Submitted Date:

Submitted by:

Due Date:

Report for Period Ending: (Mark the appropriate reporting period)

1st Trimester / October 1 – January 31
2ndTrimester / February 1– May 31
3rdTrimester / June 1 – September 30

Please fill in the numbers for each reporting period.

Item / 1st Trimester / 2nd Trimester / 3rd Trimester / Total
Case Management: Total Active Caseload
New Unduplicated Older Refugees Served This Period
Enrolled in Pre-Literate English as a Second Language (ESL) Training
Enrolled in ESL Class
Enrolled in Citizenship Preparation Class
Obtained Citizenship through Medical Waiver
Obtained Citizenship through USCIS Test
Obtained Low Income Housing
Obtained Low Cost Healthcare
Secured financial support (employment, SSI, Family Security)

SCHEDULE A: PROGRAM NARRATIVE

1. Report on major activities undertaken in the following areas during the reporting period:
Adjustment of Status
Area of Effort / Activity / Accomplishment / Challenge
a) Trends and opportunities, and expansion updates for adjustment of status efforts including efforts toward obtaining medical waivers and citizenship.
b) Developments in extended services, such as trends and/or strategies for connecting older refugees to services for adjustment of status such as ELT Classes, citizenship workshops, tutors, mentors and BIA specialists.
c) Mainstream community collaborations (elder welfare, law enforcement, etc.) including meetings (and their outcomes), challenges encountered, and advocacy efforts.
d) Coordination efforts with local Resettlement Agencies, MAA’s CBO’s, FBO, and USCIS, specifically for referrals and to address barriers to self-sufficiency.
New program initiatives: Please include only those initiatives which pertain to the areas of effort outlined in (a) through (d) above.
Case Management and Self-Sufficiency
Area of Effort / Activity / Accomplishment / Challenge
a) Significant developments in the areas of referring and assisting clients with obtaining access to appropriate mainstream aging services and benefits such as those for medical care assistance, supplemental income and support, housing assistance, legal resources, social adjustment services, emergency services, etc. / -
b) Referrals, trends and collaborative efforts with other service providers for specialized services that assist in enhancing the client’s social adjustment and self-sufficiency (such as employment, volunteer placement, educational programs, mental health care, family preservation).
2. Caseload Breakdown(This breakdown is for active cases.)
Age / Time in the US
60-65 / Over 65 / 0 - 12 months / Over 12 Months / 7 Years or More
Adjusted to Status / Not Yet Adjusted / In danger of losing SSI Benefits
Male
Female
New program initiatives: Please include only those initiatives which pertain to citizenship, medical waiver and/or adjustment of status:

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