Form OJP-7390/6 VOCA Compensation Performance Report

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Overview

Quantitative Questions
Narrative Questions
Authorized Signature
Instructions

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Sheet 1: Quantitative Questions

OMB NO.: 1121-0114

EXPIRES: 10/31/2004

VICTIMS OF CRIME ACT

U .S. Department of Justice

VICTIM COMPENSATION GRANT PROGRAM

STATE PERFORMANCE REPORT

Office for Victims of Crime

Washington, D.C. 20531

REPORT TIMEFRAME

OCTOBER 1, 2002 THROUGH SEPTEMBER 30, 2003

STATES RECEIVING VOCA CRIME VICTIMS COMPENSATION GRANT FUNDS ARE REQUIRED TO SUBMIT AN ANNUAL PERFORMANCE REPORT. THE REPORT COVERS THE FEDERAL FISCAL YEAR ENDING SEPTEMBER 30 AND IS DUE TO OVC BY DECEMBER 30 OF THE SAME YEAR.

Section

1. STATE:

I

2. CONTACT NAME

CLAIMS DATA (See instructions for definitions):

1. NUMBER OF NEW CLAIMS RECEIVED DURING REPORT PERIOD

(Place total on one line only, corresponding to your program’s general procedure)

a. Total claims, if only one claim is usually counted per crime

OR

b. Total claims, if victims and indirect victims generally

count as separate claims

Section

II

2. NUMBER OF CLAIMS APPROVED AS ELIGIBLE

a. Number approved for victims 17 and under

b. Number approved for victims 18-64

c. Number approved for victims 65 and older

3. NUMBER OF CLAIMS DENIED AS INELIGIBLE OR CLOSED

4. NUMBER OF FORENSIC SEXUAL ASSAULT EXAMINATION

CLAIMS RECEIVED DURING THE REPORT PERIOD, IF SUCH

CLAIMS ARE HANDLED THROUGH SEPARATE CLAIMS

PROCEDURE. (See instructions )

Payment Statistics By Crime Category:

Section III

a.

b.

c.

TYPE OF CRIME

NUMBER OF CLAIMS

NUMBER OF

TOTAL AMOUNT

PAID DURING

DOMESTIC VIOLENCE

PAID BY CATEGORY

REPORTING PERIOD

RELATED CLAIMS

(Include all

(Includes Column b)

PAID DURING

supplemental

REPORTING PERIOD

payments)

1. ASSAULT

$

2. HOMICIDE

$

3. SEXUAL ASSAULT

$

4. CHILD ABUSE (including sexual & physical abuse)

$

5. DWI/DUI

$

6. OTHER VEHICULAR CRIMES

$

7. STALKING

$

8. ROBBERY

$

9. TERRORISM

$

10. KIDNAPPING

$

11. ARSON

$

12.OTHER (please specify)

$

13. TOTAL:

0

0

$

0

INDICATE TOTAL EXPENSES PAID BY SERVICE:

Section IV

1. MEDICAL/DENTAL (Except Mental Health)

$

2. MENTAL HEALTH (Include Mental Health Related Medications)

$

3. ECONOMIC SUPPORT (Lost Wages, Loss of Support)

$

4. FUNERAL/BURIAL (Include all Funeral Related Expenses)

$

5. CRIME SCENE CLEAN–UP

$

6. FORENSIC SEXUAL ASSAULT EXAMS

$

7.OTHER: (Please specify types of expenses and amount paid)

$

8. TOTAL

$

0

Please see "Narrative Questions" tab to provide narrative descriptions

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Sheet 2: Narrative Questions

Section V			PLEASE RESPOND TO THE FOLLOWING QUESTIONS.
			ADDITIONAL INFORMATION MAY BE ATTACHED IF NECESSARY.
			1. DESCRIBE THE IMPACT THAT VOCA FUNDS HAVE HAD ON YOUR PROGRAM’S ABILITY TO MEET THE NEEDS OF CRIME VICTIMS.
			(Text area below will automatically expand to fit all text entered)
			2. HOW DO YOU MEASURE YOUR PROGRAM’S EFFICIENCY AND EFFECTIVENESS IN REDUCING THE FINANCIAL IMPACT OF CRIME ON VICTIMS? WHAT ARE THE RESULTS? For example, if your program measures average processing time, please provide that data and a brief explanation of how that average is measured, i.e., whether you use a median or an average of all claims; whether the processing time is measured through automated means or is estimated.
			(Text area below will automatically expand to fit all text entered)
			3. DID YOUR STATE USE VOCA ADMINISTRATIVE FUNDS?
			Yes
			No
			0
			(Text area below will automatically expand to fit all text entered)
		X
			Please go to the "Authorized Signature" tab and provide the name of the person authorized to provide this information

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Sheet 3: Authorized Signature

Authorized Signature

MM

DD

YYYY

/

/

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Sheet 4: Instructions

VOCA COMPENSATION GRANT PROGRAM

STATE PERFORMANCE REPORT

INSTRUCTIONS - DEFINITIONS

States receiving VOCA crime victim compensation grant funds are required to submit an Annual Performance Report that is provided by OVC. The Report requests specific information about claims for compensation. The Performance Report covers the Federal Fiscal Year ending September 30 and is due to OVC by December 30 of the same year. States must submit a Report each year.

DEFINITIONS

A victim is a person who suffers personal injury or death, directly or indirectly, or who suffers any economic loss covered by the program. This definition includes family members and other indirect victims.

A claim is an application or claim form received by the program from or on behalf of a victim or a family member. The definition does not include supplemental claims or requests for benefits, but rather only the initial claim filed.

Domestic Violence is a crime in which there is a past or present familial, household, or other intimate relationship between the victim and the offender, including spouses, ex-spouses, boyfriends and girlfriends, ex-boyfriends and ex-girlfriends, and any family members or persons residing in the same household as the victim.

Forensic Sexual Assault Claims are claims made solely or primarily for payment of expenses relating to forensic sexual assault exams and are handled by the program through a separate claims form and procedure other than the regular compensation form and process.

SECTION 1. STATE GRANT IDENTIFICATION
1-2. Complete items as indicated.

SECTION II. CLAIMS DATA

1a-b. Indicate the total number of claims or applications received during the reporting period, October 1 through September 30. Place the total on either line a, or line b., depending on whether (a) the program usually counts only one claim per crime, regardless of the number of indirect victims or family members receiving benefits from that claim; or (b) the program generally counts each victim and indirect victim as a separate claim, so that more than one claim be can counted per crime. Do not include on line 1(a) or (b) claims made solely or primarily for payment of forensic sexual assault exams, if such claims are made through a process other than your regular compensation claim. Include such claims only on line 5.

2. Indicate the number of claims that meet the state's eligibility requirements/criteria, whether payments are subsequently made or not. In other words, include claims that are determined eligible, but for which no payment is made because there is not a compensable expense. Do not include forensic sexual assault claims in any information provided on line 2 or 2a-c.

2a-c. Of the claims that meet the state's eligibility requirements/criteria, indicate the number approved. Indicate on lines a-c the age of victims receiving benefits. If your program counts only one claim per victimization or crime, count the claim in the category relating to the direct victim’s age, i.e., in a homicide case, count one claim in the category corresponding to the deceased’s age. However, if your program counts more than one claim per crime, count each claimant separately, e.g., if a homicide victim is between the age of 18-64, and more than one claim for that crime is declared eligible, including one from a minor, count one claim in the 18-64 category and one claim in the 17 and under category.

3. Indicate the number of claims that your program has determined are ineligible for failure to meet statutory requirements, or which your program has denied or closed because of a lack of information or for other reasons

4. Indicate the total number of Forensic Sexual Assault Examination claims received during the reporting period only if your program handles such claims with a separate form and procedure other than your regular compensation claim form and process. If your program pays for forensic sexual assault examinations through its regular claim form and process, leave this space blank.

SECTION III. PAYMENT STATISTICS, BY CRIME CATEGORY

For each of the listed crimes, report in column (a) the total number of claims in which payments have been made during the reporting period, including claims involving domestic violence; and report in column (b) the number of claims involving domestic violence in which payments have been made (except crimes listed on lines 4,5,6, and 9). See definition of domestic violence above. Report in column ( c ) the total amount paid to victims in each crime category, including supplemental payments.

2. and 5. Include drunk-driving deaths on line 5 rather than on line 2.

3. and 4. Do not include on line 3 or line 4 any claims or payments made for forensic sexual assault exams if such claims are handled through a separate claim or process other than a regular compensation claim. Do not include on line 3 sexual assaults against children; these should be included on line 4. Payments for forensic sexual assault examinations that are not part of a regular compensation claim should be included only in Section IV, item 6.

4. Crimes against children perpetrated by either family or nonfamily members should be included in column (a) of line 4.

12. Other: If possible, provide a listing of the crime categories you include in the "other" category.

SECTION IV. PAYMENT STATISTICS, BY TYPE OF SERVICE
Indicate the total expenses paid for the following services:

1. Medical/Dental. Report the total amount paid for all medical/dental-related expenses, including doctors, dentists, hospitals, physical therapy, ambulance, and other medically-related expenses such as transportation costs, prosthetic devices and pharmaceuticals.

2. Mental Health. These include payments made for mental health treatment, both in-patient and out-patient, including psychiatric care, counseling, therapy, and medication management.

3. Economic Support. Includes payments made to cover lost wages, loss of support, education benefits, annuities, and other related subsistence payments.

4. Funeral/Burial. These include payments made for funeral, burial and all other related expenses.

5. Crime Scene Clean-up. Report all expenses related to cleaning a crime scene.

6. Forensic Sexual Assault Exams. These include amounts awarded regardless of whether each payment is part of a compensation claim or paid through a separate process.

7. Other. If payments are made for services other than those listed in items 1-6, please identify the type of service and the total amount paid for that service. Include an additional sheet if necessary to identify other expenses.

8. Total. The totals reported on line 13 of Section III may differ from the totals reported on line 8 of Section IV when payments for forensic sexual assault exams are included on line 6 of Section IV.

SECTION V. NARRATIVE DESCRIPTIONS

Please answer each of the questions in this section in sufficient detail to provide a full description of your program.


Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. We try to create forms and instructions that are accurate, can be easily understood, and which impose the least possible burden on you to provide us with information. The estimated average time to complete and file this information is 120 minutes or 2 hours. If you have comments regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the State Compensation and Assistance Division, Office for Victims of Crime, U.S. Department of Justice, 810 7th Street, N.W., Washington, D.C. 20531.

OJP ADMIN FORM 7390/6 (Rev. 10/01)