<p> Responsive Energy Self-Sufficiency & Outreach Activities Report</p><p>To demonstrate program impact, maintain accountability, and identify best practices, Service Providers are required to report on their Responsive Energy Self-Sufficiency (ESS) and Outreach activities using this form. Please use the Proactive Energy Self-Sufficiency Report (A16) to report on approved Proactive ESS activities.</p><p>Agency Information Service Provider name:</p><p>Report Instructions Responsive Energy Self-Sufficiency & Outreach Activity Reports must, at minimum, include the information required on this form, but may also include additional supporting information or documentation. The report format is based on the A16 section of the FFY17 EAP Local Plan; refer to your agency’s FFY17 EAP Local Plan for reference. Add additional rows to tables to report your activities, if needed. Service Providers must use the information they logged in eHEAT and other documentation to complete and submit this report form to the DOC A16 Coordinator via [email protected] by October 16, 2017.</p><p>Responsive Energy Self-Sufficiency (ESS) Preparation activities for conducting Responsive ESS Describe activity (how, when, Activity who) Building Network of Local Resources: Familiarize Staff with Local & Government Resources: Training Staff to Elicit Client Needs:</p><p>Providing clients with specific referrals # of Brief description of common resources households were referred referrals to. Add rows, if applicable. for FFY17 [Example: Resolve energy emergency by referring to County Crisis Services] [Example: SNAP] [Example: MFIP]</p><p>Providing applicants with list of referral agencies # of your total clients who received the list: FFY2017 EAP Policy Manual Chapter 9 Appendix 9C Energy Self-Sufficiency & Outreach Activities Report Updated 2016 Assisting households to build self-sufficiency # of househol ds for Description of most common activities. Add rows, if applicable. FFY17 [Example: provide household with energy conservation pamphlet] [Example: provide household with financial literacy pamphlet] [Example: informal financial literacy counselling]</p><p>Outreach Targeted Outreach: Targeted Populations and Veterans Outreach: Describe the Service Provider’s outreach activities and partnerships for reaching targeted populations (i.e. seniors, individuals with disabilities. and families with children under age six) and veterans during the program year.</p><p>Making applications available # of applications Description of event, location and/or method distributed</p><p>Providing informational materials Description of informational material # distributed</p><p>Acknowledgement and Certification The Service Provider Executive Director and EAP Coordinator affirm the accuracy of this report. Agency Certification</p><p>Executive Director: EAP Coordinator: </p><p>Signature: Signature: </p><p>Date: Date: </p><p>FFY2017 EAP Policy Manual Chapter 9 Appendix 9C Energy Self-Sufficiency & Outreach Activities Report Updated 2016</p>