Form 1 FVPSA State and Territory Grants Performance Progress Re

OMB #: 0970-0280
EXPIRATION DATE: XX/XX/XXXX

Performance Progress Report (PPR) and Instructions for Family Violence Prevention and Services
Act (FVPSA) -funded States and Tribes
(SP-State Portion and Section G-Service Outcome Data Sections are optional for tribal grantees)
Enter the below information into the Online Data Collection System at www.grantsolutions.gov. Contact your Project
Officer for a user name and password.

Cover Page
1.

Federal Agency and Organizational
Element to Which Report is Submitted

2.
3a.

Federal Grant or Other Identifying
Number Assigned by the awarding
Federal agency
DUNS Number

3b.

EIN

4.

Recipient Organization

5.

Recipient Account Number or Account
Number

6.

Project/Grant Period

7.
8.

Reporting Period End Date
Final Report

9.
10.

Report or Frequency
Performance Narrative

11.

Other Attachments

12a
.
12b
.
12c
.
12d
.
12e
.

Certification – Name
Certification - Signature
Certification – Phone

Enter the name of the awarding Federal agency and organizational
element identified in the award document or otherwise instructed
by the agency. The organizational element is a sub-agency within
an awarding Federal agency.
Enter the grant/award number contained in the award document.
Enter the recipient organization's Data Universal Numbering
System (DUNS) number or Central Contract Registry extended
DUNS number.
Enter the recipient organization's Employer Identification Number
(EIN) provided by the Internal Revenue Service.
Enter the name of recipient organization and complete address,
including ZIP code.
Enter the account number or any other identifying number
assigned by the recipient to the award. This number is strictly for
the recipient's use only and is not required by the awarding
Federal agency.
Enter the federal fiscal year covered by this performance progress
report.
Enter the ending date of the reporting period.
Mark appropriate box. Check “yes” only if this is the final report for
the project/grant period specified in Box 6.
Select “annual” for report frequency.
Attach a separate document with the labeled responses to each of
the elements in Section H.
Attach a separate document per the instructions on the cover
page.
Type or print the name and title of the Authorized Certifying
Official.
The Authorized Certifying Official should sign here.

Certification – Email

Enter the area code, phone number and extension of the
Authorized Certifying Official.
Enter the email address of the Authorized Certifying Official.

Certification – Date

Enter the date (month, day, year) the report is submitted.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering data on
your grant program to understand the design and effectiveness of the program and to inform technical assistance needs. Public reporting burden for this
collection of information is estimated to average 5-10 hours per grantee, 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 (Pub. L. 105-285, section 680(b) as
amended). 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. The OMB # is 0970-OXXXX and the expiration date is
XX/XX/XXXX. If you have any comments on this collection of information, please contact Brian Pinero, Program Specialist, Division of Family Violence
Prevention and Services, by email at [email protected].
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OMB #: 0970-0280
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SP – State Portion
Information on FVPSA grants/funds awarded should include any funds awarded by the state during the federal fiscal
year reporting period. For example, if during the past federal fiscal year (Oct- Sep), the State made awards to
subawardees in July, then the State should report on the grants and funds awarded in July and any other funds awarded
during the federal fiscal year reporting period. The State’s aggregate report of services provided by FVPSA subawardees
should include all services/grant activities that occurred throughout the federal fiscal year reporting period (Oct – Sep).
Total funds awarded to subawardees by the State
Total amount of state administrative costs
[Total funds awarded to subgrantees by the State: Report the total amount of grant awards or contracts made to
subgrantees (i.e., domestic violence programs) during the reporting period.]
[Total amount of state administrative costs: Report the total amount of grant funds used to support State/Territory costs
for the administration of FVPSA funding.]

Subawardee List
Subawardee
City State Zip Website
Name

Classification
Underserved or
FVPSA
of urban,
culturally- and
Type of
Funding
rural,
Subawardee linguistically-specific
Amount
suburban or
population
frontier

Notes on the
Subawardee

Types of Subawardee Options (choose one):
Shelter
Non-shelter
Other
Underserved or culturally- and linguistically-specific population:
[Write in which population the subawardee primarily serves. Culturally and linguistically specific services refers to
community-based services that offer full linguistic access and culturally specific services and resources, including
outreach, collaboration and support mechanisms primarily directed toward culturally specific communities.
Underserved populations means populations who face barriers in accessing and using victim services, and includes
populations underserved because of geographic location, religion, sexual orientation, gender identity, underserved
racial and ethnic populations, and populations underserved because of special needs including language barriers,
disabilities, immigration status, and age. Individuals with criminal histories due to victimization and individuals with
substance use disorders and mental health issues are also included in this definition (45 CFR § 1370.2). ]
Classification for Rural-Urban Communities (choose one):
Rural
Suburban
Urban
Frontier
[Subawardees will self-identify with the classification that most closely matches their service area. To determine if a
program is designated as frontier, go to www.ruralhealthinfo.org. Click on the Am I Rural? Tool. Run a report based on
the program address. If the program receives a Frontier and Remote Area Code, then you may select frontier.]
Notes on the Subawardee could include:
Additional explanation on other as the type of subawardee
Additional explanation of underserved
Additional description on the type of population such as ‘refugees from Syria’
Additional explanation on the chosen classification for rural-urban
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Subawardee Portion
This information in this section should be collected by each subawardee and compiled by the state into this following
section. Tribal grantees will complete for their programs. This report is a compilation of all domestic violence services
regardless of funding source, not just FVPSA funds, used to provide the below services to victims. For the narrative
responses (section H), the State should choose what information to include from the subawardees and may include
information about FVPSA funds retained by the State.

Section A – General Program Information
Total domestic violence program budget
FVPSA grant amount
Number of shelter facilities
Number of non-shelter service sites
[Total Domestic Violence Program Budget: This is the sum of the total annual budgets for each local domestic violence
program at the same point in time. Each local domestic violence program will report its total budget that is used to
provide the services to victims included in this report. This number could include additional funding from other sources
or it may be the same as the FVPSA grant amount listed in the FVPSA grant amount. The FVPSA State Administrator then
totals each of the entries from the local programs and enters the number here.
For example, the total program budget would include all funding sources, i.e., FVPSA dollars and state dollars to provide
shelter to victims. Grant dollars set aside to provide separate services to sexual assault victims would not be included
here. In addition, a domestic violence program that is located within a larger social service agency would only include its
budget for domestic violence programming. For example, a local domestic violence program that receives $50,000 in
FVPSA funds, $20,000 from the state for DV services and $10,000 from a private funder would report $80,000 as its total
domestic violence program budget.]
[FVPSA Grant Amount: List total amount of FVPSA funds received within your current fiscal year.]
[Number of Shelter Facilities: This is a count of shelter facilities providing immediate housing to victims of domestic
violence and their children managed by the domestic violence program. This normally includes only communal living
spaces and other buildings owned or rented by the program. This number should not include safe homes, motels or
shelter beds provided by other programs. Although this count of shelter facilities only includes property managed by
the program, Section B Clients Served in Shelter below asks programs to count the number of clients who were provided
shelter whether that be in a building managed by the program or a hotel or safe home.]
[Non-Shelter Services Sites: List the total number of service sites (i.e., office locations) where a program provides nonresidential services. This may include the coordination of shelter for victims through hotels and safe homes where there
is not a shelter facility. This number should be one (1) if the program has a single program site with no shelter facility. If
a program maintains satellite locations, they should be counted here, i.e., one main office and two satellite offices
should be reported as three (3) sites. This is not a count of the number of hotels and safe homes used.]

Section B – People Served
[If the grantee has concerns that providing the data below will allow a report reader to personally identify a victim,
please use the boxes for “not specified” or “unknown” for that client’s data.]
Clients Served in Shelter
Number of Children/Youth
Adults:
Number of Women
Number of Men
Number Not-specified/Other
Total
[Auto Sum]
[Clients Served in Shelter: Number of new domestic violence victims (clients) seen for the first time during this reporting
period who received shelter services (including a shelter facility managed by the program, safe home or hotel). Clients
should be counted once regardless of the number of times served during the fiscal year. For example, if a client spent 30
days in the shelter in November, exited the shelter and then came back to the shelter in March, then she would only be
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counted one time. Clients who received shelter should only be counted in this element and not counted in Clients
Served with Non-Shelter Services even though they may have received non-shelter services also. Clients who were
referred to another domestic violence shelter program should not be counted here. The count will be within program
only and should not be unduplicated across programs statewide.]
Clients Served with Non-Shelter Services
Number of Children/Youth
Adults:
Number of Women
Number of Men
Number Not-specified Other
Total
[Auto Sum]
[Clients Served with Non-Shelter (supportive services only): Number of new domestic violence victims (clients) seen for
the first time during this reporting period who received only non-shelter services. Include only clients that received
supportive services only and no shelter by your program. Calls to a crisis line or hotline should not be counted here and
should be counted in Section C instead. Count should be within program only and not unduplicated across programs
statewide.]
Age
0-12
13-17
Unknown Child Age
18-24
25-59
60+
Unknown Adult Age
Total
[Auto Sum]
[Age: Report the ages of the clients served, including children and youth. These age demographic totals should equal the
program’s numbers totaled in Clients Served in Shelter and Clients Served with Non-Shelter. For example, if the program
served 30 women, 62 children and 2 men (94 total), the total for all the ages should also add up to 94.]
Race/Ethnicity
Black or African American
American Indian/ Alaska Native
Asian
Hispanic or Latino
Native Hawaiian/ Other Pacific Islander
White
Unknown/Other
[Race/Ethnicity: Report the race and/or ethnicity of the clients served, including children and youth. Clients may selfidentify in more than one category, e.g., White and Hispanic.]
Other Demographics
Number needing language services, such as interpretation
Number self-identifying as lesbian, gay, bisexual, transgender or queer (LGBTQ)
Number of youth age 13-17 receiving services due to being a victim of dating
violence
[Language Services: Provision of interpretation and/or translation. Provision of English as a second language class.]
[LGBTQ: This is a count of clients who self-identify as lesbian, gay, bisexual, transgender or queer.]
[Teen dating violence: This is a count of all of the youth age 13-17 receiving services due to being a victim of dating
violence in their own relationships. These youth could be receiving services on their own, as an emancipated minor or
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other minor eligible to receive services, or could be a youth who accompanies their parent to shelter and self-identifies
as needing their own services.]

Section C – Shelter Services and Crisis Calls
Shelter Nights
Unmet Requests for Shelter
Crisis/Hotline Calls
[Shelter Nights: Indicate the number of shelter nights for each person who arrives and is provided a bed, including onsite shelter, safe home or hotel room. Include victims of domestic violence and their dependents. Count the number of
people housed times the number of nights. For example, a victim and her 3 children stay in the shelter or safe house for
5 nights; this means 4 people x 5 nights = 20 shelter nights.
Shelter includes onsite shelter managed by the domestic violence program, program-sponsored hotel rooms and safe
homes (residences of volunteers who offer their private homes for short-term crisis situations) or other temporary
housing that your program arranges. Nights that a victims stays in a shelter not managed by your program should not be
counted (e.g., a shelter in a nearby county).]
[Unmet Requests for Shelter: Count the number of unmet requests for shelter due to program shelter, safe homes or
sponsored hotel rooms being at capacity or unavailable. Count adult victims of domestic violence only. This count should
not include individuals who were not served because their needs were inappropriate for the services of your program,
e.g., homelessness not related to domestic violence. Count the total number of times requests for shelter were declined,
even if the program provided other services.]
[Crisis/Hotline Calls: Calls received on any agency line that relate to an individual or family in need of some kind of
service. A program does not have to have a dedicated hotline to count these calls. Count all calls including repeat callers
and calls from third parties such as a family member. Do not count calls about donations or for general information
about program or violence issues unrelated to a specific individual or family, calls from the media, etc.]

Section D – Services to Victims
Number of children/youth receiving crisis intervention
Number of children/youth receiving victim advocacy services
Number of children/youth receiving individual or group
counseling/support group
Number of adult victims receiving crisis intervention
Number of adult victims receiving victim advocacy services
Number of adult victims receiving individual or group counseling/support
group
Number of adult victims receiving criminal/civil legal advocacy
Number of adult victims receiving medical accompaniment
Number of adult victims receiving transportation services
[Report the number of clients who received each service. Count each client only once for each type of service that the
client received.]
[Individual/Group Counseling: Individual or group counseling or support provided by a volunteer, staff or advocate.]
[Crisis intervention: 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 with an established client. This does not include hotline calls where the caller isn’t a
client receiving services.]
[Victim Advocacy Services: Actions designed to help the victim/survivor obtain needed resources or services including
employment, housing, shelter services, health care, victim’s compensation, etc.]
[Criminal/Civil Legal Advocacy: Assisting a client with civil legal issues, including preparing paperwork for protection
orders; accompanying a client to a protection order hearing, or other civil proceeding; and all other advocacy within the
civil justice system. This also includes accompanying a client to an administrative hearing, such as unemployment, Social
Security, TANF, or food stamp hearing. Assisting a client with criminal legal issues including notifying the client of case
status, hearing dates, plea agreements, and sentencing terms; preparing paperwork such as victim impact statements;
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accompanying a client to a criminal court proceeding or law enforcement interview; and all other advocacy within the
criminal justice system.]
[Medical Accompaniment: Accompanying a domestic violence victim to, or meeting a victim at, a hospital, clinic, or
medical office.]
[Transportation Services: Provision of transportation, either directly or through bus passes, taxi fares, or other means of
transportation.]

Section E – Community Education
Adults/General Population
Number of Presentations
Number of Participants
[Adults/General Population: Count the total number of presentations or trainings about domestic violence and/or
services related to victims of domestic violence and their children. In addition, count the number of individuals in
attendance. Some examples may be a training for health professionals or a workshop for tribal leaders. Include all
presentations for a mixed-age audience. This number does not include health fairs, media interviews or advertising.]
Youth Targeted Education
Number of Presentations
Number of Participants
[Youth Targeted: Count the total number of presentations or trainings about domestic violence, dating violence, healthy
relationships or available services for victims. In addition, count the number of individuals in attendance. Some
examples may be a presentation to youth in school on healthy relationships or a workshop for youth at a Safety Day
event.]

Section F – Narrative Responses
H-1 - For services supported in whole or in part by your FVPSA grant, share a story about a client (without sharing any
personally-identifying information), service or community initiative that could be shared with other stakeholders.
H-2 - What does the FVPSA grant allow you to do that you wouldn’t be able to do without this funding?
H-3 - Describe any efforts supported in whole or in part by your FVPSA grant to meet the needs of underserved
populations in your community, including populations underserved because of ethnic, racial, cultural or language
diversity, sexual orientation or gender identity or geographic isolation. Describe any ongoing challenges.
H-4 - Describe significant prevention and outreach activities, supported in whole or in part by your FVPSA grant, during
the program year.
H-5 - Provide information on the evaluation of the effectiveness of your domestic violence programming.
H-6 - (Optional) Provide any additional information that you would like us to know about your FVPSA-supported
domestic violence program, i.e., the unmet needs of victims in your community, other funding sources used for
programming or service trends that are emerging in your community.
[These responses should be entered directly into the Online Data Collection System in the associated text boxes. This
allows FVPSA to review all of the responses from the grantees at one time. FVPSA understands that this may affect the
formatting of the responses and makes it more difficult to read. If you are concerned about this, you may provide a
separate attachment as a pdf or Word file, but this would be in addition to entering the information directly into the text
boxes.]

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Section G – Service Outcome Data
Know more about community resources
Survey Type

I-01

Shelter survey

I-02

Support services and
advocacy survey

I-03

Counseling survey

I-04

Support group survey

I-05

TOTAL

Number of
Surveys
Completed

Number of Yes
Responses to
Resource
Outcome

Know more ways to plan for safety

Percent
Number of
Responses Surveys
Completed
[autocalc]

Number of Yes
Responses to
Safety
Outcome

Percent
Responses
[autocalc]

[Domestic violence programs should be collecting outcome information from their clients served. A manual and
instructions from the Documenting Our Work Project are available online at the Outcomes webpage from the National
Resource Center on Domestic Violence at http://nrcdv.org/FVPSAOutcomes. There are two mandated questions that
must be asked of clients.
Because of the services I received, I feel:
• I know more about community resources (yes or no).
• I know more ways to plan for my safety (yes or no).
Outcome information may be collected for each service – shelter, support services and advocacy, counseling and
support group. However, at a minimum, FVPSA requests outcome information on shelter services from programs that
provide shelter services.
For each service, count the number of surveys completed and the number of yes responses to each question. It is
expected that the number of surveys completed would be the same for each, but there may be instances when it differs,
e.g., a client doesn’t answer one of the questions.
• I know more about community resources (Resource Outcome).
• I know more ways to plan for my safety (Safety Outcome).]

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