Form 1 Client Characteristics and Enrollment Form

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

Domestic Victims of Human Trafficking Program Grantee
Client Characteristics and Program Entry Form
Complete this form for every new client or when a client's case has reopened (previously served but case closed).
Information should reflect client's status at assessment, as collected at intake and/or during the following 90 days.
Grantee
Reporting Period Start Date

Client Identifier

Reporting Period End Date

Intake Date

Referral Source

Report Type

Type of Intake

Referral Date

Service Eligibility Status

Was the client enrolled in the DVHT program?

If no, select the primary reason why the client did not
enroll into the program.

Does the client have family members receiving services from grantee?

If grantee is serving family members of the client who experienced trafficking, please indicate the number of the client's
parents/guardians, siblings, spouses, children, and/or other household members receiving services as well.
Parent(s)/Guardian(s)

Sibling(s)

Spouse

Other Household Members

Child(ren) < 18

Child(ren) 18 or Older

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN:
Through this information collection, ACF is gathering data on the grant program to assess program performance, inform evaluation, tailor technical assistance, report to stakeholders,
and inform policy and program development. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing
instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required to retain a benefit (22 USC 7105,
Trafficking Victims Protection Act). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the
Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information, please contact Flavia KeenanGuerra, Office on Trafficking in Persons, by email at [email protected].

Client Demographics and Characteristics
Date of Birth

Age at time of intake

Sex

Does client identify as LGBTQ?

Does the client have a disability?
(check all that apply)

Race/Ethnicity (check all that apply)
American Indian or Alaska Native

Hearing Difficulty

Asian

Vision Difficulty

Black or African American

Cognitive Difficulty

Native Hawaiian or Other Pacific Islander

Ambulatory Difficulty

White

Self-Care Difficulty

Hispanic or Latino
Unknown
Other
If client identifies as an American Indian or Alaska Native, in what Tribe are they enrolled?

If known, record the client's country of origin. If
unknown or unclear then record unknown.
Current Living Situation

Country

If client is a minor, are they enrolled in school?

For the following questions on employment and job training, select the response category that most accurately reflects the
client's employment status.
Is client employed?

Is client enrolled in job training?

If yes, what is the type of employment?

If no, is the client seeking employment?

Client's Presenting Needs
What needs or services did the client have (check all that apply)?
Basic Necessities

Child Care

Crisis Intervention

Dental Health Services

Education Assistance

Employment Assistance

Family Reunification

Financial Assistance

Housing and/or Shelter Services

Interpreter and/or Translator

Legal Advocacy and Services

Life Skills

Mental and/or Behavioral Health Services

Medical Services

Safety Planning Services

Substance Use Assessment and/or Treatment

Traditional Medicine and Cultural Practices

Transportation

Victim Advocacy

Vision Care

None

Unknown

Other
What public benefits does the client need? (check all that apply)
Child Care Subsidy

Food Benefits (SNAP, WIC, Tribal Commodities)

General Assistance

Housing Subsidies (Section 8, HUD Vouchers)

Medicaid, Medicare, or SCHIP

State-Specific Health Benefits

Social Security Disability (SSDI or SSI)

Temporary Assistance for Needy Families (TANF)

Unaccompanied Alien Children Program

Unemployment Insurance

None

Unknown

Other
Specify the geographic location where the client is or will be receiving the majority of services.
County or Parish

State or Territory

Tribal Land or Reservation

Trafficking Experience
The following section records sensitive information about the client's trafficking experience. While this information may be
disclosed by the client, the grantee should not require the client to disclose specific details about the trafficking experience in
order to receive services through the program. Grantee should mark unknown when the information is not provided or known.
Type of Trafficking

Client Relationship to Trafficker

Exploitation Industry
Agriculture/Field Labor

Arts/Entertainment

Bar/Cantina/Nightclub

Begging/Peddling

Carnival

Cartel/Gang

Commercial Cleaning

Construction

Domestic Work

Elder Care

Escort Services

Factories/Manufacturing

Fishing

Forced Criminal/Illicit Activities

Forestry/Logging

Herding/Livestock

Health/Beauty

Health Care

Hotel/Hospitality

Illicit Massage/Health/Beauty

Landscaping

Mining/Quarrying/Fracking

Pornography/Remote Interactive Sexual Acts

Prostitution/Outdoor Solicitation

Prostitution/Residential

Recreation/Sports

Religious Institution

Restaurant/Food Service

Retail Sales

Sexual Servitude

Stripping/Exotic Dancing

Traveling Sales Crew

Transportation

Unknown

Other
If known, record the location of the trafficking incident. Partial information is acceptable.
County or Parish

Tribal Land or Reservation

State or Territory

Country of Trafficking Incident