Form 1 SOT Program Data Points

Generic Performance Progress Report

SOT Program Data Points FORM NOV_ 2017_Final

Survivors of Torture Program Data Points

OMB: 0970-0490

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OMB NO: 0970-0490

EXPIRATION DATE: 1/31/2020

ACF Office of Refugee Resettlement

Services for Survivors of Torture

Program Data Points Form


Agency: Administration for Children and Families (ACF)/Office of Refugee Resettlement (ORR)


Form: Survivors of Torture – Program Data Points (SOT-PDP)

Grantee Name:


Grant Number:


Point of Contact:

Reporting Period

From: MM/DD/YYYY

To:

MM/DD/YYYY


Reporting: Submit annual program data with the second semi-annual report each year of the project period. Please use the narrative report to explain or highlight key program indicators and illustrate changes in psychosocial well-being indicators.

PROGRAM INDICATORS1

Data Point

Description

Indicators

No. of Clients Served


01


Client count during reporting period


New primary

New secondary

Continuing primary

Continuing secondary

Clients exiting the program


_____

_____

_____

_____

_____

_____


02




Age when first subjected to torture



(primary survivors only)


Under 5 years

5 – 17 years

18 – 44 years

45 – 64 years

65 years and over


_____

_____

_____

_____

_____


03






Type(s) of torture suffered




(primary survivors only)


Asphyxiation

Beating

Burning

Deprivation

Electrical

Forced postures

Kidnapping and disappearances

Rape and sexual torture

Sensory stress

Severe humiliation

Threats and psychological torture

Witnessing torture of others

Wounding/maiming

Other: Please specify___________



_____

_____

_____

_____

_____

_____

_____

_____

_____

_____

_____

_____

_____

_____


Data Point

Description


Indicators


No. of Clients Served

04





Reason(s) for torture




(primary survivors only)



Ethnicity

Nationality

Political reasons

Religion

Social activism

Social group (e.g., clan, gender, sexual orientation)

Other: Please specify____________




_____

_____

_____

_____

_____

_____

_____

_____



05


Country where torture occurred


(primary survivors only)


Country 1:

Country 2:

Country 3:

Country 4: …


(report all countries)



_____

_____

_____

_____


06



Client goal(s) at intake



Emotional/psychological

Interpersonal/social

Legal

Occupational

Physical/medical

Substance abuse




_____

_____

_____

_____

_____

_____


07

Gender



Female

Male

Other




_____

_____

_____


08

Immigration category/status

at intake


Asylum seeker

Asylee (include derivatives)

Refugee (include derivatives)

Special Immigrant Visa Holder

Lawful Permanent Resident

Former refugee (include derivatives)

Former asylee (include derivatives)

Other former: Please specify_______

U.S. Citizen

Former refugee (include derivatives)

Former asylee (include derivatives)

Other former: Please specify______

Other at intake: Please specify________



_____

_____

_____

_____

_____

_____

_____

_____

_____

_____

____

____

_____

Data Point

Description

Indicators

No. of Clients Served

09

Age at intake



Under 5 years

5 – 17 years

18 – 44 years

45 – 64 years

65 years and over



_____

_____

_____

_____

_____

10





Education prior to arrival



(for clients > 18 years of age at intake)



Less than 1 year

1-4 years

5-8 years

9-12 years

13-16 years

More than 16 years



____

____

____

____

____

____






11










Employment in the U.S at intake



(for clients > 18 years of age at intake)




No work authorization

Unemployed and not seeking employment (e.g., students, elderly, disabled, and primary caregivers)

Unemployed, work authorized, and seeking employment

Employed with work authorization (PT/FT)



_____


_____


_____


_____


12


Length of time in the U.S. at intake




Less than one year

1- 5 years

More than 5 years





_____

_____

_____


13



Country of origin



Country 1:

Country 2:

Country 3:

Country 4: ….


(report all countries)



_____

_____

_____

_____



14


Ethnicity



Ethnicity 1:

Ethnicity 2:

Ethnicity 3:

Ethnicity 4: ….


(report all ethnicities)



_____

_____

_____

_____



Data Point

Description


Indicators


No. of Clients Served

15


Religion



Buddhists

Christians

Hindus

Jews

Muslims

None

Other: Please specify_____________



_____

_____

_____

_____

_____

_____

_____

16

Languages used


Language 1:

Language 2:

Language 3:

Language 4: …


(report all languages used)



_____

_____

_____

_____

_____


17

Clients served by service category


Emotional/psychological

Interpersonal/social

Legal

Occupational

Physical/medical

Substance abuse



_____

_____

_____

_____

_____

_____


18

People trained by profession


Community

Education

Interpreters/translators

Law enforcement

Legal

Medical

Mental health

Social

Other: Please specify____________



_____

_____

_____

_____

_____

_____

_____

_____

19

Hours contributed by pro bono service


Administrative, managerial, and other

professional services

Financial and grant writing

Information technology and research

Interpreters/translators

Legal

Medical

Mental health

Social

Other: Please specify_______________

Number of hours

_____

_____

_____

_____

_____

_____

_____

_____

_____

_____







OUTCOME INDICATORS2

  • Indicate how many clients included in this section have been receiving services by length of time:

_____ < 6 months _____ 6-12 months _____ >12 months

  • Indicate the tool from which you have derived the client-level data you are reporting here in the aggregate:

SOT-PWI-S ____ Our Program Tool ____ Case File Review____ Other: Please specify_____________

  • Complete all of the boxes for each data point below to show aggregate changes in the level of need.


Data Point

Description

Level of Need

END

1

In Crisis

2

Vulnerable

3

Stable

4

Safe


20

Legal-immigration




S

T

A

R

T

1

In Crisis

N=





2

Vulnerable

N=






3

Stable

N=






4

Safe

N=






21

Housing

Level of Need

END

1

In Crisis

2

Vulnerable

3

Stable

4

Safe




S

T

A

R

T

1

In Crisis

N=





2

Vulnerable

N=






3

Stable

N=






4

Safe

N=









Data Point

Description

Level of Need

END

1

In Crisis

2

Vulnerable

3

Stable

4

Safe

22

Physical health




S

T

A

R

T

1

In Crisis

N=





2

Vulnerable

N=






3

Stable

N=






4

Safe

N=






23


Mental health



Level of Need

END

1

In Crisis

2

Vulnerable

3

Stable

4

Safe




S

T

A

R

T

1

In Crisis

N=





2

Vulnerable

N=






3

Stable

N=






4

Safe

N=
























Data Point

Description

Level of Need

END

1

In Crisis

2

Vulnerable

3

Stable


4

Safe


24

Access to community resources





S

T

A

R

T

1

In Crisis

N=





2

Vulnerable

N=






3

Stable

N=






4

Safe

N=






25



Support system in the U.S.




Level of Need

END

1

In Crisis

2

Vulnerable

3

Stable


4

Safe




S

T

A

R

T

1

In Crisis

N=





2

Vulnerable

N=






3

Stable

N=






4

Safe

N=
















THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)


Public reporting burden for this collection of information is estimated to average ?? hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.


An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.



1 Refer to the Program Data Points User Guide for all definitions and a List of Ethnic Groups (Appendix A)

2 Use the Survivor of Torture Psychosocial Well-being Index (Short Version) (SOT-PWI-S) © 2016 Hodges-Wu & Zajicek-Farber to aggregate the data for these indicators. (See User Guide, Appendix D)


PowerPlusWaterMarkObject9617713 Program Data Points pg. 9

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