DHSI_2019_Program_Profile_Form.pdf

Developing Hispanic-Serving Institutions Program Program Profile Form

ALL applicants must submit this form. You may copy or recreate this form, but do not amend or modify the required information or format. Please complete all sections. Upon completion, upload this document in .pdf format to the “Other Attachments Form” in Grants.gov. See complete instructions below.

1.Name of Institution/Campus:

Institution/Campus OPE ID#: DUNS#:

2. Applicant Address:

City: State: Zip:

3. Activities proposed in this application: (check all that apply.)

Purchase, rent, lease lab equipment ___; Construction/renovation of facilities: ____; Faculty Development: ___;

Curriculum Development: ___; Academic instruction: ___; Faculty fellowships: ___; Purchase of books/supplies/educational materials: ___; Articulation/transfer program: _____Tutoring:___; Counseling: ___;

Mentoring: _____FYE program: _____; Summer Bridge program:____; Funds mgmt./Admin. Mgmt.: ___;

Equipment/Software purchase: ____; Establishing development office to strengthen alumni/private contributions:___; Endowment Fund: ___; Distance learning instruction incl. purchase of technology:____;

teacher preparation program:_____; Community outreach to elementary/secondary students: ____: Expanding instruction/resources for graduate/professional students:____; Financial literacy program: ______ Other: _____________________

4. Competitive Preference Priorities, if applicable:

Are you responding to CPP #1 –Projects that serve graduate and professional students? YES Are you responding to CPP#2 –Projects that support financial literacy instruction? YES Will not respond to either

5. Level of Effort (time commitment) of Project Director position proposed in this application: _____%

5a. List active grants for which the proposed Project Director already serves: (If Project Director is To Be Hired, state “N/A.”

PR Award Number of grant: Level of effort: Final year of performance period:

1. ________%

2. ________%

3. ________%

6. Endowment Fund Assurance (Check here if you propose an Endowment Fund activity.):

The institution certifies that it proposes to use no more than twenty percent (20%) of the Developing Hispanic- Serving Institutions Program development grant, made under the authority of Title V, of the Higher Education Act of 1965, as amended to establish or increase the institution’s endowment fund. The institution agrees to abide by the Department of Education’s regulations governing the Endowment Challenge Grant Program, 34 CFR Part 628, the program statute, and the program regulations, 34 CFR Part 606. The institution further agrees to raise the required matching funds.

7. Dual Submission Certification: If an institution applies for a grant this fiscal year under Title III, Parts A or B programs, it must indicate the programs. (Check all that apply.)

Strengthening Institutions Program (SIP) American Indian Tribally Controlled Colleges and Universities Program (TCCU) Asian American Native Pacific Islander Serving Institutions (AANAPISI) Program Alaska Native-Native Hawaiian Serving Institutions (ANNH) Program Historically Black Colleges and Universities (HBCU) Program Predominately Black Institutions (PBI) Program N/A

7a. If your application ranks in funding range for one of the above Title III programs and the Title V, Part A (DHSI) Program, please state your preferred award acceptance (i.e. Title V, Part A or Title III).

8. Current Title III grant status: Please list the PR Award numbers for all current Title III, Part A and Part B grants:

PR Award Number of grant: Final year of performance period:

1.

2.

3.

9. Past Performance: If applicable, please list the PR Award numbers of all Title V, Part A (DHSI) grants that your institution has held in the past 5 years.

1.

2.

3.

10. Institutional Assurance Statistics: See complete instructions below. For the purpose of verifying demographic data, please provide information for school year 2017-2018 in boxes 10a and 10b.

10a. HSI Assurance (institutional state reported data):

Total Undergraduate FTE Enrollment Count:

Hispanic Undergraduate FTE Enrollment Count:

Hispanic Undergraduate FTE Percent (%):

10b. IPEDS Reported Data:

Total Undergraduate FTE Enrollment Count:

Hispanic Undergraduate FTE Count:

Hispanic Undergraduate FTE Percent (%):

10c. Eligibility Documentation: Please provide us with the documentation the institution relied upon in determining that at least 25 percent of the institution’s undergraduate FTE students are Hispanic.

11. Tiebreaker Information: Enter information below for school year 2017-2018. See the Application Guide and Federal Register Notice for instructions on calculating FTE enrollment.

a) Total FULL-TIME EQUIVALENT (FTE) students =

b) Total market value of endowment fund for 2017-2018

c) Total expenditures for library material during 2017-2018

Note: Failure to provide information requested in items a) and b) above may result in the Department not considering the application under a tie-breaker situation

12. Certifying Official (i.e. President, VP, Chancellor, etc.):

Name:

Title:

Contact Number:

Email:

13. By checking this box, the applicant and President of the institution certify that the Institution of Higher Education (IHE) will comply with the statutory requirements, program standards, and program assurance cited in the HSI program regulations 34 CFR Part 606.

Attach additional pages if needed.