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.
File Type | application/msword |
Author | Susan Howley |
Last Modified By | kobrien |
File Modified | 2007-05-17 |
File Created | 2007-05-17 |