Form 1 SOR Program Data Points

OMB NO: 0970-0490

EXPIRATION DATE: 1/31/2020

ACF Office of Refugee Resettlement

Services for Survivors of Torture

Program Data Points Form

Agency: Administration for Children and Families (ACF)/Office of Refugee Resettlement (ORR) Form: Survivors of Torture – Program Data Points (SOT-PDP)			Grantee Name: Grant Number: Point of Contact:	Reporting Period From: MM/DD/YYYY To: MM/DD/YYYY
Reporting: Submit annual program data with the second semi-annual report each year of the project period. Please use the narrative report to explain or highlight key program indicators and illustrate changes in outcome indicators.
PROGRAM INDICATORS1
Data Point	Description	Indicators		No. of Clients Served
01	Client count during reporting period	New primary New secondary Continuing primary Continuing secondary Clients exiting the program		_____ _____ _____ _____ _____ _____
02	Age when first subjected to torture (primary survivors only)	Under 5 years 5 – 17 years 18 – 44 years 45 – 64 years 65 years and over		_____ _____ _____ _____ _____
03	Type(s) of torture suffered (primary survivors only)	Asphyxiation Beating Burning Deprivation Electrical Forced postures Kidnapping and disappearances Rape and sexual torture Sensory stress Severe humiliation Threats and psychological torture Witnessing torture of others Wounding/maiming Other: Please specify___________		_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
Data Point	Description	Indicators		No. of Clients Served
04	Reason(s) for torture (primary survivors only)	Ethnicity Nationality Political reasons Religion Social activism Social group (e.g., clan, gender, sexual orientation) Other: Please specify____________		_____ _____ _____ _____ _____ _____ _____ _____
05	Country where torture occurred (primary survivors only)	Country 1: Country 2: Country 3: Country 4: … (report all countries)		_____ _____ _____ _____
06	Client goal(s) at intake	Emotional/psychological Interpersonal/social Legal Occupational Physical/medical Substance abuse		_____ _____ _____ _____ _____ _____
07	Gender	Female Male Other		_____ _____ _____
08	Immigration category/status at intake	Asylum seeker Asylee (include derivatives) Refugee (include derivatives) Special Immigrant Visa Holder Lawful Permanent Resident Former refugee (include derivatives) Former asylee (include derivatives) Other former: Please specify_______ U.S. Citizen Former refugee (include derivatives) Former asylee (include derivatives) Other former: Please specify______ Other at intake: Please specify________		_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ ____ ____ _____
Data Point	Description	Indicators		No. of Clients Served
09	Age at intake	Under 5 years 5 – 17 years 18 – 44 years 45 – 64 years 65 years and over		_____ _____ _____ _____ _____
10	Education prior to arrival (for clients > 18 years of age at intake)	Less than 1 year 1-4 years 5-8 years 9-12 years 13-16 years More than 16 years		____ ____ ____ ____ ____ ____
11	Employment in the U.S at intake (for clients > 18 years of age at intake)	No work authorization Unemployed and not seeking employment (e.g., students, elderly, disabled, and primary caregivers) Unemployed, work authorized, and seeking employment Employed with work authorization (PT/FT)		_____ _____ _____ _____
12	Length of time in the U.S. at intake	Less than one year 1- 5 years More than 5 years		_____ _____ _____
13	Country of origin	Country 1: Country 2: Country 3: Country 4: …. (report all countries)		_____ _____ _____ _____
14	Ethnicity	Ethnicity 1: Ethnicity 2: Ethnicity 3: Ethnicity 4: …. (report all ethnicities)		_____ _____ _____ _____
Data Point	Description	Indicators		No. of Clients Served
15	Religion	Buddhists Christians Hindus Jews Muslims None Other: Please specify_____________		_____ _____ _____ _____ _____ _____ _____
16	Languages used	Language 1: Language 2: Language 3: Language 4: … (report all languages used)		_____ _____ _____ _____ _____
17	Clients served by service category	Emotional/psychological Interpersonal/social Legal Occupational Physical/medical Substance abuse		_____ _____ _____ _____ _____ _____
18	People trained by profession	Community Education Interpreters/translators Law enforcement Legal Medical Mental health Social Other: Please specify____________		_____ _____ _____ _____ _____ _____ _____ _____
19	Hours contributed by pro bono service	Administrative, managerial, and other professional services Financial and grant writing Information technology and research Interpreters/translators Legal Medical Mental health Social Other: Please specify_______________		Number of hours _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

OUTCOME INDICATORS2 Indicate how many clients included in this section have been receiving services by length of time: _____ < 6 months _____ 6-12 months _____ >12 months Indicate the tool from which you have derived the client-level data you are reporting here in the aggregate: SOT-PWI-S ____ Our Program Tool ____ Case File Review____ Other: Please specify_____________ Complete all of the boxes for each data point below to show aggregate changes in the level of need.
Data Point	Description	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
20	Legal-immigration	S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=
21	Housing	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
		S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=

Data Point	Description	Level of Need		END
				1 In Crisis	2 Vulnerable			3 Stable		4 Safe
22	Physical health	S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=
23	Mental health	Level of Need		END
				1 In Crisis	2 Vulnerable		3 Stable		4 Safe
		S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=

Data Point	Description	Level of Need		END
				1 In Crisis	2 Vulnerable			3 Stable		4 Safe
24	Access to community resources	S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=
25	Support system in the U.S.	Level of Need		END
				1 In Crisis		2 Vulnerable	3 Stable		4 Safe
		S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden for this collection of information is estimated to average 5 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

1 Refer to the Program Data Points User Guide for all definitions and a List of Ethnic Groups (Appendix A)

2 Use the Survivor of Torture Psychosocial Well-being Index (Short Version) (SOT-PWI-S) © 2016 Hodges-Wu & Zajicek-Farber to aggregate the data for these indicators. (See User Guide, Appendix D)