SBA Form | OMB # 3245-0423 | Expiration Date 12/31/2021

Community Navigators Pilot Program

Client and Program Information Form

Please select which of the following applies to you:

Entrepreneur and/or small business ownerAdvisor / supporter of small business ownersTeam member of one of the organizations above

Use of Information Collected: Information collected from SBA Form 3516 will only be published in summary or aggregate form as a means of providing SBA management officials, Congress, the White House and OMB with reports on program activity and participant outcomes. SBA expects to produce annual reports to the White House, OMB and Congress on the impact of the Community Navigator Pilot Program leveraging aggregate data to illustrate program objectives and outcomes have been met. Please note, SBA may match Form 3516 information with other data sets for program evaluation purposes. In all cases, SBA will protect individual privacy and confidentiality and only aggregate and summary data would be published.

Intake Organization

Organization:

City of Office Location:

State of Office Location:

SBA Form | OMB # 3245-0423 | Expiration Date 12/31/2021

Have you completed this form before?

YesNoI'm not sure

SBA Form | OMB # 3245-0423 | Expiration Date 12/31/2021

What are you trying to record?

Intake form for an entrepreneurSession for an entrepreneurSession for an advisorTraining Session or event

SBA Form | OMB # 3245-0423 | Expiration Date 12/31/2021

SBA Intake Form

First Name:

Middle Initial

Last Name:

What are your pronouns?

He, Him, HisShe, Her, HersThey, Them, TheirsMy pronouns are not listed above.

My pronouns are:

Email Address:

Phone Number:

Business Questions

Name of Business:

If your business does not have a name, please write n/a.

Mailing Address:

If currently in business include the business address. If not, include an address where you can receive mail.

City/Town:

State:

Zip Code:

Are you currently in business?

YesNo

Date Business Started:

Taxpayer ID #:

What licensing or certifications have you secured for your business?

Other Legal Entity:

Total Number of Employees:

For your most recent business year, please list your:

Gross Revenues	Profits	Losses

Have you applied for or received any SBA services in last 5 years?

YesNo

Which program(s) (check all that apply)?

Which SBA services?

Did you receive the support that you applied for?

YesNoI received some of the support I applied for

If you did not receive the support you applied for, please explain why. We aim to ensure equitable access to services and funding, including SBA funding. To do this, we want to better understand the barriers facing small businesses in accessing support.

Do you conduct business in a language other than English?

YesNo

What language(s) do you conduct business in?

Are you seeking support in a language other than English?

YesNo

Which language are you receiving support in?

Is this a woman-owned business? (A business is woman-owned if at least 51% of the business or stock is owned by one or more women and the management and daily business operations are controlled by one or more women.)

YesNo

Is this a minority-owned business? (A business is considered minority-owned if at least 51% of the business or stock is owned by one or more person who identifies with the following - Asian-Indian, Asian-Pacific, Black, Hispanic and Native American - and the management and daily business operations are controlled by members of the above "minority groups")

YesNo

Are you the only leader or owner of your business or do you have co-owners or partners?

IndividualI have co-owners or partners

How did you hear about us?

Name of Employee

Name of Organization:

Other way to hear about us:

What type of support are you looking for?

Assistance Starting a BusinessFunding, loan or grant supportSBA Contracting CertificationOther

Do you wish to provide feedback on an advising session now?

YesNo

SBA Form | OMB # 3245-0423 | Expiration Date 12/31/2021

Session Feedback Form

About You:

First Name:

Last Name:

Email Address:

Business Name:

Name of Advisor:

Business Metrics

SBA requests this information so they can identify business growth and progress through this program. Please update this information if it has changed:

Full Time Employees	Part Time Employees

For your most recent business year, what were your gross revenues?

SBA Form | OMB # 3245-0423 | Expiration Date 12/31/2021

Training Feedback Form

About the Workshop Leader / Trainer

Trainer's First Name:

Trainer's Last Name:

Trainer's Email Address:

Providing this information helps Salesforce identify the correct individual

Date of Training:

Number of sessions:

Total Training Hours:

Title of Training:

Live TrainingVirtual

Location of Training:

Participant Information:

How many people attended?

Please estimate what percentage of the group identifies with each of these groups:

	Currently in Business	Not Yet in Business
Business Status (these should add to 100%)

	These do not need to add to 100% since individuals may identify with more than one category below:
People with Disabilities
Veterans
Women
LGBTQIA+

	Please estimate the percentage of the participant group that would identify with each of the following racial groups.
Asian
Black or African American
Indigenous Peoples, First Nations, Native American, or Alaska Native
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White or Caucasian
I am not sure
A different racial group

	Please estimate the percentage of the participant group that would identify with each of the following:
Hispanic or Latino/a/x
Not Hispanic or Latino/a/x
I am not sure
A different ethnicity

Which additional partners participated in this training?

Which other language(s) was used?

SBA Disclosures

SBA Form | OMB # 3245-0423 | Expiration Date 12/31/2021

Disclosures from the SBA

Paperwork Reduction Act: You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. The total estimated annual burden for responding to this information collection is 20 minutes for grantees and 10 minutes for small business clients. Comments or questions on the burden estimate should be sent to U.S. Small Business Administration, Director, Records Management Division, 409 3rd Street. S.W. Washington, D.C. 20416 and/or SBA Desk Officer, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503

Please note that the OMB number mentioned in the paragraph above is listed at the top of each page:

SBA Form | OMB # 3245-0423 | Expiration Date 12/31/2021

Privacy Act Statement (5 U.S.C. 552a)

Use of Information Collected: The information in this form is provided by individuals and businesses seeking assistance from a Community Navigator. The information is collected to help SBA’s oversight and management of the Community Navigator Program, ensure program equity and integrity and to meet Congressional and Executive Branch reporting requirements. Some of the information collected is voluntary however it is important to SBA to help assess how well the program is serving different communities and to ensure equitable treatment of all people. Only you, the Community Navigator from which you are seeking assistance and SBA will be privy to the individualized confidential and proprietary information. Any personal information collected, including the client’s Social Security Number, will be protected to the extent permitted by law, including the Privacy Act of 1974 and the Freedom of Information Act. SBA has instituted procedures to protect confidentiality and only aggregate and summary data will be provided in public reports to the Congress and the White House.

Providing your social security number is voluntary. SBA uses your social security number to verify whether you received SBA assistance (financial or otherwise). You are asked to voluntarily provide your social security number to assist SBA in distinguishing you from other individuals with the same or similar name, or other personal identifiers. Not providing your social security number will not affect any right, benefit or privilege to which you are entitled. This request is permitted under EO 9397.

This form asks for your taxpayer ID as an optional question if you have an established business. In some cases, this should be your business taxpayer ID, but this statement is included as this may be a personal taxpayer ID for some.

THANK YOU

Thank you for completing this form and participating in the SBA's Community Navigators Pilot Program.

Accommodation Food Services	Administrative and Support
Agriculture	Arts
Construction	Education Services
Entertainment	Finance/Insurance
Fishing	Forestry
Health Care Social Assistance	Information
Management of Companies and Enterprises	Manufacturing
Mining/Utilities	Professional
Public Administration	Real Estate Rental Leasing
Recreation	Retail/Trade
Scientific and Technical Services	Transportation
Warehousing	Waste Management and Remediation Services
Wholesale	Other Services except Public Administration
Other

Paycheck Protection Loan/Forgiveness	Covid Economic Injury Disaster Loan
Restaurant Revitalization Fund	Shuttered Venues Grant
Other SBA Disaster Loans	7(a) loan
504 loan	Microloan
Export Loan	Other Loan
State/local grant	Other grant
Other

Creole	English	French
Portuguese	Spanish	A different language

Paycheck Protection Loan/Forgiveness	Covid Economic Injury Disaster Loan
Restaurant Revitalization Fund	Shuttered Venues Grant
Other SBA Disaster Loans	7(a) loan
504 loan	Microloan
Export Loan	Other Loan
State/local grant	Other grant
Other

Business start-up/preplanning	Business Plan
Business Financing/Capital Sources	Covid Financing Programs
International Trade	eCommerce
Business Financials/Cash FlowCredit Counseling	Government Contracting
Disaster Preparedness/Recovery	Business Operations
Management	Marketing
Other (please specify)

Asian	Black or African American
Indigenous Peoples, First Nations, Native American, or Alaska Native	Middle Eastern or North African
Native Hawaiian or other Pacific Islander	White or Caucasian
Prefer not to say	My racial group is not listed above

Asian	Black or African American
Hispanic or Latino/a/x	Indigenous Peoples, First Nations, Native American, or Alaska Native
Middle Eastern or North African	Native Hawaiian or other Pacific Islander
White or Caucausian	Prefer not to say
Their ethnic/racial group is not listed above

Business Financials/Cash Flow	Business Financing/Capital Sources
Business Operations	Business Plan
Business start-up/preplanning	Covid Financing Programs
Credit Counseling	Disaster Preparedness/Recovery
eCommerce	Government Contracting
International Trade	Management
Marketing	Other

Community Navigators Pilot Program

Client and Program Information Form

Session Feedback Form

Training Feedback Form

Advisor Session Feedback

SBA Disclosures

Disclosures from the SBA

THANK YOU