Agency of Human Services
Department for Children and Families
Child Development Division
Welcome to the Child Development Division’s
PCC Master Grantee Performance Measure Report

PART I -- Contact Information:
Today's Date*
Month Day Year
Company/Organizational Name*
Agreement # (i.e., "03440-######-17-PCC")*
Point of Contact*
First Name Last Name
Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Phone Number*
Area Code Phone Number
E-mail*

PART II -- Performance Measures:
Quantity (How Much Are You Doing?):
1. # of parents/caregivers served by PCC services:*
2. # of children served:*
This includes sum of: # children served in home visits and # children served through early childhood services which will be identified in data collection. Home visiting services reported in this data set will exclude home visiting services supported by CIS funding.
3. # of parent education support activities:*
The PCC should include a brief anecdotal description of Parent Education and Peer Support activities.
4. # of playgroup conducted:*

Breakdown of Services to Families:

	Amount Spent	# of Children Served	# of Adults Served	# of Families Served	# of Children with Disabilities Served	# of Parents with Disabilities Served
Auto/Transportation: Includes gas, insurance, tickets, car repairs, bus fare, inspection, etc.
Clothing/Personal: Family expenses, employment assistance, personal hygiene supplies, etc.
Food: For families, workshops, teen parents, parent ed groups, etc.
Utilities: Electric, heat, telephone, etc.
Housing Assistance: Rent, transitional housing, motel, shelter, etc.
Education: Adult and teen education programs, parent education workshops, etc.
Child Care Assistance: Payment, finding child care, etc.
Children: Diapers, formula, safety gates, hygiene products, cribs, etc.
Medical: Prescriptions, over the counter medications, doctor's bills, insurance premiums, etc.
Coordination: Staffing to organize this program
Miscellaneous: Any other services you provide that are not listed above.
Admin Costs:

6. Community Development Activities:
a. # of community development activities (Family Engagement)*
b. # of community development activities (Advocacy/Systems)*
For each activity, indicate the PCC role(s):
Participant Leader Host Contributed Staff Time Provided Funding
Family Engagement:
Advocacy/Systems:
Quality (How Well Are You Doing It?):
7. Average satisfaction rating of families served by PCC services:*
This includes summary across home visiting services, early childhood services, parent education and peer support activities, playgroups and concrete supports which will be identified in data collection.
Impact (Is anyone Better Off?):
8. % of families reporting positive impact on their lives because of PCC activities:*
9. % of families reporting perceived increase in protective factors:*
Should be Empty:

	Participant	Leader	Host	Contributed Staff Time	Provided Funding
Family Engagement:
Advocacy/Systems: