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City of Jersey City
Community Services Block Grant
Quarterly Activity Report
INSTRUCTIONS:
By completeing the data requested below, the Quarterly Activity Report will calculate the totals
and reduce the need to enter data more than once.
Input data cells are shaded yellow on all forms.
INPUT DATA:
1. Name of Agency: Your Agency
2. Name of Program: Your Program
3. Name of Director: Your Director
4. Name of Report Preparer: Preparer's name
Agency Name Your Agency Date Submitted
Program Name Your Program Period: Projections
Director Your Director Start Date: 10/1/2009
Food Pantry
Preparer Preparer's name End Date: 9/30/2010
Services or
Goals Problem, Need, Situation Measure Outcome Measure
Activities/Outputs
1 2 3 4 5 6
Policy Planning Programming Projection Actual YTD Impact Projection Actual YTD
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Agency Name Your Agency Date Submitted
Program Name Your Program Period: Projections
Director Your Director Start Date: 10/1/2009
Food Pantry
Preparer Preparer's name End Date: 9/30/2010
Services or
Goals Problem, Need, Situation Measure Outcome Measure
Activities/Outputs
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Agency Name Your Agency Date Submitted
Program Name Your Program Period: Projections
Director Your Director Start Date: 10/1/2009
Food Pantry
Preparer Preparer's name End Date: 9/30/2010
Services or
Goals Problem, Need, Situation Measure Outcome Measure
Activities/Outputs
1 2 3 4 5 6
Policy Planning Programming Projection Actual YTD Impact Projection Actual YTD
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Agency Name Your Agency Date Submitted
Program Name Your Program Period: Projections
Director Your Director Start Date: 10/1/2009
Food Pantry
Preparer Preparer's name End Date: 9/30/2010
Services or
Goals Problem, Need, Situation Measure Outcome Measure
Activities/Outputs
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Policy Planning Programming Projection Actual YTD Impact Projection Actual YTD
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Agency Name Your Agency Date Submitted
Program Name Your Program Period: Projections
Director Your Director Start Date: 10/1/2009
Food Pantry
Preparer Preparer's name End Date: 9/30/2010
Services or
Goals Problem, Need, Situation Measure Outcome Measure
Activities/Outputs
1 2 3 4 5 6
Policy Planning Programming Projection Actual YTD Impact Projection Actual YTD
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Agency Name Your Agency Date Submitted
Program Name Your Program Period: Projections
Director Your Director Start Date: 10/1/2009
Food Pantry
Preparer Preparer's name End Date: 9/30/2010
Services or
Goals Problem, Need, Situation Measure Outcome Measure
Activities/Outputs
1 2 3 4 5 6
Policy Planning Programming Projection Actual YTD Impact Projection Actual YTD
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Food Pantry
Evaluation Tools
7
Accountability
A. Tools for Measurement
B. Where Data Maintained
C. Source of Data
D. Frequency of Collection
E. Processing of Data
Food Pantry
Evaluation Tools
7
Accountability
Food Pantry
Evaluation Tools
7
Accountability
Food Pantry
Evaluation Tools
7
Accountability
Food Pantry
Evaluation Tools
7
Accountability
Food Pantry
Evaluation Tools
7
Accountability
CITY OF JERSEY CITY
DIVISION OF COMMUNITY DEVELOPMENT
COMMUNITY SERVICES BLOCK GRANT (CSBG)
QUARTERLY ACTIVITY REPORT
Agency: Your Agency
Program: Your Program
Director: Your Director Report Preparer: Preparer's name
Reporting
Period: October, November, December Date Submitted:
I. STATISTICAL DATA
A. QUARTERLY STATISTICS
1. New Participants
2. Carry Overs/Duplicated
3. Reporting Period Levels of Service 0
Total of Lines 1 and 2 must equal Line 3. All participants are considered new in the first quarter of the fiscal year.
COUNT NEW PARTICIPANTS ONLY FOR SECTIONS B - F
B. Ethnic Breakdown
Hispanic or Latino Not Hispanic or Latino
B1. Race
Non-
Hispanic Non-Hispanic Hispanic Hispanic
White Black/African American
Asian Asian & White
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native & White
Black/African American & White
Am. Indian/Alaskan Native & Black/African American
Asian/Pacific Islander
Other Multi-Racial
C. Gender Identification: Female Male
D. Number of Female Heads of Household:
E. Number of Handicapped Persons Served:
F. Number of Homeless Persons Served:
All clients who are served in the First Quarter are considered NEW regardless of previous participation. Only those clients that were not reported in the First
Quarterly Report are considered new in the remaining reports.
I certify that the information contained in this quarterly activity report is true in all respects and in accordance with provisions of the contract.
Your Director
Executive Director Signature Date
B. Ethnic Breakdown B1. Race (Hispanic) B1. Race (Non-Hispanic)
C. Gender Identification
II. eLogic Model
Please use this page to report how services provided are impacting your clients. Goals must coincide with the goals your agency has identified
in the subgrantee agreement.
Problem,
Services or
Need, Measure Outcome Measure Evaluation Tools
Activities/Outputs
Situation
2 3 4 5 6 7
Planning Programming Projection Actual YTD Impact Projection Actual YTD Accountability
0 0 #N/A 0 #N/A
0 0 0 0 A. Tools for Measurement
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 B. Where Data Maintained
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 0 #N/A 0 #N/A 0
0 0 0 0 C. Source of Data
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 D. Frequency of Collection
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 0 #N/A 0 #N/A 0
0 0 0 0 E. Processing of Data
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
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0 #N/A 0 #N/A
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0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
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0 #N/A 0 #N/A
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0 0 #N/A 0 #N/A
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0 0 #N/A 0 #N/A
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0 #N/A 0 #N/A
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0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
Please use additional sheets if necessary.
III. PROBLEMS (PLEASE EXPLAIN)
IV. PERSONNEL CHANGES
Please use this space to report any additions/terminations in personnel. (Be specific. List names, titles, and dates of change).
V. ADDITIONAL COMMENTS
CITY OF JERSEY CITY
DIVISION OF COMMUNITY DEVELOPMENT
COMMUNITY SERVICES BLOCK GRANT (CSBG)
QUARTERLY ACTIVITY REPORT
Agency: Your Agency
Program: Your Program
Director: Your Director Report Preparer: Preparer's name
Reporting
Period: January, February, March Date Submitted:
I. STATISTICAL DATA
A. QUARTERLY STATISTICS
1. New Participants
2. Carry Overs/Duplicated
3. Reporting Period Levels of Service 0
Total of Lines 1 and 2 must equal Line 3. All participants are considered new in the first quarter of the fiscal year.
COUNT NEW PARTICIPANTS ONLY FOR SECTIONS B - F
B. Ethnic Breakdown
Hispanic or Latino Not Hispanic or Latino
B1. Race
Non-
Hispanic Non-Hispanic Hispanic Hispanic
White Black/African American
Asian Asian & White
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native & White
Black/African American & White
Am. Indian/Alaskan Native & Black/African American
Asian/Pacific Islander
Other Multi-Racial
C. Gender Identification: Female Male
D. Number of Female Heads of Household:
E. Number of Handicapped Persons Served:
F. Number of Homeless Persons Served:
All clients who are served in the First Quarter are considered NEW regardless of previous participation. Only those clients that were not reported in the First
Quarterly Report are considered new in the remaining reports.
I certify that the information contained in this quarterly activity report is true in all respects and in accordance with provisions of the contract.
Your Director
Executive Director Signature Date
II. eLogic Model
Please use this page to report how services provided are impacting your clients. Goals must coincide with the goals your agency has identified
in the subgrantee agreement.
Problem,
Services or
Need, Measure Outcome Measure Evaluation Tools
Activities/Outputs
Situation
2 3 4 5 6 7
Planning Programming Projection Actual YTD Impact Projection Actual YTD Accountability
0 0 #N/A 0 #N/A
0 0 0 0 A. Tools for Measurement
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 B. Where Data Maintained
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 0 #N/A 0 #N/A 0
0 0 0 0 C. Source of Data
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 D. Frequency of Collection
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 0 #N/A 0 #N/A 0
0 0 0 0 E. Processing of Data
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
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0 #N/A 0 #N/A
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0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
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0 #N/A 0 #N/A
0 0 0 0
0 0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
Please use additional sheets if necessary.
III. PROBLEMS (PLEASE EXPLAIN)
IV. PERSONNEL CHANGES
Please use this space to report any additions/terminations in personnel. (Be specific. List names, titles, and dates of change).
V. ADDITIONAL COMMENTS
CITY OF JERSEY CITY
DIVISION OF COMMUNITY DEVELOPMENT
COMMUNITY SERVICES BLOCK GRANT (CSBG)
QUARTERLY ACTIVITY REPORT
Agency: Your Agency
Program: Your Program
Director: Your Director Report Preparer: Preparer's name
Reporting
Period: April, May, June Date Submitted:
I. STATISTICAL DATA
A. QUARTERLY STATISTICS
1. New Participants
2. Carry Overs/Duplicated
3. Reporting Period Levels of Service 0
Total of Lines 1 and 2 must equal Line 3. All participants are considered new in the first quarter of the fiscal year.
COUNT NEW PARTICIPANTS ONLY FOR SECTIONS B - F
B. Ethnic Breakdown
Hispanic or Latino Not Hispanic or Latino
B1. Race
Hispanic Non-Hispanic N
Hispanic on-Hispanic
White Black/African American
Asian Asian & White
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native & White
Black/African American & White
Am. Indian/Alaskan Native & Black/African American
Asian/Pacific Islander
Other Multi-Racial
C. Gender Identification: Female Male
D. Number of Female Heads of Household:
E. Number of Handicapped Persons Served:
F. Number of Homeless Persons Served:
All clients who are served in the First Quarter are considered NEW regardless of previous participation. Only those clients that were not reported in the First
Quarterly Report are considered new in the remaining reports.
I certify that the information contained in this quarterly activity report is true in all respects and in accordance with provisions of the contract.
Your Director
Executive Director Signature Date
II. ACCOMPLISHMENTS
Please use this page to report how services provided are impacting your clients. Goals must coincide with the goals your agency has identified
in the subgrantee agreement.
Problem,
Services or
Need, Measure Outcome Measure Evaluation Tools
Activities/Outputs
Situation
2 3 4 5 6 7
Planning Programming Projection Actual YTD Impact Projection Actual YTD Accountability
0 0 #N/A 0 #N/A
0 0 0 0 A. Tools for Measurement
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 B. Where Data Maintained
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 0 #N/A 0 #N/A 0
0 0 0 0 C. Source of Data
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 D. Frequency of Collection
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 0 #N/A 0 #N/A 0
0 0 0 0 E. Processing of Data
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
Please use additional sheets if necessary.
III. PROBLEMS (PLEASE EXPLAIN)
IV. PERSONNEL CHANGES
Please use this space to report any additions/terminations in personnel. (Be specific. List names, titles, and dates of change).
V. ADDITIONAL COMMENTS
CITY OF JERSEY CITY
DIVISION OF COMMUNITY DEVELOPMENT
COMMUNITY SERVICES BLOCK GRANT (CSBG)
QUARTERLY ACTIVITY REPORT
Agency: Your Agency
Program: Your Program
Director: Your Director Report Preparer: Preparer's name
Reporting
Period: July, August, September Date Submitted:
I. STATISTICAL DATA
A. QUARTERLY STATISTICS
1. New Participants
2. Carry Overs/Duplicated
3. Reporting Period Levels of Service 0
Total of Lines 1 and 2 must equal Line 3. All participants are considered new in the first quarter of the fiscal year.
COUNT NEW PARTICIPANTS ONLY FOR SECTIONS B - F
B. Ethnic Breakdown
Hispanic or Latino Not Hispanic or Latino
B1. Race
Hispanic Non-Hispanic N
Hispanic on-Hispanic
White Black/African American
Asian Asian & White
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native & White
Black/African American & White
Am. Indian/Alaskan Native & Black/African American
Asian/Pacific Islander
Other Multi-Racial
C. Gender Identification: Female Male
D. Number of Female Heads of Household:
E. Number of Handicapped Persons Served:
F. Number of Homeless Persons Served:
All clients who are served in the First Quarter are considered NEW regardless of previous participation. Only those clients that were not reported in the First
Quarterly Report are considered new in the remaining reports.
I certify that the information contained in this quarterly activity report is true in all respects and in accordance with provisions of the contract.
Your Director
Executive Director Signature Date
II. ACCOMPLISHMENTS
Please use this page to report how services provided are impacting your clients. Goals must coincide with the goals your agency has identified
in the subgrantee agreement.
Problem,
Services or
Need, Measure Outcome Measure Evaluation Tools
Activities/Outputs
Situation
2 3 4 5 6 7
Planning Programming Projection Actual YTD Impact Projection Actual YTD Accountability
0 0 #N/A 0 #N/A
0 0 0 0 A. Tools for Measurement
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 B. Where Data Maintained
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 0 #N/A 0 #N/A 0
0 0 0 0 C. Source of Data
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 D. Frequency of Collection
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 0 #N/A 0 #N/A 0
0 0 0 0 E. Processing of Data
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 #N/A 0 #N/A 0
0 0 0 0 0
0 0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
0 #N/A 0 #N/A
0 0 0 0
Please use additional sheets if necessary.
III. PROBLEMS (PLEASE EXPLAIN)
IV. PERSONNEL CHANGES
Please use this space to report any additions/terminations in personnel. (Be specific. List names, titles, and dates of change).
V. ADDITIONAL COMMENTS
Goals
Goals
The number of low-income individuals served by
Community Action who sought emergency assistance
and the number of those individuals for whom
assistance was provided.
CAMP e Logic Model™
Column 2
PROBLEM, NEEDS, SITUATION
Low-income families/individuals do not have adequate resources to
purchase food to meet their dietary requirements.
Click here to allow
deletion of 'New'
CAMP e Logic Model™ Activities
Column 3
SERVICES OR ACTIVITIES/OUTPUTS AND BENCHMARKS UNITS
Provide a balanced food package to low-income individuals and families. Persons
Provide vouchers for purchase of a balanced food package. Persons
other Other
Click here to allow
deletion of 'New'
CAMP e Logic Model™ Outcomes
Column 5
ACHIEVEMENT OUTCOMES GOALS AND INDICATORS UNITS
Individuals/Families have an adequate supply of nutritional food to prevent hunger on Persons
a temporary basis.
other other
CAMP eLogic Model™
A. Tools For Measurement
Bank accounts
Construction log
Database
Enforcement log
Financial aid log
Intake log
Interviews
Mgt. Info. System-automated
Mgt. Info. System-manual
Outcome scale(s)
Phone log
Plans
Pre-post tests
Post tests
Program specific form(s)
Questionnaire
Recruitment log
Survey
Technical assistance log
Time sheets
B. Where Data Maintained
Agency database
Centralized database
Individual case records
Local precinct
Public database
School
Specialized database
Tax Assessor database
Training center
C. Source of Data
Audit report
Business licenses
Certificate of Occupancy
Code violation reports
Counseling reports
Employment records
Engineering reports
Environmental reports
Escrow accounts
Financial reports
GED certification/diploma
Health records
HMIS
Inspection results
Lease agreements
Legal documents
Loan monitoring reports
Mortgage documents
Payment vouchers
Permits issued
Placements
Progress reports
Referrals
Sale documents
Site reports
Statistics
Tax assessments
Testing results
Waiting lists
Work plan reports
D. Frequency of Collection
Daily
Weekly
Monthly
Quarterly
Biannually
Annually
Upon incident
E. Processing of Data
Computer spreadsheets
Flat file database
Manual tallies
Relational database
Statistical database
