Form 3.0 CSBG Annual Report - 3.0 version

OMB #0970-0492

Expiration Date:

Community Services Block Grant

Annual Report
Version 3.0

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this collection is to meet the requirement of the Community Services Block Grant (CSBG) Act (42 U.S.C. § 9901, et seq) that all states that receive CSBG funding participate in a performance management system (Section 678E(a)(1)(A))) and submit a report to the Secretary on an annual basis (Section 678E(a)(2)). Public reporting burden for this collection of information is estimated to average 198 hours per grantee and 697 hours per sub- 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 per the Community Services Block Grant (CSBG) Act (42 U.S.C. § 9901, et seq) Section 678E(a)(1)(A)) and Section 678E(a)(2). 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. If you have any comments on this collection of information, please contact CSBGData@acf.hhs.gov.

Contents

State Administration – Module 1 3

Section A: CSBG Lead Agency, CSBG Authorized Official, CSBG Point of Contact 4

Section B: CSBG Eligible Entity Update 5

Section C: Organizational Standards for Eligible Entities 6

Section D: State Use of Funds 7

Section E: State Training and Technical Assistance 11

Section F: State Linkages and Communication 12

Section G: Monitoring, Corrective Action, and Fiscal Controls 13

Section H: Performance Measurement 16

Eligible Entity Administration – Module 2 18

Section A: CSBG Expenditures by CSBG Eligible Entity 19

Section B: CSBG Eligible Entity Capacity Building 20

Section C: Allocated Resources per CSBG Eligible Entity 21

Individual and Family Level – Module 3 24

Section A: Individual and Family Services 25

Section B: Individual and Family NPIs 34

Section C: All Characteristics Report 40

Community Level – Module 4 44

Section A: Community Initiative Status 45

Section B: Community National Performance Indicators (NPIs) 34

Section C: Community Strategies List 44

State and Territory Administration – Module 1

Note: The reporting timeframes for all information in the state or territory administration module is based on the federal fiscal year (FFY), which runs from October 1 of a given calendar year until September 30 of the following calendar year. When completing the annual report, respondents will first indicate the FFY for which the state is submitting data. The On-Line Data Collection (OLDC) will then pre-populate the State Administration module with information from the appropriate year (year 1 or year 2, as applicable) in the accepted CSBG State Plan. Grant recipients will be able to update information in these sections, as necessary.

Community Services Block Grant (CSBG)

Annual Report – State and Territory Administration Module

Section A: CSBG Administrative Information

A.1. Lead Agency: Review and update (as applicable) the following information in relation to the lead agency designated to administer the CSBG in the state, as required by Section 676(a) of the CSBG Act.

A.1a. Lead agency

A.1b. Cabinet or administrative department of this lead agency

• ☐ Community Services Department

• ☐ Human Services Department

• ☐ Social Services Department

• ☐ Governor’s Office

• ☐ Community Affairs Department

• ☐ Other, describe:

A.1c. Cabinet or Administrative Department Name: Provide the name of the cabinet or administrative department of the CSBG authorized official.

A.1d. Authorized official of the lead agency

Name: ­­­­­­­­­­­­­­­_____________ Title: ______________

A.1e. Street address

A.1f. City

A.1g. State

A.1h. Zip code

A.1i. Work Telephone number and Extension (if applicable)

A.1j. Fax number

A.1k. Email address

A.1l. Lead agency website

Section B: CSBG Eligible Entity Update

B.1. Changes to Eligible Entities: The table below includes a list of CSBG eligible entities receiving 90 percent funds within the state, as reported within the CSBG State Plan for this reporting period.

Did the list of eligible entities change during the reporting year (FFY)? If yes, briefly describe the changes. Please also update the Master List prior to the submission of your next CSBG State Plan.

If the eligible entity was designated or re-designated, de-designated or voluntarily relinquished, or merged with another eligible entity(ies), provide additional details in the next submission of the CSBG State Plan.

CSBG Eligible Entity	Geographical Area Served (by county)	Public or Nonprofit	Type of Entity	A change occurred during the reporting period (FFY)	Briefly describe changes
				Yes, please describe No Designated or re-designated De-designated or voluntarily relinquished Merged Addition	Describe changes for each eligible entity for which you select “Yes”

Instructional Note: Limited Purpose Agency refers to a CSBG eligible entity that was designated as a limited purpose agency under Title II of the Economic Opportunity Act of 1964 for the fiscal year 1981, that served the general purposes of a community action agency under Title II of the Economic Opportunity Act; did not lose its designation as a limited purpose agency under Title II of the Economic Opportunity Act as a result of failure to comply with that Act; and has not lost its designation as a CSBG eligible entity under the CSBG Act.

Instructional Note: 90 percent funds are the funds a state provides to eligible entities to carry out the purposes of the CSBG Act, as described under Section 675C of the CSBG Act. A state must provide “no less than 90 percent” of their CSBG allocation, under Section 675B, to the eligible entities.

B.2. Total number of CSBG eligible entities:

Section C: Organizational Standards for Eligible Entities

C.1. Assessment of Organizational Standards

Review and update where applicable, how the state assessed CSBG eligible entities in meeting organizational standards.

• Peer-to-Peer Review

• Self-Assessment

• State-Authorized Third-Party Validation

• Routine, On-Site CSBG Monitoring

• Other

C.1.b. Describe in detail, the assessment process as implemented by the state. Include any changes in the assessment process occurring since the most recent CSBG State Plan. With the exception of regular on-site CSBG monitoring, all assessment options above may include on-site, desk review, or a combination of both. The specific state process should be included in the response.

C.2. Technical Assistance for Unmet Organizational Standards

Did the state provide technical assistance specifically for eligible entities with unmet organizational standards to assist in meeting the standards in a reasonable timeframe?

 Yes  No

C.2.a. If yes, provide the number of eligible entities actively receiving technical assistance for unmet organizational standards. The numerical response should be between 0-99.

C.2.b. Describe in detail, how the state provided technical assistance. This can include the type of tools, strategies, and outcome.

Section D: State Use of Funds

Note: The purpose of this section is to report on the funds received and spent during the

federal fiscal year (FFY), October 1 – September 30. Please review the final award letter

received during the FFY for the reporting period and the Federal Financial Report

(FFR) submitted using standard form 425 (SF-425) for this reporting period. Please ensure that

any allocations, obligations, and carry-over amounts reported below are for funds awarded in

this FFY and are reconciled with the amounts reported in the FFR.

D1. State Distribution Formula: Did the state institute any changes in the distribution formula for the CSBG eligible entities during the reporting period covered by this report?

☐ Yes ☐ No

D.1.a. If yes, please describe any specific changes and describe how the state complied with the assurances provided in Question 14.8 of the CSBG State Plan as required under Section 676(b)(8) of the State CSBG Act?

D.2. Planned vs. Actual Allocation and Expenditures: Using the table below, specify the actual allocation of 90 percent of CSBG funds to CSBG eligible entities, as described under Section 675C(a) of the CSBG Act. This table must be based on actual dollars allocated, obligated to, and expended (liquidated) for each CSBG eligible entity during the FFY. For each CSBG eligible entity receiving CSBG funds, provide the Funding Amount allocated to the CSBG eligible entity during the FFY.

Note: The Amount Allocated and the Amount Obligated are going to be an exact match the majority of the time. Amounts expended (liquidated) should reflect actual payments made to eligible entities.

CSBG Eligible Entity	Planned Allocations	Actual Amount of Allocations (The Amount Allotted to each entity based on State Formula from current FFY funding)	Actual Amount of Obligations (The actual amount made available through sub- awards to each entity during the FFY from current FFY funding)	Actual Expenditures (The actual amount liquidated to each entity during the FFY from current FFY funding)	Carryover Expenditures (The actual amount liquidated to each entity during the FFY from prior FFY funding)
Total

Administrative Funds [Section 675C(b)(2) of the CSBG Act]

D.3. State Administrative Funds: What amount of state CSBG funds did the state obligate for administrative activities during the FFY? The amount must be based on actual dollars allocated during the FFY. If you provided a percentage in Question 7.6 in the CSBG State Plan, please convert to dollars.

CSBG State Plan Target	Actual Amount of Allocation (The amount allotted for state administrative activities)	Actual Amount of Obligation (The actual amount formally committed for procurement or direct expenditure activities during the FFY through state)	Actual Amount of Expenditures (The actual amount liquidated through procurement or direct expenditure activities during the FFY through state)	Actual Carryover Expenditures (The actual amount liquidated through procurement or direct expenditure activities from prior year FFY through state)

D.4. Staff Positions Funded: How many state staff positions were funded in whole or in part with CSBG funds in the reporting period (FFY)?

CSBG State Plan	Actual Number

D.5. State FTEs: How many state Full Time Equivalents (FTEs) were funded with CSBG funds in the reporting period (FFY)?

CSBG State Plan	Actual Number

Remainder/Discretionary Funds [Section 675C(b) of the CSBG Act]

D.6. Describe how the state used remainder or discretionary funds in the table below.

Instructional Note: This table in the administrative report must be based on actual dollars

obligated to each budget category using funds awarded in this federal fiscal year. States that do

not have remainder or discretionary funds will not complete this item. If a funded activity fits

under more than one category in the table, allocate the funds among the categories.

For example, if the state provides funds under a contract with the state Community Action

Association to provide TTA to CSBG eligible entities and to create a statewide data system, the

funds for that contract should be allocated appropriately between Row a and Row c. If an

allocation is not possible, the state may allocate the funds to the main category with which the

activity is associated.

Note: This information is associated with State Accountability Measures 3Sa.

Remainder or Discretionary Fund Uses (See 675C(b)(1) of the CSBG Act)	Planned Allocation	Actual Allocation (The Actual Amount Allotted)	Description of Activities
D.6a. Training and Technical Assistance to eligible entities
D.6b. Coordination of state-operated programs or local programs
D.6c. Statewide coordination and communication among eligible entities
D.6d. Analysis of distribution of CSBG funds to determine if targeting greatest need
D.6e. Asset-building programs
D.6f. Innovative programs or activities by eligible entities or other neighborhood groups
D.6g. State charity tax credits
D.6h. Other activities, specify
Totals

D.7. What types of organizations, if any, did the state work with (by grant or contract using remainder or discretionary funds) to carry out some or all of the activities in Table C.6. (above)? Check all that apply and provide a narrative where applicable.

☐ State Offices (if checked, include the name of the state office(s))

☐ CSBG Eligible Entities (if checked, include the expected number of CSBG eligible entities to receive funds)

☐ Other community-based organizations

☐ State Community Action Association

☐ Regional CSBG technical assistance provider(s)

☐ National technical assistance provider(s)

☐ Individual consultant(s)

☐ Tribes and Tribal Organizations

☐ Other

☐ None (the state will carry out activities directly)

D.8. Total Obligations and Expenditures: Total CSBG funds obligated and expended from CSBG funds awarded for the FFY. Review and confirm from the chart below).

Category	Actual Obligations	Actual Expenditures
D.8a. CSBG eligible entities Funds (from state CSBG 90% formula funds)
D.8b. State Administrative Costs
D.8c. Remainder or Discretionary Funds
D.8d. Total

Section E: State Training and Technical Assistance

E.1. Training and Technical Assistance: Describe how the state delivered CSBG-funded training and technical assistance to CSBG eligible entities by completing the table below. Add a row for each activity: indicate the timeframe; whether it was training, technical assistance, or both; and the topic.

Training, Technical Assistance, Both	Topic	Evaluation Measures for TTA	TTA Organization	Brief Description
From Table 8.1 of the CSBG State Plan Training Technical Assistance Both	From Table 8.1 of the CSBG State Plan Fiscal Governance or Tripartite Boards Organizational Standards – General Organizational Standards – for Eligible Entities with unmet standards on TAPs or QIPs Correcting Significant Deficiencies Among CSBG Eligible Entities Reporting ROMA Community Assessment Strategic Planning Monitoring Communication Technology Other		CSBG Eligible Entities Other community-based organizations State Community Action Association Regional CSBG Technical Assistance Provider(s) National Technical Assistance Provider(s) Individual consultant(s) Tribes and Tribal Organizations Other	Provide additional brief explanation of the technical assistance activities implemented. If “Other” was selected in Column 3, describe in this column. Indicate the types of organizations through which the state provided training or technical assistance and briefly describe their involvement.

Section F: State Linkages and Communication

F.1. Workforce Innovation and Opportunity Act (WIOA) Employment and Training Combined Plan Activities (if applicable): If the state included CSBG employment and training activities as part of a WIOA Unified or Combined State Plan as a required one-stop partner program designated under Section 121(b)(1)(B)(x) of WIOA and/or as an optional combined plan partner program , provide a brief narrative describing the status of WIOA coordination activities, including web links, if available, to any publicly accessible WIOA plans and reports.

F.2. Coordination and feedback among CSBG Eligible Entities and the State Community Action Association: Review and update state activities that took place to support coordination among the CSBG eligible entities and the State Community Action Association.

Section G: Monitoring, Corrective Action, and Fiscal Controls

G.1. Monitoring Schedule: Update the monitoring schedule below. Briefly describe the actual monitoring visits conducted during the FFY, including: full on-site reviews; on-site reviews of newly designated entities; follow-up reviews – including return visits to entities that failed to meet state goals, standards, and requirements; and other reviews as appropriate.

If a monitoring visit was planned during the year but not implemented, provide a brief explanation in the far-right column of the table below.

CSBG Eligible Entity	Monitoring Type	Review Type	Monitoring Start Date	Monitoring End Date	Brief Description of Purpose
	Dropdown Options: Full onsite Newly Designated Follow-up Other No Review	Dropdown Options: Onsite Review Desk Review	[Enter Date]	[Enter End Date]	Note: If the visit was not a part of the original monitoring plan, provide a brief explanation for the purpose of the visit (e.g. a follow-up regarding a special issue). This section should not be used to outline findings.

G.2. Monitoring Policies: Were any modifications made to the state’s monitoring policies and procedures during the reporting period (FFY)?

☐Yes ☐No

If changes were made to state monitoring policies and procedures, attach or provide a hyperlink to the modified documents.

G.3. Initial Monitoring Reports: Were all state monitoring reports conducted in a manner consistent with state monitoring policies and procedures and disseminated to CSBG eligible entities within 60 calendar days?

☐Yes ☐No

Corrective Action, Termination, and Reduction of Funding and Assurance Requirements

(Section 678C of the CSBG Act)

G.4. Technical Assistance (TA): How many CSBG eligible entities within the state are receiving technical assistance due to issues of noncompliance during the FFY? [INSERT NUMBER]

Of the CSBG eligible entities receiving technical assistance, how many were not resolved during the FFY and why? [NARRATIVE]

G.5. Quality Improvement Plans (QIPs): How many CSBG eligible entities within the state are on a QIP due to issues of noncompliance during the FFY? [INSERT NUMBER]

Of the CSBG eligible entities on a QIP, how many were not resolved during the FFY and

why? [NARRATIVE]

G.6. Single Audit Review: Pass through entities are required by 2 CFR 200.331(f) to verify that every sub-recipient is audited as required by 2 CFR 200.501. In the table below, provide the information for any CSBG eligible entity Single Audit in the Federal Audit Clearinghouse (FAC) submitted during FFY.

2 CFR 200.521 requires pass-through entities to provide a management decision for findings related to federal awards the pass-through makes to the sub-recipients. If applicable, provide the information regarding these decisions.

Eligible Entity	Eligible Entity Required to Report Single Audit in FAC	Eligible Entity Submitted a Single Audit in FAC?	Date Audit was Accepted by Federal Audit Clearinghouse	If Entity did not submit as required, has the state taken steps to ensure compliance?	State Management Decision Required? (As Applicable)	Date Management Decision Issued (As applicable)

G.7. Single Audit Management Decisions: Briefly describe any management decisions issued according to state procedures of CSBG eligible entity single audit. Provide the audit finding reference number from the Federal Audit Clearinghouse and describe any required actions and timelines for correction.

G.8. Actual Distribution Timeframe: Did the state make funds available to CSBG eligible entities no later than 30 days after OCS distributed the federal award?

☐Yes ☐No

G.8a. If no, did the state implement procedures to ensure funds were made available to CSBG eligible entities consistently and without interruption?

☐Yes ☐No

G.8b. If the state was not able to make CSBG funds available within 30 calendar days after OCS distributed the federal award and was not able to ensure that funds were made available consistently and without interruption, provide an explanation of the circumstances below along with a description of planned corrective actions.

Section H: Performance Measurement

H.1. Performance Measurement System Participation: Confirm the performance measurement system that the state and CBSG eligible entities use, as required by Section 678E(a) of the CSBG Act and the assurance under Section 676(b)(12) of the CSBG Act.

☐ The Results Oriented Management and Accountability (ROMA) System

☐ Performance measurement system that meets the requirements of Section 678E(b) of the CSBG Act

☐ An alternative system for measuring performance and results

H.1a. If ROMA was selected in G.1, provide an update on any changes in procedures or to data collection systems that were initiated or completed in the reporting period.

H.1b. If ROMA was not selected in Item G.1, describe the system the state used for performance measurement. Provide an update on any changes in procedures or to data collection systems that were initiated or completed in the reporting period.

H.2. State Performance Measurement System Support: How did the state support the CSBG eligible entities in using a performance measurement system to promote continuous improvement? For example, describe any data systems improvements, support for community needs assessment, support for strategic planning, data analysis, etc.

H.3. State Review of CSBG Eligible Entity Data: Describe the procedures and activities the state used to review the Performance Measurement data from CSBG eligible entities for completion and accuracy (e.g. methodology used for validating the data submitted annually by the local agencies).

H.4. State Feedback on Data Collection, Analysis, and Reporting: State Accountability Measure 5S(ii) requires states to submit written feedback to each CSBG eligible entity regarding the entity’s performance in meeting goals, as measured through National Performance Indicator (NPI) data, within 60 calendar days of submitting the state’s Annual Report. Has the state provided each CSBG eligible entity with timely feedback (within at least 60 days of the submission) regarding the entity’s performance in meeting ROMA goals as measured through national performance data?

☐Yes ☐No

If no, please describe.

H.5. State and CSBG Eligible Entity Continuous Improvement: Provide 2 – 3 examples of changes made by CSBG eligible entities to improve service delivery and enhance impact for individuals, families, and communities with low-incomes based on their in-depth analysis of performance data.

Eligible Entity Administration – Module 2

Note: The reporting timeframes for all information in the eligible entity expenditures, capacity, and resources module is based on the federal fiscal year, which runs from October 1 of a given calendar year until September 30 of the following calendar year.

Section A: CSBG Expenditures by CSBG Eligible Entity meets the Congressional requirement for an explanation of the total amount of CSBG funding expended during the reporting period (identified below) based on categories referenced in the CSBG Act.

CSBG funding expended during federal fiscal year should be identified in the domain that best reflects the services delivered and strategies implemented, as well as the administrative costs associated with the domains.

Section B: CSBG Eligible Entity Capacity Building provides detail on agency capacity building funded by CSBG and other funding sources.

Section C: Allocated Resources per CSBG Eligible Entity provides data on resources allocated to, administered through, and generated by the CSBG Eligible Entity. This report provides valuable information on how CSBG leverages funds from multiple federal, state, local, and private sources as required in the CSBG Act.

Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity

Name of CSBG Eligible Entity Reporting:
State:	UEI:

A.1. CSBG Expenditures Domains	CSBG Funds
A.1a. Employment
A.1b. Education
A.1c. Income and Asset Building
A.1d. Housing
A.1e. Health and Nutrition
A.1f. Civic Engagement and Community Involvement
A.1g. Transportation
A.1h. Linkages (e.g. partnerships that support multiple domains)
A.1i. Agency Capacity Building (detailed below in Table A.4)
A.1j. Other (e.g. emergency management or disaster relief)
A.2k. Total CSBG Expenditures (auto calculated)	$0

A.2. Of the CSBG funds reported above, report the total amount used for Administration. For more information on what qualifies as Administration, refer to IM 37.

Module 2, Section B: CSBG Eligible Entity Capacity Building

Name of CSBG Eligible Entity Reporting:
State:	UEI:

B.1. Volunteer Hours of Agency Capacity Building (e.g. program support, service delivery, fundraising):	Hours
B.1a. Total number of volunteer hours donated to the agency
B.1a.1. Of the above, the total number of volunteer hours donated by individuals with low-incomes

B.2. Number of organizations, both public and private, that the CSBG Eligible Entity actively works with to expand resources and opportunities in order to achieve family and community outcomes:	Unduplicated Number of Organizations
B.2a. Non-Profit
B.2b. Faith Based
B.2c. Local Government
B.2d. State Government
B.2e. Federal Government
B.2f. For-Profit Business or Corporation
B.2g. Consortiums or Collaborations
B.2h. School Districts
B.2i. Institutions of Post-Secondary Education orTraining
B.2j. Financial or Banking Institutions
B.2k. Health Service Organizations
B.2l. Statewide Associations or Collaborations

Module 2, Section C: Allocated Resources per CSBG Eligible Entity

Name of CSBG Eligible Entity Reporting:
State:	UEI:

C.1. Federal Resources Allocated (Other than CSBG)
C.1a. Weatherization (DOE) (include oil overcharge $$)							C.1a.
C.1b. Health and Human Services (HHS)
	C.1b.1.		LIHEAP - Energy Assistance (Excluding Weatherization) (include oil overcharge $$)				C.1b.1.
	C.1b.2.		LIHEAP - Weatherization (include oil overcharge $$)				C.1b.2.
	C.1b.3.		Head Start				C.1b.3.
	C.1b.4.		Early Head Start				C.1b.4.
	C.1b.5.		Older Americans Act				C.1b.5.
	C.1b.6.		Social Services Block Grant (SSBG)				C.1b.6.
	C.1b.7.		Medicare or Medicaid				C.1b.7.
	C.1b.8.		Temporary Assistance for Needy Families (TANF)				C.1b.8.
	C.1b.9.		Child Care Development Block Grant (CCDBG)				C.1b.9.
	C.1b.10.		Community Economic Development (CED)				C.1b.10.
	C.1b.11.		Other HHS Resource Description
		C.1b.11.i.			CFDA #:		C.1b.11.i.
		C.1b.11.ii.			CFDA #:		C.1b.11.ii.
		C.1b.11.iii.			CFDA #:		C.1b.11.iii.
		C.1b.11.iv.			CFDA #:		C.1b.11.iv.
		C.1b.12. Total Other HHS Resources					C.1b.12.
C.1c. Department of Agriculture (USDA)
	C.1c.1.		Special Supplemental Nutrition for Women, Infants, and Children (WIC)				C.1c.1.
	C.1c.2.		All USDA Non-Food programs (e.g. rural development)				C.1c.2.
	C.1c.3.		All other USDA Food programs				C.1c.3.
C.1d. Department of Housing and Urban Development (HUD)
	C.1d.1.		Community Development Block Grant (CDBG) - Federal, State, and Local				C.1d.1.
	C.1d.2.		Section 8				C.1d.2.
	C.1d.3.		Section 202				C.1d.3.
	C.1d.4.		Home Tenant-Based Rental Assistance (HOME TBRA)				C.1d.4.
	C.1d.5.		HOPE for Homeowners Program (H4H)				C.1d.5.
	C.1d.6.		Emergency Solutions Grant (ESG)				C.1d.6.
	C.1d.7.		Continuum of Care (CoC)				C.1d.7.
	C.1d.8.		All other HUD programs, including homeless programs				C.1d.8.
C.1e. Department of Labor (DOL)
	C.1e.1.		Workforce Innovation and Opportunity Act (WIOA) *previously WIA				C.1e.1.
	C.1e.2.		Other DOL Employment and Training programs				C.1e.2.
	C.1e.3.		All other DOL programs				C.1e.3.
C.1f. Corporation for National and Community Service (CNCS) programs							C.1f.
C.1g. Federal Emergency Management Agency (FEMA)							C.1g.





C.1h. Department of Transportation							C.1h.
C.1i. Department of Education							C.1i.
C.1j. Department of Justice							C.1j.
C.1k. Department of Treasury							C.1k.
C.1l. Other Federal Resources
		C.1l.i.			CFDA #:		C.1l.i.
		C.1l.ii.			CFDA #:		C.1l.ii.
		C.1l.iii.			CFDA #:		C.1l.iii.
		C.1l.iv.			CFDA #:		C.1l.iv.
C.1m. Total Other Federal Resources							C.1m.
C.1n. Total: Non-CSBG Federal Resources Allocated							C.1n.
C.2. State Resources Allocated
	C.2a.		State appropriated funds used for same purpose as Federal CSBG funds				C.2a.
	C.2b.		State Housing and Homeless programs (include housing tax credits)				C.2b.
	C.2c.		State Nutrition programs				C.2c.
	C.2d.		State Early Childhood Programs (e.g. Head Start, Day Care)				C.2d.
	C.2e.		State Energy programs				C.2e.
	C.2f.		State Health programs				C.2f.
	C.2g.		State Youth Development programs				C.2g.
	C.2h.		State Employment and Training programs				C.2h.
	C.2i.		State Senior programs				C.2i.
	C.2j.		State Transportation programs				C.2j.
	C.2k.		State Education programs				C.2k.
	C.2l.		State Community, Rural and Economic Development programs				C.2l.
	C.2m.		State Family Development programs				C.2m.
	C.2n.		Other State Resources
		C.2n.i.					C.2n.i.
		C.2n.ii.					C.2n.ii.
		C.2n.iii.					C.2n.iii.
		C.2n.iv.					C.2n.iv.
		C.2o. Total Other State Resources					C.2o.
C.2p. Total: State Resources Allocated							C.2p.



C.3. Local Resources Allocated
	C.3a.		Amount of unrestricted funds appropriated by local government				C.3a.
	C.3b.		Amount of restricted funds appropriated by local government				C.3b.
	C.3c.		Value of Contract Services				C.3c.
	C.3d.		Value of in-kind goods or services received from local government				C.3d.
C.3e. Total: Local Resources Allocated							C.3e.
C.4. Private Sector Resources Allocated
	C.4a.		Funds from foundations, corporations, United Way, other nonprofits				C.4a.
	C.4b.		Other donated funds				C.4b.
	C.4c.		Value of other donated items, food, clothing, furniture, etc.				C.4c.
	C.4d.		Value of in-kind services received from businesses				C.4d.
	C.4e.		Payments by clients for services				C.4e.
	C.4f.		Payments by private entities for goods or services for low income				C.4f.
			clients or communities
C.4g. Total: Private Sector Resources Allocated							C.4g.
C.5. Total Non-CSBG Resources Allocated: (Federal, State, Local & Private)							C.5.
C.6. Total Resources in CSBG Eligible Entity (including CSBG)							C.6.

Individual and Family Level Module 3

Note: The reporting timeframes for all information in the individual and family level module is based on the federal fiscal year, which runs from October 1 of a given calendar year until September 30 of the following calendar year.

The data collected in this module relates to Goal 1: Individuals and families with low incomes are stable and achieve economic security.

Section A: Individual and Family Services provides information on the work CSBG Eligible Entities did to help individuals and families achieve the outcomes listed in Section B. This standardized Individual and Family Services list will aid in analysis of the relationship between individuals, services, and outcomes.

Section B: Individual and Family NPIs is comprised of indicators to report outcomes that fall under National Goal 1: Individuals and families with low incomes are stable and achieve economic security. The indicators are the vehicle by which CSBG Eligible Entities measure and report the outcomes they have achieved for individuals and families. All Individual and Family NPIs are optional.

Section C: The All-Characteristics Report collects data on all individuals and households, whether or not funded directly by CSBG. This demographic information strengthens the CSBG Annual Report by demonstrating who is being served by CSBG Eligible Entities.

Module 3, Section A: Individual and Family Services

Service Delivery and Access

Name of CSBG Eligible Entity Reporting:	UEI
State:
Service Delivery	Unduplicated Number Served
SDA 1a. The number of individuals receiving eligibility determinations.
SDA 1b. The number of individuals receiving referrals.
SDA 1c. The number of individuals receiving case management services.

Employment Services

Name of CSBG Eligible Entity Reporting:	UEI
State:
Employment Services (SRV 1)	Unduplicated Number Served
Pre-Employment Readiness (SRV 1a-c)
SRV 1a. The number of youth who received skills training and opportunities for job readiness (e.g.: vocational training, apprenticeship, self-employment).
SRV 1b. The number of adults who received skills training and opportunities for job readiness (e.g.: vocational training, apprenticeship, self-employment).
SRV 1c. The number of individuals who received employment supplies for employment readiness or sustainment (e.g., uniforms, work boots, equipment).
Post-Employment (Retention and Growth) (SRV 1d)
SRV 1d. The number of individuals who received services for employment retention and growth (e.g.: referrals, employer interaction, career pathways).
Other Employment Services (SRV 1e)
SRV 1e. Other Employment Service (Please Describe)

Education Services

Name of CSBG Eligible Entity Reporting:	UEI
State:
Education and Youth Development Services (SRV 2)	Unduplicated Number Served
Childcare, Early Childhood, Young Adult Education Services (SRV 2a-g)
SRV 2a. The number of individuals (age 0-3) who received Early Head Start Services.
SRV 2b. The number of individuals (age 3-5) who received Head Start services.
SRV 2c. The number of individuals receiving childcare subsidies or payments.
SRV 2d. The number of individuals who received early childhood education (0-5), outside of Early Head Start and Head Start.
SRV 2e. The number of individuals who received K-12 education support services (e.g.: English, literacy, etc.)
SRV 2f. The number of youth who attended young adult literacy classes.
SRV 2g. The number of individuals who received college or post-secondary readiness support (e.g.: applications, scholarships, textbooks, computers).
School Supplies (SRV 2h)
SRV 2h. The number of individuals who received school supplies and equipment.
Youth Programs and Skills Developments (SRV 2i-k)
SRV 2i. The number of youth who attended before and after school activities.
SRV 2j. The number of youth who participated in summer youth programs (e.g.: recreational and educational).
SRV 2k. The number of youth who received life skills and coaching services.
Adult Education and Skills Development Programs (SRV 2l-q)
SRV 2l. The number of individuals who attended adult literacy classes.
SRV 2m. The number of adults who attended English Language classes (e.g.: English for Speakers of Other Languages).
SRV 2n. The number of individuals who attended high school equivalency classes.
SRV 2o. The number of individuals who attended applied technology classes.
SRV 2p. The number of adults who received life skills and coaching services.
Home Visits (SRV 2r)
SRV 2q. The number of households that participated in a home visiting program.
Other Childcare, Early Childhood, Youth Development, and Adult Education Services (SRV 2s)
SRV 2r. Other Education, Childcare, and Youth Development Service (Please Describe)

Income and Asset Building Services

Name of CSBG Eligible Entity Reporting:	UEI
State:
Income and Asset Building Services (SRV 3)	Unduplicated Number Served
Training and Counseling Services (SRV 3a-b)
SRV 3a. The number of individuals who received training and counseling services for income management and asset building (e.g.: VITA, tax preparation services, credit repair, financial literacy, financial management, budgeting, homebuying, foreclosure avoidance).
SRV 3b. The number of individuals who received business or self-employment services (e.g.: micro-loans, business development loans, business development, entrepreneurial support).
Benefit Coordination and Advocacy (SRV 3c)
SRV 3c. The number of individuals who received benefit coordination services (e.g.: child support, health insurance, SSI, Veterans, TANF, SNAP).
Other Income and Asset Building Services (SRV 3d)
SRV 3d. Other Income and Asset Building Services (Please Describe).

Housing Services

Name of CSBG Eligible Entity Reporting:	UEI
State:
Housing Services (SRV 4)	Unduplicated Number Served
Housing Assistance (SRV 4a-b)
SRV 4a. The number of individuals who received rental payment assistance (e.g.: emergency rental payments and deposits).
SRV 4b. The number of individuals who received housing payment assistance (e.g.: down payments and emergency mortgage payments).
SRV 4c. The number of individuals who received rapid re-housing and housing placement services (e.g.: temporary, transitional, and permanent housing placements).
Eviction Prevention Services (SRV 4c)
SRV 4d. The number of individuals who received eviction prevention services (e.g.: housing counseling, eviction counseling, landlord or tenant mediations and rights).
Utility Assistance Services (SRV 4d)
SRV 4e. The number of individuals who received utility payment assistance (to include deposits, arrears, and assistance).
Housing Maintenance & Improvements (SRV 4f)
SRV 4f. The number of individuals who received housing maintenance and improvement services (e.g.: structural, accessibility improvements, emergency home repairs, water safety, healthy home).
Weatherization and Energy Efficiency Services (SRV 4g)
SRV 4g. The number of households that received weatherization and energy efficiency services.
Other Housing Services (SRV 4h)
SRV 4h. Other Housing Service (Please Describe).

Health and Nutrition Services

Name of CSBG Eligible Entity Reporting:	UEI
State:
Health and Nutrition Services (SRV 5)	Unduplicated Number Served
Health Services, Screening and Assessments (SRV 5a-c)
SRV 5a. The number of individuals who received immunizations.
SRV 5b. The number of individuals who received health screenings (e.g.: physicals, chronic health screenings).
SRV 5c. The number of individuals who received developmental delay screening.
Health Insurance Coverage & Payment (SRV 5d-e)
SRV 5d. The number of older adults who received healthcare payment assistance (e.g.: prescription payments, doctor visit payments).
SRV 5e. The number of individuals who received Health Insurance Options Counseling.
Maternal and Child Health & Reproductive Health Services (SRV 5f-g)
SRV 5f. The number of individuals who received reproductive health services (e.g.: family planning, contraceptives, STI or HIV prevention).
SRV 5g. The number of individuals who received maternal child or health services (e.g.: breastfeeding support, safe sleeping, postpartum support).
Wellness Services and Education (SRV 5h-j)
SRV 5h. The number of individuals who received general wellness services (e.g.: medication management, mindfulness, exercise, fitness).
SRV 5i. The number of older adults who received a home visit (e.g.: nursing, chores, personal care services).
SRV 5j. The number of older adults who participated in elder day centers or senior centers.
Mental and Behavioral Health (SRV 5k-m)
SRV 5k. The number of individuals who received substance use or misuse services (e.g.: intake, screening, counseling, support groups, and hotline, crisis or call in-response).
SRV 5l. The number of individuals who received mental health services (e.g.: intake, screening, counseling, support group, hotline, crisis or call in-response).
SRV 5m. The number individuals who received domestic violence prevention/support services (e.g.: support groups and hotline, crisis or call in-response).
Dental Services, Screenings and Exams (SR
SRV 5n. The number of adults who received dental services (e.g.: screenings, exams, procedures).
SRV 5o. The number of children who received dental services (e.g.: screenings, exams, procedures).
Food and Nutrition (SRV 5p-5s)
SRV 5p. The number of individuals who received food or nutrition skills classes (cooking, nutrition).
SRV 5q. The number of individuals who received prepared meals (e.g.: through a congregate nutrition site, Meals on Wheels, a prepared food delivery or pickup program.
SRV 5r. The number of individuals who received food distribution services (bags, boxes, food share, groceries).
SRV 5s. The number of individuals who participated in community gardening activities.
Basic Health Needs and Supplies (SRV 5t-5w)
SRV 5t. The number of hygiene kits or supplies (e.g.: hygiene kits, toothpaste, soap, deodorant, menstrual products) provided to individuals and families.
SRV 5u. The number of diapers or diapering supplies (e.g.: diapers, wipes) provided to individuals and families.
SRV 5v. The number of individuals accessing hygiene utilization services (e.g.: showers, toilets, sinks, laundry facilities) to individuals and families.
SRV 5w. The number of individuals who received clothing assistance.
Other Health and Nutrition (SRV 5x)
SRV 5x. Other Health and Nutrition Services (Please Describe).

Civic Engagement and Community Involvement Services

Name of CSBG Eligible Entity Reporting:	UEI
State:
Civic Engagement and Community Involvement Services (SRV 6a-d)	Unduplicated Number Served
SRV 6a. The number of individuals who received Voter Education and Access services.
SRV 6b. The number of individuals who participated in a Tri-partite Board.
SRV 6d. The number of individuals who engaged in volunteer opportunities.
Other Civic Engagement and Community Involvement (SRV 6e)
SRV 6e. Other Civic Engagement and Community Involvement Services (Please Describe).

Transportation Services

Name of CSBG Eligible Entity Reporting:	UEI
State:
Transportation Services (SRV 7)	Unduplicated Number Served
Transportation (SRV 7a-e)
SRV 7a. The number of public transportation voucher or passes provided to individuals and families.
SRV 7b. The number of gas cards provided to individuals and families.
SRV 7c. The number non-medical transportation rides provided to individuals and families.
SRV 7d. The number of medical transportation rides provided to individuals and families.
SRV 7e. The number rideshare or taxi vouchers provided to individuals and families.
SRV 7f. The number of individuals receiving transportation repair services (includes both automobiles and non-automotive transportation).
SRV 7g. The number of individuals receiving automotive support (e.g.: insurance premiums, car payment assistance, car repairs).
Other Transportation Service (SRV 7h)
SRV 7h. Other Transportation Services (Please Describe).

Module 3, Section B: Individual and Family NPIs

Employment Indicators

Employment (FNPI 1)	I.) Number Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV]	V.) Performance Target Accuracy (III/II = V]
FNPI 1a. The number of unemployed youth who increased skills to obtain employment.
FNPI 1b. The number of unemployed adults who increased skills to obtain employment.
FNPI 1c. The number of youth who obtained employment. .
FNPI 1d. The number of adults who obtained employment.
FNPI 1e. The number of employed individuals who increased wage or salary income from employment.
FNPI 1f. Other (Please Describe)

Comments:

Education Indicators

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Education and Youth Development (FNPI 2)	I.) Number Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV]	V.) Performance Target Accuracy (III/II = V]
FNPI 2a. The number of children (0-5) who received childcare or early childhood education services.
FNPI 2b. The number of youth participated in education and skills development programs.
FNPI 2c. The numbers of adults who improved their basic education skills.
FNPI 2d. The number of individuals who increased their education by obtaining a high school diploma or obtained an equivalency certificate or diploma.
FNPI 2e. The number of individuals who increased their education by obtaining a recognized credential, certificate, or degree relating to the achievement of educational or vocational skills.
FNPI 2f. The number of individuals who increased their education through enrollment in a post-secondary degree program (e.g., associates, bachelors, etc.)
FNPI 2g. The number of individuals who obtained a post-secondary degree.
FNPI 2h. Other (Please Describe)

Income and Asset Building Indicators

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Income and Asset Building (FNPI 3)	I.) Number Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV]	V.) Performance Target Accuracy (III/II = V]
FNPI 3a. The number of individuals completing income and asset building training.
FNPI 3b. The number of individuals with an increase in one or more assets (e.g.: savings account, IDA, home purchase, reduced debt).
FNPI 3c. The number of individuals who started a business or other forms of self-employment.
FNPI 3d. The number of individuals with an increase in public benefits to assist with income (e.g., child support, health insurance, SSI, Veterans, TANF, SNAP).
FNPI 3e. Other (Please Describe)

Housing Indicators

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Housing (FNPI 4)	I.) Number Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV]	V.) Performance Target Accuracy (III/II = V]
FNPI 4a. The number of individuals experiencing homelessness who obtained safe temporary shelter.
FNPI 4b. The number of individuals who obtained safe and affordable housing.
FNPI 4c. The number of individuals who avoided eviction.
FNPI 4d. The number of individuals who avoided foreclosure.
FNPI 4e. The number of individuals who experienced improved home health and safety due to improvements (e.g. weatherization, water safety, reduction or elimination of lead, radon, carbon monoxide or fire hazards or electrical issues, etc.).
FNPI 4f. The number of individuals who avoided utility shut-off or had utility service restored.
FNPI 4g. The number of individuals served with improved water safety in their homes.
FNPI 4h. Other (Please Describe)

Health and Nutrition Indicators

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Health and Nutrition (FNPI 5)	I.) Number Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV]	V.) Performance Target Accuracy (III/II = V]
FNPI 5a. The number of individuals served who then improved their health and well-being through preventative measures.
FNPI 5b. The number of individuals with increased access to health coverage.
FNPI 5c. The number of individuals whose health issue was treated by receiving health services.
FNPI 5d. The number of individuals who reproductive health issue was resolved by receiving reproductive services.
FNPI 5e. The number of individuals with increased access to wellness services.
FNPI 5f. The number of older adults (age 65+) with increased access to home visiting services.
FNPI 5g. The number of older adults (age 65+) who maintained an independent living situation.
FNPI 5h. The number of individuals served who then improved their mental health, behavioral health or well-being.
FNPI 5i. The number of adults served who then improved their oral health.
FNPI 5j. The number of children served who then improved their oral health .
FNPI 5k. The number of individuals receiving increased access to healthy food options.
FNPI 5l. Other (Please Describe)

Civic Engagement and Community Involvement Indicators

Name of CSBG Eligible Entity Reporting:
State:	UEI:
Civic Engagement and Community Involvement Indicators (FNPI 6)	I.) Number Served in program(s) (#)	II.) Target (#)	III.) Actual Results (#)	IV.) Percentage Achieving Outcome [III/ I = IV]	V.) Performance Target Accuracy (III/II = V]
FNPI 6a. The number of individuals with low-income who increased skills, knowledge, and abilities to help improve conditions in their community.
FNPI 6b. Other (Please Describe)

Module 3, Section C: All Characteristics Report

Name of CSBG Eligible Entity Reporting:
State:		UEI
A. Total unduplicated number of all INDIVIDUALS about whom one or more characteristics were obtained:
B. Total unduplicated number of all HOUSEHOLDS about whom one or more characteristics were obtained:
C. INDIVIDUAL LEVEL CHARACTERISTICS
1. Gender Identity						Number of Individuals
a. Male
b. Female
c. Transgender, non-binary or another gender
d. Unknown or not reported
e. TOTAL (auto calculated)
2. Age						Number of Individuals
a. 0-4
b.5-17
c. 18-24
d. 25-34
e. 35-44
f. 45-64
g. 65-84
h. 85 and older
i. Unknown or Not reported
j. TOTAL
3. Education Levels				Number of Individuals
				[ages 5-24]		[ages 25+]
a. Grades 0-8
b. Grades 9-12 or Non-Graduate
c. High School Graduate, GED, or Equivalency Diploma
e. 12 grade + Some Post-Secondary
f. 2 or 4 years College Graduate
g. Graduate of other post-secondary school
h. Unknown or not reported
i. TOTAL
4. Disconnected Youth							Number of Individuals
a. Youth ages 14-24 who are neither working or in school
5. Health							Number of Individuals
a. Provide the number of individuals with a disability.
			Yes		No		Unknown
b. Health Insurance*
*If an individual reported that they had Health Insurance please identify the source of health insurance below.
Health Insurance Sources
c.1. Medicaid
c.2. Medicare
c.3. State Children’s Health Insurance Program
c.4. State Health Insurance for Adults
c.5. Military Health Care
c.6. Direct-Purchase
c.7. Employment Based
c.8. Unknown or not reported
c.9. TOTAL
6. Race and Ethnicity							Number of Individuals
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Hispanic or Latino
e. Middle Eastern or North African
f. Native Hawaiian and Pacific Islander
g. White
h. Multiracial or Multiethnic (two or more of the above)
i. Unknown or not reported
j. TOTAL

7. Military Status			Number of Individuals
a. Veteran
b. Active Military
c. Never Served in the Military
d. Unknown or not reported
e. TOTAL
8. Work Status (Individuals 18+)			Number of Individuals
a. Employed Full-Time
b. Employed Part-Time
c. Migrant or Seasonal Farm Worker
d. Unemployed (Short-Term, 6 months or less)
e. Unemployed (Long-Term, more than 6 months)
f. Unemployed (Not in Labor Force)
g. Retired
h. Unknown or not reported
i. TOTAL
D. HOUSEHOLD LEVEL CHARACTERISTICS
9. Household Type			Number of Households
a. Single Person
b. Two Adults no children
c. Household with multiple adults with no children
d. Single Parent Female
e. Single Parent Male
f. Two Parent Household
g. Non-related Adults with Children
h. Multigenerational Household
i. Other
j. Unknown or not reported
k. TOTAL
10. Household Size			Number of Households
a. Single Person
b. Two
c. Three
d. Four
e. Five
f. Six or more
g. Unknown or not reported
h. TOTAL
11. Housing			Number of Households
a. Own
b. Rent
c. Other permanent housing
d. Homeless
e. Other
f. Unknown or Not reported
g. TOTAL
12. Level of Household Income			Number of Households
a. Up to 50%
b. 51% to 75%
c. 76% to 100%
d. 101% to 125%
e. 126% to 150%
f. 151% to 175%
g. 176% to 200%
h. 201% to 250%
i. 251% and over
j. Unknown or Not reported
k. TOTAL
13. Sources of Household Income			Number of Households
a. Income from Employment Only
b. Income from Employment and Other Income Source
c. Income from Employment, Other Income Source, and Non-Cash Benefits
d. Income from Employment and Non-Cash Benefits
e. Other Income Source Only
f. Other Income Source and Non-Cash Benefits
g. No Income
h. Non-Cash Benefits Only
i. Unknown/not reported
j. TOTAL

Community Level – Module 4

Section A: Community Initiative Status is where CSBG Eligible Entities identify initiatives intended to achieve community level outcomes. This form provides a central place to report valuable information about a single community initiative that started, continued, or ended during the current reporting period. The information reported on the status form will be selected via a dropdown

Section B: Community NPIs Data provides an opportunity for CSBG Eligible Entities to enter data for the community level outcomes reported in Section A, Line 14. Entities may select from the indicators outlined in this section, or create their own indicator if none of the provided indicators captures what the CSBG Eligible Entity is trying to achieve. To facilitate the reporting, use, and learning from Community NPIs the Annual Report provides two types of indicators (Counts of Change and Rates of Change).

The first way to report impact is the Counts of Change indicators. These are basic measures that provide the number of units being measured, e.g. jobs, houses, resources, etc. that have been added (created) or subtracted (eliminated), and in some cases maintained, in the community the CSBG Eligible Entity has targeted.

The second way to report impact is the Rates of Change indicators. While requiring a bit more information, these indicators tell the full story of the magnitude of the impact a community initiative (usually involving multiple organizations) has had in a community.

Section C: Community Strategies List provides a basic identification of strategies, arranged by Domain and by topic area. The list cannot be all-inclusive; as such, an “other” category is included. This standardized list will aid in local and state analysis of the relationship between community-level strategies and outcomes.

Module 4, Section A: Community Initiative Status

Name of CSBG Eligible Entity Reporting:
State:	UEI:
	Use the dropdown menu to select the response where appropriate.
1. Initiative Name
2. Initiative Year	1-7+ years
3. Problem Identification	Narrative (Provide a narrative on the scope of the problem)
4. Goal or Agenda	Narrative (Provide a narrative on the goal or agenda)
5. Issue/CSBG Community Domains	Employment; Education and Cognitive Development; Income, Infrastructure, and Asset Building; Housing; Health and Social/Behavioral Development; or Civic Engagement and Community Involvement
6. Ultimate Expected Outcome	Community Level National Performance Indicators (NPIs) (Reference the Community NPIs listed in Section B)
7. Identified Community	Neighborhood, City, School District, County, Service Area, State, Region, or Other
8. Expected Duration	Narrative (Provide the range in years, e.g.: 1-3 years)
9. Partnership Type	Independent CAA Initiative, CAA is the core organizer of multi-partner Initiative, or CAA is one of multiple active investors and partners
10. Partners	Narrative (Provide a narrative on the key 1-3 partners)
11. Strategy(ies)	Select from the Community Level Strategies listed in Section C
12. Progress on Outcomes/Indicators	No Outcomes to Report, Interim Outcomes, Final Outcomes
13. Impact of Outcomes	Narrative (Provide additional information on the scope of the impact of these outcomes. E.g.: if an initiative created a health clinic, please describe how many individuals and families are expected to be impacted.)
14. Outcomes/Indicators to Report	Community Level National Performance Indicators (NPIs) (Reference the Community NPIs listed in Section B)
15. Final Status	Initiative Active, Initiative Ended Early, Initiative Ended as Planned, Completed Still Delivering Value
16. Lessons Learned	Narrative

Module 4, Section B: Community National Performance Indicators (NPIs)

Name of CSBG Eligible Entity Reporting:
State:		UEI:
Counts of Change	Counts of Change for Employment Indicators (CNPI 1)		I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 1a Number of jobs created to increase opportunities for individuals with low incomes in the identified community.
	CNPI 1b Number of job opportunities maintained in the identified community.
	CNPI 1c Number of “living wage” jobs created in the identified community*.
	CNPI 1d Number of “living wage” jobs maintained in the identified community*.
	CNPI 1e Number of jobs created in the identified community with a benefit package.

*When reporting on indicators related to living wage, agencies can provide their own definition or select from national or locally-defined models. Please indicate the living wage definition used in the General Comment box.

Other	Other Counts of Change for Employment Indicators (CNPI 1z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
Counts of	CNPI 1z.1 Other
Change	CNPI 1z.2 Other
	CNPI 1z.3 Other

Rates of Change	Rates of Change for Employment Indicators (CNPI 1)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
	CNPI 1f Percent decrease of the unemployment rate.
	CNPI 1g Percent decrease of the youth unemployment rate.
	CNPI 1h Percent decrease of the underemployment rate.

Other Rates of	Other Rates of Change for Employment Indicators (CNPI 1z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 1z.4 Other
	CNPI 1z.5 Other
	CNPI 1z.6 Other

General comments:

Name of CSBG Eligible Entity Reporting:
State:		UEI:
Counts of Change	Counts of Change for Education and Cognitive Development Indicators (CNPI 2)		I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 2a Number of accessible and affordable early childhood or pre-school education assets or resources added to the identified community.
	CNPI 2b Number of accredited or licensed affordable childcare facilities added in the identified community.
	CNPI 2c Number of new Early Childhood Screenings offered to children (ages 0-5) of families with low-incomes in the identified community.
	CNPI 2d Number of accessible and affordable education assets or resources added for school age children in the identified community. (e.g., academic, enrichment activities, before/after school care, summer programs)
	CNPI 2e Number of accessible and affordable post-secondary education assets or resources added for newly graduating youth in the identified community. (e.g. college tuition, scholarships, vocational training, etc.)
	CNPI 2f Number of accessible and affordable basic or secondary education assets or resources added for adults in the identified community. (e.g. literacy, ESL, ABE/GED, etc.)

Other Counts of Change	Other Counts of Change for Education and Cognitive Development Indicators (CNPI 2z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 2z.1 Other
	CNPI 2z.2 Other
	CNPI 2z.3 Other

	Rates of Change for Education and Cognitive Development Indicators (CNPI 2)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Rates of Change	CNPI 2g Percent increase of children in the identified community who are kindergarten ready.
	CNPI 2h Percent increase of children in the identified community at (or above) the basic reading level.
	CNPI 2i Percent increase of children in the identified community at (or above) the basic math level.
	CNPI 2j Percent increase in high school (or high school equivalency) graduation rate in the identified community.
	CNPI 2k Percent increase of the rate of youth in the identified community who attend post-secondary education.
	CNPI 2l Percent increase of the rate of youth in the identified community who graduate from post-secondary education.
	CNPI 2m Percent increase of adults in the identified community who attend post-secondary education.
	CNPI 2n Percent increase of adults in the identified community who graduate from post-secondary education.
	CNPI 2o Percent increase in the adult literacy rate in the identified community.

Other Rates of	Other Rates of Change for Education and Cognitive Development Indicators (CNPI 2z) - Please specify below.	I.) Identified Community (auto populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 2z.4 Other
	CNPI 2z.5 Other
	CNPI 2z.6 Other

General comments:

Name of CSBG Eligible Entity Reporting:
State:		UEI:
Counts of Change	Counts of Change for Infrastructure and Asset Building Indicators (CNPI 3)		I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 3a Number of new accessible assets/resources created in the identified community:
	CNPI 3a.1 Commercial
	CNPI 3a.2 Financial
	CNPI 3a.3 Technological/ Communications (e.g. broadband)
	CNPI 3a.4 Transportation
	CNPI 3a.5 Recreational (e.g. parks, gardens, libraries)
	CNPI 3a.6 Other Public Assets/Physical Improvements
	CNPI 3b Number of existing assets/resources made accessible to the identified community:
	CNPI 3b.1 Commercial
	CNPI 3b.2 Financial
	CNPI 3b.3 Technological/ Communications (e.g. broadband)
	CNPI 3b.4 Transportation
	CNPI 3b.5 Recreational (e.g. parks, gardens, libraries)
	CNPI 3b.6 Other Public Assets/Physical Improvements

Other Counts of Change	Other Counts of Change for Infrastructure and Asset Building Indicators (CNPI 3z) - Please specify below.	I.) Identified Community (auto populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 3z.1 Other
	CNPI 3z.2 Other
	CNPI 3z.3 Other

	Rates of Change for Infrastructure and Asset Building Indicators (CNPI 3)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	VII.) Performance target accuracy (% auto calculated)
Rates of Change	CNPI 3c Percent decrease of abandoned or neglected buildings in the identified community.
	CNPI 3d Percent decrease in emergency response time measured in minutes in the identified community. (EMT, Police, Fire, etc.).
	CNPI 3e Percent decrease of predatory lenders and/or lending practices in the identified community.
	CNPI 3f Percent decrease of environmental threats to households (toxic soil, radon, lead, air quality, quality of drinking water, etc.) in the identified community.
	CNPI 3g Percent increase of transportation services in the identified community.
Other Rates of	Other Rates of Change for Infrastructure and Asset Building Indicators (CNPI 3z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 3z.4 Other
	CNPI 3z.5 Other
	CNPI 3z.6 Other

General comments:

Name of CSBG Eligible Entity Reporting:
State:		UEI:
Counts of Change	Counts of Change for Housing Indicators (CNPI 4)		I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 4a Number of safe and affordable housing units developed in the identified community (e.g. built or set aside units for individuals with low incomes).
	CNPI 4b Number of safe and affordable housing units maintained and/or improved through WAP or other rehabilitation efforts in the identified community.
	CNPI 4c Number of shelter beds created in the identified community.
	CNPI 4d Number of shelter beds maintained in the identified community.

Other	Other Counts of Change for Housing Indicators (CNPI 4z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
Counts of Change	CNPI 4z.1 Other
	CNPI 4z.2 Other
	CNPI 4z.3 Other

	Rates of Change for Housing Indicators (CNPI 4)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Rates of Change	CNPI 4e Percent decrease in the rate of homelessness in the identified community.
	CNPI 4f Percent decrease in the foreclosure rate in the identified community.
	CNPI 4g Percent increase in the rate of home ownership of individuals with low incomes in the identified community.
	CNPI 4h Percent increase of affordable housing in the identified community.
	CNPI 4i Percent increase of shelter beds in the identified community.
		I.) Identified	II.) Baseline	III.) Target	IV.) Expected %	V.) Actual Results	VI.) Actual %	VII.) Performance
		Community	existing starting	(%)	change from	(%)	change from	target accuracy
	Other Rates of Change for Housing Indicators (CNPI 4z)	(auto populated)	point used for		baseline		baseline	(% auto calculated)
Other Rates of	- Please specify below.		comparisons (%)		(Target % auto calculated)		(% auto calculated)
Change
	CNPI 4z.4 Other
	CNPI 4z.5 Other
	CNPI 4z.6 Other

General comments:

Name of CSBG Eligible Entity Reporting:
State:		UEI:
Counts of Change	Counts of Change for Health and Social/Behavioral Indicators (CNPI 5)		I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
	CNPI 5a Number of accessible and affordable physical health assets or resources created in the identified community.
	CNPI 5b Number of accessible and affordable behavioral and mental health assets or resources created in the identified community.
	CNPI 5c Number of public safety assets and resources created in the identified community.
	CNPI 5d Number of accessible and affordable healthy food resources created in the identified community.
	CNPI 5e Number of activities designed to improve police and community relations within the identified community.

Other Counts of	Other Counts of Change for Health and Social/Behavioral Indicators (CNPI 5z) - Please specify below.				I.) Identified Community (auto-populated)	II.) Target (#)	III.) Actual Results (#)	IV.) Performance target accuracy (% auto calculated)
Change	CNPI 5z.1 Other
	CNPI 5z.2 Other
	CNPI 5z.3 Other
	Rates of Change for Physical Health, Wellbeing, and Development Indicators (CNPI 5)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Rates of Change	CNPI 5f Percent decrease in infant mortality rate in the identified community.
	CNPI 5g Percent decrease in childhood obesity rate in the identified community.
	CNPI 5h Percent decrease in adult obesity rate in the identified community.
	CNPI 5i Percent increase in child immunization rate in the identified community.
	CNPI 5j Percent decrease in uninsured families in the identified community.

	Rates of Change for Behavioral and Mental health, Emotional Wellbeing, and Development Indicators (CNPI 5)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Rates of Change	CNPI 5k Percent decrease in the teen pregnancy rate in the identified community.
	CNPI 5l Percent decrease in unplanned pregnancies in the identified community.
	CNPI 5m Percent decrease in substance abuse rate in the identified community. (e.g. cigarettes, prescription drugs, narcotics, alcohol).
	CNPI 5n Percent decrease in domestic violence rate in the identified community.
	CNPI 5o Percent decrease in the child abuse rate in the identified community.
	CNPI 5p Percent decrease in the child neglect rate in the identified community.
	CNPI 5q Percent decrease in the elder abuse rate in the identified community.
	CNPI 5r Percent decrease in the elder neglect rate in the identified community.
	Rates of Change for Public Safety Indicators (CNPI 5)	I.) Identified Community (auto populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Rates of Change	CNPI 5s Percent decrease in recidivism rate in the identified community.
	CNPI 5t Percent decrease in non-violent crime rate in the identified community.
	CNPI 5u Percent decrease in violent crime rate in the identified community.
	CNPI 5v Percent decrease in teens involved with the juvenile court system in the identified community.
Other Rates of	Other Rates of Change for Health and Social/Behavioral Indicators (CNPI 5z) - Please specify below.	I.) Identified Community (auto populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 5z.4 Other
	CNPI 5z.5 Other
	CNPI 5z.6 Other

General comments:

Name of CSBG Eligible Entity Reporting:
State:		UEI:
	Rates of Change for Civic Engagement and Community Involvement Indicators - Goal 2 (CNPI 6)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)		V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Rates of Change	CNPI 6 G2a Percent increase of donated time to support the CSBG Eligible Entity's delivery of services and/or implementation of strategies to address conditions of poverty in the identified community.
	CNPI 6 G2b Percent increase of donated resources to support the CSBG
	Eligible Entity's delivery of services and/or implementation of strategies
	to address conditions of poverty in the identified community.
	CNPI 6 G2c Percent increase of individuals participating in public hearings,
	policy forums, community planning, or other advisory boards related to the CSBG Eligible Entity's delivery of service and/or implementation of
	strategies to address conditions of poverty in the identified community.

Other Rates of	Other Rates of Change for Civic Engagement and Community Involvement Indicators - Goal 2 (CNPI 6 G2z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 6 G2z.4 Other
	CNPI 6 G2z.5 Other
	CNPI 6 G2z.6 Other
Other Counts of Change	Other Counts of Change for Civic Engagement and Community Involvement Indicators - Goal 2 (CNPI 6 G2z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
	CNPI 6 G2z.1 Other
	CNPI 6 G2z.2 Other
	CNPI 6 G2z.3 Other

General comments:

Name of CSBG Eligible Entity Reporting:
State:		UEI:
Rates of	Rates of Change for Civic Engagement and Community Involvement Indicators - Goal 3 (CNPI 6)	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 6 G3a Percent increase of individuals with low incomes who support
	the CSBG Eligible Entity's delivery of service and/or implementation of
	strategies to address conditions of poverty in the identified community.
	CNPI 6 G3b Percent increase of individuals with low incomes who acquire
	and maintain leadership roles with the CSBG Eligible Entity or other
	organizations within the identified community.

Other Rates of	Other Rates of Change for Civic Engagement and Community Involvement Indicators - Goal 3 (CNPI 6 G3z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
Change	CNPI 6 G3z.4 Other
	CNPI 6 G3z.5 Other
	CNPI 6 G3z.6 Other
Other Counts of Change	Other Counts of Change for Civic Engagement and Community Involvement Indicators - Goal 3 (CNPI 6 G3z) - Please specify below.	I.) Identified Community (auto-populated)	II.) Baseline existing starting point used for comparisons (%)	III.) Target (%)	IV.) Expected % change from baseline (Target % auto calculated)	V.) Actual Results (%)	VI.) Actual % change from baseline (% auto calculated)	VII.) Performance target accuracy (% auto calculated)
	CNPI 6 G3z.1 Other
	CNPI 6 G3z.2 Other
	CNPI 6 G3z.3 Other

General comments:

Module 4, Section C: Community Strategies List

Name of CSBG Eligible Entity Reporting:
State:	UEI:
	Employment Strategies (STR 1)
STR 1a	Minimum/Living Wage Campaign
STR 1b	Job Creation/Employment Generation
STR 1c	Job Fairs
STR 1d	Earned Income Tax Credit (EITC) Promotion
STR 1e	Commercial Space Development
STR 1f	Employer Education
STR 1g	Employment Policy Changes
STR 1h	Employment Legislative Changes
STR 1i	Other Employment Strategy: (please specify)

	Education and Cognitive Development Strategies (STR 2)
STR 2a	Preschool for All Campaign
STR 2b	Charter School Development
STR 2c	After School Enrichment Activities Promotion
STR 2d	Pre K-College/Community College Support
STR 2e	Children’s Trust Fund Creation
STR 2f	Scholarship Creation
STR 2g	Child Tax Credit (CTC) Promotion
STR 2h	Adoption Child Care Quality Rating
STR 2i	Adult Education Establishment
STR 2j	Education and Cognitive Development Policy Changes
STR 2k	Education and Cognitive Development Legislative Changes
STR 2l	Other Education and Cognitive Development Strategy: (please specify)

	Infrastructure and Asset Building Strategies (STR 3)
STR 3a	Cultural Asset Creation
STR 3b	Police/Community Relations Campaign
STR 3c	Neighborhood Safety Watch Programs
STR 3d	Anti-Predatory Lending Campaign
STR 3e	Asset Building and Savings Promotion
STR 3f	Develop/Build/Rehab Spaces
STR 3g	Maintain or Host Income Tax Preparation Sites
STR 3h	Community-Wide Data Collection Systems Development
STR 3i	Local 211 or Resource/Referral System Development
STR 3j	Water/Sewer System Development
STR 3k	Community Financial Institution Creation
STR 3l	Infrastructure Planning Coalition
STR 3m	Park or Recreation Creation and Maintenance
STR 3n	Rehabilitation/Weatherization of Housing Stock
STR 3o	Community Center/Community Facility Establishment
STR 3p	Asset Limit Barriers for Benefits Policy Changes
STR 3q	Infrastructure and Asset Building Policy Changes
STR 3r	Infrastructure and Asset Building Legislative Changes
STR 3s	Other Infrastructure and Asset Building Strategy: (please specify)

	Housing Strategies (STR 4)
STR 4a	End Chronic Homelessness Campaign
STR 4b	New Affordable Single Unit Housing Creation
STR 4c	New Affordable Multi- Unit Housing Creation (Single Resident Occupancy (SRO), temporary housing, transitional housing)
STR 4d	Tenants’ Rights Campaign
STR 4e	New Shelters Creation (including day shelters and domestic violence shelters)
STR 4f	Housing or Land Trust Creation
STR 4g	Building Codes Campaign
STR 4h	Housing Policy Changes
STR 4i	Housing Legislative Changes
STR 4j	Other Housing Strategy: (please specify)

	Health and Social/Behavioral Development Strategies (STR 5)
STR 5a	Health Specific Campaign
STR 5b	Farmers Market or Community Garden Development
STR 5c	Grocery Store Development
STR 5d	Gun Safety/Control Campaign
STR 5e	Healthy Food Campaign
STR 5f	Nutrition Education Collaborative
STR 5g	Food Bank Development
STR 5h	Domestic Violence Court Development
STR 5i	Drug Court Development
STR 5j	Alternative Energy Source Development
STR 5k	Develop or Maintain a Health Clinic
STR 5l	Health and Social/Behavioral Development Policy Changes
STR 5m	Health and Social/Behavioral Development Legislative Changes
STR 5n	Other Health and Social/Behavioral Development Strategy: (please specify)

	Civic Engagement and Community Involvement Strategies - Goal 2 (STR 6 G2)
STR 6 G2a	Development of Health and Social Service Provider Partnerships
STR 6 G2b	Recruiting and Coordinating Community Volunteers
STR 6 G2c	Poverty Simulations
STR 6 G2d	Attract Capital Investments
STR 6 G2e	Build/Support Increased Equity
STR 6 G2f	Equity Awareness Campaign
STR 6 G2g	Coordinated Community-wide Needs Assessment
STR 6 G2h	Civic Engagement and Community Involvement in Advocacy Efforts
STR 6 G2i	Civic Engagement Policy Changes
STR 6 G2j	Civic Engagement Legislative Changes
STR 6 G2k	Other Civic Engagement and Community Involvement Strategy: (please specify)

	Civic Engagement and Community Involvement Strategies - Goal 3 (STR 6 G3)
STR 6 G3a	Empowerment of Individuals/Families with Low-Incomes
STR 6 G3b	Campaign to Ensure Individuals with Low-Incomes are Represented on Local Governing Bodies
STR 6 G3c	Social Capital Building Campaign for Individuals/Families with Low-Incomes
STR 6 G3d	Campaign for Volunteer Placement and Coordination
STR 6 G3e	Civic Engagement Policy Changes
STR 6 G3f	Civic Engagement Legislative Changes
STR 6 G3g	Other Civic Engagement and Community Involvement Strategy: (please specify)

	Community Support Strategies (STR 7)
STR 7a	Off-Hours (Non-Traditional Hours) Child Care Development
STR 7b	Transportation System Development
STR 7c	Transportation Services Coordination and Support
STR 7d	Community Support Policy Changes
STR 7e	Community Support Legislative Changes
STR 7f	Other Community Support Strategy: (please specify)

	Emergency Management Strategies (STR 8)
STR 8a	State or Local Emergency Management Board Enhancement
STR 8b	Community wide Emergency Disaster Relief Service Creation
STR 8c	Disaster Preparation Planning
STR 8d	Emergency Management Policy Changes
STR 8e	Emergency Management Legislative Changes
STR 8f	Other Emergency Management Strategy: (please specify)