Form 1122-0009 Semi-annual Progress Report for the Safe Havens:Supervis

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1122-0009
Expiration Date: 07/31/2004
09/30/2007

U.S. Department of Justice
Office on Violence Against Women
SEMI-ANNUAL PROGRESS REPORT FOR
Safe Havens: Supervised Visitation and
Safe Exchange Grant Program
Brief Instructions: This form must be completed for each Safe Havens: Supervised Visitation and Safe Exchange
Grant Program (Supervised Visitation) grant received. The grant administrator or coordinator must ensure that the
form is completed fully with regard to all grant activities. If the program involves more than one site (either for provision of services or for planning), there will still be only one form completed for each program. Grant partners,
however, may complete sections relevant to their portion of the grant. Grant administrators or coordinators are responsible for compiling and submitting a single report that reflects all information collected from grant partners.
All grantees should read each section to determine which items they must answer, based on the activities engaged in under this grant during the current reporting period. Sections A1, B, C2, C3, E, and F of this form must be
completed by all grantees. In subsections A2, C1, and C4, and section D, grantees must answer an initial question
about whether they engaged in certain activities during the current reporting period. If the response is yes, then
the grantee must complete that section or subsection. If the response is no, the rest of that section or subsection
is skipped.
For example, if you receive funds to hire staff for the purposes of planning and protocol development, you will complete sections A, B, C2, C3, C4, E, and F (and answer ‘no’ in C1 and D); or if you receive funds to hire staff for services and training, you will complete sections A, B, C1, C2, C3, D, E, F (and answer ‘no’ in C4).
The activities of volunteers or interns may be reported if they are coordinated or supervised by Supervised Visitation Program-funded staff or if Supervised Visitation Program funds substantially support their activities.
For further information on filling out this form, refer to the separate set of instructions, which contains detailed
definitions and examples, illustrating how questions should be answered.

SECTION
Section A:
Section B:
Section C:
C1:
C2:
C3:
C4:
Section D:
Section E:
Section F:
Appendix A:

General Information
Program Activities
Function Areas
Training and Staff Development
Coordinated Community Response
Policies
Planning
Services
Community Measures
Narrative
Status of Goals and Objectives Table

Page Number
1
4
5
5
7
8
9
10
14
15
16

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GENERAL INFORMATION
Grant information

A1

All grantees must complete this section.

1.

Date of report

2.

Current reporting period

3.

Grantee name

4.

Grant number

(format date with 6 digits - 01/31/04)
✔

January 1-June 30

✔

July 1-December 31

(Year)

(the federal grant number assigned to your Supervised Visitation Program grant)

5.

Type of implementing agency/organization (Check one.)
Court (state or local)
Domestic violence program
State government
Supervised exchange center
Supervised visitation center
Supervised visitation and exchange center
Tribal government
Unit of local government
Other (specify):

6.

Grant description
(Check all that apply and report the number of sites for each type of grant.)
Type of grant
Number of sites

Supervised Visitation Program (planning)
Supervised Visitation Program (implementation)
Supervised Visitation Program (demonstration)
7.

Point of contact
(person responsible for the day-to-day coordination or administration of the grant)
First Name
Name
Agency/organization name
Agency/organization
name
(if different from grantee
name)
(if different from grantee name)
Address
Address

MI

Last Name

State

City
Telephone
Telephone

Zip Code

Facsimile
Facsimile

E-mail
E-mail

8.

Does this grant specifically address tribal populations?
(Check yes if your Supervised Visitation Program grant focuses on tribal populations, and indicate which
tribes or nations you serve or intend to serve.)
Yes

No

If yes, which tribes/nations:

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9.

What percentage of your Supervised Visitation Program grant funds were directed to each of
these areas?
(Report the area[s] addressed by your Supervised Visitation Program grant during the current reporting period and estimate the approximate percentage of funds [or resources] used to address each area [consider
training, victim services, etc.]. The grantee may choose how to make this determination.)
Throughout this form, the term sexual assault includes both assaults committed by offenders who are
strangers to the victim/survivor and assaults committed by offenders who are known to, or related by blood
or marriage to, or in a dating relationship with the victim. The term domestic violence applies to any pattern
of coercive behavior that is used by one person to gain power and control over a current or former intimate
partner. Stalking is defined as a course of conduct directed at a specific person that places that person in
reasonable fear of the death of, or serious bodily injury to, herself or himself, a member of her/his immediate family, or her/his spouse or intimate partner. Child abuse means a threat to a child’s health or welfare
by physical, mental, or emotional injury or impairment, sexual abuse or exploitation, deprivation of essential
needs, or lack of protection from these, by a person responsible for the child (or as defined by your state’s
statutes).
Percentage of grant funds
Sexual assault
Domestic violence
Stalking
Child abuse
TOTAL

100%0%

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Staff information

A2

Were Supervised Visitation Program funds used to fund staff positions during the current reporting
period?
Check yes if Supervised Visitation Program grant funds were used to pay staff, including part-time staff and
contractors.
Yes—answer question 10
No—skip to Section B

10. Staff
(Report the total number of full-time equivalent [FTE] staff funded by the Supervised Visitation Program grant
during the current reporting period. Include employees who are part-time and/or only partially funded with
these grant funds as well as contractors. If an employee or contractor was not employed or utilized over the
entire reporting period, report the average. Round to the second decimal. See separate instructions for
examples of how to calculate FTEs for part-time staff and contractors.)
Staff

Grant-funded staff

Administrator (fiscal manager, executive director)
Counselor
Program coordinator (training coordinator, visitation services coordinator)
Security
Supervision staff for visitation and exchange
Support staff (administrative assistant, receptionist)
Other (specify):
TOTAL

0.00

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Program Activities

B

All grantees must complete this section.

For the purposes of the Supervised Visitation Program, grant funds may be used to support supervised
visitation and safe exchange of children, by and between parents, in situations involving domestic violence,
child abuse, sexual assault, or stalking.

11. Program activities
(Check all program activities supported by Supervised Visitation Program grant funds during the current
reporting period.)
Check ALL
that apply

Program activities
Establishment or expansion of supervised visitation and exchange services.
Development of community-based advisory committees to plan and/or implement
visitation and exchange services.
Development and implementation of policies and procedures regarding security,
intake, case referral, record keeping, and confidentiality.
Enhancement of program services to address special needs of the target population
(e.g., therapeutic services, directed visitation services, parent education groups).
Development and implementation of effective training for project staff and volunteers.

12. Program priorities addressed by your grant
(In addition to the program activities identified above, the Supervised Visitation Grant Application and
Program Guidelines may have identified program priority areas that would receive priority consideration. If
your program addressed any of these priority areas during the current reporting period, list them below.)

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FUNCTION AREAS
Training and Staff Development

C1

Were your Supervised Visitation Program funds used for training and/or staff development during the
current reporting period?
Check yes if Supervised Visitation Program-funded staff provided training or staff development, or if grant
funds directly supported the training or staff development.
Yes—answer questions 13-16
No—skip to C2.
For the purposes of this reporting form, training means providing information on sexual assault, domestic
violence, child abuse, and/or stalking that enables a person to improve her/his response to victims/
survivors as it relates to her/his role in the system. Staff development is training attended by staff
funded under your Supervised Visitation Program grant.

13. Training and staff development events provided
(Report the total number of training events and the total number of staff development events provided during
the current reporting period with Supervised Visitation Program funds.)
Total number of training events provided (excluding staff development events)
Total number of staff development events provided

14. Number of people trained
(Report the number of people trained during the current reporting period by Supervised Visitation Programfunded staff or training supported by Supervised Visitation Program funds. Use the category that is most
descriptive of the people attending the training event. Do not include staff funded under your Supervised
Visitation Program grant who attended staff development events.)
People trained
Attorneys/law students

Number

People trained
Multidisciplinary group

Batterer Intervention Program staff

Prosecutors

Child welfare workers/advocates

Social service organization staff

Community advocacy organization
staff (NAACP, Gray Panthers)

Supervised visitation and exchange
center staff (staff not funded under
your Supervised Visitation Program
grant))

Correction personnel (probation,
parole, and correctional facilities)
Court personnel (judges, clerks)

Tribal government/tribal government
agency

Government agency staff (vocational
rehabilitation, food stamps, TANF)

Victim advocates

Health professionals (doctors, nurses)
Law enforcement officers
Legal services staff

Number

Victim-witness specialists
Volunteers
Other (specify):

Mental health professionals
TOTAL

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15. Training content areas
(Indicate all topics covered in training events provided with your Supervised Visitation Program funds during
the current reporting period. Do not include topics covered in staff development events. See definitions of
training and staff development at beginning of subsection C1. Check all that apply. )
Domestic violence, sexual assault and child abuse
Advocate response

Underserved populations
Issues specific to families who:

Child abuse overview, dynamics, and services

live in rural areas

Child protective services

are American Indian or Alaska Native

Child witnesses

are Asian

Custody statutes/codes

are black or African American

Confidentiality

are disabled

Domestic violence overview, dynamics,
and services

are elderly

Dynamics relating to non-offending parents
and offending parents

are homeless or living in poverty

are Hispanic or Latino
are immigrants, refugees, or asylum seekers

Family law
Parenting issues

are lesbian, gay, bisexual, transgender, or
intersex

Resources for families

are Native Hawaiian or other Pacific Islander

Safety planning

have mental health problems

Sexual assault overview, dynamics, and services

have substance abuse problems

Stalking overview, dynamics, and services

Other (specify):

Supervised visitation and exchange
Other (specify):

Organization and community issues
Collaboration

Justice system

Coordinated community response

Civil court procedures

Technology

Child abuse statutes/codes

Other (specify):

Custody statues/codes
Domestic violence statutes/codes
Expert testimony
Family law
Judicial response
Law enforcement response
Mandatory reporting requirements
Probation response
Protection orders (including full faith and credit)
Sexual assault statutes/codes
Stalking statutes/codes
Supervised visitation and exchange
Other (specify):

16. Number of staff who attended staff development events
(Report the number of staff funded under your Supervised Visitation Program grant who attended staff
development events.)
Number of people
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Coordinated Community Response

C2

All grantees must complete this section.

17. Coordinated community response activities
(Check the appropriate boxes to indicate the agencies or organizations, even if they are not memorandum of
understanding [MOU] partners or advisory board members, that you provided family referrals to, received referrals from, engaged in consultation with, provided technical assistance to, and/or attended meetings with,
during the current reporting period, according to the usual frequency of the interactions. If the interactions
were not part of a regular schedule, you will need to estimate the frequency with which these interactions occurred during the current reporting period. Indicate which of these agencies/organizations are advisory board
members for your Supervised Visitation Program grant. In the last column, indicate the agencies or organizations with which you have an MOU for the purposes of the Supervised Visitation Program grant.
If you have a planning grant, report planning meetings, advisory board members and MOU partners.
Agency/organization

Family referrals, consultations,
technical assistance
Daily

Weekly

Monthly

Meetings

Advisory Board
MOU
Member
Partner

Weekly Monthly Quarterly

Batterer intervention
program
Child advocacy program
Child protective services
Community advocacy
organization (NAACP,
Gray Panthers)
Corrections (probation,
parole, and correctional
facilities)
Court
Domestic violence program
Faith-based organization
Government agency (INS,
Social Security, TANF)
Health/mental health
organization
Law enforcement agency
Legal services organization
(legal services, bar association, law school)
Prosecutor’s office
Sexual assault program
Social service organization
Tribal government/Tribal
government agency
Other (specify):

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Policies

C3

All grantees must complete this section.

18. Types of policies or protocols developed, substantially revised, or implemented during the current
reporting period
(Check all the types of policies or protocols developed, substantially revised, or implemented during the current reporting period. Check all that apply.)
Center operations
Confidentiality
Flexible hours of operation
Income-based fees (sliding scale)
Program does not charge fees
Recordkeeping and report writing
Staff, board, and/or volunteers represent the diversity of your service area
Other (specify):
Service provision
Appropriate response to underserved populations
Child-friendly (toys, games, appropriate décor)
Court feedback procedures
Courtesy monitoring
Document exchange procedures
Mandatory training on domestic violence, sexual assault, child abuse, and stalking
Out-of-jurisdiction referrals
Parent education program procedures
Supervised exchange procedures
Other (specify):
Security and safety
Different entrances for parties
Escort for children and custodial parent
Metal detectors
Panic button(s)
Private, secure drop-off locations for children
Private, secure entrances for children and custodial parent
Security guards
Security measures in place (cameras, staff, etc.)
Security staff observations
Staggered arrival/departure times
Other (specify):

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Planning

C4

Did you receive a Supervised Visitation Program planning grant?
Check yes if you have a Supervised Visitation Program planning grant. Only those grantees who received a
Supervised Visitation Program planning grant will answer questions 19-21.
Yes—answer questions 19-21
No—skip to Section D

19. Planning meetings
(Report the total number of planning meetings and the total number of people attending planning meetings
during the current reporting period.)
Total number of planning meetings

Total number of people attending

20. Planning activities conducted (Check all that apply.)
Conducting needs assessments
Creating goals and objectives
Creating personnel and agency policies
Identifying location(s) for visitation center(s)
Identifying resources
Identifying visitation center models
Other (specify):

21. Number of site visits to visitation and/or exchange centers
(Report the number of site visits to visitation and/or exchange centers.)
Number of visits

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Services

D

Were your Supervised Visitation Program funds used to provide services to families during the current
reporting period?
Check yes if Supervised Visitation Program-funded staff provided services to families, or if Supervised
Visitation Program grant funds were used to support services to families during the current reporting period.
Yes—answer questions 22-31
No—skip to Section E

22. Number of families served, partially served, and families seeking services who were not served
Please do not attempt to answer this question without referring to the separate set of instructions for further
explanation and examples of how to distinguish among these categories. (Report the following, to the best of
your ability, as an unduplicated count for each category during the current reporting period. This means that
each family who sought or received services during the current reporting period should be counted only once
and in only one of the listed categories. Do not count or report families that do not meet grant eligibility or
statutory requirements.)
Number of families
A. Served: Families who received the service(s) they needed, if those services were
provided under your Supervised Visitation Program grant
B. Partially served: Families who received some service(s), but not all of the services
they needed, if those services were provided under your Supervised Visitation Program grant
C. Families seeking services who were not served: Families who sought services
and did not receive service(s) they needed, if those services were provided under
your Supervised Visitation Program grant

23. Reasons families seeking services were not served or were partially served
(Check all that apply. If you check “Party(ies) not accepted into program,” report on the reason[s] in question
24.)
Reasons not served or partially served
Program reached capacity
Hours of operation
Program rules not acceptable to party(ies)
Services not appropriate for party(ies)
Transportation problems
Services inappropriate or inadequate for people with substance abuse problems
Services inappropriate or inadequate for people with mental health problems
Insufficient/lack of culturally appropriate services
Insufficient/lack of services for people with disabilities
Insufficient/lack of adequate language capacity (including sign language)
Geographic or other isolation of party(ies)
Party(ies) not accepted into program
Other (specify):

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24. Number of families not accepted into program and reasons
(Report the total number of families who were not accepted into the program during the current reporting
period by the reason they were not accepted.)
Reason

Number of families declined

Too dangerous
Conflict of interest
Client unwilling to agree with program rules
Other (specify):
0

TOTAL

25. Demographics of family members served or partially served
(Report the numbers of parents and children served. These numbers should be based on the individuals
in the families counted in question 22A and 22B. This should be an unduplicated count for “gender” and
“age.”)
Race/ethnicity (individuals may be counted for
each ethnicity that applies)

Custodial
parents

Non-custodial
parents

Children

Black or African American
American Indian and Alaska Native
Asian
Native Hawaiian and other Pacific Islander
Hispanic or Latino
White
Unknown
Gender
Female
Male
Unknown
0

TOTAL

0
Number of victims/survivors

0

Age
0 to 6
7 to 12
13 to 17
18 to 24
25 to 59
60+
Unknown
0

TOTAL

0

Other demographics
People with disabilities
People with limited English proficiency
People who are immigrants/refugees/asylum seekers
People who live in rural areas

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26. Number of families by primary victimization and referral source
(Report the number of families by primary type of victimization and referral source. This is an unduplicated
count and each family should only be counted once. This should equal the sum of 22A and 22B. Refer to the
separate set of instructions for further explanation and examples.)
Referral Source

Total number
of families

Sexual
assault

Domestic
violence

Child
abuse

Stalking

Child welfare agency
Other social services
Criminal court order
Family court order
Juvenile court order
Protection order
Other civil court order
Self-referral
Other (specify):

0

TOTAL

0

0

0

27. Family issues
(Report all of the issues identified for each family, including victimization and other problems or challenges).
The column “total number of families” should equal the sum of 22A and 22B and should be identical to the
numbers in the “total number of families” column reported in question 26. Multiple victimizations and problems may be reported for each family. The numbers reported in the remaining columns may exceed the sum
of 22A and 22B).
Total
number of
families

Sexual Domestic
assault violence

Stalking

Child
abuse

Emotional
abuse

Threat of
Substance parental
abuse
abduction

Mental
illness

Violation
of court
orders

Other
(specify)

28. Services provided with Supervised Visitation Program funds
(Report the number of families receiving each of these services and the number of times the services were
provided during the current reporting period. See separate instructions for examples and for the definition of
therapeutic supervision.)
Type of service

Number of families

Number of times services provided

Group supervision
One-to-one supervision
Parent education program
Supervised exchange
Telephone monitoring
Therapeutic supervision
Other (specify):

TOTAL

0

0

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29. Visits Terminated
(Document each supervised visitation that is terminated for any reason. Report the total number of visits
terminated during the current reporting period. See definition of terminated in the separate instructions.)
Reason

Custodial

Total occurrences
Non-custodial

Child

Child’s wishes
Non-compliance with program rules
No-shows
Other (specify):

0

TOTAL

0

0

30. Safety and security problems
(Report the number of safety and security problems, including the number of parental abduction cases that
occurred during supervised visitation and/or supervised exchange funded under the Supervised Visitation
Program grant during the current reporting period.)
Safety or security problem

Number of occurrences

Attempted parental abductions
Parental abductions
Threats
Violence
Other (specify):

0

TOTAL

31. Services terminated or completed
(Report the number of families whose services were terminated or completed during the current reporting
period. Check the primary reason.)
Reason terminated or completed

Number of families

Cessation of threats/use of violence
Change in court order
Child refuses to participate
Habitual non-compliance with program rules
Habitual no-shows or cancellations
Mutual agreement of both parties
Parent completed treatment program
Supervisor’s discretion
Other (specify):

TOTAL

0

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Community Measures

E

All grantees must complete this section.

32. Parental abductions
(Report the number of parental abduction cases, identified through criminal prosecution and custody violation
court records, that occurred in the judicial districts that routinely use your supervised visitation and/or exchange center[s] during the current reporting period.)
Number of parental abductions
Criminal
Civil

33. Limitations
(If the information provided in question 32 is limited in any way, describe the efforts you made to obtain
that information, the reasons for the limitations, and what steps you are taking to address those limitations.
For example, if the data includes non-parental abductions, and/or if your jurisdiction’s data collection methods do not provide information on parental abductions, and/or if you have begun to implement different
data collection tools, please report that here.)

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F. NARRATIVE

F

All grantees must answer question 34.
Please limit your response to four pages. To answer this question go to

Page 16.

34. Report on the status of your Supervised Visitation grant goals and objectives as of the end of
the current reporting period.
(Using Appendix A as a guide, report on the status of the goals and objectives for your grant as of the end of
the current reporting period, as they were identified in your grant proposal or as they have been added or revised. Indicate whether the activities related to your objectives for the current reporting period have been
completed, are in progress, are delayed, or have been revised. Comment on your successes and challenges,
and provide any additional explanation you feel is necessary for us to understand what you have or have not
accomplished relative to your goals and objectives. If you have not accomplished objectives that should have
been accomplished during the current reporting period, you must provide an explanation.)

All grantees must answer questions 35 and 36 on an annual basis. Submit responses on the
January to June reporting form only.
Please limit your response to two pages for each question.
35. What do you see as the most significant areas of remaining need, with regard to increasing the
safety of families? To answer this question go to Page 19.
(Consider geographic regions, underserved populations, service delivery systems, types of victimization,
and challenges and barriers unique to your state or service area.)

36. What has the Supervised Visitation Program funding allowed you to do that you could not do
prior to receiving this funding? (e.g. expand hours, develop new services and/or programs, build
partnerships, and provide additional security) To answer this question go to Page 21.
Question 37 is optional.
Please limit your response to two pages. To answer this question go to

Page 23.

37. Provide any additional information that you would like us to know about your Supervised
Visitation Program grant and/or the effectiveness of your grant.
(If you have other data or information regarding your program that would more fully or accurately reflect the
effectiveness of your Supervised Visitation Program other than the data you have been asked to provide on
this form, answer this question. If you have not already done so elsewhere on this form, feel free to discuss
any of the following: policies, and/or protocols, community collaboration, the removal or reduction of barriers
and challenges for families, promising practices, positive or negative unintended consequences, and parental abductions.)

Public Reporting Burden
Paperwork Reduction Act Notice. Under the Paperwork Reduction Act, a person is not required to respond to a collection
of information unless it displays a currently valid OMB control number. We try to create forms and instructions that are
accurate, can be easily understood, and which impose the least possible burden on you to provide us with information.
The estimated average time to complete and file this form is 60 minutes per form. If you have comments regarding the
accuracy of this estimate, or suggestions for making this form simpler, you can write to the Office on Violence Against
Women, U.S. Department of Justice, 810 7th Street, NW, Washington, DC 20531.

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APPENDIX A

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Describe your goals and objectives, as outlined in your grant proposal, or as revised - Question #34
Back to Instructions

Status

Goals/Objectives

Key Activities

Comments

Back to Instructions

Status

Goals/Objectives

Key Activities

Comments

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APPENDIX A
Describe your goals and objectives, as outlined in your grant proposal, or as revised -

Back to Instructions

Status

Back to Instructions

Status

OMB Clearance # 1122-0009
Expiration Date: 09/30/2007
Question #34 (cont. 1)

Goals/Objectives

Key Activities

Comments

Goals/Objectives

Key Activities

Comments

Safe Havens Semi-annual Progress Report • 17 • Office on Violence Against Women

APPENDIX A

OMB Clearance # 1122-0009
Expiration Date: 09/30/2007

Describe your goals and objectives, as outlined in your grant proposal, or as revised - Question #34 (cont. 2)

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Status

Back to Instructions

Status

Goals/Objectives

Key Activities

Comments

Goals/Objectives

Key Activities

Comments

Safe Havens Semi-annual Progress Report • 18 • Office on Violence Against Women

What do you see as the most significant areas of remaining need, with regard to increasing the safety of
families? - Question #35

Safe Havens Semi-annual Progress Report • 19 • Office on Violence Against Women

OMB Clearance # 1122-0009
Expiration Date: 09/30/2007

Back to Instructions

What do you see as the most significant areas of remaining need, with regard to increasing the safety of
families? - Question #35 (cont.)

OMB Clearance # 1122-0009
Expiration Date: 09/30/2007

Back to Instructions
Safe Havens Semi-annual Progress Report • 20 • Office on Violence Against Women

What has Supervised Visitation Program funding allowed you to do that you could not do prior to
receiving this funding - Question #36

OMB Clearance # 1122-0009
Expiration Date: 09/30/2007

Back to Instructions
Safe Havens Semi-annual Progress Report • 21 • Office on Violence Against Women

What has Supervised Visitation Program funding allowed you to do that you could not do prior to
receiving this funding - Question #36 (cont.)

Safe Havens Semi-annual Progress Report • 22 • Office on Violence Against Women

OMB Clearance # 1122-0009
Expiration Date: 09/30/2007

Back to Instructions

Provide any additional information that you would like us to know about your Supervised Visitation
Program grant and/or the effectiveness of your grant - Question #37

Safe Havens Semi-annual Progress Report • 23 • Office on Violence Against Women

OMB Clearance # 1122-0009
Expiration Date: 09/30/2007

Back to Instructions

Provide any additional information that you would like us to know about your Supervised Visitation
Program grant and/or the effectiveness of your grant - Question #37 (cont.)

Safe Havens Semi-annual Progress Report • 24 • Office on Violence Against Women

OMB Clearance # 1122-0009
Expiration Date: 09/30/2007

Back to Instructions

OMB Clearance # 1122-0009
Expiration Date: 09/30/2007

Validate