Form 1103-0066 National Center for Victims of Crime: Service Referral Q

2000 M Street Suite 480

Washington, DC 20036

PHONE (202) 467-8700

FAX (202) 467-8701

SERVICE REFERRAL QUESTIONNAIRE -2007

OMB Control Number 1103-0066

Join Our Service Referral Network

If you work with victims of crime, the National Center wants to be able to refer callers to you. Complete our on-line Service Referral Questionnaire to get referrals to your organization.

For more information about our program, e-mail the Victim Services Staff at [email protected]

This Questionnaire can also be filled out on the Internet at: http://www.ncvc.org/ncvc/main.aspx?dbID=DB_ProviderQ658

AGENCY NAME: _____________________________________________________________________

CONTACT PERSON: _________________________________________________________________

TITLE: _____________________________________________________________________________

ADDRESS: __________________________________________________________________________

____________________________________________________________________________________

CITY: ___________________ COUNTY: _______________ STATE:________ ZIP: _______________

COUNTIES SERVED: ________________________________________________________________________

HOURS: ___________________________________________________________________________________

OFFICE PHONE: (____) _____________________________________

HOTLINE: (____) ___________________________________________

TDD/TTY: (____) ___________________________________________

TOLL-FREE: (____) _________________________________________

FAX: (____)________________________________________________

Agency E-mail:_________________________________________

Additional E-mail: ______________________________________

Web Site: http://________________________________________

Please indicate the languages in which you can provide services, other than spoken English:

___American Sign Language

___French

___Hmong

___Korean

___Spanish

___Vietnamese

___Other: ___________________________________________________________

Please indicate if these services are provided by:

Paid Staff__________ Volunteer____________ Outside interpreters_____________

Agency Type:

Nonprofit ________For-profit Criminal justice _________Other Government

Please indicate if your services are:

Local_______ Statewide______ Nationwide______ International________ College_______

Please indicate if you charge fees for your services Yes______ No______

If yes, please indicate if you offer a sliding fee scale Yes______ No______

VOCA:

____ Yes ____ No

Groups Served:

Males Females

___All Ages ___All Ages

___Children (0-12) ___Children (0-12)

___Teens (13-18) ___Teens (13-18)

___Adults ___Adults

___Elderly ___Elderly

Please indicate whether your agency is specially trained or equipped to meet the needs of victims who are or have:

___Deaf/Hearing Impaired

___Developmentally disabled

___Gay/Lesbian/Transgender

___Living with HIV

___Military families

___Physically disabled

___Visually impaired

___Immigrants

___Psychiatric History

___Native American

___Other: ___________________________________________________________________________ ____________________________________________________________________________________

Services Provided by Your Agency:

____Address Confidentiality Program

____Assistance in Filing Compensation Claims

____ Assistance with Restitution

____Attorney Referral

____Case Advocacy

____Case Management

____Court Accompaniment

____Crisis Intervention

____Counseling

____Financial Assistance

____Hotline

____Housing/Housing Assistance

____Individual Counseling

____Information and Referral

____Legal Advocacy

____Legal Services

____Medical Accompaniment

____Notification

____ Shelter/Safe House

____Support Group

____Training/ Technical Assistance

____ Transportation

____Restraining orders

____Victim/ offender mediation

____Victim’s Rights Enforcement

____Other Services: _____________________________________________________________________________

__________________________________________________________________________________________________

Types of Crime Victims Principally Served:

____General (provide services to any type of

crime victim) OR:

____Arson

____Assault (general)

____Bullying

____Burglary

____Car jacking

____Car theft

____Child Abuse/Neglect

____Child Sexual Abuse/Incest

____Clergy Abuse

____Dating Violence (teen)

____Domestic Violence

____Domestic Violence Stalking

____Drunk/Drugged Driving

____Elder/ Vulnerable Adult Abuse

____Fraud

____Gang Violence

____Harassment

____Hate Crime

____Hit and Run

____Homicide

____Identity Theft

____Missing Adults

____Missing Children

____Non-criminal event

____Property Crime

____Robbery

____September 11

____Sexual Assault

____Stalking

____Terrorism

____Trafficking

____Other: _________________________________________________________________________

Other Comments: _________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

DISCLAIMER

I understand the National Center for Victims of Crime will be using the above information to direct victims, service providers and general callers to our services. I am authorized by this agency to give permission to the National Center for Victims of Crime to use and release said information.

________________________________ _______________________________ ____________

Name Title Date

Paperwork Reduction Act: The COPS Office and its grantees try to create forms and instructions that are accurate and easily understood. The public burden for this form is estimated at 15 minutes per respondent, including time for reviewing instructions and completing this form. There is no estimated record keeping burden associated with the information collection. The COPS Office welcomes your comments regarding this burden estimate or any other aspects of this form, including suggestions for reducing this burden. Send comments to: COPS Office, PPSE Division, 1100 Vermont Avenue, NW, Washington, DC 20530, and to the Office of Management and Budget, Paperwork Reduction Project: OMB No. 1103-0066, Washington DC 20530.

OMB Number 1103-0066

Expiration date 7/31/07

Respondents are not required to respond to this information collection unless it displays a currently valid OMB Control Number.