Form 1122-0028 Semi-annual Progress Report Form for Children Exposed to

Semi-annual Progress Report for Children and Youth Exposed to Violence Program

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Semi-annual progress report for the Children and Youth Exposed to Violence Program

OMB: 1122-0028

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1122-0028 can be found here:

2022-04-20 - Extension without change of a currently approved collection

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THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.
OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

U.S. Department of Justice
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you will primarily serve children [12 and younger], please explain the circumstances under which you
provided those services. For example, you served three siblings, ages 9, 12, and 15 years old. It
was very important for the family’s treatment to include the 15-year-old sibling in the treatment as
comparable services for youth are not available in your community.) (Maximum — 2,000 characters)

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(Report the total number of non-abusing parents/caregivers and accompanying family members
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reporting period. This should be an unduplicated count for both non-abusing parents/caregivers and
accompanying family members. This means that each non-abusing parent/caregiver 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 to non-abusing parents/
caregivers and accompanying family members. The number of bed nights is computed by multiplying
the number of non-abusing parents/caregivers and accompanying family members by the number of
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number of non-abusing parents/caregivers and accompanying family members. For example, one nonabusing parent and her three children all stayed in the shelter for 10 nights. The number of bed nights
would be 4 multiplied by 10, or 40.)
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THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.
OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

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CEV Program-funded victim services staff provided assistance to non-abusing parents/caregivers
and children or youth during the current reporting period. Indicate whether protection orders were
obtained for the non-abusing parent/caregiver, for the child or children, or for both. 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.)
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THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.
OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

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(Use the space below to discuss the effectiveness of services provided to child victims, children
indirectly exposed to violence, and non-abusing parents and caregivers that were funded or supported
by your CEV grant, and to provide any additional information you would like to share about these
activities beyond what you have provided in the data above. For example, parents and caregivers
report that they have seen improvements in the behavior of children indirectly exposed to violence
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of parents and caregivers who are including children in their protection orders.) (Maximum — 2,000
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OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

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Indicate whether the activities related to your objectives for the current reporting period have been
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challenges, and provide any additional explanation you feel is necessary for us to understand what
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objectives that should have been accomplished during the current reporting period, you must provide
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(For example, we used CEV Program funds to hire a Somali advocate who trains staff at programs
serving children in that community to identify and appropriately refer children indirectly exposed to
sexual assault, domestic violence, dating violence, and stalking.)
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questions on this form that demonstrate the effectiveness of your CEV 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 children and victims/survivors, promising practices,
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CEV Program funds supported staff—e.g. victim advocates, child advocates, etc.—but did not report
any corresponding 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.)
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THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.
OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

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THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

Back to Instructions.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.
OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

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THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

Back to Instructions.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.
OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

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THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

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THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

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Back to Instructions.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.
OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

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THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

Back to Instructions.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.
OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

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Back to Instructions.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.
OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

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Back to Instructions.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.
OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

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Back to Instructions.

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Expiration Date: 12/31/2015

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Back to Instructions.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.
OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

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THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

Back to Instructions.

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OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

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supported staff—e.g. victim advocates, child advocates, etc.—but did not report any corresponding services,
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reporting period, please explain how program funds were used, if you have not already done so.)
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THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

Back to Instructions.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.
OMB Clearance # 1122-0028
Expiration Date: 12/31/2015

&(93URJUDP6HPLDQQXDO3URJUHVV5HSRUW2IÀFHRQ9LROHQFH$JDLQVW:RPHQ
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THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

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THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

File Type	application/pdf
File Modified	2013-02-12
File Created	2013-02-12