Fillable FORM FY 2021 ANNUAL: THE ANNUAL REPORT REPORT

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FORM FY 2021 ANNUAL: THE ANNUAL REPORT REPORT

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PAGE 1:
THE ANNUAL REPORT
FORM FY 2021 ANNUAL
REPORT
1. Complete all requested information:
a. List Contractor Name, School, Tribe or IEC
b. List Contact Person (program coordinator/director)
c. List Address, City, State, Zip Code and Telephone Number
d. List Contract Period
2.
List all schools/project sit
es served
3. Signatory Authority: The individual who is authorized to sign the contract documents
must sign on the line entitled, “Contractor’s Representative.” The report will be
returned if it is not signed.
PAGE 2 - SECTION II:
1. Complete all sections for each page utilized.
2. Refer to your contract to see how many approved education plans were included in your
application (include any approved modifications if the education plans w ere revised). If
your approved application contained three (3) education plans, you will need to copy
page 2 three times and complete an education plan for each component.
3. All information needed (except objectives achieved) for Section II A. (1) Will come from
the education plans in your approved application, including the measurable objectives. It
is your responsibility to meet the objectives, as outlined in your education plan(s), and to
be able to document whether or not the stated objectives were met.
PAGE 3:
Indian Education Committee Report: All sections are to be completed by the Indian Education
Committee (p
arent committee). It is a vital component of the Annual Report. The page must be
signed and dated by the IEC Chairperson. The report will be returned if it is not completed and
signed by the IEC chairperson. PLEASE ATTACH IE C MINUT ES SHOWING APPROVAL OF THIS ANNUAL REPORT.
JOHNSON O’MALLEY
ANNUAL
REPORT
FISCAL YEAR 2021
CITY STATE ZIP
SCHOOL DISTRICT
PROGRAM CONTACT PERSON
E-MAIL
ADDRESS:
TELEPHONE:
CONTRACT PERIOD: 10/1/20-9/30/21
FAX
SCHOOL / PROJECT SITES CONTAINED IN THIS CONTRACT
NAME ADDRESS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
SIGNATURES:
SIGNATORY AUTHORITY
School Representative date
MCN Field Specialist date
MCN JOM Program Manager date
Page 1 of 3
Duplicate as needed
JOHNSON O’MALLEY - ANNUAL REPORT
Section II
SECTION II TO BE COMPLETED FOR EACH EDUCATION GOAL AND RESPONDING MEASURABLE OBJECTIVE LISTING IN YOUR
CONTRACT UNDER PART III # 2 & 3 OF THE FINAL UPDATED APPLICATION and PART III # 6 & 7 OF THE FINAL BUDGET REVISION
Name of school/pre-school/project site
Person in charge
No. Of eligible students actually served Pre-K K-6 7-12
No. Of students actually served Pre-K K-6 7-12
A. (1) QUANTITATIVE EVALUATION OF EFFECTIVENESS OF PROGRAMS IN
MEETING STATED OBJECTIVES.
Describe the activities that were carried out during the year to meet the objectives as outline in your approved Education
Plan.
Program Grade Level
This section must include your measurable objective quantitative results showing %’s or
number based statistics
Measurable objectives for the period covered by the contract Objectives Achieved (explain)
Evaluation (2) If objective(s) were not achieved or fully achieved, describe problems encountered
and recommended corrective actions. (Describe any unusual achievements or successes.)
B. Comments: (Regarding administrative, fiscal, and/or programmatic aspects)
Page 2 of 3
JOHNSON O’MALLEY - ANNUAL REPORT
Section III
INDIAN EDUCATION COMMITTEE REPORT
School/Project Site: Administrator
Number of Indian Education Committee members:
Briefly explain how the IEC was involved in the planning, implementation and evaluation of the
Johnson-O’Malley programs.
Does the IEC, after receiving the annual report, recommend the continued operation of the entire
Johnson O’Malley program described?
Yes, (comments)
Yes, with changes/alternations (explain)
No, (explain)
What was the average number of IEC members who attended the Johnson O’Malley meetings?
How many meetings were held:
Dates of meetings
SIGNATURE:
IEC Chairperson DATE
Please attach IEC minutes showing approval of this annual report
Page 3 of 3
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FORM FY 2021 ANNUAL: THE ANNUAL REPORT REPORT

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Completed 1 February 2022

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