1 SASIC Data Point Form

OFFICE OF REFUGEE RESETTLEMENT

Services to Afghan Survivors Impacted by Combat

Program Data Points Form

Agency: Administration for Children and Families (ACF)/Office of Refugee Resettlement (ORR) Form: Services to Afghan Survivors Impacted by Combat – Program Data Points (SASIC-PDP)		Grant Recipient 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 INDICATORS
Data Point	Description		Indicators	No. of Clients Served
01	Client count during reporting period		Total active client count New clients Continuing clients Clients who exited the program	____ ____ ____ ____
02	Age at intake		Under 5 years 5 – 17 years 18 – 44 years 45 – 64 years 65 years and over	_____ _____ _____ _____ _____
03	Sex		Female Male	_____ _____ _____ _____
04	Length of time in the U.S. at intake		≤ 1 year >1 year Unknown	_____ _____ _____
05a	Type of combat exposure/ experience of trauma (Primary survivors only) (Primary survivors: Individuals who directly experienced or were directly affected by a traumatic event/s).		Participated in combat Sustained physical injury Physical violence Psychological violence Sexual violence Deprivation of basic needs Forced labor Kidnapping or disappearances Environmental/community exposure to combat and trauma Other: Specify_____	_____ _____ _____ _____ _____ _____ _____ _____ _____ _____

Data Point	Description	Indicators	No. of Clients Served
05b	Type of combat exposure/experience of trauma (Secondary survivors only) (Secondary survivors: Individuals indirectly affected by a traumatic event(s) because of their close relationship with primary survivors)	Spouse Child Caregiver Parent Other: Specify_____	_____ _____ _____ _____ _____
06	Self-report of either prior service with the Afghan military or provision of support to the U.S. or Afghan government (Primary survivors only)	Served with the Afghan military Supported the U.S. or Afghan government Other: Specify_____	_____ _____ _____
07	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	_____ _____ _____ _____ _____ _____
08	Immigration category/status at intake	Afghan Refugee Afghan Asylee Afghan Special Immigrant Visa (SIV) holder Afghan Individuals with SI/SQ Parole (aka Afghan Special Immigrant Parolee) Afghan Individuals with Special Immigrant Conditional Permanent Residence (SI CPR) Afghan Humanitarian Parolee Unknown Status Other: Specify_____	_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
09	Employment in the U.S. at intake (For clients > 18 years of age at intake)	Unemployed and not seeking employment (e.g., older adult, disabled, and primary caregivers) Employed part-time Employed full time Student	_____ _____ _____ _____

Data Point	Description	Indicators	No. of Clients Served
10	Clients served by overall service category	Mental health Physical health Social services	_____ _____ _____
11	Service-related program activities	Individual therapy Family therapy Group therapy Primary/specialty medical services Community support Employment services Housing services Language/Interpretation services Vocational/education referrals Other: Specify_____	_____ _____ _____ _____ _____ _____ _____ _____ _____
12a	Professional training areas for staff	Interpretation/translation Mental health Medical health Social services Other: Specify_____	_____ _____ _____ _____ _____
12b	Professional training areas for community	Interpretation/translation Mental health Medical health Social services Other: Specify_____	_____ _____ _____ _____ _____

OUTCOME INDICATORS Complete data points 13 14 and 15 below for each service your program offers to show aggregate change in the level of risk. Please specify the duration of services for clients included in this section: -------1 year -------2 years ------3 years Please provide the number of clients served in the following categories: Clients who were enrolled in the previous program year --------- Clients who were enrolled in the current program year ----------
Data Point	Description	Risk Level		END
13	Mental Health Services (N=)			1 In Crisis	2 Vulnerable	3 Stable	4 Safe
		START	1 In Crisis
			2 Vulnerable
			3 Stable
			4 Safe
Data Point	Description	Risk Level		END
14	Physical Health Services (N=)			1 In Crisis	2 Vulnerable	3 Stable	4 Safe
		START	1 In Crisis
			2 Vulnerable
			3 Stable
			4 Safe
Data Point	Description	Risk Level		END
15	Social Services (N=)			1 In Crisis	2 Vulnerable	3 Stable	4 Safe
		START	1 In Crisis
			2 Vulnerable
			3 Stable
			4 Safe

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to monitor SASIC grant recipients activities. Public reporting burden for this collection of information is estimated to average 5 hours per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information under INA § 412(c)(1)(A), 8 U.S.C. 1522(c)(1)(A). 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. The OMB # is 0970-0490 and the expiration date is 03/31/2026. If you have any comments on this collection of information, please contact Francine White at francine.white@acf.hhs.gov.

In immediate response to priorities of the current administration, this form has been updated with the following changes prior to approval by the Office of Management and Budget (OMB), as required by the Paperwork Reduction Act (PRA) of 1995 (44. USC. 3501 et seq.). The PRA requires that agencies obtain OMB approval before requesting information from the public, and OMB review and approval for most changes to an approved information. ACF is working to process these changes through OMB to come into compliance with the PRA but has implemented changes to the OMB-approved form to ensure compliance with the following Executive Orders: Executive Order(s) 14168 and/or 14151, 14173, 14224. Other than these changes, this form is approved under OMB #: 0970-0490.

SASIC Program Data Points Form