Tribal Self-Governance Study
Description of Program, Service, Function or Activity (PSFA)
DATA COLLECTION FORM (template)
Reference Questions

1. Agency Name:

2. Program Name:

3. CFDA #:

4. Program Objectives:

5. Titles and Descriptions of at least Three Funded Grantees:

AUTHORITY

6. Authorizing Statute(s):

7. Regulatory/Administrative Requirements:

8. Mandatory Statutory Changes Needed to Operate PSFA as a Demonstration:

APPLICANTS, BENEFICIARIES and FORMULAS

9. Type of Funding:

10. Eligible Applicants:

11. Allotment Formulas, Etc.:

12. Applicant Provisions/Allotments in Law for Indians:

13. Eligible Beneficiaries:

14. Beneficiary Provisions/Allotments in Law for Indians:

15. Amount and Percent of Total that is Mandatory for Indians:

FINANCIAL

16. Total FY 2000 Funding:

17. Amount and Percent of Total Funding Awarded to Indians:

18. For Awards to Tribes: Number, Range and Average Amounts:

19. Total FY 2001 Funding and Amount for Indians, If Known:

OTHER

20. -- how long assistance is funded

-- fund use restrictions

-- reporting requirements

-- audit requirements

CONTACTS

21. DHHS Workgroup Contact:

22. HHS Agency/Program Contact: