RevisedPartIILocalServiceProviderSurveyFINAL JULY 2008[1]

Part II: Local Service Provider Survey

State: _________________ Grant Amount: $__________

Name of Grantee: _________________________

Data on Services Provided During: (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) 

Important Reminders:

1. Allowable Use of Access and Visitation Grant Funds

According to Federal law (42 U.S.C. 669b), services funded through the Access and Visitation (AV) Grant program must be used to further the statutory goal of the program which is “....to support and facilitate non-custodial parents’ access to and visitation of their children...”. The Federal Office of Child Support Enforcement (OCSE) is responsible for administering this grant program.

2. Purpose of the “State Child Access Program Survey”

The purpose of the survey is to collect data and provide information to Congress and the public – through annual publication of the report “Child Access and Visitation Grant: State Profiles” -- on the status of programs funded through the Federal Grants to States for Access and Visitation (AV) Grant. Furthermore, this survey is the method by which States and/or local grantees comply with legislatively-mandated program reporting requirements.

3. Data Collection Requirements

All grantees in receipt of State AV Grant funds are required to collect program data on an annual basis and as specified under Part II: Local Service Provider Survey which is contained in the Federally-mandated State Child Access Program Survey. The State AV Program Agency is responsible for completing Part I: State Agency Program Survey which is based upon the data collected and submitted by local grantees.

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 “Part II: Local Service Provider Survey”

is 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 “Part II: Local Service Provider

Surveys” – 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.

COMPLETE THE FOLLOWING:

A. Local Provider Contact Information

• Name of service provider:

• Primary contact person:

• Name of access/visitation program:

• Street address:

• City, state, & zip code:

• Telephone number:

2. Services Provided: (check all that apply) Mandatory,

Voluntary, or Both

1. Mediation _____ __________

2. Development of Parenting Plans _____ __________

Mandatory,

Voluntary, or

Both

3. Counseling _____ _______

4. Parent Education _____ _______

5. Neutral Drop-Off/Pick-Up _____ _______

6. Supervised Visitation _____ _______

7. Visitation Enforcement _____ _______

C. Geographic Areas Served: (check one)

• Urban _____

• Rural _____

• Both _____

.

D. Local Service Provider Worksheet

1. complete attached Excel spreadsheet; and

2. refer to attached “Guidance” for instructions on how to complete the

spreadsheet)

GUIDANCE

To be used in completing

D. LOCAL SERVICE PROVIDER WORKSHEET

Name and Address of Local Service Provider

Include the name of the service provider, AV program, and address.

Case Reference/Identification Number

These are numbers given by service provider to identify parents and/or clients (e.g., grandparents and legal guardians) as recipients of access and visitation services and to protect the privacy of clients.

Client Referral

Identify the entity that referred parents to the service provider and/or indicate whether clients requested services directly.

Client Information

Custodial parent usually means that the parent has primary legal and physical custody of the child and/or that the child’s primary residence is with that parent.

Important: “Number of children in common” refers to the number of children

between the biological parents or number of children being cared for by

grandparents or legal guardians.

Marital Status

Between biological parents only, upon entry into the program.

Race/Ethnicity

Self-explanatory.

Annual Income of Client in Thousands

Self-explanatory.

Client Participation by Service Category

(Count clients once per service area that they participated in; do not report frequency of services provided).

Definition of services:

1. Mediation: includes, but is not limited to, court-connected or

community-based services involving professionals (certified and trained as family mediators) who meet with both parents to: a) resolve parenting

disputes; and b) develop a parenting plan and visitation agreement with the goal of increasing NCP parenting time among others (e.g., increase child support etc.).

2. Development of Parenting Plan: includes, but is not limited to, the development of formal or informal parenting plans or parenting agreements

that result in increased NCP parenting time with children; plans may or may not be filed with the court.

3. Counseling: includes, but is not limited to, services provided by mental health professionals, social workers, etc., to help parents work through their inter- personal conflicts by focusing on the best interests of the child and the

importance of shared parenting; desired results include reduced parental

conflict, increased NCP access to his or her children, and/or an improvement in parenting relationships.

4. Parent Education: includes, but is not limited to, parent education classes provided by the courts or community-based organizations to inform parents on a range of issues (e.g., consequences of divorce on children, shared parenting, court procedures involved in visitation and custody orders, etc.) that, in the end, encourage the development of parenting plans, increase NCP parenting time, and shared parenting.

5. Neutral Drop-Off/Pick-Up: includes, but is not limited to, services for high- conflict parents and their children by providing a safe, neutral environment for the exchange of a child from one parent to another. These services are often available through professionally-recognized community and faith-based organizations and/or supervised visitation centers.

6. Supervised Visitation: includes, but is not limited to, monitored, therapeutic, and supervised visitation services for a noncustodial parent – usually ordered by the court – who would otherwise be denied access to his or her child.

7. Visitation Enforcement: includes, but is not limited to, services – usually court-connected -- designed to monitor parental compliance of a court order for visitation and/or custody, or parenting plan agreement and/or to resolve disputes over non-compliance. For example, Parenting Coordinators are trained professionals often used to fulfill this role.

8. Outcome Information: Increase in NCP Parenting Time with

Children. Record the number of noncustodial fathers and mothers who gained increased parenting time with their children as a result of participation in AV services.

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Part II: Local Service Provider Survey