SSP MOE DATA REPORT - SECTION 1
DISAGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER THE
STATE SEPARATE PROGRAMS

GENERAL INFORMATION

													3.	Reporting Month
1.	State FIPS Code				2.	County FIPS Code								Year					Month				4.	Stratum

														Y	Y	Y	Y		M	M

FAMILY LEVEL DATA

			5.	Case Number - Separate State MOE											6.	ZIP Code					7.	Disposition			8.	Number of Family Members			9.	Type of Family for Work Participation



ASSISTANCE RECEIVED BY THE FAMILY

			10.	Has the Family Received Assistance Under a State (Tribal) TANF Program Within the Past Six Months							11.	Has the Family Received Assistance Under a State (Tribal) TANF Program Within the Past Six Months						12.	Receives Medical Assistance				13.	Receives Food Stamps				14.	Amount of Food Stamps Assistance


			15.	Receives Subsidized Child Care						16.	Amount of Subsidized Child Care							17.	Amount of Child Support						18.	Amount of the Family's Cash Resources





AMOUNT OF ASSISTANCE RECEIVED AND THE NUMBER OF MONTH THAT THE FAMILY HAS RECEIVED EACH TYPE OF ASSISTANCE UNDER STATE SEPARATE PROGRAMS
		19.	Cash and Cash Equivalent
		A.	Amount							B.	Number of Months


		20.	Child Care																	21.	Transportation
		A.	Amount					B.	Number of Children Covered				C.	Number of Months							A.	Amount						B.	Number of Months


		22.	Transitional Services																	23.	Other Assistance
		A.	Amount							B.	Number of Months										A.	Amount						B.	Number of Months



REASON FOR AND AMOUNT OF REDUCTION IN ASSISTANCE
24.	Reason for and Amount of Reduction In Assistance:
	A.:	Sanctions:
	i.	Total Dollar Amount of Reduction Due to Sanctions					ii.	Work Requirements Sanction			iii.	Family Sanction for an Adult with No High School Diploma or Equivalent				iv.	Sanction for Teen Parent Not Attending School			v.	Non-cooperation in Child Support			vi.	Failure to Comply with Individual Responsibility Plan					vii.	Other Sanction


	B.	Recoupment of Prior Overpayment							C.	Other:
									i.	Total Dollar Amount of Reductions Due to Other Reasons (excludes Sanctions and Recoupment)									ii.	Family Cap			iii.	.Reduction Based on Length of Receipt of Assistance						iv.	Other, Non-sanction


25.	Waiver Evaluation Experimental and Control Group



PERSON LEVEL DATA

ADULT AND MINOR CHILD HEAD-OF-HOUSEHOLD CHARACTERISTICS

Adult														28.	Date of Birth (Age)
			26.	Family Affiliation			27.	Non-Custodial Parent Indicator						Y	Y	Y	Y	M	M	D	D		29.	Social Security Number
	1																									-			-
	2																									-			-
	3																									-			-
	4																									-			-
	5																									-			-
	6																									-			-

			30.	Race/Ethnicity
			Ethnicity						Race
Adult			A.	Hispanic or Latino					B.	American Indian of Alaska Native				C.	Asian			D.	Black or African American				E.	Native Hawaiian or Pacific Islander				F.	White
	1
	2
	3
	4
	5
	6

						32.	Receives Disability Benefits
Adult			31.	Gender		A.	Receives Federal Disability Insurance Benefits			B.	Receives Benefits Based on Federal Disability Status			C.	Receives Aid Under Title XIV-APDT			D.	Receives Aid Under Title XVI-AABD			E.	Receives Aid Under Title XVI-SSI				33.	Marital Status
	1
	2
	3
	4
	5
	6

Adult			34.	Relation to Head of Household					35.	Parent with Minor Child in Family					36.	Needs of a Pregnant Woman						37.	Educational Level						38.	Citizen-ship / Alienage
	1
	2
	3
	4
	5
	6

Adult			39.	Cooperation in Child Support						40.	Employment Status					41.	Work-Eligible Individual Indicator							42.	Work Participation Status
	1
	2
	3
	4
	5
	6


ADULT WORK PARTICIPATION ACTIVITIES

Adult																		46.	Work Experience
			43.	Unsubsidized Employment				44.	Subsidized Private Sector				45.	Subsidized Public Sector				A.	Hours of Participation			B.	Excused Absences			C.	Holidays				47.	On-the-Job Training
	1
	2
	3
	4
	5
	6

Adult			48.	Job Search and Job Readiness Assistance																	49.	Community Service Programs
			A.	Hours of Participation			B.	Excused Absences			C.	Holidays									A.	Hours of Participation			B.	Excused Absences			C.	Holidays
	1
	2
	3
	4
	5
	6

			50.	Vocational Educational Training																	51.	Job Skills Training Directly Related to Employment
Adult			A.	Hours of Participation			B.	Excused Absences			C.	Holidays									A.	Hours of Participation			B.	Excused Absences			C.	Holidays
	1
	2
	3
	4
	5
	6

			52.	Education Directly Related to Employment for Individuals with No High School Diploma or Certificate of High School Equivalency																	53.	Satisfactory School Attendance for Individuals with No High School Diploma or Certificate of High School Equivalency
Adult			A.	Hours of Participation			B.	Excused Absences			C.	Holidays									A.	Hours of Participation			B.	Excused Absences			C.	Holidays
	1
	2
	3
	4
	5
	6

			54.	Providing Child Care Services to an Individual Who is Participating in a Community Service Program
Adult			A.	Hours of Participation			B.	Excused Absences			C.	Holidays				55.	Other Work Activities				56.	Number of Deemed Core Hours for Overall Rate					57.	Number of Deemed Core Hours for Two-Parent Rate
	1
	2
	3
	4
	5
	6

AMOUNT OF INCOME, BY TYPE

								59.	Amount of Unearned Income
Adult			58.	Amount of Earned Income				A.	Earned Income Tax Credit-EITC				B.	Social Security				C.	SSI				D.	Worker's Compensation				E.	Other Unearned Income
	1
	2
	3
	4
	5
	6


CHILD CHARACTERISTICS
Child										61.	Date of Birth (Age)
			60.	Family Affiliation						Y	Y	Y	Y	M	M	D	D		62.	Social Security Number
	1																					-			-
	2																					-			-
	3																					-			-
	4																					-			-
	5																					-			-
	6																					-			-
	7																					-			-
	8																					-			-
	9																					-			-
	10																					-			-

			63.	Race/Ethnicity
			Ethnicity						Race
Child			A.	.Hispanic or Latino					B.	.American Indian of Alaska Native				C.	.Asian			D.	.Black or African American				E.	.Native Hawaiian or Pacific Islander				F.	.White
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10

							65.	Receives Disability Benefits:
Child			64.	Gender			A.	Receives Benefits Based on Federal Disability Status						B.	Receives Aid Under Title XVI-SSI					66.	Relationship to Head of Household				67.	Parent with Minor Child in the Family				68.	Educational Level
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10


									70.	Amount of Unearned Income
Child			69.	Citizenship / Alienage					A.	SSI					B.	Other Unearned Income
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10