TIMS Online Data Collection form

Reset Form
Data Collection Forms: Client Management

Trafficking Population Form

One form per client. Please fill out as many fields as possible.
Fields marked with an asterisk (*) are required.

*Client ID: ________________________________________________________________
Client Intake Information
*Intake Date:

____________________ Case Name:

*Primary Case Manager:
Secondary Case Manager:
Is this client an eligible family member? Yes

No If so, note the principal client’s ID:

Client Demographics
*Gender of Client (select one):

Female

Does the client identify as LGBQ?

Yes

Male

Transgender

No

Client Date of Birth (if known):
*Is this client a minor at intake?

Yes

No

*Country where client has citizenship:
Is this client a Lawful Permanent Resident (LPR)?

Yes

No

Immigration status upon entry to the United States (select one):
Marriage Visa (K Visa)

Violence Against Women Act (VAWA)

Student Visa (F or M Visa)

Victims of Criminal Activity (U1 Visa)

Temporary Work Visa (H Visa)

U Derivative Visa (U2—U5)

No Documentation

Human Trafficking Visa (T1 Visa)

Visitor/Tourist Visa (B Visa)

T Derivative Visa (T2—T6)

Diplomatic Visa (A or G Visa)

Asylee

Out of Status

Refugee

Religious Worker Visa (R Visa)

Other (specify):____________________

False Documents

Primary Language Spoken:

Trafficking Population Form

Page 1 of 3

Client ID: ________________

Data Collection Forms: Client Management

Trafficking Population Form

One form per client. Please fill out as many fields as possible.
Fields marked with an asterisk (*) are required.

Translator/Interpreter (select one):
No assistance needed
Needs assistance with spoken English
Needs assistance with written English
Needs assistance with spoken and written English

Race/Ethnicity
White or Caucasian
Hispanic or Latino
Black or African American
Asian American

American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Bi-racial or Multi-racial
Other

Trafficking Information
*Primary Type of Trafficking (pick one):
Sex

Sex and

Labor

Unknown

Labor
Primary Type of Trafficking Exploitation:
Child Care/Day Care

Escort Service

Prostitution

Cleaning Services

Field Labor

Restaurant/Food Services

Construction/Landscaping

Healthcare

Retail Sales

Cosmetology/Beauty Services

Herding/Livestock

Servile Marriage

Domestic Servitude

Manufacturing

Stripping/Exotic Dancing

Drug Trafficking/Dealing

Panhandling

Transportation Services

Elder Care

Pornography

Setting of Trafficking:
Agricultural Field/Farm

Bus Station/Truck Stop

Factory/Manufacturing

Apartment Complex

Caregiving Facility

Group Home

Bar/Cantina

Carnival/Circus

Hospital/Clinic

Beauty Salon/Spa

Casino

Hotel/Motel

Brothel

Construction Site

Massage Parlor

(continued on next page)
Trafficking Population Form

Page 2 of 3

Data Collection Forms: Client Management

Trafficking Population Form

One form per client. Please fill out as many fields as possible.
Fields marked with an asterisk (*) are required.

*Client ID: _______________________________________________________________
Office

Public/Private School

Street

Parking Lot

Restaurant

Strip Club

Private Home

Retail Business

Other

Is this client associated with an established investigation or prosecution? (select one):
Yes (Federal level)
Yes (State level)
No

How was this client referred to your OVC Project? (select one):
Attorney

Local Law Enforcement

Civic/Business Community

Medical/Public Health Providers

Community-based Providers

Mental Health/Substance Abuse Providers

Concerned Citizen

National Human Trafficking Resource Center

Consulate

Other Client/Victim

Faith-based Organizations/Religious

Probation/Parole

Family Member

Prosecutors

Federal Agencies Other Than Law Enforcement

Schools/Educational Institutions

Federal Law Enforcement

Self/Word of Mouth

Friend

Street Outreach

Housing/Shelter

Trade/Professional Affiliation Associations

Immigrant/Ethnic Service Providers

Victim Service Providers

Legal Providers

Vision/Dental Providers

Legislators/Lawmakers

Other (specify): _____________________

Local Government Agencies Other Than Law
Enforcement

Trafficking Population Form

Page 3 of 3

Data Collection Forms: Client Management

Funding & Case Closure

One form per client. Please fill out as many fields as possible.
Fields marked with an asterisk (*) are required.

*Funding
*Client ID:
*Grant Assigned:
*Assignment Date:

Reassignment Date:

______

Second Grant Assigned (if applicable):
Assignment Date:

Reassignment Date:

*OVC-Eligibility Information (fill in date for each of the criteria):
Date determined as a victim of trafficking as defined by the TVPA:
Date OVC approved exception for the above criteria:

Funding and Case Closure Form

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Data Collection Forms: Client Management

Funding & Case Closure

One form per client. Please fill out as many fields as possible.
Fields marked with an asterisk (*) are required.

*Case Closure
*Date Case Closed:
*Reason for Case Closure (select one):
Client is not a victim of trafficking as defined in the TVPA
Client does not agree to cooperate with law enforcement
Client is not a foreign national
Client chooses to no longer work with organization
Client has repatriated
Client has moved out of service jurisdiction
Client has returned to trafficker(s)
Client is not a U.S. citizen or LPR
Client has aged out of program
Client did not return after initial intake
Client transferred to another OVC service provider (specify):
Client became certified
Client completed program
Client LPR status approved
Client eligible for another grant
Other (specify):

Funding and Case Closure Form

Page 2 of 2

Data Collection Forms: Client Management

Client Service Provision

One form per client. Fields marked with an asterisk (*) are required.

*Client ID:

_______________________________________________________

*Grant: __________________________

*Month/Year of Services: ____________________________

*Date of
*# of
Service
Units
*Service Provider
Time Service Provision (1 unit = 15 Minutes) See Service Provision Chart in User Guide for more detail

Service

Client Intake
Client Orientation
Crisis Intervention or 24-Hour Hotline
Criminal Justice System-based Victim Advocacy
Emotional/Moral Support
Employment Assistance
Family Reunification
Housing/Shelter Advocacy
Ongoing Case Management
Protection/Safety Planning
Repatriation
Social Service Advocacy/ Explanation of Benefits

Legal Services
Screening/General Consultation
Family Law Services
Immigration Legal Services
Employment/Wage and Hour
Victims’ Rights/Criminal Justice Advocacy
Public Benefits Law
Expungement/Sealing of Criminal Records

Incident Services Provision (1 unit = 1 Incident) See Service Provision Chart in User Guide for more detail
Child Care
Dental (Emergency/ Long-Term)
Education
Housing/Rental Assistance
Interpreter/Translator
Medical (Emergency/ Long-Term)
Mental Health Service
Substance Abuse Treatment
Transportation
Other (specify):

Other Units of Measurement See Service Provision Chart in User Guide for more detail
Financial Assistance (1 unit equals $1)
Personal Items (1 unit equals 1-10 items of
clothing, 1 trip to clothing bank, 1 day of meals, or
1 use of laundry or shower facilities)

Notes:

Client Service Provision Form

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Data Collection Forms: Client Management

Client Service Provision

One form per client. Fields marked with an asterisk (*) are required.

*Client ID:
_______________________________________________________

*Date of
*# of
Service
Units
*Service Provider
Time Service Provision (1 unit = 15 Minutes) See Service Provision Chart in User Guide for more detail

Service

Client Intake
Client Orientation
Crisis Intervention or 24-Hour Hotline
Criminal Justice System-based Victim Advocacy
Emotional/Moral Support
Employment Assistance
Family Reunification
Housing/Shelter Advocacy
Ongoing Case Management
Protection/Safety Planning
Repatriation
Social Service Advocacy/ Explanation of Benefits

Legal Services
Screening/General Consultation
Family Law Services
Immigration Legal Services
Employment/Wage and Hour
Victims’ Rights/Criminal Justice Advocacy
Public Benefits Law
Expungement/Sealing of Criminal Records

Incident Services Provision (1 unit = 1 Incident) See Service Provision Chart in User Guide for more detail
Child Care
Dental (Emergency/ Long-Term)
Education
Housing/Rental Assistance
Interpreter/Translator
Medical (Emergency/ Long-Term)
Mental Health Service
Substance Abuse Treatment
Transportation
Other (specify):

Other Units of Measurement See Service Provision Chart in User Guide for more detail
Financial Assistance (1 unit equals $1)
Personal Items (1 unit equals 1-10 items of
clothing, 1 trip to clothing bank, 1 day of meals, or
1 use of laundry or shower facilities)

Notes:

Client Service Provision Form

Page 2 of 2

Data Collection Forms: Client Management

Client Immigration Status

One form per client. Please fill out as many fields as possible.
Fields marked with an asterisk (*) are required.
*Client ID: ________________________ Funding Grant: __________________________________
Current Immigration Status (select one):
Marriage Visa (K Visa)
Student Visa (F or M Visa)
Temporary Work Visa (H Visa)
No Documentation
Visitor/Tourist Visa (B Visa)
Diplomatic Visa (A or G Visa)

Current Certification Status (select one):

U Derivative (U2-U5 Visa)
Human Trafficking Visa (T Visa)
T Derivative Visa (T2-T6)
Asylee
Refugee
Other (specify): ___________

Out of Status
Religious Worker Visa (R Visa)
False Documents
Violence Against Women Act
(VAWA)
Victims of Crime (U Visa)

Pre-certified

Certified

Immigration Actions Taken for Trafficking Victims (please fill in relevant dates):
Continued Presence
Date Requested by
Advocate:
Date Granted:
Date Renewed:
Date Denied:
Certification

Date Process Began:
Date Granted:
Date Denied:

Law Enforcement Authorization for
Visa

Date Sought:
Date Granted:
Date Denied:

T-Visa Application

Date Filed:
Date Granted:
Date Denied:

U-Visa Application

Date Filed:
Date Granted:
Date Denied:

Other Immigration Relief

Date Filed:
Date Granted:
Date Denied:

Other Action Taken (specify):

Date Acted:
Date Granted:
Date Denied:

Client Immigration Status Form

Page 1 of 1

OMB# 1121-0336
Date of Expiration:
March 31, 2015

Data Collection Forms: Client Management

Housing Information

One form per client. Please fill out as many fields as possible.
Fields marked with an asterisk (*) are required.

*Client ID:
*Emergency Housing
*Funding Grant:
*Date Placed:

__________

Date Exited:

_______

Location (select one):
Hotel/Motel

Shelter – Men

Living Independently in a Home or Apartment

Shelter – Women

Living With Friends or Family

Shelter – Youth

Shelter – Children

Shelter – Trafficking Victims

Shelter – DV

Staying With Other Victims or Clients

Shelter – Homeless

Other (specify):

*Transition Housing
*Funding Grant:
*Date Placed:

__________

Date Exited:

_______

Location (select one):
Hotel/Motel

Shelter – Men

Living Independently in a Home or Apartment

Shelter – Women

Living With Friends or Family

Shelter – Youth

Shelter – Children

Shelter – Trafficking Victims

Shelter – DV

Staying With Other Victims or Clients

Shelter – Homeless

Other (specify):

*Long-Term Housing
*Funding Grant:
*Date Placed:

__________

Date Exited:

_______

Location (select one):
Hotel/Motel

Shelter – Men

Living Independently in a Home or Apartment

Shelter – Women

Living With Friends or Family

Shelter – Youth

Shelter – Children

Shelter – Trafficking Victims

Shelter – DV

Staying With Other Victims or Clients

Shelter – Homeless

Other (specify):

Housing Information Form

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OMB# 1121-0336
Date of Expiration: March 31, 2015

Data Collection Form:

Collaborative Partners

Please fill out as many fields as possible.
Fields marked with an asterisk (*) are required.

*Partner Organization Name:
*Partner Type (select one):
Key Partner

Informal Partner

*Select the Category That Best Describes This Partner (select one):
Advocacy/Awareness Group or Organization

Mental Health/Substance Abuse Treatment

Civic/Business Community

Providers

Community Center or Coalition

Prosecutors

Embassy or Consulate

Schools/Educational Institutions

Faith-based Organizations/Religious Institutions

Social Services Provider

Federal Agencies Other Than Law Enforcement

State and Local Government Agencies Other

Federal Law Enforcement

Than Law Enforcement

Financial Institutions

State/Local Law Enforcement

Housing/Shelter

Task Force

Immigrant/Ethnic Service Providers

Trade/Professional Affiliation Associations

Legal Providers

Victim Service Providers

Legislators/Lawmakers

Vision/Dental Providers

Media Outlet

Youth Services Provider

Medical/Public Health Providers

Other (specify):

*Date partner first began to work with the OVC Project:

Collaborative Partners Form

___________

OMB# 1121-0336
Date of Expiration:
March 31, 2015

Data Collection Forms: Organizational Activity

Community Outreach

Please fill out as many fields as possible. Fields marked with an asterisk (*) are required.

*Activity Date:
*Funding Grant:
*Primary Outreach Organization (OVC Grantee or Partner Organization):
Secondary Outreach Organization (if applicable: OVC Grantee or Partner Organization):
*Type of Outreach Activity (select one):
Billboards/Posters

Walk/Run Event

Direct/Street Outreach

Fundraising Event

Flyers/Brochures/Quick Reference Guides

Conference

Newspaper Article

Community Event/Forum/Meeting

Panel Discussion

Discussion/Lecture

Public Service Announcement

Volunteer Interest Training

Radio/TV Interview

Online Communication/Campaign/Blog

Table/Booth Display

Other (specify):_________________________

Awareness Presentation
Target Audience:
Location of Activity:
Duration of Activity (in minutes):
Number of Materials Shared:
Description of Materials Shared:

Community Outreach Form

OMB# 1121-0336
Date of Expiration:
March 31, 2015

Data Collection Forms: Organizational Activity

Technical Assistance

Please fill out as many fields as possible.
Fields marked with an asterisk (*) are required.
*Activity Date:
*Funding Grant:
*Primary Training Organization (OVC Grantee or Partner Organization):
Secondary Training Organization (if applicable: OVC Grantee or Partner Organization):
*Requesting Organization:
*
Requesting Organization Type (select one):
Advocacy/Awareness Group or Organization

Mental Health/Substance Abuse Treatment Providers

Civic/Business Community

Prosecutors

Community Center or Coalition

Schools/Educational Institutions

Embassy or Consulate

Social Service Providers

Faith-based Organizations/Religious Institutions

Legislators/Lawmaker

Federal Agencies Other Than Law Enforcement

State and Local Goverment Agencies Other than Law
Enforcement

Federal Law Enforcement
Financial Institutions

State and Local Law Enforcement

Immigrant/Ethnic Service Providers

Trade/Professional Affiliation Associations

Legal Providers

Task Force

Victim Service Providers

Victim Service Providers

Legislators/Lawmakers

Vision/Dental Providers

Media Outlet

Youth Service Providers

Medical/Public Health Providers

Other (specify):_______________________________

Case Consultation Hours:
General Information Hours:
Information on Services Hours:
Other Assistance Hours:

Technical Assistance Form

OMB# 1121-0336
Date of Expiration: March 31, 2015

Training Attendance Sheet

The purpose of this form is to document information about the attendees
of each training event conducted by key partners within the OVC Initiative.
In the “Type of Organization” column, please select from the following categories the one that best
represents your organization.
Fed Gov—Federal Agencies Other Than
Law Enforcement
FLE—Federal Law Enforcement
State/Local Gov—State and Local
Government Agencies Other Than Law
Enforcement
SLLE—State/Local Law Enforcement
VSP—Victim Service Providers
IESP—Immigrant/Ethnic Service Providers
Legal—Legal Providers
P—Prosecutors
MPHP—Medical/Public Health Providers

MHSA—Mental Health/Substance Abuse
Providers
FBO—Faith-based Organizations/Religious
Institutions
HS—Housing/Shelter
L—Legislators/Lawmakers
Biz—Civic/Business Community
SEI—Schools/Educational Institutions
VD—Vision/Dental Providers
TPAA—Trade/Professional Affiliation
Associations
O—Other (Specify)

Training Title:
Funded by Grant ID/Number:
Primary Organization Providing Training:
Training Date: ______________________
(mm/dd/yyyy)
Attendee Name

Organization

Organization
Type

Contact Information
(address, phone number,
e-mail)

Attendee Name

Organization

Organization
Type

Contact Information
(address, phone number,
e-mail)

OMB# 1121-0336
Date of Expiration:
March 31, 2015

Data Collection Forms: Organizational Activity

Training

Please fill out as many fields as possible.
Fields marked with an asterisk (*) are required.
*Funding Grant:
*Training Date:
*Primary Training Organization (OVC Grantee or Partner Organization):
Secondary Training Organization (if applicable: OVC Grantee or Partner Organization):
*Training Title:
Duration (in hours):
Was this training evaluated? (select one):

Yes

No

Topics (select all that apply):
Collaboration and Building Multidisciplinary Relationships

Procedures for Reporting HT Victims

Culturally and Linguistically Appropriate Services for HT Victims

Techniques for Screening/Interviewing HT Victims

Definition of Human Trafficking

Health and Trauma Consequences of HT

Global Dimensions of Human Trafficking

Local/Regional Dimensions of Human Trafficking

Identification of HT Victims

Services Available to Victims of Human Trafficking

Legal Assistance for HT Victims

Corporate Social Responsibility

Faith Response to Human Trafficking

Risk Factors for Human Trafficking

Activism on Human Trafficking

Other (specify):

Volunteer Training
Target Audience (please enter the number of attendees for each category):
Advocacy/Awareness Group or Organization

Mental Health/Substance Abuse Treatment Providers

Civic/Business Community

Prosecutors

Community Center or Coalition

Schools/Educational Institutions

Embassy or Consulate

Social Service Providers

Faith-based Organizations/Religious Institutions

Legislators/Lawmakers

Federal Agencies Other Than Law Enforcement

State and Local Government Agencies Other Than

Federal Law Enforcement

Law Enforcement

Financial Institutions

State and Local Law Enforcement

Housing/Shelter

Trade/Professional Affiliation Associations

Immigrant/Ethnic Service Providers

Task Force

Legal Providers

Victim Service Providers

Legislators/Lawmakers

Vision/Dental Providers

Media Outlet

Youth Service Providers

Medical/Public Health Providers

Other (specify):

Training Form