1 Client Characteristics and Enrollment Form

OMB Control Number: 0970-0467
Expiration Date: 01/31/2023

Trafficking Victim Assistance 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

Report Type

Intake Date

Type of Intake

Was client matched to a service provider within 48 hours of referral?

Referral Date

Does the client have family members receiving
services from grantee?

Referral Source

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

Sibling(s)

Spouse

Child(ren) < 18

Child(ren) 18 or Older

Service Eligibility Status

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average 1 hours per response, including the time for reviewing instructions,
gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number.

Client Demographics and Characteristics
Date of Birth

Age at time of intake

Gender Identity

Does client identify as LGBTQ2S+?

Unknown

Yes

Race/Ethnicity (check all that apply)

Does the victim have a disability?
(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 known, record the client's country of origin. If unclear or unknown then record unknown in space provided.
Country

Current Living Situation

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

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

Transportation

Victim Advocacy

None

Unknown

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

SNAP (Food Stamps)

General Assistance

Section 8 and/or Permanent Housing Assistance

Medicaid

ORR Match Grant

ORR Targeted Assistance Grant (TAG)

ORR Wilson/Fish Program

Refugee Cash Assistance

Refugee Medical Assistance

Refugee Social Services

State-Specific Health Benefits

Social Security Disability (SSDI or SSI)

Temporary Assistance for Needy Families (TANF)

Unaccompanied Alien Children Program

Unemployment Insurance

WIC

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

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

State or Territory

Country of Trafficking Incident