Form 1 Mandatory Organizations

OMB Control Number: 0970-XXXX
Expiration date: XX/XX/XXXX

National Human Trafficking Training and Technical Assistance Center
Organizational Scholarship Application for Survivor Professional Development
Thank you for your interest in the National Human Trafficking Training and Technical
Assistance Center (NHTTAC) Organizational Scholarships for Survivor Professional
Development Program. NHTTAC offers organizational professional development
scholarships to agencies hosting conferences that wish to provide scholarships to survivors
of human trafficking who have at least one year of experience working with human
trafficking survivors and/or populations at risk of human trafficking. Scholarships are
awarded to enhance the recipient’s ability to deliver a public health response to human
trafficking. This application will allow us to learn more about your organization and the
event for which you are applying.
NHTTAC must receive the completed application at least 90 calendar days prior to the
event or the request will be rejected - NO EXCEPTIONS.
For assistance, please contact NHTTAC by calling toll free (844) 648-8822 or emailing
[email protected]

Section A: Organization Information
In this section, provide information about your organization.

1. Name of Organization:
2. Name and Title of Organization’s Chief Executive:
3. Street Address:
4. City:

5. Phone:

State:

Zip Code:

Fax:

Website:

6. Point of Contact:
7. Phone:

E-mail:

8. Type of Organization: Select all that apply.
Type of Organization
 Anti-trafficking organization
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Business/for-profit organization
Coalition/Multidisciplinary Team/Task Force
Federal government
Faith-based organization
State/Local Government
Nonprofit/community-based organization
Survivor led organization
Tribal government
Union/worker advocacy organization
Victim service provider

Professional Capacity and Types of Services
 Behavioral health professional (psychologist, psychiatrist, mental health/substance
use counselor)
 Child welfare (state agency staff; child welfare contractor; non-profit personnel)
 Corrections Based Services
 Criminal justice (e.g., law enforcement, prosecutor, probation, court)
 Educator (teacher, professor, school administrator)
 Health care (physician, physician assistant, nurse practitioner, dentist, nurse,
pharmacist)
 Housing (case worker, shelter director, public housing authority agencies)
 Legal (civil and/or rights-based attorney and/or paralegal, clinic)
 Public health (health department staff, health care executive, community health
workers)
 Social worker (case manager, school counselor, supervisor, administrator)
 Survivor Empowerment and Mentoring
 Other (Specify): __________________

9. Does your organization/agency provide services to human trafficking survivors and/or
populations at risk of trafficking throughout your state (for statewide conferences) or on
a nationwide scale (for national conferences)?

10. Has your organization received support via NHTTAC in the past 12 months? __ Yes __ No
(If yes, please select what type of support)
__ Short Term Training and Technical Assistance
__ Specialized Training and Technical Assistance
__ Other - please explain: _________________________________

Section B: Event Information
In this section, provide information about the event you are planning.

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11. Event Title:
12. Date(s):
13. Location (Facility Name, City, State):
14. Event Website:
15. Expected number of attendees:
16. Intended audience: Select all that apply.
 Behavioral health professionals (psychologists, psychiatrists, mental
health/substance use counselors)
 Child welfare (state agency staff; child welfare contractors; non-profit personnel)
 Corrections Based Services
 Criminal justice (e.g., law enforcement, prosecutors, probation, court)
 Educators (teachers, professors, school administrators)
 Health care (physicians, physician assistants, nurse practitioners, dentist, nurses,
pharmacists)
 Housing (case workers, shelter directors, public housing authority agencies)
 Legal (civil and/or rights-based attorney and/or paralegal, clinic)
 Public health (health department staff, health care executive, community health
workers)
 Social worker (case manager, school counselor, supervisor, administrator)
 Survivors of human trafficking
 Victim service providers
 Other (Specify): __________________
17. Please attach the draft agenda and any other promotional materials when submitting
this form. The following information should be included for each session or activity:
 Date
 Time (example: 1:00 p.m. to 3:00 p.m.)
 Title & Description

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Organizational Scholarship Application for Survivor Professional Development (Continued)

Section C: Scholarship Administration Information
In this section, provide information about your organization’s past experience with managing
scholarship programs.

18. Please describe your organization’s prior experience managing a scholarship program.
Include the following information for no more than the last two scholarship programs
administered:
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The associated event names and dates
Total funds administered
Items the scholarships covered
Number of scholarships awarded
Source of funding
The process used to administer scholarships

19. Please provide the scholarship application your organization will use to determine
scholarship award for this event. The application must include the following information:
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Recipients must have at least 1 year of volunteer or professional experience in
working with human trafficking survivors and/or populations at risk of human
trafficking.
The threshold your organization is using for determining that a recipient
demonstrates financial need.
Recipients must explain how they plan to implement the skills and knowledge
acquired as a result of attending the conference in their ongoing work with human
trafficking survivors and/or populations at risk of human trafficking.

Section D: Budget Information
This section provides information regarding the allowable expenses your organization can request.
Please complete the recipient budget and organization budget forms.

The Organizational Scholarship is administered by NHTTAC as a reimbursement to your
organization. Your organization must first pay for approved expenses for survivor
scholarship awardees; then, NHTTAC will reimburse your organization upon receipt of
itemized receipts Employees of the requesting organization are not eligible to receive
scholarship support.
Allowable expenses include transportation and lodging. Applicants are eligible to receive up
to $500 per individual recipient for transportation expenses (such as airfare, train, or bus
fare), and lodging expenses (Up to the federal government rate in that area, for current
rates, please visit www.gsa.gov), up to a total of $1,000. Organizations are encouraged to
use the least costly mode of transportation to and from the event. Rental car services are
not reimbursable under any circumstances. Lodging is not covered by the scholarship if the
recipient lives within 50 miles of the event.
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Please Note: Organizational scholarship approval is not guaranteed and it is advised that you
do not make any financial commitment until you receive confirmation from NHTTAC.
Please include the breakdown under the line item column and the total expense for each line item
for which you are requesting OTIP support.
Requested Scholarship Budget
Line Item

Total

Lodging Example: $133.00 (Fed Gov. rate) + $19.95 (15% tax) x 5 individuals (number of
scholarship awardees x 1 (number of nights requested per individual awardee) = $764.75

Calculation: $ _______ (Fed Gov. rate) + _______(15% tax) x _______ (total
number of scholarship recipients x ________ (total number of nights
requested per scholarship recipient) = $__________
Travel Example: $250.00 (estimated airfare) x 3 (number of recipients) = $750.00
Calculation: $_______ (estimated airfare) x _______ (total number of
recipients) = $__________
Total Request:
Applying Organization’s Budget
Line Item
Organization’s current total operating budget.
Of the total operating budget, how much is allocated to supporting this
conference?
List conference co-sponsors (if applicable) and amount they are contributing.

Total

Section E: Pre-Conference Requirements
These action items must be completed and documentation returned to NHTTAC within 14 days of the
notice of the award for you to receive reimbursement for the approved scholarship expenses.

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Identify NHTTAC as a conference cosponsor on all conference promotional materials
and electronic announcements. (NHTTAC logo will be provided in award notification.)

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Include NHTTAC-provided language on all conference promotional materials and
electronic announcements. (Language will be provided in award notification.)

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Provide list of scholarship recipients 1 week prior to the event date to NHTTAC.

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Section F: Post-Conference Requirements
The following forms will be included in an award e-mail upon approval. They must be completed and
documentation returned to NHTTAC within 30 days of the event for you to receive reimbursement for
your expenses.

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Recipient Reimbursement Expense Voucher
Your organization must first reimburse scholarship awardees; then, NHTTAC will
reimburse your organization upon demonstration of payment to individuals. The
request for reimbursement must include documentation for all individual scholarship
awardees. Original itemized receipts are required for all expenses for which you are
seeking reimbursement.

Section G: Scholarship Concurrence
This ensures that the information provided in Sections A to D, to the best of your knowledge, is
accurate.

I certify that:
(1) my organization is unable to completely underwrite professional development
scholarships for human trafficking survivors wishing to attend our conference;
(2) the scholarship recipients must be survivors of human trafficking with at least 1
year of volunteer service experience to other survivors and/or at risk populations;
(3) my organization has the experience and capacity to administer a scholarship
program;
(4) any support obtained via the Organizational Scholarships for Survivor
Professional Development Program will not be used to replace funding previously
allocated to support scholarships for conference attendees;
(5) my organization will reimburse survivor awardees. Upon proof of reimbursement,
NHTTAC will then reimburse my organization;
(6) funding for scholarships will not be used in any manner to support the expenses
of our organization’s staff/contractor labor, travel, lodging, per diem, etc., before,
during, or after the conference;
(7) this conference is verifiably nationwide or statewide in scope and audience;
(8) my organization will act in accordance with the Organizational Scholarships for
Survivor Professional Development Program guidelines, terms, and conditions,
will perform all actions requested in this application, and will not take any actions
that go beyond the scope of this program; and
(9) information provided in this application is accurate and verifiable.
I understand and agree that any false information, misrepresentation, or willful or negligent
failure to disclose any information pertinent to this application or my organization will
constitute sufficient grounds for the removal of my application from consideration, the
return of funding by my organization to National Human Trafficking Training and Technical
Assistance Center if funding has been granted, and/or disqualification of my organization
from future scholarship opportunities.

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Organizational Scholarship Application for Survivor Professional Development (Continued)

__________________________________________
Signature of Organization’s Chief Executive

_________________________
Date

________________________________________________________________________
Name of Organization
___________________________
Phone Number

______________________________
E-mail Address

Please email the completed application to [email protected] with the subject line stating,
“Organizational Scholarship Application for Survivor Professional Development.”

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden of this collection of information is estimated to average 19 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing 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.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to DHHS/ACF Reports Clearance Officer; 370 L’Enfant Promenade, S.W.;
Washington, D.C. 20447

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