CloneFamily Violence Prevention & Services Quarterly Performance Progress Report

Program Name:*

Name of Individual Completing the Report:*

First NameLast Name

Email*

example@example.com

Date*

Date

Reporting Period*

1. People Served

A. Clients Served in Shelter

Instructions: Number of NEW domestic violence victims (clients) seen for the first time during this reporting period who received shelter services (including a shelter facility managed by the program, safe home or hotel). Clients should be counted once regardless of the number of times served during the fiscal year. For example, if a client spent 30 days in the shelter in November, exited the shelter and then came back to the shelter in March, then she would only be counted one time. Clients who received shelter should only be counted in this element and not counted in Clients Served with Non-Shelter Services even though they may have received non-shelter services also. Clients who were referred to another domestic violence shelter program should not be counted here. The count will be within program only and should not be unduplicated across programs statewide.

A1.*

Number of Children/Youth

A2.*

Number of Adult Women

A3. *

Number of Adult Men

A4.*

Number Not-Specified/Other

Total:*

B. Clients Served with Non-Shelter Services

Instructions: Number of NEW domestic violence victims (clients) seen for the first time during this reporting period who received only non-shelter services. Include only clients that received supportive services only and no shelter by your program. Calls to a crisis line or hotline should not be counted here and should be counted in Section C instead. Count should be within program only and not unduplicated across programs statewide.

B1.*

Number of Children/Youth

B2. *

Number of Adult Women

B3.*

Number of Adult Men

B4.*

Number Not-specified/Other

Total:*

2. DEMOGRAPHICS

A. Race/Ethnicity

Report the race and/or ethnicity of the new clients served, including children and youth. Clients may self-identify in more than one category, e.g., White and Hispanic.

The total for race/ethnicity demographics must equal total reported in Question 1 (Clients Served in Shelter & Clients Served with Non-Shelter Services).

A1.*

Black or African American

A2.*

American Indian/Alaska Native

A3.*

Asian

A4.*

Hispanic or Latino

A5.*

Native Hawaiian/Other Pacific Islander

A6. *

White

A7.*

Unknown/Other

Total must equal the number reported in Question 1 (Clients Served in Shelter & Clients Served with Non-Shelter Services)*

B. Age

Report the ages fo the clients served, including children and youth.

The total for age demographics must equal total reported for Question 1 (Clients served in Shelter & Clients Served with Non-Shelter Services).

B1.*

0-12

B2.*

13-17

B3.*

Unknown Child Age

B4.*

18-24

B5.*

25-59

B6.*

60 and Older

B7.*

Unknown Adult Age

Total must equal the number reported in Question 1 (Clients Served in Shelter & Clients Served with Non-Shelter Services)*

C. Other Demographics

Number of individuals needing language services, such as interpretation during the reporting period. Provision of interpretation and/or translation. Provision of English as a second language class. (count individuals one time) *

Number of individuals self-identifying as lesbian, gay, bisexual, transgender or queer (LGBTQ) during the reporting period. This is a count of clients who self-identify as lesbian, gay, bisexual, transgender or queer. (count individuals one time)*

Number of youth age 13-17 receiving services due to being a victim of dating violence during the reporting period. This is a count of all the youth age 13-17 receiving service due to being a victim of dating violence in their own relationships. These youths could be receiving services on their own, as an emancipated minor or other minor eligible to receive services, or could be a youth who accompanies their parent to shelter and self-identifies as needing their own services. (count individuals one time)*

3. SHELTER SERVICES AND CRISIS CALLS

Number of Shelter Nights. Indicate the number of shelter nights for each person who arrives and is proved a bed, including onsite shelter, safe home or hotel room. Include victims of domestic violence and their dependents. Count the number of people housed times the number of nights. For example, a victim and her 3 children stay in the shelter or safe house for 5 nights; this means 4 people x 5 nights = 20 shelter nights. (Shelter includes onsite shelter managed by the domestic violence program, program-sponsored hotel rooms and safe homes (residences of volunteers who off their private homes for short-term crisis situations) or other temporary housing that your program manages. Nights that a victim stays in a shelter not managed by your program should not be counted).*

Number of Unmet Requests for Shelter. Count the number of unmet requests for shelter due to program shelter, safe homes or sponsored hotel rooms being at capacity or unavailable. Count adult victims of domestic violence only. This count SHOULD NOT include individuals who were not served because their needs were inappropriate for the services of your program, e.g., homelessness not related to domestic violence. Count the total number of times requests for shelter were declined, even if the program provided other services. *

Number of Crisis/Hotline Calls. Calls received on any agency line that relate to an individual or family in need of some kind of service. A program does not have to have a dedicated hotline to count these calls. Count all calls including repeat callers and calls from third parties such as a family member. DO NOT count calls about donations or for general information about program or violence issues unrelated to a specific individual or family, calls from the media, etc.*

4. Services to Victims

Report the number of individuals who received each service. Count each individual only once for each type of service that the individual received.

Individual/Group Counseling: Individual or group counseling or support provided by a volunteer, staff or advocate.

Crisis Intervention: Process by which a person identifies, assesses, and intervenes with an individual in crisis so as to restore balance and reduce the effects of the crisis in his/her life. In this category, report crisis intervention that occurs in person and/or over the telephone with an established client. This does not include hotline calls where the caller isn't a client receiving services.

Victim Advocacy Services: Actions designed to help the victim/survivor obtain needed resources or services including employment, housing, shelter services, health care, victim's compensation, etc.

Criminal/Civil Legal Advocacy: Assisting a client with civil legal issues, including preparing paperwork for protection orders; accompanying a client to a protection order hearing, or other civil legal proceedings; and all other advocacy within the civil justice system. This also includes accompanying a client to an administrative hearing, such as unemployment, Social Security, TANF, or food stamp hearing. Assisting a client with criminal legal issues including notifying the client of case status, hearing dates, plea agreements, and sentencing terms; preparing paperwork such as victim impact statements; accompanying a client to a criminal court proceeding or law enforcement interview; and all other advocacy within the criminal justice system.

Medical Accompaniment: Accompanying a domestic violence victim to, or meeting a victim at, a hospital, clinic, or medical office.

Transportation Services: Provision of transportation, either directly through bus passes, taxi fares, or other means of transportation.

A. Number of children/youth receiving crisis intervention:*

B. Number of children/youth receiving victim advocacy services:*

C. Number of children/youth receiving individual or group counseling/support group: *

D. Number of Adult individuals receiving crisis intervention:*

E. Number of Adult individuals receiving victim advocacy services:*

F. Number of Adult individuals receiving individual or group counseling/support group:*

G. Number of Adult individuals receiving criminal/civil legal advocacy:*

H. Number of Adult individuals receiving medical accompaniment:*

I. Number of Adult individuals receiving transportation services:*

5. Community Education

A. Adults/General Population: (Count the total number of presentations or training's about domestic violence and/or services related to victims of domestic violence and their children. In addition, count the number of individuals in attendance. Some examples may be a training for health professionals or workshop for tribal leaders. Include all presentations for a mixed-age audience. This number does not include health fairs, media interviews or advertising).*

Number of Presentations

*

Number of Participants

B. Youth Targeting Education: (Count the total number of presentations or training's about domestic violence, dating violence, healthy relationships or available services for victims. In addition, count the number of individuals in attendance. Some examples may be a presentation to youth in school on healthy relationships or a workshop for youth at a Safety Day event).*

Number of Presentations

*

Number of Participants

6. Service Outcome Data

Domestic violence programs should be collecting outcome information from their clients served. A manual and instructions from the Documenting OUR Work Project are available online at the Outcomes webpage from the National Resource Center on Domestic Violence at http://nrcdv.org/FVPSAOutcomes.

There are two mandated questions that must be asked of clients.

Because of the services I received, I feel:

I know more about community resources (yes or no)
I know more ways to plan for my safety (yes or no)

Outcome information may be collected for each service-shelter, support services and advocacy, counseling and support group. However, at a minimum, FVPSA requests outcome information on shelter services from programs that provide shelter services.

FOr each service, count the number of surveys completed and the number of yes responses to each question. It is expected that the total number of surveys completed would be the same for each, but there may be instances when it differs, e.g., a client doesn't answer one of the questions.

I know more about community resources (Resource Outcome).
I know more ways to plan for my safety (Safety Outcome).

Question 1: I know more about community resources

A. Number of Surveys completed for:

1.*

Shelter Safety

2.*

Support Services and Advocacy Survey

3.*

Counseling Survey

4.*

Support Group Survey

Total Number of Surveys Completed*

B. Number of Yes Responses to Resource Outcome for:

1.*

Shelter Safety

2.*

Support Services and Advocacy Survey

3.*

Counseling Survey

4.*

Support Group Survey

Total Number of YES Responses to Resource Outcome*

Question 2: I know more ways to plan for safety

A. Number of Surveys completed for:

1. *

Shelter Safety

2.*

Support Services and Advocacy Survey

3. *

Counseling Survey

4. *

Support Group Survey

Total Number of Surveys Completed*

B. Number of Yes Responses to Safety Outcome

1.*

Shelter Safety

2.*

Support Services and Advocacy Survey

3. *

Counseling Survey

4.*

Support Group Survey

Total Number of YES Responses to Safety Outcome*

7. Total Domestic Violence Program Budget: (This is the sum for your total annual budget. Report total for ALL funding sources that are directly used to operate your domestic violence program.)*