2 Client Service Use and Delivery Form

OMB Control Number: 0970-0467
Expiration Date: 11/30/2018

Trafficking Victim Assistance Program Grantee
Client Service Use and Delivery Form
Grantee
Reporting Period Start Date

Reporting Period End Date

Report Type

Complete this form for every client by the end of the reporting period to describe benefits and services accessed.

Client Identifier

Did client apply for HHS
Certification/Eligibility?

Did client receive HHS
Certification/Eligibility?

What services did the client receive during the reporting period? (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
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average .25 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.

What public benefits did the client access during the reporting period? (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