9 Victim Outreach Form

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

Domestic Victims of Human Trafficking Grantee Victim Outreach Reporting Form
Complete all of the following sections for the outreach activities conducted during the reporting period.
Grantee:

Reporting Period Start Date

Reporting Period End Date

Report Type

Select all of the settings where grantee conducted outreach during the reporting period.
Outreach Settings
Agricultural Settings

Commercial Establishments

Consulates

Court-Based Settings

Day Labor Settings

Detention Settings

Education Settings

Health Care Settings

Hotel/Hospitality Settings

Massage Parlors

Shelter Settings

Strip Clubs

Youth Care Settings
Other
Populations Targeted during the Reporting Period

What screening tool was used?

How many victims of trafficking were identified?

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 .3 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.