Form 1 Staate PPR

Performance Progress Report (PPR)
Family Violence Prevention and Services Act (FVPSA Program) / Family and Youth Services Bureau (FYSB) /
Administration on Children, Youth and Families (ACYF) / Administration for Children and Families (ACF) /
U.S. Department of Health and Human Services (HHS)
State/Territory Grant Report Cover Page
1. Federal Agency and Organization Element
to Which Report is Submitted

2. Federal Grant or Other Identifying
Number Assigned by Federal Agency

3a. DUNS Number
3b. EIN

FVPSP/FYSB/ACYF/ACF/HHS
4. Recipient Organization (Name and Complete Address Including Zip Code)

5. Recipient Identifying Number or
Account Number

6. Project Reporting Period

8. Final Report?

7. Reporting Period End
Date

Start Date: (Month, Day, Year)

End Date: (Month, Day, Year)

(Month, Day, Year)

10/1/2013

9/30/2014

9/30/2014

■

Yes
No

9. Report Frequency
■

annual
quarterly

semi-annual
other

10. Performance Narrative
Attach a separate document with the labeled responses to each of the elements in Section H.

11. Other Attachments
Attach a spreadsheet of the subgrantees and contracts awarded under this grant. Only list each subgrantee once.
Column 1 - Name of Subgrantee
Column 2 - Mailing Address [Do not include if it is a confidential location and there is no PO Box.]
Column 3 - City
Column 4 - Zip Code
Column 5 - FVPSA Funding Amount
Column 6 - Indicate categories: shelter, non-shelter, coalition, tribal, culturally-specific (indicate which, e.g., Latin@)
12. Certification: I certify to the best of my knowledge and belief that this report is correct and complete for
performance of activities for the purposes set forth in the award documents.
12a. Typed or Printed Name and Title of Authorized Certifying Official

12c. Telephone (area code, number and
extension)

12d. Email Address

12b. Signature of Authorized Certifying Official

12e. Date Report Submitted (Month, Day, Year)

13. Agency Use Only

1

OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014

Performance Progress Report (PPR)
State/Territory Grant Report (continued)
1. Federal Agency and Organization Element
to Which Report is Submitted

2. Federal Grant or Other Identifying
Number Assigned by Federal Agency

FVPSP/FYSB/ACYF/ACF/HHS

0

3a. DUNS Number

0

3b. EIN

0

Section SP - State Portion
Information on FVPSA grants/funds awarded should include any funds awarded by the state during the federal fiscal
year reporting period. For example, during the past federal fiscal year (Oct- Sep), the State made awards to
subgrantees in July. The State should report on the grants and funds awarded in July and any other funds awarded
during the federal fiscal year reporting period. The State’s aggregate report of services provided by FVPSA subgrantees
should include all services/grant activities that occurred throughout the federal fiscal year reporting period (Oct – Sep).
Label

Additional Information on Grantee or Grant Project

SP-01

Total funds awarded to subgrantees by the State

SP-02

Total number of subgrants awarded

SP-03

Total amount of state administrative costs

SP-04

Total number of subgrants to programs with shelters

SP-05

Total number of subgrants to programs without a shelter
facility

SP-06

Total number of subgrants to culturally and linguistically
specific services programs

Response

Comments on responses to above section (optional)

2

OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014

Performance Progress Report (PPR)
Family Violence Prevention Services Program Performance Report

Subgrantee Information
1. Federal Agency and Organization Element
to Which Report is Submitted

FVPSP/FYSB/ACYF/ACF/HHS
(This line is for
subgrantee use only)

2. Federal Grant or Other Identifying
Number Assigned by Federal Agency

3a. DUNS Number

0
3b. EIN

0

0

Subgrantee organization name

Subgrantee location

Subgrantee Information: This information in sections A-I should be collected by each subgrantee and compiled by the
state into this one section. This report is a compilation of all domestic violence services regardless of funding source,
not just FVPSA funds, used to provide the below services to victims. For the narrative responses (section H), the State
should chose what information to include from the subgrantees and may include information about FVPSA funds
retained by the State.
Section A – General Program Information
Label

Information Requested

A-01

Total domestic violence program budget

A-02

FVPSA grant amount

A-03

Number of shelter facilities

A-04

Number of non-shelter service sites

A-05

Number of volunteers

A-06

Number of volunteer hours

3

Response

Explanation (optional)

OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014

Performance Progress Report (PPR)
Subgrantee Information (continued)
1. Federal Agency and Organization Element
to Which Report is Submitted

FVPSP/FYSB/ACYF/ACF/HHS

2. Federal Grant or Other Identifying
Number Assigned by Federal Agency

3a. DUNS Number

0
3b. EIN

0

0

Section B—People Served (Unduplicated)
Include all victims served. Do not include clients served only in Batterers Intervention Services; count them in Section F.
Shelter
(including safe homes)

Women

Men

Not
Specified

Children

Youth
IPV
Victim

Women

Men

Not
Specified

Children

Youth
IPV
Victim

Black or
African
American

American
Indian/
Alaska
Native

Asian

0-17

18-24

25-59

Unduplicated Count of
Clients Served

B-01

Non-Shelter
(supportive services
only)
Unduplicated Count of
Clients Served

B-02

Race/Ethnicity

B-03

Native
Unknown/
Hawaiian/
Hispanic
White
Other
Other
or Latino
Pacific
Islander

Clients
Age

B-04

60+

Unknown

Clients

4

OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014

Performance Progress Report (PPR)
Subgrantee Information (continued)
1. Federal Agency and Organization Element
to Which Report is Submitted

2. Federal Grant or Other Identifying
Number Assigned by Federal Agency

FVPSP/FYSB/ACYF/ACF/HHS

0

3a. DUNS Number

0

3b. EIN

0

Section C—Shelter Services
Indicate the number of shelter nights for each person that arrives and is provided a bed, including on-site shelter, safe
home or hotel room. Count the # of people housed times the number of nights.
C-01

Shelter Nights

C-02

Unmet Requests for
Shelter

Section D—Supportive Services for Adults
Indicate the number of service contacts provided regardless of length.
Crisis/Hotline Calls
D-01 Cri

Total Calls

sis/Hotline Calls
Supportive Counseling
& Advocacy

D-02

Individual Supportive
Counseling & Advocacy

D-03 Grou

p Supportive
Counseling & Advocacy

Number of Service
Contacts

Section E—Supportive Services for Children
Indicate the number of service contacts provided regardless of length.
Supportive Counseling
& Advocacy

Number of Service
Contacts

E-01 Individual
E-02 Grou

p
Activities for Children
& Youth

E-03 Individual
E-04 Grou

5

Number of Service
Contacts

Activities
p Activities

OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014

Performance Progress Report (PPR)
Subgrantee Information (continued)
1. Federal Agency and Organization Element
to Which Report is Submitted

2. Federal Grant or Other Identifying
Number Assigned by Federal Agency

FVPSP/FYSB/ACYF/ACF/HHS

0

3a. DUNS Number

0
3b. EIN

0

Section F—Batterer Intervention Services
Report only if these services are funded by FVPSA.
Gender

F-01

Male

Female

Not
Specified

0-17

18-24

25-59

Unduplicated Count of
Clients Receiving
Batterer Intervention
Services
Age

F-02

60+

Unknown

Batterer Intervention
Clients
Intervention/
Counseling Services

F-03

Individual Counseling

F-04

Group Counseling

Number
of
Service
Contacts

Section G—Community Education and Public Awareness
Indicate the total number of training and community education presentations and the total number of individuals
attending.
Community
Education
G-01

Adults/General
Population

G-02

Youth Targeted
Community
Awareness Activities

G-03

Number of
Presentations

Number of
Participants

Number of
Activities

Awareness Activities

6

OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014

Performance Progress Report (PPR)
Subgrantee Information (continued)
1. Federal Agency and Organization Element
to Which Report is Submitted

2. Federal Grant or Other Identifying
Number Assigned by Federal Agency

FVPSP/FYSB/ACYF/ACF/HHS

0

3a. DUNS Number

0

3b. EIN

0

Section H—Narrative Responses
Attach a separate document with the labeled responses to each of the below elements.
H-01

For services supported in whole or in part by your FVPSA grant, share
a story about a client, service or community initiative that could be
shared with other stakeholders.

H-02

What does the FVPSA grant allow you to do that you wouldn’t be able
to do without this funding?

H-03

Describe any efforts supported in whole or in part by your FVPSA grant
to meet the needs of underserved populations in your community,
including populations underserved because of ethnic, racial, cultural or
language diversity, sexual orientation or gender identity or geographic
isolation. Describe any ongoing challenges.

H-04

Describe significant prevention and outreach activities, supported in
whole or in part by your FVPSA grant, during the program year.

H-05

Provide information on the evaluation of the effectiveness of your
domestic violence programming

H-06

(Optional) Provide any additional information that you would like us to
know about your FVPSA-supported domestic violence program, i.e.,
the unmet needs of victims in your community, other funding sources
used for programming or service trends that are emerging in your
community.

7

OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014

Performance Progress Report (PPR)
Subgrantee Information (continued)
1. Federal Agency and Organization Element
to Which Report is Submitted

FVPSP/FYSB/ACYF/ACF/HHS

2. Federal Grant or Other Identifying
Number Assigned by Federal Agency

3a. DUNS Number

0
3b. EIN

0

0

Section I—Service Outcome Data
For each service area from which you collected outcome data, indicate how many surveys were completed and how
many YES responses you received to each of the outcome questions (resources and safety).
Survey Type

I-01

Shelter survey

I-02

Support services and
advocacy survey

I-03

Counseling
survey

I-04

Support group survey

I-05

TOTAL

8

Number of Surveys
Competed

Number of Yes
Responses to
Resource
Outcome

Number of Yes
Responses to
Safety Outcome

OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014

Performance Progress Report (PPR)
Instructions for Completion of the Performance Progress Report

Instructions for Cover Page
Item

Data Element

Instructions

1.

Federal Agency and
Organizational Element to Which
Report is Submitted

Enter the name of the awarding Federal agency and organizational
element identified in the award document or otherwise instructed by the
agency. The organizational element is a sub-agency within an awarding
Federal agency.

2.

Federal Grant or Other Identifying
Number Assigned by the
awarding Federal agency

Enter the grant/award number contained in the award document.

3a.

DUNS Number

Enter the recipient organization's Data Universal Numbering System
(DUNS) number or Central Contract Registry extended DUNS number.

3b.

EIN

Enter the recipient organization's Employer Identification Number (EIN)
provided by the Internal Revenue Service.

4.

Recipient Organization

Enter the name of recipient organization and complete address, including
ZIP code.

5.

Recipient Account Number or
Account Number

Enter the account number or any other identifying number assigned by the
recipient to the award. This number is strictly for the recipient's use only
and is not required by the awarding Federal agency.

6.

Project/Grant Period

Enter the federal fiscal year covered by this performance progress report.

7.

Reporting Period End Date

Enter the ending date of the reporting period.

8.

Final Report

Mark appropriate box. Check “yes” only if this is the final report for the
project/grant period specified in Box 6.

9.

Report or Frequency

Select “annual” for report frequency.

10.

Performance Narrative

Attach a separate document with the labeled responses to each of the
elements in Section H.

11.

Other Attachments

Attach a separate document per the instructions on the cover page.

12a.

Certification – Name

Type or print the name and title of the Authorized Certifying Official.

12b.

Certification - Signature

The Authorized Certifying Official should sign here.

12c.

Certification – Phone

Enter the area code, phone number and extension of the Authorized
Certifying Official.

12d.

Certification – Email

Enter the email address of the Authorized Certifying Official.

12e.

Certification – Date

Enter the date (month, day, year) the report is submitted.

Instructions for Section SP - State Portion
Item

Data Element

SP-01

Total funds awarded to
subgrantees by the State

9

Instructions
Report the total amount of grant awards or contracts made to subgrantees (i.e.,
domestic violence programs) during the reporting period.

OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014

Performance Progress Report (PPR)
Item

Data Element

Instructions

SP-02

Total number of
subgrants awarded

Count the number of grant awards or contracts made to subgrantees.

SP-03

Total amount of state
administrative costs

Report the total amount of grant funds used to support State/Territory costs for
the administration of FVPSA funding.

SP-04

Total number of
subgrants to programs
with shelters

Count the number of grant awards or contracts made to domestic violence
programs that have a shelter facility.

SP-05

Total number of
subgrants to programs
without a shelter facility

Count the number of grant awards or contracts made to domestic violence
programs that do not have a shelter facility and provide supportive services only.

SP-06

Total number of
subgrants to culturally
and linguistically specific
services programs

Count the number of grant awards or contracts made to culturally and
linguistically specific services programs. Culturally and linguistically specific
services refers to community-based services that offer full linguistic access and
culturally specific services and resources, including outreach, collaboration and
support mechanisms primarily directed toward culturally specific communities.

Instructions for Section A – General Program Information
Item

Data
Element

Instructions

Explanation of information to be collected: This report is a compilation of all of the domestic violence services provided
by local domestic violence programs for victims of domestic violence and their dependents – whether or not the service
is provided with FVPSA funds. In consultation with FVPSA state administrators, tribal program coordinators and
coalition representatives, it was determined that this report would include a count of all domestic violence services
provided through FVPSA-funded programs, including those supported through other funding sources. In order to
accurately report the proportion of services supported through FVPSA funding, grantees are required to report the total
domestic violence budget (A-01) and the FVPSA grant amount (A-02). These figures are used to determine the
percentage of the program budget /services funded through FVPSA. It is imperative that the total domestic violence
program budget (A-01) are accurate numbers.
This is the sum of the total annual budgets for each local domestic violence program at the
same point in time. Each local domestic violence program will report its total budget that is
used to provide the services to victims included in this report, This number could include
additional funding from other sources or it may be the same as the FVPSA grant amount listed
in A-02. The FVPSA State Administrator then sums up each of the entries from the local
programs and enters the number here.

A-01

Total
Domestic
Violence
Program
Budget

A-02

FVPSA
Grant
Amount

List total amount of FVPSA grant received within this fiscal year.

A-03

Number of
Shelter
Facilities

List the total number of shelter facilities providing immediate housing to victims of domestic
violence and their children managed by the domestic violence program. This number should not
include safe homes, motels or shelter beds provided by other programs.

10

For example, the total program budget would include all funding sources, i.e., FVPSA dollars
and state dollars to provide shelter to victims. Grant dollars set aside to provide separate
services to sexual assault victims would not be included here. In addition, a domestic violence
program that is located within a larger social service agency would only include its budget for
domestic violence programming. For example, a local domestic violence program that receives
$50,000 in FVPSA funds, $20,000 from the state for DV services and $10,000 from a private
funder would report $80,000 as its total domestic violence program budget.

OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014

Performance Progress Report (PPR)
Item

Data
Element

Instructions

A-04

Non-Shelter
Services
Sites

List the total number of service sites (i.e., office locations) where a program provides nonresidential services. This may include the coordination of shelter for victims through hotels and
safe homes where there is not a shelter facility. This number should be one (1) if the program
has a single program site with no shelter facility. If a program maintains satellite locations, they
should be counted here, i.e., one main office and two satellite offices should be reported as
three (3) sites. This is not a count of the number of hotels and safe homes used.

A-05

Volunteers

Count number of individuals from all areas, including programmatic (i.e., advocacy, and
transportation) and administrative services (i.e., board members and data entry).

A-06

Volunteer
Hours

Count total time rounded to nearest hour.

Instructions for Section B – People Served
Item

Data Element

Instructions

If the grantee has concerns that providing the data below will allow a report reader to personally identify a victim, then
use the boxes for “not specified” or “unknown” for that client’s data.

B-01

B-02

B-03

B-04

Shelter
(including safe
homes)

Number of new domestic violence victims (clients) seen for the first time during this
reporting period who received shelter services (including a shelter facility managed by the
program, safe home or hotel). Clients should be counted once regardless of the number
of times served during the fiscal year. Clients who received shelter should only be
counted in this element and not counted in B-02 even though they may have received
non-shelter services also. Clients who were referred to another domestic violence shelter
program should not be counted here. Count will be within program only and not
unduplicated across programs statewide.

Non-Shelter
(supportive
services only)

Clients who received only non-shelter services should be counted in this category.
Exclude clients served only by Batterer Intervention Programs (they are counted in Sec.
E) and those served by a hotline only. Count should be within program only and not
unduplicated across programs statewide.

Youth IPV
Victim

Count the number of youth under the age of 18 who were identified as victims of intimate
partner violence (IPV). This number is a subset of the total number of children served.
For example, a program served 100 children & youth of which 8 identified as Youth IPV
Victims. Report as Children & Youth – 100; Youth IPV Victim – 8 which means the 8
Youth IPV Victims are counted in both fields. Child abuse cases do not count as IPV
victims.

Race/Ethnicity

Report the race and/or ethnicity of the clients served, including children and youth.
Clients may self-identify in more than one category, i.e., White and Hispanic. Therefore,
the total number may exceed the total number in B-01 plus B-02.

Age

Report the ages of the clients served, including children and youth. These demographic
totals should equal the program’s numbers totaled in B-01 plus B-02. For example, if the
program served 30 women, 62 children and 2 men, the total for all the ages should add up
to 94.

11

OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014

Performance Progress Report (PPR)

Instructions for Section C –Shelter Services
Item

C-01

C-02

Data Element

Shelter Nights

Unmet Requests
for Shelter

Instructions
Indicate the number of shelter nights for each person who arrives and is provided a bed,
including on-site shelter, safe home or hotel room. Include victims of domestic violence
and their dependents. Count the number of people housed times the number of nights.
For example, a victim and her 3 children stay in the shelter or safe house for 5 nights – 4
people x 5 nights = 20 shelter nights.
Shelter includes onsite shelter managed by the domestic violence program, programsponsored hotel rooms and safe homes (residences of volunteers who offer their private
homes for short-term crisis situations) or other temporary housing that your program
arranges. Nights that a victims stays in a shelter (i.e., a shelter in a nearby county) not
managed by your program should not be counted.
Count the number of unmet requests for shelter due to program shelter, safe homes or
sponsored hotel rooms being at capacity or unavailable. Count the adult victims of
domestic violence only. This count should not include individuals who were not served
because their needs were inappropriate for the services of your program, i.e.,
homelessness not related to domestic violence. Count the total number of times requests
for shelter were declined, even if the program provided other services.

Instructions for Section D – Supportive Services for Adults
Item

D-01

D-02

Data Element
Crisis/Hotline
Calls

Individual

Instructions
Calls received on any agency line that relate to an individual or family in need of some kind
of service. A program does not have to have a dedicated hotline to count these calls.
Count all calls including repeat callers and calls from third parties. Do not count donations,
general information about program or violence issues unrelated to a specific individual or
family, calls from the media, etc.
Count the total number of service contacts provided regardless of length. A contact could
be a thirty minute counseling session in shelter or several hours to accompany a survivor
to court. Do not count brief encounters such as distribution of toiletries, giving out a survey
to complete, etc.
Supportive services are services such as crisis intervention, safety planning, individual
counseling, educational services, legal advocacy, personal advocacy, housing advocacy,
medical advocacy, information/referral, transportation and home visits.

D-03

Group

Count the total number of sessions for each individual in attendance at the group. For
example, 5 support groups with 10 individuals at each = 50 service contacts. Some
examples of groups are support groups or psycho-educational groups.

Instructions for Section E – Supportive Services for Children
Item

Data Element

Instructions

Supportive Counseling/Advocacy for Children & Youth

12

OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014

Performance Progress Report (PPR)
Item

E-01

E-02

Data Element

Instructions

Individual

Count total number of service contacts with children under the age of 18. These
supportive services provided to children may be crisis intervention, safety planning,
individual counseling or educational services. For example, if an advocate meets 3
different times with a client to have a safety planning session, drive to an
appointment and provide crisis counseling, then the count would be 3 service
contacts.

Group

Count the total number of sessions for each individual in attendance at the group.
For example, 4 groups with 8 individuals at each = 32 service contacts. Some
examples of groups are support groups for children who are exposed to domestic
violence or art therapy groups.

Activities for Children & Youth
Counts in this section are non-IPV related services provided.
E-03

Individual

Count total number of service contacts with children that fall outside of child
advocacy including contacts such as mentoring or recreational opportunities.

E-04

Group

Count the total number of service contacts that fall outside of child advocacy
including recreational activities, child care, etc. For example, a field trip to a park for
4 children residing in shelter = 4 service contacts.

Instructions for Section F – Batterer Intervention Services
Item

Data Element

Instructions

Batterer intervention services include a provision of sessions based on a specific model of intervention designed to
address accountability for abusive behavior including re-education programs for those who abuse their intimate
partners.
Report in this section only if these services are funded by FVPSA.

F-01

Unduplicated Count of
Clients Receiving
Batterer Intervention
Services

Number of new clients seen for the first time during this reporting period who
received batterer intervention services (either individual or group services) using
FVPSA funds. Clients should be counted once regardless of the number of times
served during the fiscal year.

F-02

Age

Report the ages of the clients served in batterer intervention, including youth. These
demographic totals should equal the totals for F-01.

F-03

Individual

Count the total number of service contacts with clients who received batterer
intervention services. For example, if a provider meets with a client 12 separate
times to provide a series of counseling sessions, then that is 12 service contacts.

Group

Count the total number of service contacts with clients who received group batterer
intervention services. For example, if a support group was held with 12 clients that
met for 24 weeks, then the number of service contacts would be 12 times 24 to equal
288.

F-04

Instructions for Section G – Community Education and Public Awareness
Item

Data Element

13

Instructions
OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014

Performance Progress Report (PPR)
Item

G-01

Data Element
Adults/ General
Population

Instructions
Count the total number of presentations or trainings about domestic violence and/or
services related to victims of domestic violence and their children. In addition, count
the number of individuals in attendance. Some examples may be a training for health
professionals or a workshop for tribal leaders. Include all presentations for a mixedage audience.

G-02

Youth Targeted

Count the total number of presentations or trainings about domestic violence, dating
violence, healthy relationships or available services for victims. In addition, count the
number of individuals in attendance. Some examples may be a presentation to youth
in school on healthy relationships or a workshop for youth at a Safety Day event.

G-03

Public Awareness
Activities

Report any domestic violence-focused information forums where domestic violence
information is distributed, yet an exact count of audience can not be obtained, such
as a press conference, booth at a health fair or a Pow Wow.

Instructions for Section H – Narrative Responses
Item
H-01
through
H-06

Data Element
Narrative Responses

Instructions
Attach a separate document with the labeled responses to each of the listed
elements (H-01 through H-06) on the form.

Instructions for Section I – Service Outcome Data
Item

Data Element

Instructions
Domestic violence programs should be collecting outcome information from their
clients served. A manual and instructions from the Documenting Our Work Project
are available online at the Outcomes webpage from www.vawnet.org homepage
(Special Project Participants drop down menu at the bottom right corner -->
FVPSA Outcomes --> same username and password - "outcomes”). There are
two mandated questions that must be asked of clients.

I-01
through
I-05

Service Outcome Data

Because of the services I received, I feel:
• I know more about community resources (yes or no).
• I know more ways to plan for my safety (yes or no).
Outcome information may be collected for each service – shelter, support services
and advocacy, counseling and support group. However, at a minimum, FVPSA
requests outcome information on shelter services from programs that provide
shelter services.
For each service, count the number of surveys completed and the number of yes
responses to each question:
• I know more about community resources (Resource Outcome).
• I know more ways to plan for my safety (Safety Outcome).

14

OMB Approval Number: 0970-0280
Expiration Date: 11/30/2014