefits Eligibility Screening or Application Assistance (such as SNAP, WIC, TANF, Child Care, Medicaid/CHIP) ____
Health Insurance (enrollment and other supports) ____
Legal Aid ____
Accompaniment services ____
How many expectant and parenting participants received any of the following services or supports through the PAF program either through direct service or referrals provided by PAF program staff during the federal grant year (July 1-June 30):
Parenting education and resources (including co-parenting) ____
Healthy relationship education, skill building, and resources ____
Communication skills ____
Time management ____
Stress management support _____
Questions 6-7 are only required for those grantees who are implementing comprehensive violence prevention services as defined by the Pregnancy Assistance Fund Funding Opportunity Announcement.
How many individuals from government, private non-profit, and other agencies serving victims of stalking, sexual assault, and IPV received training on violence against expectant and parenting teens and women through the PAF grant? ______
How many expectant and parenting female participants who are victims of IPV, sexual violence, sexual assault, or stalking received any of the following services directly through the PAF program? Indicate the number in each category below.
Supportive social services (e.g., individual or group counseling) ____
Accompaniment services (e.g., assisting, representing, and accompanying women during court proceedings) ____
Intervention services (e.g., referral to 24 hour telephone hotline services for police protection and referral to shelters) ____
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX. The time required to complete this information collection is estimated to average 583/60 hours per respondent, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Tara Rice |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |