1 Proposed MG Data Collection Form

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Overview

Client Information Form
MG Enrollment Form
MG Status Form

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Sheet 1: Client Information Form

																																		OMB #: 0970-XXXX
Voluntary Agencies Matching Grant Program Data Submission																																		Expiration Date: XX/XX/XXXX
Client Information Form
1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	21	22	23	24	25	26	27	28	29	30	31	32	33	34	35
Alien Number	Corrected Alien Number	First Name	Middle Name	Last Name	DOB	Immigration Status	Gender	Nationality	Street Address	Zip Code	City	State	County	Email	Phone Number	Eligibility Date	Entry Date	EAD Application Submitted	EAD Application Submitted Date	EAD Received	EAD Received Date	Social Security Card Application Submitted	Social Security Card Application Submitted Date	Social Security Card Received	Social Security Card Received Date	SNAP Application Submitted	SNAP Application Submitted Date	SNAP Approval	SNAP Approval Date	Temporary Housing	Temporary Housing Type	Temporary Housing Date	Long-term Housing	Long-term Housing Date
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, the Office of Refugee Resettlement (ORR) is gathering data to better understand client demographics, services utilized, and the outcomes achieved by the population served. The data will be used to inform evidence-based policy making. Public reporting burden for this collection of information is estimated to average 252 hours per grantee in the initial year and 192 hours per year in subsequent years. This includes the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information [Immigration and Nationality Act, section 412(a)(3)]. 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-XXXX and the expiration date is XX/XX/XXXX.If you have any comments on this collection of information, please contact DRSPrograms@acf.hhs.gov.

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Sheet 2: MG Enrollment Form

										OMB #: 0970-XXXX
Voluntary Agencies Matching Grant Program Data Submission										Expiration Date: XX/XX/XXXX
Matching Grant Enrollment Form
1	2	3	4	5	6	7	8	9	10	11
Alien Number	First Name	Middle Name	Last Name	DOB	MG Case ID	Principal Applicant (PA) Alien Number	Relationship to PA	Affiliate Code	MG Enrollment Date	Employable
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, the Office of Refugee Resettlement (ORR) is gathering data to better understand client demographics, services utilized, and the outcomes achieved by the population served. The data will be used to inform evidence-based policy making. Public reporting burden for this collection of information is estimated to average 252 hours per grantee in the initial year and 192 hours per year in subsequent years. This includes the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information [Immigration and Nationality Act, section 412(a)(3)]. 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-XXXX and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact DRSPrograms@acf.hhs.gov.

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Sheet 3: MG Status Form

																														OMB #: 0970-XXXX
Voluntary Agencies Matching Grant Program Data Submission																														Expiration Date: XX/XX/XXXX
Matching Grant Status Form
1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	21	22	23	24	25	26	27	28	29	30	31
Alien Number	Affiliate Code	MG Case ID	Individual Case Status	180 Day Status	180 Day Status Date	180 Day Status Comments	240 Day Status	240 Day Status Date	240 Day Status Comments	Current Employment Status	Occupation Categories	Has Benefits	Hourly Wage	Hours Per Week	Job Start Date	Job End Date	Employment Status - Job 2	Occupation Categories	Has Benefits	Hourly Wage	Hours Per Week	Job Start Date	Job End Date	Employment Status - Job 3	Occupation Categories	Has Benefits	Hourly Wage	Hours Per Week	Job Start Date	Job End Date
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, the Office of Refugee Resettlement (ORR) is gathering data to better understand client demographics, services utilized, and the outcomes achieved by the population served. The data will be used to inform evidence-based policy making. Public reporting burden for this collection of information is estimated to average 252 hours per grantee in the initial year and 192 hours per year in subsequent years. This includes the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information [Immigration and Nationality Act, section 412(a)(3)]. 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-XXXX and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact DRSPrograms@acf.hhs.gov.