Office of Refugee Resettlement Services to Afghan Survivors of Combat (SASIC) Program Notification Letter and Pre-Monitoring Questionnaire (PMQ)

Services to Afghan Survivors Impacted by Combat (SASIC) Program

Pre-Monitoring Questionnaire

Recipient Name

Program Director

February 16, 2023 – [date of formal notification letter]

Period Under Review

Monitoring Dates

Instructions: The primary recipient should complete the questionnaire, working collaboratively with any sub-recipients or partners to ensure accuracy of responses prior to submission. The completed questionnaire should be sent electronically to ORR by the due date identified in the notification letter. The “period under review” includes the full project period to the date of the formal notification letter.

SASIC Caseload Information

1. Please complete the below table with your SASIC caseload information for the full project to date (February 16, 2023, to date of the formal monitoring notification letter).

Basic Caseload Information	Responses
Client Enrollment:
How many clients have you enrolled since the start of the project? Count brand new enrollments from February 16, 2023, to date.	#
Client Enrollment by Immigration Status or Category:
How many Afghan Humanitarian Parolees (AHPs) have you enrolled since the start of the project? Count all AHPs enrolled February 16, 2023, to date.	#
How many asylees have you enrolled since the start of the project? Count all asylees enrolled February 16, 2023, to date.	#
How many refugees have you enrolled since the start of the project? Count all refugees enrolled February 16, 2023, to date.	#
How many Special Immigrant Visa (SIV) holders, Special Immigrants with Conditional Permanent Resident Status, and Special Immigrant (SI/SQ) Parolees have you enrolled since the start of the project? Count all SIVs, Special Immigrants with Conditional Permanent Resident Status, and SI/SQ Parolees enrolled February 16, 2023, to date and provide one aggregate total for these categories.	#
Case Closure:
How many cases have you closed since the start of the project? Count all SASIC cases closed from February 16, 2023, to date.	#

2. Have you encountered any challenges in meeting client enrollment targets since the start of the project? If so, please describe.

2. Client Referrals

   1. What are the main sources of client referrals to your SASIC Program?

2. Please describe your program’s referral process.

2. Please briefly describe your eligibility confirmation process. Please note how your SASIC Program determines individuals’ eligibility for enrollment and services, including eligible immigration status and/or category and self-reported experience of combat-related services, while ensuring non-duplication of other federally-funded services.

Program Area 1: Direct Core Services

2. In the below table, please provide an overview of the Direct Core Services your program provides. Please note if your agency provides services directly or if an external partner provides the services. Please indicate N/A for any services not included in your SASIC Program. Please enter each new provider on its own row, adding rows as needed.

Direct Core Service	Provider Please list recipient or external provider agency name as relevant.	Short Description of Service Please briefly describe how the program provides this direct core service and if service provision is in-person or telehealth/remote.	External Partner Coordination If an external partner provides the service, please briefly describe the referral process.

2. How do you track the progress of clients your program refers to other agencies for core and/or supportive services? 

2. Has your program provided any crisis intervention(s) in response to beneficiary emergencies (e.g., life-threatening health or mental health emergency, serious crime or safety incident, legal child protection intervention, other events which threatened client well-being)? If so, please describe the emergency and your agency’s response. Please do not include any beneficiary personally identifiable information (PII) (e.g., name, age, address, etc.).

2. Please list and briefly describe the in-house services, including any group activities, designed to address specialized needs of the following populations:

   1. LGBTQ:

2. Female:

3. Adolescent:

4. Pediatric: 

2. Please describe the following processes. Include a description of the tools or forms you use for each process.

   1. Enrollment:

2. Intake assessment:

2. Please describe how you develop wellness plans with beneficiaries, including how often you update plans and how you document beneficiary progress over time.

2. How does your SASIC Program incorporate a whole-family approach, including family-focused service plans and family-strengthening interventions?

2. How do you determine when to close a case?

Program Area 2: Organizational Capacity Development

2. Describe any external and/or internal conditions or factors that have impacted, or may impact, SASIC Program performance. For example, has your agency experienced significant organizational changes, significant changes in your caseload or program enrollment, or otherwise been impacted by external events?

   1. Positive internal or external conditions:

2. Negative internal or external conditions:

Staffing

2. List all SASIC staff members supported with program funds using the following format. Include any vacant positions and/or newly created positions. Please also include information for the required positions that are pre-filled in the table. If a listed party works with the program but is not paid with SASIC Program funds (i.e., a party at a partnering organization), please indicate ‘0’ in the SASIC full-time employee (FTE) column.

Name	Position Title	Professional Credentials and Licensures	Hours/ Week	SASIC FTE	Languages Spoken	Primary Functions
	Medical Director		#	#
	Behavioral Health Advisor		#	#
	Pediatric Health Advisor		#	#
	Case Management Coordinator		#	#
			#	#
			#	#
			#	#
			#	#
Total:			#	#

2. If your organizational/staffing chart has changed significantly since your original application for funding, please discuss those changes and any resulting impact on program activities and outcomes.

2. What onboarding and ongoing training do you provide to SASIC Program staff?

2. If your agency uses unpaid volunteers/interns to assist in delivering required SASIC services, please describe your volunteer recruitment, screening, training, and supervision protocols.

Partnerships

2. In the table below, please list SASIC Program partnerships. Expand the table as needed.

Partner Name	Type of Service Provided	Level of Partnership	Partnership Start Date
			month/year
			month/year
			month/year
			month/year
			month/year

Program Management

2. Please describe your practices to ensure internal quality assurance and continuous improvement of program outcomes, addressing the following:

   1. Staff-client ratio:

2. Peer or supervisory case file review:

3. Structured, regular meetings to discuss active clients:

4. Client engagement or feedback (e.g., satisfaction surveys, focus groups, etc.):

5. Employee oversight:

2. If relevant, please describe any advisory boards and mentorship programs involved with your SASIC Program. Include information about the board’s role and composition, including refugee and immigrant community and/or former client involvement.

2. How are you using an equity lens (i.e., ensuring equitable service delivery to all clients across gender, sexual orientation, religion, and other factors) to review existing programming and develop any new programming?

2. How do you ensure compliance with Title VI? Consider accessibility of limited English proficiency policies and procedures; staff training by type, frequency, etc.; methods for notifying clients of their right to language assistance without charge; mechanisms for measuring effectiveness of language assistance; and procedures for addressing clients who decline language assistance/interpreter services in favor of assistance from family or friends.

2. How do you ensure the protection of any PII?

Project Monitoring and Evaluation

2. Please briefly describe how you collect ORR’s required SASIC Program Data Points.

2. Please briefly describe how you assess client outcomes. Which tool(s), system(s), and/or software do you use to assess client outcomes, and how frequently do you conduct assessments?

2. Which staff perform these tasks?

Fiscal Management

2. How do you ensure that SASIC funds are properly allocated and used only for eligible individuals and allowable expenses?

2. Please describe your agency’s time-keeping procedures, including how you ensure staff accurately allocate their time to the correct funding source.

2. In addition to SASIC Program funds from ORR, what other funding sources contribute to the implementation of your SASIC Program? If applicable, please note the amount and source of these funds in the following table for the period under review. Expand as needed.

Source of Funds	Amount
	$
	$
	$
	$
Total Funds	$

2. Please list any revenue-generating streams outside of grant funding (e.g., revenue from medical billing), if applicable. If not applicable to your SASIC Program, please write “N/A.”

Program Area 3: Community Engagement and Education

2. Please provide an overview of your program’s community engagement and education activities (e.g., outreach to Afghan refugee and immigrant communities, educational workshops to Afghan communities, stakeholder coordination, capacity building for healthcare professionals and other service providers, and public awareness outreach).

2. Please describe the nature of your program’s relationship with the following stakeholders, including descriptions of how you may coordinate, consult, or partner with each stakeholder type:

   1. State Refugee Coordinator and State Refugee Health Coordinator:

2. Afghan community-based organizations:

3. Other service providers:

2. Community Events: Please list the SASIC Program-related community outreach and awareness events and/or educational workshops you have hosted or participated in since the start of the SASIC Program. Please indicate whether your count refers to the number of ‘events’ or ‘participating individuals.’ Add rows as needed.

Event Type	Event Description(s)	Date(s)	Target Audience	Proposed Number of Events or Participating Individuals	Actual Number of Events or Participating Individuals
Total

2. Trainings: In the table below, please list any specialized, professional SASIC-related trainings your program offered to other providers since the start of the SASIC Program. Identify each training iteration in a separate row. Please indicate whether your count refers to the number of ‘events’ or ‘individuals trained.’ Add rows as needed.

Area of Professional Training	Training Description(s)	Date(s)	Target Audience	Proposed Number of Events or Individuals Trained	Actual Number of Events or Individuals Trained
Total

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to monitor SASIC grant recipients activities. Public reporting burden for this collection of information is estimated to average 5 hours per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information under INA § 412(c)(1)(A), 8 U.S.C. 1522(c)(1)(A). 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 0970-0558 and the expiration date is 11/30/2023. If you have any comments on this collection of information, please contact Francine White (francine.white@acf.hhs.gov).