1 State Program Survey

Part I: State Agency Program Survey:

I N S T R U C T I O N S

Purpose

The purpose of this survey is to collect data and provide information to Congress and the public on the status of State-administered child access programs as funded through the Federal Grants to States for Access and Visitation (AV). The State Child Access Program Survey is the method by which States comply with legislatively-mandated program reporting requirements.

This mandatory, formula grant program was authorized by Congress through the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (42 U.S.C. 669b). It is administered by the Office of Child Support Enforcement (OCSE) which is a component of the Administration for Children and Families, Department of Health and Human Services.

States must ensure that services funded relate directly to the goal of the grant program which is to facilitate noncustodial parents’ access to or visitation with their children.

Allowable Services

The goal of this program is to enable States to establish and administer programs to support and facilitate noncustodial parents’ access to and visitation with their children.

States are directed to accomplish this goal through the provision of services including:

1. mediation (mandatory and voluntary);

2. development of parenting plans;

3. counseling;

4. parent education;

5. neutral drop-off and pick-up;

6. supervised visitation;

7. visitation enforcement; and

8. development of guidelines for visitation and alternative

custody arrangements.

State Management

It is up to the discretion of the State to determine: a) the type of services to be provided; b) the level of funding and award of grants to service providers (e.g., other State agencies, courts, and/or local non-profit organizations including community and faith-based organizations); c) the geographic areas where the services will be provided; and d) the clients to be served (e.g., divorced, separated, or unmarried parents).

Annual Program Reporting Requirements

According to the Federal statute, States are required to monitor, evaluate, and report on programs funded through this grant -- on an annual basis -- in accordance with regulations prescribed by the Secretary of the Department of Health and Human Services (45 CFR 303.109).

Submission of Survey Data:

How It Works

Step 1: Local Service Providers complete “Part II: Local Service Provider

Survey” and submit to the State AV Program Agency.

Step 2: State Agency must ensure that “Local Service Provider Surveys” are completed by all direct service grantees.

Step 3: State Agency completes “Part I: State Agency Program Survey”

based on the data contained in “Part II: Local Service Provider

Survey.”

Step 4: State Agency is to retain all copies of the “Local Service Provider

Survey” – as submitted by each grantee – and submits a completed

survey (Part I: State Agency Program Survey) to the Federal Office

of Child Support Enforcement by December 31 of each year.

Additional Step 4:

If a State AV Program Agency transfers its child access grant funds to another

State entity (e.g., Office of the Courts) for administration which, in turn, awards

funds to direct service providers, the State AV Program Agency must ensure

that the identification of the direct service providers and program data is

contained in the survey that is submitted to OCSE each year.

Reporting Period

This survey instrument is to be used by State and/or local grantees to collect data on the provision of child access and visitation services provided to parents during the following time periods:

Due Date of Survey to

OCSE: Services Provided to Clients During this Time Period

December 31, 2009 FY 2009: (October 1, 2008 – September 30, 2009)

December 31, 2010 FY 2010: (October 1, 2009 – September 30, 2010)

December 31, 2011 FY 2011: (October 1, 2010 – September 30, 2011)

Annual Submission of State Surveys to OCSE:

December 31 of each year that the survey is authorized.

Survey Format

The survey has been developed in MS Word and Excel formats. States are required to complete the survey form and submit it to the Federal Office of Child Support Enforcement (OCSE) either electronically or by mailing a hard copy.

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is #0970-0204. The maximum time required to complete this information collection is estimated at 15 hours per response and includes the time to review instructions, search existing data resources, gather the data needed including outcomes, and to complete and review the information collected. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Confidentiality

Any information that would permit identification of the individual respondents will be held in strict confidence, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any purpose except as required by law.

Send the completed “State Agency Program Survey” to:

Tracie Pogue

Office of Child Support Enforcement

Administration for Children and Families

U.S. Department of Health and Human Services

370 L’Enfant Promenade, SW

4^th Floor West

Washington, DC 20447

[email protected]

PART I: STATE AGENCY PROGRAM SURVEY

Name of State: _______________

Federal Grant Amount: $_______ State Match: $ ________

Services Provided in Federal Fiscal Year: (check one)

FY 2009 (October 1, 2008 – September 30, 2009) □

FY 2010 (October 1, 2009 – September 30, 2010) □

FY 2011 (October 1, 2010 – September 30, 2011) □

1. State Agency Contact Information

• Name of State AV Program Contact:

• Name of Designated State AV Program Agency:

• Street address:

• City, State, & zip code:

• Telephone number:

• Fax number:

• E-mail:

B. Services Funded: (check all that apply)

1. Mediation (mandatory and voluntary) _____

2. Development of Parenting Plans _____

3. Counseling _____

4. Parent Education _____

5. Neutral Drop-off/Pick-up _____

6. Supervised Visitation _____

7. Visitation Enforcement _____

8. Other _____

(The expenditure of AV grant funds by the State NOT captured in

“Part II: Local Service Provider Survey” such as funds used for training, development of information materials (e.g., shared parenting, pro se materials, etc.), videos, and/or other services or

activities.)

Please provide information on each of these “other” expenditures

using the following format, and attach it to the survey submitted to

OCSE:

Name of Grantee or Recipient of Funds (if applicable):

Brief Description of Activity or Project:

Length of Project (time period):

Target Audience:

No. of Parents Served (if applicable)

Funds Allocated: $ _____________

2. Were State AV Funds Used for Development of Guidelines for Visitation

And Alternative Custody Arrangements?

NO □

YES □ (if yes, please describe)

______________________________________________________________

______________________________________________________________

_______________________________________________________________

D. Description of State Child Access Program

(e.g., brief statement of the State’s overall AV program design and funding

strategy during this time period); maximum 500 word count.

E. Accomplishment of Program Goals

(Compare the actual accomplishments with the goals and objectives established

for the period set forth in the State’s grant application. Provide the reason the

initial goals and objectives were not accomplished, if applicable).

F. Summary Description of State’s Estimated Program Costs vs.

Actual Expenses

(e.g., provide a comparison of your anticipated program costs – contained in your

grant application – with your actual expenses for the grant period. These costs

should include a breakdown of service categories and administrative costs.)

G. Funds from Other Sources

In the boxes below, indicate if the State’s Child Access and Visitation Program is funded only with funds from the Federal program (and any required State match)

and/or whether the State is receiving additional funds from other sources.

1. Federal Access and Visitation Grant Funds and

Required State Match Only: 

2. Combined with funds from other sources: 

Name each additional funding source (e.g., General Revenue Funds,

TANF, etc.) used to increase and support your State's Child Access and

Visitation Grant Program. Please include the estimated

dollar amount.

Source $ Amount

a.

b.

c.

H. SUMMARY TABLE: State AV Program Data

1. Clients Served

(Total Number of Clients = fathers + mothers+ grandparents/legal guardians. Count each person

served only once)

Total No. of Clients Served	No. of Noncustodial Fathers	No. of Custodial Fathers	No. of Noncustodial Mothers	No. of Custodial Mothers	No. of Grandparents & Legal Guardians

2. Children of Clients Served

(Total Number of Children Involved = Number of children of biological parents and those under the

care of grandparents and/or legal guardians)

Total Number of Children in Common

3. Services Provided to Clients

(Report the total number of clients who received services under each category; some clients may

have received more than one service; clients should only be counted once under each service

category; the frequency of service is not to be reported)

Mediation	Parenting Plans	Counseling	Parent Education	Neutral Drop-off	Supervised Visitation	Visitation Enforcement

4. Marital Status Between Biological Parents

(Marital status between biological parents only; do not report marital status of grandparents or legal

guardians)

Never Married to Each Other	Married to Each Other	Separated from Each Other	Divorced from Each Other	Data Not Reported

5. Annual Income

(Information for each client served: parents, grandparents, and legal guardians)

Less than $10,000	$10,000 to $19,999	$20,000 to $29,999	$30,000 to $39,999	$40,000 & Above	Data Not Reported

6. Race/Ethnicity

(Information for each client served: parents, grandparents, and legal guardians)

American Indian or Alaska Native	Asian	Black or African-American	Hispanic or Latino	Native Hawaiian or Other Pacific Islander	White	Two or More Races	Data Not Reported

7. Source of Client Referrals to Services

(Information for each client served: parents, grandparents, and legal guardians)

Self	Court	Child Support Agency	Domestic Violence Agency	Child Protection Agency	Other	Data Not Reported

8. Outcome Data

(Information for biological parents only)

Number of NCPs Who Gained Increased Parenting Time with Children

NCP mothers: #

NCP fathers: #

9. Grantee and/or Sub-Grantee Agency Profile

Name, Address, & Program Contact	Grant Amount $	Grant Period	Services Provided	Voluntary, Mandatory or Both	Service Areas: Urban, Rural, Both	No. of Parents Served
1.
2.
3.
4.

• Add more lines if needed

I. Complete “Summary of State-Funded Local AV Programs” Spread Sheet -- see attached (in Excel format)

11

Part I: State Agency Survey