Form 1 FVPSA State Domestic Violence Coalitions Grants Performa

OMB #: 0970-0280
EXPIRATION DATE: XX/XX/XXX
ACF-ACFY-FYSB-FVPS-PPR COVER PAGE
Family Violence Prevention and Services Program (FVPSP)
Family and Youth Services Bureau (FYSB) /Administration for Children and Families (ACF)
U.S. Department of Health and Human Services (HHS)
Domestic Violence Coalition Grant Report
1. Federal Agency and Organization
Element to Which Report is Submitted

FVPSP/FYSB/ACF/HHS

2. Federal Grant or Other
Identifying Number Assigned by
Federal Agency

3a. DUNS Number:

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3b. EIN

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4. Recipient Organization (Name and Complete Address Including Zip Code)

5. Recipient Identifying Number
or Account Number

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6. Project Reporting Period

7. Reporting Period
End Date

8. Final Report?
Yes
No

Start Date: (Month, Day, Year)

(Month, Day, Year)

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enter text.

(Month, Day, Year

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enter text.

9. Report
Frequency
Annually

10. Performance Narrative (performance narrative is covered in the attached PPR forms)

11. Other Attachments

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12. Certification: I certify to the best of my knowledge and belief that this report is correct and complete
for performance of activities for the purposes set forth in the award documents.
12a. Typed or Printed Name and Title of Authorized Certifying Official

12c. Telephone (area code, number and
extension)

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12d. Email Address

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12b. Signature of Authorized Certifying Official

12e. Date Report Submitted (Month, Day, Year)

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10. Agency Use Only

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 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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Instructions for Completion
This is the paper copy of the form to be completed for your reference. To submit this Performance Progress
Report to FVPSA, you will enter the information electronically into the Online Data Collection System (OLDC)
at https://extranet.acf.hhs.gov/ssi. For help accessing OLDC, please contact 866‐577‐0771.

Family Violence Prevention and Services Act (FVPSA) Funds
Purpose
This report is a compilation of all of the domestic violence programming/services provided by state and
territorial domestic violence coalitions – whether or not the programming/service is provided with FVPSA
funds. Because of the manner in which coalitions utilize the FVPSA funds in their respective agency, it is not
feasible to consistently and accurately identify the specific grant activities (including the level of effort) that
are funded by FVPSA dollars. Therefore, in consultation with FVPSA state administrators, tribal program
coordinators and coalition representatives, it was determined that this report would include a count of all
domestic violence programming/services provided, including those supported through other funding sources.
The FVPSA program will use the percentage of FVPSA funding received by the coalition to the total coalition
budget in order to determine the level of services supported by FVPSA funding. Grantees are required to
report the total coalition budget and the FVPSA grant amount.
Dual Coalition
Check here if your coalition is both an HHS‐designated sexual assault (Centers for Disease Control) and
domestic violence coalition (Administration on Children and Families/Family and Youth Services Bureau/FVPSA
Program).
Total Coalition Budget
This is the total annual organizational budget for your coalition including sexual assault funding if a dual
program. This number will include funding from other sources in addition to your FVPSA grant amount. For
example, the total coalition budget would include all funding sources of the coalitions, i.e., FVPSA dollars
(including any pass through amounts), state dollars, private foundations.
Total FVPSA Amount
Fill in the total State Domestic Violence Coalition FVPSA award amount for the year of this report.
Amount of Pass‐Through Dollars
If your coalition receives funds from the state to fund local domestic violence shelter and supportive services,
enter that here. This includes FVPSA, State General Funds, VOCA, VAWA, and other funds for domestic
violence that are passed through the coalition directly to local programs.
Percentage of the Budget Funded by FVPSA
(Total FVPSA Coalition Grant Amount) / (Total Coalition Budget – Pass‐Through Dollars) = Percentage of the
Budget Funded by FVPSA
State FVPSA Dollars to the Coalition
In addition to the FVPSA Coalition Grant, the FVPSA office provides formula funding to each state. Some state
offices contract part of this money to the state domestic violence coalition. If your coalition receives FVPSA
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dollars from the state, check yes here and give a brief explanation of what those dollars are for, e.g., training
and TA, support of a statewide data collection system.

Coalition Members
Number of Organizational Members Table
This chart asks you to place each of the organizational members of your coalition into categories. The left
column contains categories for types of service provider members. The top row contains categories for types
of organizations. Each member should have only one category of type of service provider (left column) and
one type of organization (top row) reported as a number in the corresponding cell. For example, a coalition
may have 6 members who are domestic violence service providers so the total for the first row would be 6. If
one of the programs is within a government agency, a 1 would be reported in the first row/second column. If
2 of the programs are tribal specific programs, then 2 would be reported in the first row/fourth column. The
next rows would be filled out similarly.
Definitions:
Domestic Violence Service Providers– these are the domestic violence service providers whose primary
purpose is to serve victims of domestic violence.
Sexual Assault/ Domestic Violence Dual Service Providers – these are providers that provide both domestic
violence and sexual assault services to victims.
Sexual Assault Service Providers or Rape Crisis Centers – these providers provide services to victims of sexual
assault.
Other victim service providers – these are providers that serve victims in some way, but do not fit in the above
categories.
Other Organizational Members – these are providers that don’t fit into the above four categories, but not
individual members.
Government Agency – these organizations are located within the state or local government structure.
Culturally‐specific Program – these organizations provide services that offer full linguistic access and culturally
specific services and resources, including outreach, collaboration and support mechanisms primarily directed
toward culturally specific communities. These programs are not exclusive to the targeted population.
Tribal‐specific – these organizations fit the above definition for culturally‐specific with a focus on serving
Native Americans.
All others – these organizations do not fit into the previous three categories.
Example – Coalition X has a total of 67 organizational members, not including any individual members. 17 of
these members are DV service providers (not dual programs). Of those 17, four are located within a local
government human service program, one is the Latino Women’s DV Program, and another is the Pamunkey
Indian Tribal DV Program. Eleven of them are stand‐alone DV non‐profit organizations. Note that this is not a
count of individual members.

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Number of Organizational Members
Type of Service Provider
Government
Agency
Domestic Violence Service
Providers
SA/DV Dual Service Providers
Sexual Assault Service
Providers or Rape Crisis
Centers
Other Victim Service Providers
Other Organizational
Members
TOTAL

4

Culturally‐
specific
Program

Tribal‐
specific

All Others

TOTAL

1

1

11

17

16

18

20

22

2
2
8
14

2
3

3

10
47

67

Number of Domestic Violence Service Providers in the State/Territory
This is the total number of domestic violence service providers whose primary purpose is to provide domestic
violence services to victims. This is a count of all of the providers in the state, not only the ones that are
members of your coalition. A primary‐purpose domestic violence service provider is one that operates a
project of demonstrated effectiveness, carried out by a nonprofit, nongovernmental, private entity or a tribe
or tribal organization, that has as its project’s primary purpose the operation of shelters for victims of
domestic violence and their dependents; or provides counseling, advocacy, or self‐help services to victims of
domestic violence.
How many of the primary purpose domestic violence service providers are members of your coalition?
This is the number of primary‐purpose domestic violence service providers that are members of your coalition.

Narrative Questions
1. Describe your progress during the reporting period in completing the activities described in your most

recent application. This may be a work plan table or a narrative response. Note: If you report serving on
a board, commission or other planning group (e.g. Governor’s Commission on Domestic Violence, Criminal
Justice coordinating Council, etc.) please briefly describe what was accomplished during the reporting period.

2. Please write a success story about your coalition’s work that is ready for publication on the ACF
website.
o Topic(s): An example of a survivor who has a positive life outcome or story to tell, with help
from program services; a news item reporting a workshop, conference, new program or other
event held/to be held; a story focusing on the work of a fatality review team which led to a
systems change impacting survivor outreach and awareness of services. Stories reflecting
themes or issues related to underrepresented, or underserved communities (such as LGBTQ
survivors, Native survivors, or communities of color) are especially welcome.
o Length: Submissions should be between 500 and 750 words, roughly
o Writing should be in third person narrative, and double‐checked for proper grammar, spelling
and punctuation.
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3.
4.
5.
6.
7.

o As always, use good standards of confidentiality and privacy when reporting on individual
survivors. Please change names, ages, and all other personally‐identifying information.
o A photo/image to accompany the submission is most welcome. If one is not provided, ACF will
choose one from stock images.
How does the coalition identify training and technical assistance priorities? What is the process and
who is involved?
Describe your coalition’s efforts in organizational capacity‐building and development of your members.
What are the top areas in which other coalitions, state or national audiences look to your coalition as a
leader, unique expert or innovator? (optional)
What other state coalitions do you look to as experts, leaders, or innovators on a specific topic? Name
the coalition and the topic. (optional)
What other things regarding your work would you like the FVPSA office to know? (optional)

Summary of Activities Table
This table is included as a way to help the FVPSA office know ‘at a glance’ which coalitions are working on
different program areas and priorities. Throughout the year, the FVPSA office gets requests which need to be
responded to quickly from senior leadership, members of congress and others asking what the FVPSA office is
doing around ‘fill in the blank’ issues. Rather than the piece meal approach used now which involves FVPSA
staffs’ prior knowledge of your coalition and multiple email queries to all the coalitions, this table will serve as
an overall view of the work of the coalitions by topics and allow the FVPSA office to easily identify coalitions
working on an issue and, hopefully, easily gather the information to respond.
Statutorily‐defined Program Areas and FYSB Priority Areas
The alphabetical list in the left hand column is comprised of both program areas identified in FVPSA legislation
as required work of the coalition and topics that have been identified as priority issues for FYSB or have
received multiple requests for information in the past. Additional notes about each topic are noted as a foot
note.
Level of Involvement
This second column asks you to identify your level of involvement with each topic in the first column. For each
topic, you must choose one level of involvement. The FVPSA office does not expect that each coalition will be
involved in every topic. Figuring out your level of involvement is somewhat subjective. Highly Involved in a
topic would indicate to the FVPSA office that your coalition is doing something that may be: widespread,
innovative, unique or replicable to other states. When senior leadership request information on a certain
topic, we will first look at those states that checked Highly Involved on that topic.
The statutorily‐defined program areas will not allow you to check Not Involved, as you are mandated to
address these issues, though you do not have to check Highly Involved.
Types of Activities
For any of the topics that you indicate you have some level of involvement, check all of the types pertaining to
that topic. At least one type of activity should be checked if the topic has any level of involvement checked.
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Training – this is training provided to general audiences or allied professionals. It could be face to face, as a
webinar or a conference call.
Capacity Building / Technical Assistance – this is checked if you provided programming/services to increase
the capacity of individuals or organizations to address this specific topic.
Products – if you developed any products on this topic such as a brochure, manual, newsletter, training
curriculum, training material, report, fact sheet, website, video, e‐learning module or recorded webinar, check
this box.
Public Awareness – if you conducted any awareness events around this topic, check this box. An awareness
event might be rallies, speak outs, Take Back the Night, vigils, Clothesline Project, silent witness, information
tables or media campaigns on radio, TV or newspaper.
Policy / Systems Advocacy –Policy/systems advocacy is any effort to influence public policy or systems by
providing information, speaking to decision makers, demonstrating benefits for policy or systems change and
other such activities that encourage the adoption of the desired policy or systems change.
Number of People Trained
This information is helpful for the FVPSA office to respond to queries. This column is to be completed only if
Training is checked in the Types of Activities section. Estimate the number of people trained about the topic
listed in the first column. The FVPSA office understands that you may not have this information to report.
However, if it is available, report it here.
Short Response
Write a short narrative response (less than 50 words) on your efforts in this topic area. This can be a list,
bullets or 2 sentences to give the FVPSA office a little bit more information. You may also cut and paste
information from your longer narrative responses above in order to provide the snapshot intended for this
section.
References
In this column you will supply information about where the FVPSA office can get more information or
specificity on your work in this area. You will probably reference areas of your PPR Report, your application,
an annual report, a website or something else. Please include specific directions as to how to find the
information in the referenced document. For example, you may say, “see response to question 6 in the
narrative section of this report. Additional information is on page 5 of our application.” If you are linking to a
website, please provide the exact url to the page or the document. For example, to find out more about the
coalition grant program, the url would be http://www.acf.hhs.gov/programs/fysb/programs/family‐violence‐
prevention‐services/programs/state‐dv, not just www.acf.hhs.gov/fvpsa.
Other Topics
Check any of the boxes if your coalition provided training, TA or capacity building on the topic.

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Example
Types of
Activities

Not Involved
Low Involvement
Involved
Highly Involved

Training
Capacity Building
/ TA
Products
Public
Awareness
Policy/ Systems
Advocacy

Statutorilydefined
Program
Areas and
FYSB
Priority Area

Number of
People
Reached
(Training
only)

Level of
Involve
ment

AntiOppression /
Anti-Racism
X

X X

130

Child custody
and visitation
x

x

Short Response (Involved and
Highly Involved only)

References

Write a short narrative
response (less than 50 words)
on your efforts in this area. Or
cut and paste from other parts
of your report.

For additional
information go to:

Link to materials
from conference at
www.url.com; See
page 6 of our
workplan for more
info on workgroup
and TA provided.
Website for
advisory board is at
We sit on an advisory board for
www.url.com; See
DSS that focused on incorporating
Goal 3 Obj 2 of our
domestic violence screening in
workplan that
the child welfare intake process.
reports on the
outcomes.
We held an anti‐racism 2 day
conference in June. We have an
anti‐oppression workgroup which
meets quarterly. We provided TA
to 2 member programs when
internal problems arose.

Training
Report the total number of participants trained.

This report is a compilation of all of the domestic violence programming/services provided by state and territorial
domestic violence coalitions – whether or not the programming/service is provided with FVPSA funds. The FVPSA office
understands that FVPSA dollars fund only a portion of the activities reported below which is appropriately indicated in
any report out by the FVPSA office.

Report the number of training events for each type of listed trainings, regardless of topic.
Computer‐based or e‐learning module – This is different than a webinar. It is a stand‐alone program housed
on a website where users may access it on their own time. The count for this would be the number of times
users completed the training.
Conferences sponsored by the coalition – These events are coordinated by the coalition.
Workshops/seminars/presentations – These events are ones hosted by other organizations where your
coalition is asked to present. Count each time you present, even if it is to the same or a similar audience.
Teleconferences – This type of training uses the telephone only as a conference call.
Videoconferences – These events involve technology that brings participants together in separate locations
where a camera is used to see each participant.
Webinars – This type of training uses a shared technology platform so content can be shared by the presenter
to multiple users at different locations using their own computers.
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Coalition PPR

FVPSA Funds

Dual Coalition ☐yes ☐no
Total Coalition budget
Total FVPSA coalition grant amount
Amount of pass through dollars
Auto calculate % of budget funded by FVPSA
[Total FVPSA coalition grant amount / (Total Coalition Budget‐–
Pass Through Dollars)]
Does your coalition receive additional FVPSA dollars through the state to support the work of your coalition? ☐yes ☐no
If so, what do those dollars support, e.g., training and TA, support of a statewide data collection system?

Click here to enter text.

Coalition Members
Number of Organizational Members
Type of Service Provider
Government
Agency

Culturally‐
specific
Program

Tribal‐
specific

All Others

TOTAL

Domestic Violence Service
Providers
SA/DV Dual Service Providers
Sexual Assault Service
Providers or Rape Crisis
Centers
Other Victim Service Providers
Other Organizational
Members
TOTAL

Total number of primary purpose domestic violence service providers in the state/territory
How many of the primary purpose domestic violence service providers are members of your coalition?

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Narrative Questions
1. Describe your progress during the reporting period in completing the activities described in your most recent
application. This may be a work plan table or a narrative response. Note: If you report serving on a board,
commission or other planning group (e.g. Governor’s Commission on Domestic Violence, Criminal Justice
coordinating Council, etc.) please briefly describe the coalition’s participation in the group and identify the
purpose of the group, body or commission and what it accomplished during the reporting period.
2. Please write a success story about your coalition’s work during the reporting period that is ready for publication
on the ACF website.
3. What are the top areas in which other coalitions or national audiences look to your coalition as a leader, unique
expert or innovator? (optional)
4. What other state coalitions do you look to as experts or leaders on a specific topic? Identify the coalition and
the topic. (optional)
5. What other things regarding your work would you like the FVPSA office to know? (optional)

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Coalition Performance Progress Report

Summary of Activities

Policy/ Systems
Advocacy

Capacity
Building / TA
Products1
Public
Awareness2

Types of Activities

Training

Highly Involved

Involved

Statutorily-defined
Program Areas
and FYSB Priority
Area

Not Involved
Low
Involvement

Level of
Involvement

Number
of People
Trained

Short Response (Involved and Highly
Involved only)

References

Write a short narrative response (less
than 50 words) on your efforts in this
area. Or cut and paste from other
parts of your report.

For additional
information go
to:

Anti‐Oppression /
Anti‐Racism
Child Custody and
Visitation
Children’s
Programming/
Exposure to DV
Child Support
Child Welfare
Confidentiality3
Criminal or Civil Justice
Systems4
Disaster Preparedness
& Response
Economic
Empowerment5
Engaging Men
Evidence‐Informed
Practices Promotion
Brochure, Manual, Newsletter, Training curriculum, Training material, Report, Fact sheet, Web site, Video, e‐learning module, recorded webinar, Other
Rallies, speak outs, Take Back the Night, vigils, Clothesline Project, silent witness, information tables, media campaigns
3
HIPPAA, privileged communication, technology issues, FVPSA personally identifying information and confidentiality requirements
4
Law enforcement, courts, judicial, probation and parole, etc.
5
Financial literacy, Earned Income Tax Credit
10
1
2

Coalition Performance Progress Report

Policy/ Systems
Advocacy

Capacity
Building / TA
Products1
Public
Awareness2

Types of Activities

Training

Highly Involved

Involved

Statutorily-defined
Program Areas
and FYSB Priority
Area

Not Involved
Low
Involvement

Level of
Involvement

Number
of People
Trained

Short Response (Involved and Highly
Involved only)

References

Write a short narrative response (less
than 50 words) on your efforts in this
area. Or cut and paste from other
parts of your report.

For additional
information go
to:

Responsible
Fatherhood
Healthcare6
Healthy Relationships
HIV/AIDS
Home Visiting
Housing7
Immigration
Incarcerated / Former
Incarcerated
Mental Health &
Substance Abuse
Primary Prevention
Public benefits8
Reproductive Health
and Coercion
Runaway and
Homeless Youth
Trafficking
Trauma‐informed
Programming
Workplace Violence
Other:
Other:
ACA screening provisions, healthcare outreach, nurse training, emergency room personnel training, ACA insurance exchange collaborations, etc.
Emergency/immediate, transitional and permanent housing
8
TANF, food stamps and others
11
6
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Coalition Performance Progress Report

Underserved and culturally‐specific
populations
African‐American
Asian/ Pacific Islander
Immigrant/ Refugee
Latina/o
LGBTQ
Men
Native American /
Alaskan Native/
Native Hawaiian
Older Victims
Teen (ages 13 to 24)
Other culturally
specific populations

12

Policy/ Systems
Advocacy

Capacity
Building / TA
Products1
Public
Awareness2

Types of Activities

Training

Highly Involved

Involved

Statutorily-defined
Program Areas
and FYSB Priority
Area

Not Involved
Low
Involvement

Level of
Involvement

Number
of People
Trained

Short Response (Involved and Highly
Involved only)

References

Write a short narrative response (less
than 50 words) on your efforts in this
area. Or cut and paste from other
parts of your report.

For additional
information go
to:

Coalition Performance Progress Report

Other Topics
Does your coalition provide training, technical assistance or capacity‐building on the below topics?
☐Access to Services (ADA, language, programming)
☐Batterers Intervention programming and standards
☐Board Governance and Training
☐Coordinated Community Responses

☐Grants and Funding

☐Employment and job training

☐Research

☐Disabilities

☐Fundraising

Trainings
Total number of participants trained

Conferences sponsored by the coalition
Workshops/seminars/presentations
Teleconferences
Videoconferences
Webinars
Other:

☐Non‐profit Administration and Management

☐Sustainability
□ Wellness
☐Other

☐Faith/Religion
☐Fatality Reviews

Computer‐based or e‐learning module

☐Mandatory Reporting

☐Stalking

☐Evaluation

Type of Training

☐Military (programming, advocacy, system response)

Number
of Events