Performance Progress Report

PERFORMANCE PROGRESS REPORT 
HHS ADMINSTRATION FOR CHILDREN AND FAMILIES (ACF)

Title V State Sexual Risk Education (SRAE) Program
Performance Narrative

OMB Control Number:

Expiration Date:

1. Federal Agency and Organization Element to Which Report is Submitted			2. Federal Grant or Other Identifying Number Assigned by Federal Agency			3a. DUNS Number
						3b. EIN
4. Recipient Organization (Name and complete address including zip code)						5. Recipient Identifying Number or Account Number
6. Project/Grant Period (i.e., 5 years)		7. Budget Period (i.e., 1 year)				8. Final Report? Yes No
Start Date:  (Month, Day, Year)	End Date:  (Month, Day, Year)	Start Date:  (Month, Day, Year)		End Date:  (Month, Day, Year)		9. Report Frequency
						annual  semi-annual quarterly  other  (If other, describe: __________ __________________________)
10. Performance Narrative
11. Other Attachments
12. Certification:  I certify to the best of my knowledge and belief that this report is correct and complete for performance of activities for the purposes set forth in the award documents.
12a. Typed or Printed Name and Title of Authorized Certifying Official					12c. Telephone (area code, number, and extension)
					12d. Email Address
12b. Signature of Authorized Certifying Official					12e. Date Report Submitted (Month, Day, Year)
13. Agency use only

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN:

Through this information collection, ACF is gathering information about the proposed state’s program to determine whether or not the application and State Plan meets the minimum requirements for the awards. The Performance Progress Report documents the grantee’s progress, accomplishments, impact of the program, and compliance with the terms of the award.

Public reporting burden for this collection of information is estimated to average 16 hours per grantee response, 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 (42 U.S.C. § 710), as amended by Section 50502 (Pub. L. No. 115-123). 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 0970-0XXX and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact: XXXX.