Form 1 ECSH Program Data Indicators

Ethnic Commnity Self-Help (ECSH) Program Data Indicators					OMB Control Number: 0970-0490 Expiration Date: 1/31/2020
1. Grantee Name:
2. Grant Number:
3. Reporting Period End Date:
DIRECT SERVICES
Program Activities	First Reporting Period	Second Reporting Period	Cumulative Budget Period
4. Number of New Enrollments this Reporting Period
5. Number of Refugees Served
6. Number of Clients Served According to Status	First Reporting Period	Second Reporting Period	Cumulative Budget Period
6a. Refugee
6b. Asylee
6c. Other status eligible for ORR services
7. Types of Services Provided	First Reporting Period Yes ('1')/No ('0')	Second Reporting Period Yes ('1')/No ('0')
7a. Navigation Services
7b. Cultural/community orientation
7c. Health-related services
7d. Home management services
7e. Transportation
7f. Translation and interpretation services
7g. Case management services
7h. English language training
7i. Employability services
7j. Academic enrichment/college preparation
7k. Emotional wellness services
7l. Referral services
7m. Citizenship preparation/civic engagement
7n. Other (list):
ORGANIZATIONAL DEVELOPMENT
Program Activities	First Reporting Period	Second Reporting Period	Cumulative Budget Period
8. Number of New Partnerships Developed
9. Type of New Partnership Developed	First Reporting Period	Second Reporting Period	Cumulative Budget Period
9a. Educational organization
9b. Local/state government entity
9c. Medical service provider
9d. Legal service provider
9e. Faith-based group
9f. Other (list)
10. Types of Training Provided to Staff	First Reporting Period Yes ('1')/No ('0')	Second Reporting Period Yes ('1')/No ('0')
10a. Case management
10b. Case documentation
10c. Interpretation
10d. Cultural sensitivity and awareness
10e. Self-care
10f. Cultural orientation provision
10g. Public benefits
10h. Health services and systems
10i. Non-profit management
10j. Other (list)
CIVIC ENGAGEMENT
11. Types of Community Engagement Activities Conducted	First Reporting Period		Second Reporting Period
LOGIC MODEL OUTPUTS & OUTCOMES
Logic Model Outputs Progress	Semi-Annual Results				Cumulative Budget Period
	First Reporting Period		Second Reporting Period
Please list all planned Outputs from the Logic Model in the following spaces. Add more spaces as necessary.	Identify progress towards each Output for Months 1-6		Identify progress towards each Output for Months 7-12.		Describe progress towards Outputs for the current fiscal year.
Logic Model Outcomes Progress	Semi-Annual Results				Cumulative Budget Period
	First Reporting Period		Second Reporting Period
Please list all planned Outcomes from the Logic Model in the following spaces. Add more spaces as necessary.	Identify progress towards each Outcomes for Months 1-6		Identify progress towards each Outcomes for Months 7-12.		Describe progress towards each Outcome for the current fiscal year.
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.