Form 1 NewFVPSAState Tribal PPR

Draft for OMB Review

Performance Progress Report and Instructions for States and Tribes

(No State Portion or Service Outcome Data Sections for Tribes)

Enter the below information into the Online Data Collection System at www.grantsolutions.gov. Contact your Project Officer for a user name and password.

Cover Page

1.	Federal Agency and Organizational Element to Which Report is Submitted	Enter the name of the awarding Federal agency and organizational element identified in the award document or otherwise instructed by the agency. The organizational element is a sub-agency within an awarding Federal agency.
2.	Federal Grant or Other Identifying Number Assigned by the awarding Federal agency	Enter the grant/award number contained in the award document.
3a.	DUNS Number	Enter the recipient organization's Data Universal Numbering System (DUNS) number or Central Contract Registry extended DUNS number.
3b.	EIN	Enter the recipient organization's Employer Identification Number (EIN) provided by the Internal Revenue Service.
4.	Recipient Organization	Enter the name of recipient organization and complete address, including ZIP code.
5.	Recipient Account Number or Account Number	Enter the account number or any other identifying number assigned by the recipient to the award. This number is strictly for the recipient's use only and is not required by the awarding Federal agency.
6.	Project/Grant Period	Enter the federal fiscal year covered by this performance progress report.
7.	Reporting Period End Date	Enter the ending date of the reporting period.
8.	Final Report	Mark appropriate box. Check “yes” only if this is the final report for the project/grant period specified in Box 6.
9.	Report or Frequency	Select “annual” for report frequency.
10.	Performance Narrative	Attach a separate document with the labeled responses to each of the elements in Section H.
11.	Other Attachments	Attach a separate document per the instructions on the cover page.
12a.	Certification – Name	Type or print the name and title of the Authorized Certifying Official.
12b.	Certification - Signature	The Authorized Certifying Official should sign here.
12c.	Certification – Phone	Enter the area code, phone number and extension of the Authorized Certifying Official.
12d.	Certification – Email	Enter the email address of the Authorized Certifying Official.
12e.	Certification – Date	Enter the date (month, day, year) the report is submitted.

SP – State Portion

Information on FVPSA grants/funds awarded should include any funds awarded by the state during the federal fiscal year reporting period. For example, if during the past federal fiscal year (Oct- Sep), the State made awards to subawardees in July, then the State should report on the grants and funds awarded in July and any other funds awarded during the federal fiscal year reporting period. The State’s aggregate report of services provided by FVPSA subawardees should include all services/grant activities that occurred throughout the federal fiscal year reporting period (Oct – Sep).

Total funds awarded to subawardees by the State
Total amount of state administrative costs

[Total funds awarded to subgrantees by the State: Report the total amount of grant awards or contracts made to subgrantees (i.e., domestic violence programs) during the reporting period.]

[Total amount of state administrative costs: Report the total amount of grant funds used to support State/Territory costs for the administration of FVPSA funding.]

Subawardee List

Subawardee Name	City	State	Zip	Website	FVPSA Funding Amount	Type of Subawardee	Underserved or culturally- and linguistically-specific population	Classification of urban, rural, suburban or frontier	Notes on the Subawardee

Types of Subawardee Options (choose one):

Shelter

Non-shelter

Other

Underserved or culturally- and linguistically-specific population:

[Write in which population the subawardee primarily serves. Underserved populations means populations who face barriers in accessing and using victim services, and includes populations underserved because of geographic location, religion, sexual orientation, gender identity, underserved racial and ethnic populations, and populations underserved because of special needs including language barriers, disabilities, immigration status, and age. Individuals with criminal histories due to victimization and individuals with substance use disorders and mental health issues are also included in this definition (45 CFR § 1370.2). ]

Classification for Rural-Urban Communities (choose one):

Rural

Urban

Suburban

Frontier

[Subawardees will self-identify with the classification that most closely matches their service area.]

Notes on the Subawardee could include:

Additional explanation on other as the type of subawardee

Additional explanation of underserved

Additional description on the type of population such as ‘refugees from Syria’

Additional explanation on the chosen classification for rural-urban

Subawardee Portion

This information in this section should be collected by each subawardee and compiled by the state into this following section. This report is a compilation of all domestic violence services regardless of funding source, not just FVPSA funds, used to provide the below services to victims. For the narrative responses (section H), the State should choose what information to include from the subawardees and may include information about FVPSA funds retained by the State.

Section A – General Program Information

Total domestic violence program budget
FVPSA grant amount
Number of shelter facilities
Number of non-shelter service sites

[Total Domestic Violence Program Budget: This is the sum of the total annual budgets for each local domestic violence program at the same point in time. Each local domestic violence program will report its total budget that is used to provide the services to victims included in this report. This number could include additional funding from other sources or it may be the same as the FVPSA grant amount listed in the FVPSA grant amount. The FVPSA State Administrator then totals each of the entries from the local programs and enters the number here.

For example, the total program budget would include all funding sources, i.e., FVPSA dollars and state dollars to provide shelter to victims. Grant dollars set aside to provide separate services to sexual assault victims would not be included here. In addition, a domestic violence program that is located within a larger social service agency would only include its budget for domestic violence programming. For example, a local domestic violence program that receives $50,000 in FVPSA funds, $20,000 from the state for DV services and $10,000 from a private funder would report $80,000 as its total domestic violence program budget.]

[FVPSA Grant Amount: List total amount of FVPSA funds received within your current fiscal year.]

[Number of Shelter Facilities: List the total number of shelter facilities providing immediate housing to victims of domestic violence and their children managed by the domestic violence program. This number should not include safe homes, motels or shelter beds provided by other programs.]

[Non-Shelter Services Sites: List the total number of service sites (i.e., office locations) where a program provides non-residential services. This may include the coordination of shelter for victims through hotels and safe homes where there is not a shelter facility. This number should be one (1) if the program has a single program site with no shelter facility. If a program maintains satellite locations, they should be counted here, i.e., one main office and two satellite offices should be reported as three (3) sites. This is not a count of the number of hotels and safe homes used.]

Section B – People Served

[If the grantee has concerns that providing the data below will allow a report reader to personally identify a victim, please use the boxes for “not specified” or “unknown” for that client’s data.]

Clients Served in Shelter

Number of Children/Youth
Adults:
Number of Women
Number of Men
Number Not-specified/Other
Total	[Auto Sum]

[Clients Served in Shelter: Number of new domestic violence victims (clients) seen for the first time during this reporting period who received shelter services (including a shelter facility managed by the program, safe home or hotel). Clients should be counted once regardless of the number of times served during the fiscal year. Clients who received shelter should only be counted in this element and not counted in Clients Served with Non-Shelter Services even though they may have received non-shelter services also. Clients who were referred to another domestic violence shelter program should not be counted here. The count will be within program only and should not unduplicated across programs statewide.]

Clients Served with Non-Shelter Services

Number of Children/Youth
Adults:
Number of Women
Number of Men
Number Not-specified Other
Total	[Auto Sum]

[Clients Served with Non-Shelter (supportive services only): Number of new domestic violence victims (clients) seen for the first time during this reporting period who received only non-shelter services. Include only clients that received supportive services only and no shelter by your program. Calls to a crisis line or hotline should not be counted here and should be counted in Section C instead. Count should be within program only and not unduplicated across programs statewide.]

Race/Ethnicity

Black or African American
American Indian/ Alaska Native
Asian
Hispanic or Latino
Native Hawaiian/ Other Pacific Islander
White
Unknown/Other

[Race/Ethnicity: Report the race and/or ethnicity of the clients served, including children and youth. Clients may self-identify in more than one category, i.e., White and Hispanic.]

Age

0-12
13-17
Unknown Child Age
18-24
25-59
60+
Unknown Adult Age
Total	[Auto Sum]

[Age: Report the ages of the clients served, including children and youth. These age demographic totals should equal the program’s numbers totaled in Clients Served in Shelter and Clients Served with Non-Shelter. For example, if the program served 30 women, 62 children and 2 men (94 total), the total for all the ages should also add up to 94.]

Other Demographics

Number needing language services, such as interpretation
Number identifying as lesbian, gay, bisexual, transgender or queer
Number of youth age 13-17 receiving services due to being a victim of dating violence

[Language Services: Provision of interpretation and/or translation. Provision of English as a second language class.]

Section C – Shelter Services and Crisis Calls

Shelter Nights
Unmet Requests for Shelter
Crisis/Hotline Calls

[Shelter Nights: Indicate the number of shelter nights for each person who arrives and is provided a bed, including on-site shelter, safe home or hotel room. Include victims of domestic violence and their dependents. Count the number of people housed times the number of nights. For example, a victim and her 3 children stay in the shelter or safe house for 5 nights – 4 people x 5 nights = 20 shelter nights.

Shelter includes onsite shelter managed by the domestic violence program, program-sponsored hotel rooms and safe homes (residences of volunteers who offer their private homes for short-term crisis situations) or other temporary housing that your program arranges. Nights that a victims stays in a shelter (i.e., a shelter in a nearby county) not managed by your program should not be counted.]

[Unmet Requests for Shelter: Count the number of unmet requests for shelter due to program shelter, safe homes or sponsored hotel rooms being at capacity or unavailable. Count adult victims of domestic violence only. This count should not include individuals who were not served because their needs were inappropriate for the services of your program, i.e., homelessness not related to domestic violence. Count the total number of times requests for shelter were declined, even if the program provided other services.]

[Crisis/Hotline Calls: Calls received on any agency line that relate to an individual or family in need of some kind of service. A program does not have to have a dedicated hotline to count these calls. Count all calls including repeat callers and calls from third parties such as a family member. Do not count calls about donations or for general information about program or violence issues unrelated to a specific individual or family, calls from the media, etc.]

Section D – Services to Victims

Number of children/youth receiving crisis intervention
Number of children/youth receiving victim advocacy services
Number of children/youth receiving individual or group counseling/support group
Number of adult victims receiving crisis intervention
Number of adult victims receiving victim advocacy services
Number of adult victims receiving individual or group counseling/support group
Number of adult victims receiving criminal/civil legal advocacy
Number of adult victims receiving medical accompaniment
Number of adult victims receiving transportation services

[Report the number of clients who received each service. Count each client only once for each type of service that the client received.]

[Individual/Group Counseling: Individual or group counseling or support provided by a volunteer, peer, or professional.]

[Crisis intervention: Process by which a person identifies, assesses, and intervenes with an individual in crisis so as to restore balance and reduce the effects of the crisis in her/his life. In this category, report crisis intervention that occurs in person and/or over the telephone.]

[Victim Advocacy Services: Actions designed to help the victim/survivor obtain needed resources or services including employment, housing, shelter services, health care, victim’s compensation, etc.]

[Criminal/Civil Legal Advocacy: Assisting a client with civil legal issues, including preparing paperwork for protection orders; accompanying a client to a protection order hearing, or other civil proceeding; and all other advocacy within the civil justice system. This also includes accompanying a client to an administrative hearing, such as unemployment, Social Security, TANF, or food stamp hearing. Assisting a client with criminal legal issues including notifying the client of case status, hearing dates, plea agreements, and sentencing terms; preparing paperwork such as victim impact statements; accompanying a client to a criminal court proceeding or law enforcement interview; and all other advocacy within the criminal justice system.]

[Medical Accompaniment: Accompanying a victim/survivor to, or meeting a victim/survivor at, a hospital, clinic, or medical office.]

[Transportation Services: Provision of transportation, either directly or through bus passes, taxi fares, or other means of transportation]

Section E – Community Education

Adults/General Population

Number of Presentations
Number of Participants

[Adults/ General Population: Count the total number of presentations or trainings about domestic violence and/or services related to victims of domestic violence and their children. In addition, count the number of individuals in attendance. Some examples may be a training for health professionals or a workshop for tribal leaders. Include all presentations for a mixed-age audience.]

Youth Targeted Education

Number of Presentations
Number of Participants

[Youth Targeted: Count the total number of presentations or trainings about domestic violence, dating violence, healthy relationships or available services for victims. In addition, count the number of individuals in attendance. Some examples may be a presentation to youth in school on healthy relationships or a workshop for youth at a Safety Day event.]

Section F – Narrative Responses

H-01 - For services supported in whole or in part by your FVPSA grant, share a story about a client (without sharing any personally-identifying information), service or community initiative that could be shared with other stakeholders.

H-02 - What does the FVPSA grant allow you to do that you wouldn’t be able to do without this funding?

H-03 - Describe any efforts supported in whole or in part by your FVPSA grant to meet the needs of underserved populations in your community, including populations underserved because of ethnic, racial, cultural or language diversity, sexual orientation or gender identity or geographic isolation. Describe any ongoing challenges.

H-04 - Describe significant prevention and outreach activities, supported in whole or in part by your FVPSA grant, during the program year.

H-05 - Provide information on the evaluation of the effectiveness of your domestic violence programming

H-06 - (Optional) Provide any additional information that you would like us to know about your FVPSA-supported domestic violence program, i.e., the unmet needs of victims in your community, other funding sources used for programming or service trends that are emerging in your community.

Section G – Service Outcome Data

	Survey Type	Number of Surveys Competed	Number of Yes Responses to Resource Outcome	Number of Surveys Competed	Number of Yes Responses to Safety Outcome
I-01	Shelter survey
I-02	Support services and advocacy survey
I-03	Counseling survey
I-04	Support group survey
I-05	TOTAL

[Domestic violence programs should be collecting outcome information from their clients served. A manual and instructions from the Documenting Our Work Project are available online at the Outcomes webpage from the National Resource Center on Domestic Violence at http://nrcdv.org/FVPSAOutcomes. There are two mandated questions that must be asked of clients.

Because of the services I received, I feel:

• I know more about community resources (yes or no).

• I know more ways to plan for my safety (yes or no).

Outcome information may be collected for each service – shelter, support services and advocacy, counseling and support group. However, at a minimum, FVPSA requests outcome information on shelter services from programs that provide shelter services.

For each service, count the number of surveys completed and the number of yes responses to each question. It is expected that the number of surveys completed would be the same for each, but there may be instances when it differs, e.g., a client doesn’t answer one of the questions.

• I know more about community resources (Resource Outcome).

• I know more ways to plan for my safety (Safety Outcome).]

8 2/22/2018 version