Form 1 AV Survey

Grants to States for Access and Visitation

Attachment A - Grantee or Subgrantee Collection Instrument 1.xlsx

Access and Visitation Survey - Local Service Grantees

OMB: 0970-0204

Document [xlsx]
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Grantee and/or Sub-Grantee Agency Profile Summary of State AV Program Data
Grantee and/or Sub-Grantee Information

OMB Control No: 0970 - 0204
Expiration date: XX/XX/XXXX
“A Federal agency may not conduct or sponsor, and no individual or entity is required to respond to, nor shall an individual or entity be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless that collection of information displays a currently valid OMB Control Number”
Service Provided &Client Participation (Values M (Mandatory), V (Voluntary) B (Both) U, R, B Client Referral Source Client Information
Child Support Cases (Required) Marital Status Race/Ethnicity Annual Income Services Provided Frequency of Service ( Hours) (Optional) Outcome#1-Parenting Time (Required) Outcome#2 - Knowledge of Effective Co-Parenting Strategies (Optional)
Name of Grantee and/or Sub-Grantee Title of AV Program Contact Name Address Line 1 City State Zip Grant Amount Grant Period From Date Grant Period To Date Mediation Development of Parenting Plan Counseling Parent Education Neutral Drop-off/Pick-up Supervised Visitation Visitation Enforcement Geographic Area Served Self Court Child Support Agency Domestic Violence Agency Child Protection Agency Other Data Not Reported NCP Father CP Father NCP Mother CP Mother Grandparent/Legal Guardian Number of Children in Common NCP Father CP Father NCP Mother CP Mother Grandparent/Legal Guardian Never Married to Each Other Married to Each Other Separated From Each Other Divorced From Each Other Data Not Reported American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Two or More Races Data Not Reported Other Less than $10,000 $10,000 to $19,999 $20,000 to $29,999 $30,000 to $39,999 $40,000 & Above Data Not Reported Mediation Development of Parenting Plan Counseling Parent Education Neutral Drop-off/Pick-up Supervised Visitation Visitation Enforcement Mediation Development of Parenting Plan Counseling Parent Education Neutral Drop-Off/Pick-Up Supervised Visitation Visitation Enforcement NCP Fathers NCP Mothers NCP Fathers CP Fathers NCP Mothers CP Mothers
GRANTEE NUMBER 1 TITLE of AV Program 1 Mike 123 Easy Street CITY NAME ONE SS 12345 300000 1/20/1999 2/13/2015 B M


M
B 0 176 0 0 0 0 2 52 30 16 74 3 135




81 38 1 50 0 1 0 31 1 0 140 0 0 5 69 70 17 8 13 1 166 90 0 0 1 0 0






50 14



GRANTEE NUMBER 2 SPACES Bhargav 123 Slow and Annoying street CITY NAME TWO SS 98765 456789.5 2/13/1998 3/15/2020 V



V
R 0 176 0 0 0 0 2 52 36 16 74 3 135



81 38 1 60 0 1 0 31 1 0 144 1 0 0 69 70 17 8 13 1 166 90 0 0 1 0 0






50 14



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