Form 1122-0025 Semi-Annual Progress Report for the Services to Advocate

Semi-Annual Progress Report for Grantees from the Services to Advocate for and Respond to Youth Program

YouthServFormGMSSample

Semi-annual Progress Report for the Services to Advocate for and Respond to Youth Program

OMB: 1122-0025

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OMB Clearance # 1122-0025
Expiration Date: 10/31/2013

U.S. Department of Justice
Office on Violence Against Women
SEMI-ANNUAL PROGRESS REPORT FOR

Services to Advocate for and Respond to Youth Program
Brief Instructions: This form must be completed for each Services to Advocate for and Respond to
Youth Program (Youth Services Program) grant received. A grant administrator or coordinator must
ensure that the form is fully completed with regard to all grant-funded activities. Grant partners,
however, may complete sections relevant to their portion of the grant. Grant administrators or
coordinators are responsible for compiling and submitting a single report that reflects all information
collected from grant partners.
All grantees should read each section to determine which questions they must answer based on the
activities engaged in under this grant during the current reporting period. Sections B and E of this
form must be completed by all grantees. In section A, subsection A1 must be answered. In section
C, subsection C2 must be answered. In section D, and subsections A2, C1, and C3-C5, grantees
must answer an initial question about whether they engaged in certain activities during the current
reporting period. If the response is yes, then the grantee must complete that section or subsection.
If the response is no, the rest of that section or subsection is skipped.
For example, if you are a victim services agency providing coordinated community response and
victim services with staff funded under this grant, you would complete sections A1, A2, B, C1, C2, D,
and E (and answer “no” in subsections C3-C5).
The activities of volunteers or interns should be reported if they were coordinated or supervised by
Youth Services Program-funded staff or if Youth Services Program funds substantially supported
their activities.
For further information on filling out this form, refer to the separate instructions which contain
detailed definitions and examples illustrating how questions should be answered.
Section
Section

Section A:
A1:
A2:
Section B:
Section C:
C1:
C2:
C3:
C4:
C5:
Section D:
Section E:

General Information
Grant Information
Staff Information
Purpose Areas
Function Areas
Planning and Development
Coordinated Community Response
Policies
Products
Underserved Populations
Victim Services
Narrative

Page
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GENERAL INFORMATION
Grant Information

OMB Clearance # 1122-0025
Expiration Date: 10/31/2013

All grantees must complete this subsection.

(format date with 6 digits - 01/31/10)

Date of report

Current reporting period

Grantee name

Grant number
(the federal grant number assigned to your Youth Services Program grant)

Type of lead agency/organization
(Check the one answer that best describes the type of agency/organization administering Youth
Services Program funds.)

✔

January 1-June 30

✔

July 1-December 31

(Year)

Non-profit, non-governmental entity, whose primary purpose is to provide services to teen and
young adult victims of sexual assault, domestic violence, dating violence, or stalking
Community-based organization specializing in intervention or violence prevention services for
youth
Indian Tribe or tribal organization providing services primarily to tribal youth or tribal victims of
sexual assault, domestic violence, dating violence or stalking
Non-profit, non-governmental entity providing services for runaway or homeless youth affected
by domestic or sexual abuse
6.

Point of contact
(person responsible for the day-to-day coordination of the grant)
First name

Last name

Agency/organization name
Address
City

State

Telephone

Zip code

Facsimile

E-mail

Does this grant specifically address tribal populations?
(Check yes if your Youth Services Program grant focuses on tribal populations, and indicate which
tribes or nations you serve or intend to serve.)
Yes

If yes, which tribes/nations:

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What youth populations does this grant specifically address?
(Check all that apply.)
Victims/survivors who:
are African
are American Indian or Alaska Native
are Asian
are black or African American
are D/deaf or hard of hearing
are Hispanic or Latino
are homeless/runaway
are immigrants, refugees, or asylum seekers
are lesbian, gay, bisexual, transgender, or intersex
are Middle Eastern
are Native Hawaiian or other Pacific Islander
are sexually exploited
belong to a particular religion/spiritual group (specify):
have disabilities
have limited English proficiency
have mental health issues
have substance abuse issues
live in rural areas
Other (specify):

8a.

Additional information
Provide additional information about the youth populations served (for example that the victims/
survivors you are serving are: Spanish-speaking from Guatemala, the Dominican Republic, or Mexico;
victims/survivors of sex trafficking from Thailand, Cambodia, or Russia; Orthodox Jews).

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What percentage of your Youth Services Program funds was directed to each of these areas?
(Report the area[s] addressed by your Youth Services Program grant during the current reporting
period and estimate the approximate percentage of funds [or resources] used to address each area
[consider staff, planning and development, victim services, etc.]. The grantee may choose how to
make this determination.)
Throughout this form, the term sexual assault includes both assaults committed by offenders who are
strangers to the victim/survivor and assaults committed by offenders who are known to, related by
blood or marriage to, or in a dating relationship with the victim/survivor. The term domestic violence
applies to any pattern of coercive behavior that is used by one person to gain power and control over
a current or former intimate partner. The term dating violence is defined as violence committed by
a person who is or has been in a social relationship of a romantic or intimate nature with the victim.
Stalking is defined as engaging in a course of conduct directed at a specific person that would cause
a reasonable person to fear for his or her safety or the safety of others, or suffer substantial emotional
distress. (See separate instructions for more complete definitions.)
Percentage of grant funds
Sexual assault
Domestic violence
Dating violence
Stalking
TOTAL (must equal 100%)

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Staff Information

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Were Youth Services Program funds used to fund staff positions during the current reporting period?
Check yes if Youth Services Program funds were used to pay staff, including part-time staff and
contractors.
Yes--answer question 10
No--skip to section B
10. Staff
(Report the total number of full-time equivalent [FTE] staff funded by the Youth Services Program grant
during the current reporting period. Report staff by function(s) performed, not by title or location.
Include employees who are part-time and/or only partially funded with these grant funds as well as
consultants/contractors. Report grant-funded overtime. If an employee or contractor was employed or
utilized for only a portion of the reporting period, prorate appropriately. For example, if you hired a fulltime advocate in October who was 100% funded with Youth Services Program funds, you would report
that as .50 FTEs. Report all FTEs in decimals, not percentages. One FTE is equal to 1,040 hours—40
hours per week multiplied by 26 weeks. See separate instructions for examples of how to calculate
and prorate FTEs.)

Staff

FTE(s)

Administrator (director, fiscal manager)
Attorney (does not include prosecutor)
Counselor (therapy counselor, does not include financial counselor or employment counselor)
Housing advocate
Legal advocate (does not include attorney or paralegal)
Outreach worker
Paralegal
Program coordinator (training coordinator, victim services coordinator, project
coordinator, contract coordinator, clinical coordinator, volunteer coordinator)
Support staff (bookkeeper, accountant, administrative assistant)
Translator/interpreter
Victim advocate (non-governmental, includes domestic violence, sexual assault,
and dual)
Other (specify):
TOTAL

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PURPOSE AREAS

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All grantees must complete this section.

11. Statutory purpose areas
(Check all purpose areas that apply to activities supported with Youth Services Program funds during
the current reporting period.)
Check ALL
that apply

Purpose Areas
Providing direct counseling and advocacy for youth and young adults, who have
experienced domestic violence, dating violence, sexual assault or stalking
Providing linguistically, culturally, and community relevant services for underserved
populations or linkages to existing services in the community tailored to the needs of
underserved populations
Mental health services for youth and young adults who have experienced domestic
violence, dating violence, sexual assault, or stalking
Legal advocacy efforts on behalf of youth and young adults with respect to domestic
violence, dating violence, sexual assault or stalking
Working with public officials and agencies to develop and implement policies, rules, and
procedures in order to reduce or eliminate domestic violence, dating violence, sexual
assault, and stalking against youth and young adults
Providing additional services and resources for youth, including childcare,
transportation, educational support, and respite care (may use not more than 25
percent of the grant funds for this purpose area)

12. Program interest areas addressed by your grant
(In addition to the purpose areas identified above, the Youth Services Program Solicitation may have
encouraged several program interest areas. If your program addressed any of these interest areas
during the current reporting period, list them below.)

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FUNCTION AREAS

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Planning and Development

Were your Youth Services Program funds used for planning and development activities during the current
reporting period?
Check yes if you have used Youth Services Program funds for planning and development activities.
Yes—answer questions 13-17
No—skip to subsection C2
13. Planning and development meeting activities
(Report the total number of people attending planning and development meetings during the current
reporting period.)
Total number of people attending
14. Planning and development activities conducted (Check all that apply.)
Cross train with memorandum of understanding (MOU) partners
Develop collaboration charter
Develop memo outlining specific forms of project
Develop needs assessment plan and tools
Develop needs assessment report
Develop strategic plan
Focus groups and interviews
Recruit and train volunteers
Review types of MOU partners
Other (specify):

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15. Mandatory planning and development activities
(If you are in the planning phase, report the total number of planning and development meetings and
check the appropriate boxes to indicate if the agencies or organizations are MOU partners.)

Number of meetings

Agency/organization
Weekly

Biweekly

Monthly

MOU
partner

Child protective services
Civil legal services
Court
Disability organization
Domestic violence coalition
Domestic violence program
Dual coalition
Educational institute/organization
Faith/spiritual organization
Government agency (INS, food stamps, TANF)
Health organization
Homeless/housing organization
Immigrant organization
Law enforcement agency
LGBTI organization
Mental health organization
Prosecutor’s office
Sexual assault coalition
Sexual assault program
Tribal government
Tribal organization
Other (specify):

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16. Technical assistance received during planning and development
(Report the number of site visits and/or consultations received from OVW TA providers.)
Number of
site visits
conducted by
OVW TA provider

Number of
consultations
conducted by
OVW TA provider

Collaboration/coordinated community response
Focus groups and interviews
MOU partners
Needs assessment plan and tools
Planning and implementation phase reports
Strategic plan
TOTAL

17. (Optional) Additional information
(Use the space below to discuss the effectiveness of planning and development activities funded or
supported by your Youth Services Program grant and to provide any additional information you would
like to share about planning and development activities beyond what you have provided in the data
above. An example might include how the collaboration has been enhanced, or how the capacity of the
organizations involved in the collaborative has been improved.) (Maximum – 2000 characters)

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Coordinated Community Response

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All grantees must complete this subsection.

18. Coordinated community response activities
(Check the appropriate boxes to indicate the agencies or organizations, even if they are not MOU
partners, that you provided on site consultation to; attended invitational meetings with; engaged in
planning, development, and/or implementation of training with; or engaged in partnership, team
building, and cross training with during the current reporting period. In the last column, indicate the
agencies or organizations with which you have a memorandum of understanding [MOU] for purposes of
the Youth Services Program.)

Agency/organization

Victim/survivor
referrals, consultations,
technical assistance
Daily

Weekly

Monthly

Meetings

MOU
partner

Weekly Monthly Quarterly

Mandatory partnership with one of the following:
Culturally and linguistically
specific program
Domestic violence program
Dual sexual assault and
domestic violence program
Sexual assault program
Dual sexual assault and
domestic violence organization
Partnership with:
Child care provider
Child protective services
Corrections (probation, parole,
and correctional facility,
juvenile justice)
Court
Deaf organization
Disability organization (nongovernmental, non-residential)
Educational institution/
organization
Faith/spiritual-based
organization
Family planning organization
Government agency (ICE, food
stamps, TANF)
Health organization
Homeless/Housing organization
Immigrant organization (nongovernmental)
Job training organization
Law enforcement agency
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18. Coordinated community response activities (cont.)

Agency/organization

Victim/survivor referrals,
consultations, technical
assistance
Daily

Weekly

Monthly

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Meetings

MOU
partner

Weekly Monthly Quarterly

Legal organization (legal
services, bar associations, law
school)
LGBTI organization
Mental health organization
Prosecutor’s office
Social service organization
(non-governmental)
Tribal government/Tribal
government agency
Youth organization (non-governmental, does not include
immigrant organization)
Other (specify):
19. (Optional) Additional information
(Use the space below to discuss the effectiveness of coordinated community response [CCR] activities
funded or supported by your Youth Services Program grant and to provide any additional information
you would like to share about your CCR activities beyond what you have provided in the data above.
Examples might include improved understanding of issues relating to homeless and runaway youth and
LGBTI community; or greater coordination between the community-based service providers and the
targeted underserved community. ) (Maximum – 2000 characters)

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Policies

Were your Youth Services Program funds used to develop, substantially revise, or implement policies or
protocols during the current reporting period?
Check yes if Youth Services Program-funded staff developed, substantially revised, or implemented
policies or protocols, or if Youth Services Program funds directly supported the development, revision,
or implementation of policies or protocols.
Yes--answer question 20
No--skip to subsection C4
20. Types of protocols or policies developed, substantially revised, and/or implemented during the
current reporting period
(Check all that apply.)
Victim services
Access to translators/interpreters

Justice system
Access to translators/interpreters

Appropriate use of translators/
interpreters

Confidentiality/information sharing

Culturally and linguistically appropriate
response to underserved populations

Culturally and linguistically appropriate
response to underserved populations
Mandatory reporting

Dedicated domestic violence/dating
violence youth docket

Parental consent

Full faith and credit for protection orders

Safety planning

Immediate access to obtaining
protection orders

Other (specify):
Health care
Access to translators/interpreters
Appropriate use of translators/
interpreters
Culturally and linguistically appropriate
response to underserved populations
Documentation
Mandatory training on sexual assault,
domestic violence/dating violence,
and/or stalking
Routine screening for sexual assault,
domestic violence/dating violence, and/
or stalking, and referrals for culturally
and linguistically appropriate services
Other (specify):

Immediate access to protection order
information
Mandatory training on domestic violence/
dating violence, sexual assault, and/or
stalking
Policies to protect victims/survivors from
Internet disclosure of identifying
information
Procedures for anonymous, confidential,
or Jane Doe reporting of sexual assault
Providing information to victims/survivors
about victim services
Sexual assault response and protocols
Standard protection order
Strategies to assist and protect victim/
survivor during probation and parole
U-visa certification
Victim-witness notification
Other (specify):

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21. (Optional) Additional information
(Use the space below to discuss the effectiveness of policies you have developed or implemented that
were funded or supported by your Youth Services Program grant and to provide any additional
information you would like to share about your activities beyond what you have provided in the data
above. Examples might include improved advocacy response following implementation of a protocol that
provides employees with detailed information about the issue of mandatory reporting for youth victims
or working with project partners to ensure that organizational policies are responsive to the needs of
youth victims.) (Maximum – 2000 characters)

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Products

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Were your Youth Services Program funds used to develop, substantially revise, or distribute products
during the current reporting period?
Check yes if Youth Services Program-funded staff developed, substantially revised, or distributed
products or if Youth Services Program funds directly supported the development, revision, or
distribution of products.
Yes—answer question 22
No—skip to subsection C5
22. Use of Youth Services Program funds for product development, substantial revision, or distribution
(Report the number of products developed, substantially revised, or distributed with Youth Services
Program funds during the current reporting period. Report the number of new products developed or
substantially revised during the current reporting period; the title/topic and intended audience for each
product developed, revised, and/or distributed; and the number of products used or distributed. If a
product was created in or translated into a language other than English, including Braille, indicate the
language. Report on products that were newly developed during the current reporting period whether
or not they were used or distributed during the current reporting period. Do not report the number of
products printed or copied; only report the number developed or revised—in most cases that number
will be one for each product described—and/or the number used or distributed. See separate
instructions for examples of how to report under “developed or revised” and “used or distributed.”)
Youth Services Program funds during the current reporting period. Report the number of new products
Number
Number
Intended
Other
Products
developed
Title/topic
used or
audience
languages
or revised
distributed

Brochures

Manuals

Newsletters

Posters

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22. Use of Youth Services Program funds for product development, substantial revision, or distribution
(cont.)
Products

Number
developed
or revised

Title/topic

Intended
audience

Number
Other
used or
languages
distributed

Videos/
DVDs

Websites
(report
number of
page views
in the used
or distributed column)
Other
(specify):

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Underserved Populations

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Were your Youth Services Program funds used to develop or enhance standards of service for
underserved populations during the current reporting period?
Check yes if Youth Services Program-funded staff were used to develop or enhance services for
underserved populations.
Yes—answer questions 23-25
No—skip to section D
23. Activities addressing underserved populations
(Check all activities in which Youth Services Program funds were used to develop or enhance services
for underserved populations. Check the boxes in the appropriate columns to indicate whether the
activities you engaged in were for sexual assault or domestic violence/dating violence programs/
services.)

Activity

Sexual
assault

Domestic
violence

Dating
violence

Stalking

Coordinating meetings to address issues
concerning underserved populations
Developing/distributing materials for
underserved populations
Developing policy
Identifying gaps in services
Supporting representatives of historically
underserved groups to participate in
meetings
Other (specify):

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24. Underserved populations
(Indicate which underserved populations were addressed in the activities indicated in question 23.
Check all that apply.)
Victims/survivors who:
are African
are American Indian or Alaska Native
are Asian
are black or African American
are D/deaf or hard of hearing
are Hispanic or Latino
are homeless/runaway
are immigrants, refugees, or asylum seekers
are lesbian, gay, bisexual, transgender, or intersex
are Middle Eastern
are Native Hawaiian or other Pacific Islander
are sexually exploited
belong to a particular religion/spiritual group (specify):
have disabilities
have limited English proficiency
have mental health issues
have substance abuse issues
live in rural areas
Other (specify):

25. (Optional) Additional information
(Use the space below to discuss the effectiveness of activities to reach underserved populations
funded or supported by your Youth Services Program grant and to provide any additional information
you would like to share about your activities beyond what you have provided in the data above. An
example might include identifying gaps in service for immigrants and refugees through interviews with
service providers for this underserved population, resulting in the inclusion of immigrants and refugees
in two upcoming meetings to develop action steps.) (Maximum – 2000 characters)

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VICTIM SERVICES

Were your Youth Services Program funds used to provide victim services to victims/survivors during the
current reporting period?
Check yes if Youth Services Program-funded staff provided victim services, or if Youth Services Program
funds were used to support victim services during the current reporting period.
Yes—answer questions 26 - 34
No—skip to section E
26. Number of primary victims/survivors served, partially served, and victims/survivors seeking services
who were not served Please do not answer this question without referring to the separate instructions for
further explanation and examples of how to distinguish among these categories. (Report the following, to
the best of your ability, as an unduplicated count for each category during the current reporting period. This
means that each victim/survivor who requested or received services during the current reporting period
should be counted only once and in only one of the listed categories. For purposes of this question, victims/
survivors are those against whom the sexual assault, domestic violence, dating violence, and/or stalking,
was directed. If the victim/survivor experienced more than one victimization, that person should be counted
only once under the primary victimization.)
Sexual
assault
A. Served: Victims/survivors who
received the service(s) they
requested, if those services were
funded by your Youth Services
Program grant
B. Partially served: Victims/
survivors who received some
service(s), but not all of the services
they requested, if those services were
funded by your Youth Services
Program grant
TOTAL SERVED AND PARTIALLY
SERVED (26A+B)
C. Victims/survivors seeking services who were not served: Victims/
survivors who sought services and
did not receive the service(s) they
were seeking, if those services were
funded by your Youth Services
Program grant

Dating
violence

Domestic
violence

Stalking

TOTAL

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27. Reasons that primary victims/survivors seeking services were not served or were partially served
(Check all that apply.)
Reasons not served or partially served
Conflict of interest
Did not meet statutory requirements
Hours of operation
Insufficient/lack of culturally appropriate services
Insufficient/lack of language capacity (including sign language)
Insufficient/lack of services for victims/survivors who are D/deaf or hard of hearing
Insufficient/lack of services for people with disabilities
Lack of child care
Program reached capacity
Program rules not acceptable to victim/survivor
Program unable to provide service due to limited resources/priority-setting
Services inappropriate or inadequate for victims/survivors with mental health issues
Services inappropriate or inadequate for victims/survivors with substance abuse issues
Services not appropriate for victim/survivor
Transportation
Other (specify):

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28. Demographics of primary victims/survivors served or partially served
(Based on the primary victims/survivors reported in 26A and 26B, provide the total numbers for all that
apply. Because victims/survivors may identify in more than one category of race/ethnicity, the total for
“Race/ethnicity” may exceed the total number of victims/survivors reported in questions 26A and 26B.
However, the total number of victims/survivors reported under “Race/ethnicity” should not be less than
the total number of victims/survivors reported in questions 26A and 26B. The total number of victims/
survivors reported under “Gender” and the total number reported under “Age” should equal the total
number of victims/survivors reported in questions 26A and 26B. Those victims for whom gender, age,
and/or race/ethnicity is not known should be reported in the “Unknown” category.)
Race/ethnicity (Victims/survivors should be counted once in each category
of race/ethnicity that applies. Victims/survivors should not be counted
more than once in either the category “American Indian or Alaska Native” or
in the category “Native Hawaiian and other Pacific Islander.”)
American Indian and Alaska Native

Number of victims/
survivors

Asian
Black or African American
Hispanic or Latino
Native Hawaiian and other Pacific Islander
White
Unknown
TOTAL RACE/ETHNICITY

(should not be less than 0, the sum of 26A and 26B.)

Gender

Number of victims/
survivors

Female
Male
Unknown
TOTAL GENDER

(should equal 0, the sum of 26A and 26B.)

Age

Number of victims/
survivors

13-17
18-21
22-24
Unknown
TOTAL AGE

(should equal 0, the sum of 26A and 26B.)

Other demographics (optional)

Number of victims/
survivors

People with disabilities
People who are D/deaf or hard of hearing
People with limited English proficiency
People who are immigrants/refugees/asylum seekers
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Number of victims/
survivors

Other demographics (optional) (cont.)
People who live in rural areas
People who are homeless/runaways
People who are lesbian, gay, bisexual, transgender, or intersex
People with mental health issues

29. Victims/survivors’ relationship to offender by victimization
(For those victims/survivors reported as served and partially served in 26A and 26B, report the
victim/survivor's relationship to the offender by type of victimization. If a victim/survivor experienced
more than one type of victimization and/or was victimized by more than one perpetrator, count the
victim/survivor in all categories that apply. The total number of relationships in the sexual assault
column must be at least 0; the total number in the domestic violence column must be at least 0; the
total number in the dating violence column must be at least 0; and the total number in the stalking
column must be at least 0.)

Victims/survivors’ relationship to offender

Number of victim/survivor relationships
by victimization
Sexual
assault

Dating
violence

Domestic
violence

Stalking

Current or former spouse or intimate partner
Other family or household member
Acquaintance (neighbor, employee,
co-worker, classmate, student, etc.)
Current or former dating relationship
Stranger
Relationship unknown
TOTAL

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30A. Victim services
(Report the number of primary victims/survivors from 26A and 26B who received Youth Services
Program-funded services during the current reporting period. Count each victim/survivor only once
for each type of service that victim/survivor received during the current reporting period; do not
report the number of times that service was provided to the victim/survivor. The total for each type of
service should not be higher than the total of 26A and 26B, 0. Shelter services should be reported in
question 30B.)
Number of
victims/
Type of service
survivors
served
Civil legal advocacy/court accompaniment (Assisting a victim/survivor with civil legal
issues including preparing paperwork for a protection order and accompanying victim/
survivor to a protection order hearing, administrative hearing, or other civil court proceeding - does not include advocacy by attorneys and/or paralegals)
Civil legal assistance (Civil legal services provided by an attorney and/or a paralegal)
Counseling services/support group (Individual or group counseling or support provided
by a volunteer, peer, or professional)
Criminal justice advocacy/court accompaniment (Assisting a victim/survivor with
criminal legal issues including notifying the victim/survivor of case status, hearing
dates, plea agreements, and sentencing terms; preparing paperwork such as victim
impact statements; accompanying a victim/survivor to a criminal court proceeding or
law enforcement interview; and all other advocacy within the criminal justice system)
Crisis intervention (Crisis intervention is a process by which a person identifies,
assesses, and intervenes with an individual in crisis so as to restore balance and reduce
the effects of the crisis in her/his life. In this category, report crisis intervention that
occurs in person and/or over the telephone.)
Education advocacy (GED, primary, secondary)
Employment counseling (Actions designed to assist a victim/survivor in obtaining
employment, e.g., coaching on career options, skills training, job searches,
resume-writing, marketing, job interviews, and presentation of employment)
Financial counseling (Actions designed to assist a victim/survivor with issues related to
improving credit, retiring debt, setting up bank accounts, managing household finances,
negotiating with lenders or landlords, developing budgets, managing financial assets,
making major purchases such as a home or auto, filing tax returns)
Hospital/clinic/other medical response (Accompanying a victim/survivor to or meeting a
victim/survivor at a hospital, clinic, or medical office)
Housing advocacy
Job training (Providing training in specific employment-related skills to a victim/survivor,
e.g., on computer literacy)
Language services (Interpretation, translation)
Material assistance (Providing victims/survivors with clothing, food, personal items, etc.)
Respite services (Providing periodic relief for the family or primary caregiver)
Transportation (Provision of transportation, either directly or through bus passes, taxi
fares, or other means of transportation)
Victim/survivor advocacy (Actions designed to help the victim/survivor obtain needed
support, resources, or services, including employment, housing, health care, victim’s
compensation, etc.)
Other (specify):
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30B. Shelter services
(Report the total number of victims/survivors and accompanying family members who received
emergency shelter and/or transitional housing provided with Youth Services Program funds during
the current reporting period. This should be an unduplicated count for both victims/survivors and for
family members. This means that each victim/survivor and each family member who received shelter
services during the current reporting period should be counted only once. Report the total number of
bed nights provided in emergency shelter and/or transitional housing to victims/survivors and family
members. The number of bed nights is computed by multiplying the number of victims/survivors and
family members by the number of nights they stayed in the shelter. The number of bed nights will
typically be significantly higher than the number of victims/survivors and family members. For
example, one victim/survivor and her three children all stayed in the shelter for 10 nights. The number
of bed nights would be four multiplied by ten, for a total of 40 bed nights.)
Shelter service

Number of
victims/survivors

Number of
family members
(include all
children here)

Number of
bed nights

Emergency shelter
Transitional housing
31.

Hotline calls/information and referral
(Report the number of hotline calls and requests for information and referrals received from primary
victims/survivors, and the total number of hotline calls received on phone lines paid with Youth
Services Program funds or answered by Youth Services Program-funded staff during the current
reporting period. Report the specific languages (other than English) used when responding to these
requests for information or assistance. Primary victims/survivors whose calls are reported here should
not be reported as victims/survivors served in question 26 unless they also received at least one of
the services listed in questions 30A, Victim Services or 30B, Shelter Services. Victims/survivors who
receive services such as crisis intervention or victim advocacy over the telephone, in addition to basic
hotline information and/or referrals, should also be reported in question 30A. Hotline calls that
include victim advocacy or crisis intervention services are those that require more time than the
average call and involve a more intensive focus on the immediate needs and situation of the victim/
survivor. For examples of when to report only the hotline call and when to report both the hotline call
and a service or services in question 30A, see separate instructions.)

Number of
calls/requests
from primary
victims/survivors

Total number of
calls/requests

Languages
(other than
English) used
when responding
to requests for
information or
assistance

Hotline calls (Crisis or information and
referral calls received by an agency’s
hotline or office telephone, or via text
message)
Walk-in information and referrals
Web-based information and referrals
(including chat)

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32. Outreach to victims/survivors
(Report the number of unsolicited letters, phone calls, or visits to victims/survivors of specific incidents
of sexual assault, domestic violence, dating violence, and/or stalking, informing them of services and/
or providing information. Report the specific languages (other than English) used in outreach
activities. Victims/survivors who are the recipients of these outreach activities should not be reported
as victims/survivors served in question 26 unless they also received at least one of the services listed
in questions 30A, Victim Services or 30B, Shelter Services. Victims/survivors who receive services
such as advocacy in the course of a telephone or outreach visit should also be reported in question
30A.)
Number of
Languages (other
outreach
than English)
activities to
used in outreach
victims/survivors
activities
Outreach to victims/survivors (unsolicited letters, phone
calls, or visits)
33. Protection orders
(Report the total number of temporary and/or final protection orders requested and granted for which
Youth Services Program-funded victim services staff provided assistance to victims/survivors during
the current reporting period. These orders may also be referred to as protection from abuse,
protection from harassment or anti-harassment orders, restraining orders, or no-contact or stay-away
orders.)
Sexual assault protection orders

Temporary orders

Final orders

Temporary orders

Final orders

Temporary orders

Final orders

Number requested
Number granted
Domestic violence/dating
violence protection orders
Number requested
Number granted
Stalking protection orders
Number requested
Number granted

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34.

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Expiration Date: 10/31/2013

(Optional) Additional information
(Use the space below to discuss the effectiveness of victim services funded or supported by your Youth
Services Program grant and to provide any additional information you would like to share about your
victim services activities beyond what you have provided in the data above. An example might include
that your agency, as the result of Youth Services Program funding, was able to provide immigration
relief to an increased percentage of victims/survivors, which resulted in a higher percentage of
victims/survivors seeking additional support services.) (Maximum – 2000 characters)

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SECTION

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NARRATIVE

OMB Clearance # 1122-0025
Expiration Date: 10/31/2013

All grantees must answer questions 35 and 36.
PLEASE LIMIT YOUR RESPONSES TO THE SPACE PROVIDED.

35.

Report on the status of your Youth Services Program grant goals and objectives as of the end of
the current reporting period.
(Report succinctly on the status of the goals and objectives for your grant as of the end of the current
reporting period, as they were identified in your grant proposal or as they have been added or revised.
Indicate whether the activities related to your objectives for the current reporting period have been
completed, are in progress, are delayed, or have been revised. Comment briefly on your successes
and challenges, and provide any additional explanation you feel is necessary for us to understand
what you have or have not accomplished relative to your goals and objectives. If you have not
accomplished objectives that should have been accomplished during the current reporting period, you
Page 26.
must provide an explanation.)

36.

What services or resources did you provide that are specifically tailored to reach the Youth
population(s) that you serve? (e.g. staff, volunteers, or advisory board members who reflect the
Page 29.
community you serve)
All grantees must answer questions 37 and 38 on an annual basis.
Submit this information on the January to June reporting form only.
PLEASE LIMIT YOUR RESPONSES TO THE SPACE PROVIDED
(8,000 CHARACTERS) FOR EACH QUESTION.

37.

What do you see as the most significant areas of remaining need, with regard to improving services
to victims/survivors of sexual assault, domestic violence, dating violence, and stalking; increasing
victim/survivor safety; and enhancing community response (including offender accountability for
both batterers and sex offenders)?
(Consider geographic regions, underserved populations, service delivery systems, and/or challenges
Page 31.
and barriers unique to your service area and the population(s) you serve.)

38. What has Youth Services Program funding allowed you to do that you could not do prior to receiving
this funding?
(For example, before we received Youth Services Program funds, our agency did not have
appropriate staff to serve Spanish-speaking victims. Since we received this funding, we have hired a
Spanish-speaking therapist and have increased the number of Spanish- speaking victims served by
Page 33.
our program from 2 to 40.)
Questions 39 and 40 are optional.
PLEASE LIMIT YOUR RESPONSES TO THE SPACE PROVIDED
(8,000 CHARACTERS) FOR EACH QUESTION.
39. Provide any additional information that you would like us to know about your Youth Services
Program grant and/or the effectiveness of your grant.
(If you have other data or information that you have not already reported in answer to previous
questions on this form that demonstrate the effectiveness of your Youth Services Program grant,
please provide it below. Feel free to discuss any of the following: systems-level changes, community
collaboration, the removal or reduction of barriers and challenges for victims/survivors, promising
practices, and positive or negative unintended consequences. Refer to separate instructions for a fuller
explanation and examples.)
Page 35.
40. Provide any additional information that you would like us to know about the data submitted. (If
you have any information that could be helpful in understanding the data you have submitted in this
report, please answer this question. For example, if you submitted two different progress reports for
the same reporting period, you may explain how the data was apportioned to each report; or if your
Youth Services Program funds supported staff—e.g. victim advocates, attorneys, etc.—but did not
report any corresponding victim services, you may explain why; or if you did not use program funds to
support either staff or activities during the reporting period, please explain how program funds were
used, if you have not already done so.)
Page 37.
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OMB Clearance # 1122-0025
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Back to Instructions.

Report on the status of your Youth Services Program grant goals and objectives as of the end of the current
reporting period.
Question #35
Status

(100 characters)
Goals/Objectives (1,750 characters)

Key Activities (1,750 characters)

Comments (500 characters)

Goals/Objectives

Status

Key Activities

Comments

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OMB Clearance # 1122-0025
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Back to Instructions.

Report on the status of your Youth Services Program grant goals and objectives as of the end of the current
reporting period.
Question #35 (cont. 1)
Status
Goals/Objectives

Key Activities

Comments

Goals/Objectives

Status

Key Activities

Comments

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Back to Instructions.

Report on the status of your Youth Services Program grant goals and objectives as of the end of the current
reporting period.
Question #35 (cont. 2)
Status
Goals/Objectives

Key Activities

Comments

Goals/Objectives

Status

Key Activities

Comments

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Back to Instructions.

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What services or resources do you provide that are specifically tailored to reach the youth population(s)
that you serve? (e.g. staff, volunteers, or advisory board members who reflect the community you serve)
Question #36

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Back to Instructions.

OMB Clearance # 1122-0025
Expiration Date: 10/31/2013

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Back to Instructions.

OMB Clearance # 1122-0025
Expiration Date: 10/31/2013

What do you see as the most significant areas of remaining need, with regard to improving services to
victims/survivors of sexual assault, domestic violence, dating violence, and stalking; increasing victim/
survivor safety; and enhancing community response (including offender accountability for both batterers
and sex offenders)? (Consider geographic regions, underserved populations, service delivery systems,
and/or challenges and barriers unique to your service area and the population(s) you serve.)
Question #37

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Back to Instructions.

OMB Clearance # 1122-0025
Expiration Date: 10/31/2013

What do you see as the most significant areas of remaining need, with regard to improving services to
victims/survivors of sexual assault, domestic violence, dating violence, and stalking; increasing victim/
survivor safety; and enhancing community response (including offender accountability for both batterers
and sex offenders)? (Consider geographic regions, underserved populations, service delivery systems,
and/or challenges and barriers unique to your service area and the population(s) you serve.)
Question #37 (cont.)

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Back to Instructions.

OMB Clearance # 1122-0025
Expiration Date: 10/31/2013

What has Youth Services Program funding allowed you to do that you could not do prior to receiving this
funding? (For example, before we received Youth Services Program funds, our agency did not have
appropriate staff to serve Spanish-speaking victims. Since we received this funding, we have hired a
Spanish-speaking therapist and have increased the number of Spanish-speaking victims served by our
program from 2 to 40.)
Question #38

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Back to Instructions.

OMB Clearance # 1122-0025
Expiration Date: 10/31/2013

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Back to Instructions.

OMB Clearance # 1122-0025
Expiration Date: 10/31/2013

Provide any additional information that you would like us to know about your Youth Services Program
grant and/or the effectiveness of your grant. (If you have other data or information that you have not
already reported in answer to previous questions on this form that demonstrate the effectiveness of your
Youth Services Program- please provide it below. Feel free to discuss any of the following: systems-level
changes, community collaboration, the removal or reduction of barriers and challenges for victims/
survivors, promising practices, positive or negative unintended consequences. Refer to separate instructions
for a fuller explanation and examples.)
Question #39

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Back to Instructions.

OMB Clearance # 1122-0025
Expiration Date: 10/31/2013

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Back to Instructions.

OMB Clearance # 1122-0025
Expiration Date: 10/31/2013

Provide any additional information that you would like us to know about the data submitted. (If you
have any information that could be helpful in understanding the data you have submitted in this report,
please answer this question. For example, if you submitted two different progress reports for the same
reporting period, you may explain how the data was apportioned to each report; or if your Youth Services
Program funds supported staff—e.g. victim advocates, attorneys, etc.—but did not report any corresponding
victim services, you may explain why; or if you did not use program funds to support either staff or activities
during the reporting period, please explain how program funds were used, if you have not already done so.)
Question #40

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Back to Instructions.

OMB Clearance # 1122-0025
Expiration Date: 10/31/2013

Provide any additional information that you would like us to know about the data submitted. (If you have
any information that could be helpful in understanding the data you have submitted in this report, please
answer this question. For example, if you submitted two different progress reports for the same reporting
period, you may explain how the data was apportioned to each report; or if your Youth Services Program
funds supported staff—e.g. victim advocates, attorneys, etc.—but did not report any corresponding victim
services, you may explain why; or if you did not use program funds to support either staff or activities during
the reporting period, please explain how program funds were used, if you have not already done so.)
Question #40 (cont.)

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Validate

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File Type	application/pdf
File Title	Youth Services.indd
Author	jdodge
File Modified	2013-10-29
File Created	2010-09-01