QUESTIONNAIRE
FOR REFERENCE ONLY
Template

NAME and DESCRIPTION

1. What is the Federal agency/OPDIV administering the Program, Service, Function, or Activity (PSFA)?

2. What is the formal or descriptive name (and short title, if different) of the PSFA for which you are completing this questionnaire? (If only a portion of the PSFA is being described, explain what is included from this presentation.)

3. If applicable, what is the program number from the Catalog of Federal Domestic Assistance?

4. What are the objectives of the PSFA?

5. What are projects currently funded under this program (name at least 3 specific funded examples and provide brief descriptions)?

AUTHORITY

6. What are the the authorizing statute(s) for the PSFA?

7. What are pertinent regulatory or administrative requirements that apply?

8. What specific statutory changes would have to be made in order to award funds under this PSFA for a self-governance demonstration project?

APPLICANTS, BENEFICIARIES and FORMULAS

9. What type of funding does the PSFA provide for (for example: "Competitive project grant" or "State formula grant")?

10. What entities are eligible applicants for the funds (organizations which may apply for and receive funds)?

11. What are the particular allotment formulas, set-asides or taps in the statute(s) or rules of the PSFA?

12. Are American Indians/Alaskan Natives (AI/AN) implicitly or explicitly eligible applicants (either directly or indirectly as subgrantees) for funds? If "Yes," describe which and provide a full explanation of this applicant eligibility including specific allotment formulas, set-asides or taps that apply to them.

13. Who are the eligible beneficiaries under the PSFA?

14. Are AI/AN implicitly or explicitly beneficiaries (either directly or indirectly as subgrantees) of the PSFA? If "Yes," describe which and provide a full explanation of this beneficiary eligibility including specific allotment formulas, set-asides or taps that apply.

15. What percentage does any mandatory AI/AN-directed spending represent of the total?

PROGRAM FINANCIAL INFORMATION

16. For FY 2000, what was total funding for this PSFA?

17. Of this total, what amount and percent was awarded to AI/AN tribes/villages?

18. How many awards and what was the range/average amounts provided generally and to tribes?

19. For FY 2001, if known, what is the total (new and continuing) funding expected for this PSFA?

OTHER REQUIREMENTS

20. As relevant to determining feasibility for inclusion in a demonstration project, include answers to the following and indicate if it is a statutory requirement:

-- length of time the assistance is funded

-- use restrictions on the funds

-- reporting requirements

-- audit requirements

CONTACTS

21. Who is the DHHS Tribal Self-Governance Study Workgroup member (and their contact information) to contact regarding this questionnaire?

22. Who is the cognizant HHS Agency/Program Contact (and their contact information)?