OMB Control No: 0970-0381 Expiration Date: 3/31/2020 PERFORMANCE PROGRESS REPORT HHS ADMINISTRATION FOR CHILDREN AND FAMILIES State Abstinence Program Performance Narrative Page 1 of 6 1.Federal Agency and Organization Element to Which Report is Submitted 2. Federal Grant or Other Identifying Number Assigned by Federal Agency 3a. DUNS Number 3b. EIN 4. Recipient Organization (Name and complete address including zip code) 5. Recipient Identifying Number or Account Number 6. Project/Grant Period (i.e., 5 years) 7. Budget Period (i.e., 1 year) 8. Final Report ? Yes No Start Date: (Month, Day, Year) End Date: (Month, Day, Year) Start Date: (Month, Day, Year) End Date: (Month, Day, Year) 9. Report Frequency annual semi-annual quarterly other (If other, describe: __________ __________________________) 10. Performance Narrative 11. Other Attachments
PERFORMANCE PROGRESS REPORT Table A – Activity Results Page 2 of 6 1.Federal Agency and Organization Element to Which Report is Submitted Populated 2. Federal Grant or Other Identifying Number Assigned by Federal Agency Populated 3a. DUNS Populated 4. Reporting Period End Date (Month, Day, Year) Populated 3b. EIN Populated Section A—UNDUPLICATED COUNT OF CLIENTS SERVED Indicate the number of all clients served by gender, ethnicity, and age. Label Summary Ages Others Served TOTAL Unduplicated Count of Clients Served Females Calculated Calculated Calculated Label Race and Gender Asian Black Hispanic Native American Native Hawaiian White Other TOTAL Female Client(s) age 10 Female Client(s) age 11 Female Client(s) age 12 Calculated Female Client(s) age 13 Calculated Female Client(s) age 14 Calculated 20
Female Client(s) age 15 Calculated Female Client(s) age 16 Calculated Female Client(s) age 17 Calculated Female Client(s) age 18 Calculated Female Client(s) age 19 Calculated Female Client(s) age Calculated Other Female recipients or training Calculated TOTAL Calculated Calculated Calculated Calculated Calculated Calculated Calculated Calculated OMB Control No: 0970-0381 Expiration Date: 3/31/2020 PERFORMANCE PROGRESS REPORT Table A - Activity Results Continued Page 3 of 6 1.Federal Agency and Organization Element to Which Report is Submitted Populated 2. Federal Grant or Other Identifying Number Assigned by Federal Agency Populated 3a. DUNS Populated 4. Reporting Period End Date (Month, Day, 3b. EIN Populated
Year) Populated Section A (Continued)—UNDUPLICATED COUNT OF CLIENTS SERVED Indicate the number of all clients served by gender, ethnicity, and age. Label Summary Ages Others Served TOTAL Unduplicated Count of Clients Served Males Calculated Calculated calculated Unduplicated Count of Clients Served Males and Females Calculated Calculated calculated Label Race and Gender Asian Black Hispanic Native American Native Hawaiian White Other TOTAL Male Client(s) age 10 Male Client(s) age 11 Male Client(s) age 12 Calculated Male Client(s) age 13 Calculated Male Client(s) age 14 Calculated Male Client(s) age 15 Calculated 20
Male Client(s) age 16 Calculated Male Client(s) age 17 Calculated Male Client(s) age 18 Calculated Male Client(s) age 19 Calculated Male Client(s) age Calculated Other male recipients of services or training Calculated TOTAL Calculated Calculated Calculated Calculated Calculated Calculate Calculate Calculated TOTAL MALES & FEMALES Calculated Calculated Calculated Calculated Calculated Calculate Calculated Calculated OMB Control No: 0970-0381 Expiration Date: 3/31/2020 PERFORMANCE PROGRESS REPORT Table B - Activity Results Page 4 of 6 1.Federal Agency and Organization Element to Which Report is Submitted Populated 2. Federal Grant or Other Identifying Number Assigned by Federal Agency 3a. DUNS Populated 4. Reporting Period End Date (Month, Day, Year) 3b. EIN Populated
clients that complete at least 75% of the program After school abstinence curriculum Parent education Training for abstinence educators Mentoring (one-on-one) Conference, retreat rally, assembly Add’l. programs (youth presenters, drama, etc.) Other (Describe)__________________ Calculated Calculated Counts of clients that complete at least 75% of the program In-class abstinence curriculum After school abstinence curriculum Parent education Training for abstinence educators Mentoring (one-on-one) Conference, retreat rally, assembly Add’l. programs (youth presenters, drama, etc.) Other (Describe)__________________ Calculated Calculated Counts of clients that complete at least 75% of the program In-class abstinence curriculum After school abstinence curriculum Parent education Training for abstinence educators Mentoring (one-on-one) Conference, retreat rally, assembly Add’l. programs (youth presenters, drama, etc.) Other (Describe)__________________ Calculated Calculated Counts of clients that complete at least 75% of the program In-class abstinence curriculum After school abstinence curriculum Parent education Training for abstinence educators Mentoring (one-on-one) Conference, retreat rally, assembly Add’l. programs (youth presenters, drama, etc.) Other (Describe)__________________ Calculated Calculated