Form 4 Barriers to Service Delivery and Monitoring Form

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

Domestic Victims of Human Trafficking Program Grantee
Barriers to Service Delivery and Monitoring Form
Grantee
Reporting Period Start Date

Reporting Period End Date

Report Type

Select all barriers to service delivery encountered during the reporting period.
Barriers to Service Delivery Encountered (Check all that apply)
Lack of Adequate Resources

Lack of Adequate Funding

Lack of Adequate Training

Ineffective Coordination with Federal Agencies

Ineffective Coordination with Local Agencies

Language Concerns

Safety Concerns

Lack of Knowledge of Victims' Rights

Lack of Formal Rules and Regulations

Lack of Cooperation of Client

Victims' Legal Status

Feelings of No Support and Isolation

Lack of In-House Procedures

None

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 .167 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.