# General Information

1. PR/Award #:  _______________________________________2. Grantee NCES ID#:  _________________________________

*(Block 5 of the Grant Award Notification - 11 characters.)**(See instructions. Up to 12 characters.)*

3 Project Title: __________________________________________________________________________________________________

*(Enter the same title as on the approved application.)*

4. Grantee Name *(Block 1 of the Grant Award Notification.):*______________________________________________________________

5. Grantee Address *(See instructions.)*

6. Project Director *(See instructions.)*Name:_______________________________________Title: _______________________________

    Ph #:  (        ) ________ - __________   Ext: (         )Fax #:  (        ) ________ - __________  

    Email Address:  __________________________________________________

## Reporting Period Information (See instructions.)

7. Reporting Period: From: _____/_____/_______   To:  _____/_____/_______      (mm/dd/yyyy)

## Budget Expenditures (To be completed by your Business Office.  See instructions.  Also see Section B.)

8. Budget Expenditures

## Indirect Cost Information (To be completed by your Business Office.  See instructions.)

9. Indirect Costs

a. Are you claiming indirect costs under this grant?  ___Yes   ___No

If yes, please indicate which of the following applies to your grant?

 b. ___The grantee has an Indirect Cost Rate Agreement approved by the Federal Government:

       The period covered by the Indirect Cost Rate Agreement is from: ____/ _____/______ to: ____/_____/_______    (mm/dd/yyyy)

The approving Federal agency is:   ___ED   ___Other *(Please specify*): _______________________​​​__________ 

              The Indirect Cost Rate is _______%

The Type of Rate *(For Final Performance Reports Only*) is: ___ Provisional   ___ Final  ___ Other *(Please specify):*

c.___The grantee is not a State, local government, or Indian tribe, and is using the de minimus rate of 10% of modified total direct costs (MTDC) in compliance with 2 CFR 200.414(f). 

d.___The grantee is funded under a Restricted Rate Program and is you using a restricted indirect cost rate that either:

___ Is included in its approved Indirect Cost Rate Agreement; or 

___ Complies with 34 CFR 76.564(c)(2).

e.___The grantee is funded under a Training Rate Program and:

           ___Is recovering indirect cost using 8 percent of MTDC in compliance with 34 CFR 75.562(c)(2); or

            ___ Is recovering indirect costs using its actual negotiated indirect cost rate reflected in 9(b).   

## Human Subjects (Annual Institutional Review Board (IRB) Certification) (See instructions.)

10.  Is the annual certification of Institutional Review Board (IRB) approval attached?  ​___Yes ___ No ___ N/A

## Data Privacy and Security Measures Certification (See instructions.)

11. Is a statement affirming that you are aware of federal and state data security and student privacy regulations included, with supporting documentation attached? ___Yes ___ No ___ N/A

**Performance Measures Status and Certification *(See instructions.)***

12. Performance Measures Status

a. Are complete data on performance measures for the current budget period included in the Project Status Chart?  ___Yes  ___ No

b. If no, when will the data be available and submitted to the Department?  _____/_____/______   (mm/dd/yyyy)

13. By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate and the

expenditures, disbursements, and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award.  I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to

criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-33812). 

Furthermore, to the best of my knowledge and belief, all data in this performance report are true, complete, and correct and the report fully discloses all known weaknesses concerning the accuracy, reliability, and completeness of data reported.

_____________________________________________________ Title: _______________________________________

Name of Authorized Representative:

_____________________________________________________ Date: _____/_____/_______

Signature:

PR/Award # (11 characters): ________________________

**(See Instructions)**

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