Form 1 Local Spread Sheet

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Overview

Provider Form
DO NOT ENTER
State Form

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Sheet 1: Provider Form

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Sheet 2: DO NOT ENTER

Alabama		Y			1
Alaska		N			2
Arizonia					3
Arkansas		GP Father			4
California		GP Mother			5
Colorado					6
Connecticut		Am. Indian	Asian AM	Y	7
Delaware		Alaskan Nat	Pacfic Isd.	N	8
District of Columbia					9
Florida		X			10
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Neveda
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Island
Washington State
West Virginia
Wisconsin
Wisconsin
Wyoming

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Sheet 3: State Form

Name/Address of Local Service Provider
						F. Local Service Provider Spreadsheet																				FY 2013-2015
State																																														(Optional)
Ohio
	Client Referral Source						Client Information							Marital Status				Race/Ethnicity							Income in Thousands					Services Provided							Frequency of Services (Hours) (Optional)							Outcome		# Parents w/
														Upon Program Entry																																Knowledge of Eff-
																																														ective Co Parent-
																																												Required		ing Strategies
Client ID Number	Self	Court	Child Support Agency	Domestic Violence Agency	Child Protection Agency	Other	Father (noncustodial)	Father (custodial)	Mother (noncustodial)	Mother (custodial)	Grandparent/Legal Guardian	Number of Children in Common	Child Support Cases (Optional)	Never Married to Each Other	Married to Each Other	Separated from Each Other	Divorced from Each Other	American Indian or Alaska Native	Asian	Black or African-American	Hispanic or Latino	Native Hawaiian or Other Pacific Islander	White	Two or More Races	Less than $10,000	$10,000 to $19,999	$20,000 to $29,999	$30,000 to $39,999	$40,000 & Above	Mediation	Development of Parenting Plan	Counseling	Parent Education	Neutral Drop-Off/Pick-Up	Supervised Visitation	Visitation Enforcement	Mediation	Development of Parenting Plan	Counseling	Parent Education	Neutral Drop-Off/Pick-Up	Supervised Visitation	Visitation Enforcement	Noncustodial Fathers with Increased Parenting Time	Noncustodial Mothers with Increased Parenting Time	NCP Fathers #	CP Fathers #:	NCP Mothers #:	CP Mothers #:
Total	0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0