6 Partnership Development Enrollment Form

Domestic Victims of Human Trafficking Program Data

6 - OTIP-0564 - DVHT New - Partnership Development Enrollment Form CLEAN

OMB: 0970-0542

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

Domestic Victims of Human Trafficking Grantee
Partnership Development and Expansion: Enrollment Form
Grantee:
Reporting Period Start Date

Reporting Period End Date

Report Type

Name of Partner Organization/Agency

City

Enrollment Date

State/Territory

Type of Partner Organization/Agency

Number of Service Sites

Goal of Partnership

Partner Type

Increase Grantee's Capacity to Identify/Serve Victims

Referral Partnership

Increase Clients' Access to a Range of Services

Information Sharing Partnership

Increase Awareness of the Issue of Human Trafficking

Joint Service Programming
Partnership

Increase Sharing of Professional Expertise

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.

Services Provided by Subrecipient (in-house)
Basic Necessities

Child Care

Crisis Intervention

Dental Health Services

Education Assistance

Employment Assistance

Family Reunification

Financial Assistance

Housing/Shelter Services

Interpreter/Translator

Legal Advocacy and Services

Life Skills

Mental/Behavioral Health Services

Medical Services

Safety Planning Services

Substance Use Assessment/Treatment

Traditional Healing/Cultural Practices

Transportation

Victim Advocacy

None

Other
Services Provided Through Referral
Basic Necessities

Child Care

Crisis Intervention

Dental Health Services

Education Assistance

Employment Assistance

Family Reunification

Financial Assistance

Housing/Shelter Services

Interpreter/Translator

Legal Advocacy and Services

Life Skills

Mental/Behavioral Health Services

Medical Services

Safety Planning Services

Substance Use Assessment/Treatment

Traditional Healing/Cultural Practices

Transportation

Victim Advocacy

None

Other


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