Form 1 Proposed Reviesed Survey for 2015

Grants to States for Access and Visitation

Attachment B_Proposed Revised Survey for 2015 PRA.xls

Grants to States for Access and Visitation (Local Service Providers)

OMB: 0970-0204

Document [xlsx]
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Grantee and/or Sub-Grantee Agency Profile Summary of State AV Program Data
Grantee and/or Sub-Grantee Information Service Provided &Client Participation (Values M (Mandatory), V (Voluntary) B (Both) U, R, B Client Referral Source Client Information
Child Support Cases (Optional) Marital Status Race/Ethnicity Annual Income Services Provided Frequency of Service ( Hours) (Optional) Outcome#1-Parenting Time (Required) Outcome#2 - Knowledge of Effective Co-Parenting Strategies (Optional)
Name of Grantee and/or Sub-Grantee Title of AV Program Contact Name Address Line 1 City State Zip Grant Amount Grant Period From Date Grant Period To Date Mediation Development of Parenting Plan Counseling Parent Education Neutral Drop-off/Pick-up Supervised Visitation Visitation Enforcement Geographic Area Served Self Court Child Support Agency Domestic Violence Agency Child Protection Agency Other Data Not Reported NCP Father CP Father NCP Mother CP Mother Grandparent/Legal Guardian Number of Children in Common NCP Father CP Father NCP Mother CP Mother Grandparent/Legal Guardian Never Married to Each Other Married to Each Other Separated From Each Other Divorced From Each Other Data Not Reported American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Two or More Races Other Data Not Reported 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 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 NCP Fathers NCP Mothers NCP Fathers CP Fathers NCP Mothers CP Mothers
File Typeapplication/vnd.ms-excel
File TitleAV Proposed Revised Survey
File Modified2015-04-13
File Created2006-09-16

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