2 Client Service Use and Delivery Form

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

Domestic Victims of Human Trafficking Program Grantee
Client Service Use and Delivery Form
Grantee
Reporting Period Start Date

Reporting Period End Date

Report Type

Complete this form for every client by the end of the reporting period to describe benefits and services accessed.

Client Identifier

What services did the client receive during the reporting period? (check all that apply)
Basic Necessities

Child Care

Crisis Intervention

Dental Health Services

Education Assistance

Employment Assistance

Family Reunification

Financial Assistance

Housing and/or Shelter Services

Interpreter and/or Translator

Legal Advocacy and Services

Life Skills

Mental and/or Behavioral Health Services

Medical Services

Safety Planning Services

Substance Use Assessment and/or Treatment

Traditional Healing and Cultural Practices

Transportation

Victim Advocacy

Vision Care

None

Unknown

Other
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN:
Through this information collection, ACF is gathering data on the grant program to assess program performance, inform evaluation, tailor technical
assistance, report to stakeholders, and inform policy and program development. Public reporting burden for this collection of information is estimated to
average .25 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of
information. This collection of information is required to retain a benefit (22 USC 7105, Trafficking Victims Protection Act). An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless
it displays a currently valid OMB control number. If you have any comments on this collection of information, please contact Flavia Keenan-Guerra, Office
on Trafficking in Persons, by email at Flavia.Keenan-Guerra@acf.hhs.gov.

What public benefits did the client access during the reporting period? (check all that apply)
Child Care Subsidy

Food Benefits (SNAP, WIC, Tribal Commodities)

General Assistance

Housing Subsidies (Section 8, HUD Vouchers)

Medicaid, Medicare, or SCHIP

State-Specific Health Benefits

Social Security Disability (SSDI or SSI)

Temporary Assistance for Needy Families (TANF)

Unaccompanied Alien Children Program

Unemployment Insurance

None

Unknown

Other