Form 1122-0012 Progress Report for the Education and Technical Assistan

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U.S. Department of Justice
Office on Violence Against Women
SEMI-ANNUAL PROGRESS REPORT FOR
Education, Training, and Enhanced Services to End
Violence Against and Abuse of Women with Disabilities
Brief Instructions: This form must be completed for each Education, Training, and Enhanced Services to
End Violence Against and Abuse of Women with Disabilities (Disability Program) grant received. The grant
administrator or coordinator must ensure that the form is completed fully with regard to all grant-funded
activities. Grant partners, however, may complete sections relevant to their portion of the grant. Grant
administrators or coordinators are responsible for compiling and submitting a single report that reflects all
information collected from grant partners.
All grantees should read each section to determine which questions they must answer based on the activities supported under this grant during the current reporting period. Sections B and E and subsection A1 of
this form must be completed by all grantees. In section D and subsections A2 and C1-C7, grantees must
answer an initial question about whether they engaged in certain activities during the current reporting period. If the response is yes, then the grantee must complete the rest of that section or subsection. If the
response is no, the rest of that section or subsection is skipped.
The activities of volunteers or interns should be reported if they were coordinated or supervised by Disability Program-funded staff or if Disability Program funds substantially supported their activities.
For further information on filling out this form, refer to the separate instructions, which contain detailed
definitions and examples, illustrating how questions should be answered.

SECTION
Section A:
A1:
A2:
Section B:
Section C:
C1:
C2:
C3:
C4:
C5:
C6:
C7:
Section D:
Section E:

General Information
Grant Information
Staff Information
Priority Areas
Function Areas
Planning and Development
Training
Education
Policies
Technical Assistance
Coordinated Community Response
Product Development
Victim Services
Narrative

Page Number
1
1
3
4
5
5
9
12
15
18
21
23
24
32

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A1

GENERAL INFORMATION
Grant Information

All grantees must complete this subsection.
(format date with 6 digits, like - 01/31/09)

1.

Date of report

2.

Current reporting period

3.

Grantee name

4.

Grant number

5.

Type of funded organization

✔ January 1-June 30

✔ July 1-December 31

(Year)

(the federal grant number assigned to your Disability Program grant)

(Check the one answer that best describes the entity to whom the grant was awarded)
Deaf agency/organization

State government

Disability agency/organization

State sexual assault coalition

Domestic violence program

Tribal government

Dual sexual assault/domestic violence program

Tribal organization

Dual state sexual assault and domestic

Tribal sexual assault and domestic

violence coalition

violence coalition

Sexual assault program

Unit of local government

State domestic violence coalition

Other (specify):

5a. Is this a faith-based organization?
Yes

No

5b. Grant description
(Check whether your grant was in the planning and development phase and/or the implementation phase during
the current reporting period.)
Planning and development
Implementation

6.

Point of contact (person responsible for the day-to-day coordination of the grant)
First name

MI

Last name

Agency/organization name
Address
City

State

Telephone

Zip code

Facsimile

E-mail

7.

Does this grant specifically address tribal populations?

(Check yes if your grant focuses on tribal populations, and indicate which tribes or nations you serve or intend to
serve.)
Yes

No

If yes, which tribes/nations:

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8.

What percentage of your Disability Program funds was directed to each of these areas?

(Provide appropriate percentages to reflect the time and/or resources you have devoted to each of these areas
during the current reporting period. The total should equal 100%.)
Throughout this form, the term sexual assault includes both assaults committed by offenders who are strangers
to the victim/survivor and assaults committed by offenders who are known to, related by blood or marriage to, or
in a dating relationship with the victim/survivor. The term domestic violence/dating violence applies to any pattern of coercive behavior that is used by one person to gain power and control over a current or former intimate
partner or dating partner. Stalking is defined as a course of conduct directed at a specific person that would
cause a reasonable person to fear for his or her safety or the safety of others, or suffer substantial emotional
distress. (See separate instructions for more complete definitions.)

Percentage of grant funds
Sexual assault

%

Domestic violence/dating violence

%

Stalking

%

TOTAL (must equal 100 percent)

1000 %

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A2

Staff Information

Were Disability Program funds used to fund staff positions during the current reporting period?
Check yes if Disability Program funds were used to pay staff, including part-time staff and contractors.

Yes - answer question 9
No - skip to section B
9.

Staff

(Report the total number of full-time equivalent [FTE] staff funded by the Disability Program grant during the current reporting period. Report staff by function(s) performed, not by title or location. Include employees who are
part-time and/or only partially funded with these grant funds, as well as consultants/contractors. If an employee
or contractor was employed or utilized for only a portion of the reporting period, prorate appropriately. For example, if you hired a full-time victim advocate in October whose salary was 100% funded under the Disability
Program grant, you would report that as .5 FTE. Report all FTEs in decimals, not percentages. One FTE is equal
to 1,040 hours—40 hours per week x 26 weeks. See separate instructions for examples of how to calculate FTEs
for part-time staff or contractors.)

Staff

FTE(s)

Administrator (fiscal manager, executive director)
Court personnel
Deaf advocate
Disability advocate
Interpreter
Law enforcement officer
Legal advocate
Program coordinator
Prosecutor
Support staff (secretary, administrative assistant)
Trainer
Victim advocate (non-governmental, includes domestic violence, sexual assault,
and dual)
Victim assistant (governmental, includes victim-witness specialist/coordinator)
Other (specify):
TOTAL

0.00

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B

PRIORITY AREAS

All grantees must complete this section.

10. Priority areas

(Check all priority areas that apply to activities supported by Disability Program funds during the
current reporting period.)

Check
ALL that
apply

Priority Areas
Provide personnel, training, technical assistance, advocacy, intervention, risk reduction and
prevention of domestic violence, dating violence, stalking, and/or sexual assault against
disabled individuals
Conduct outreach activities to ensure that disabled individuals who are victims of domestic
violence, dating violence, stalking, and/or sexual assault receive appropriate assistance
Conduct cross-training for victim service organizations, governmental agencies, and nonprofit, nongovernmental organizations serving individuals with disabilities about risk reduction,
intervention, prevention and the nature of domestic violence, dating violence, stalking, and/
or sexual assault for disabled individuals
Provide technical assistance to assist with modifications to existing policies, protocols, and
procedures to ensure equal access to the services, programs, and activities of victim service
organizations for disabled individuals
Provide training and technical assistance on the requirements of shelters and victim services
organizations under Federal antidiscrimination laws, including the Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973
Modify facilities, purchase equipment, and provide personnel so that shelters and victim
service organizations can accommodate the needs of disabled individuals
Provide advocacy and intervention services for disabled individuals who are victims of domestic violence, dating violence, stalking, and/or sexual assault
Develop model programs providing advocacy and intervention services within organizations
serving disabled individuals who are victims of domestic violence, dating violence, stalking,
and/or sexual assault

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C1

FUNCTION AREAS
Planning and Development

Were your Disability Program funds used for planning and development during the current reporting
period?
Check yes if you have Disability Program funds and you are in the planning phase. Only those grantees who
received Disability Program funds and who are in the planning phase will answer questions 11-15.

Yes - answer questions 11-15
No - skip to C2
11. Planning and development meeting attendance
(Report the total number of people attending planning and development meetings during the current reporting
period.)

Total number of people attending
12. Planning and development activities conducted (Check all that apply.)
Develop collaboration charter
Develop memo outlining specific forms of project
Develop needs assessment plan and tools
Develop needs assessment report
Develop strategic plan
Focus groups and interviews
Review types of MOU partners
Cross training with MOU partners
Other (specify):

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13. Mandatory planning and development activities
(If you have a planning grant, report the total number of planning and development meetings and check the appropriate boxes to indicate if the agencies or organizations are memorandum of understanding [MOU] partners
and/or pilot sites.)

Agency/organization

MOU
Partner

Number of Meetings
Daily

Weekly

Monthly

Court
Deaf organization
Disability organization
Domestic violence coalition
Domestic violence program
Dual coalition
Faith-based organization
Government agency (INS, Social Security, TANF)
Health organization
Law enforcement agency
Mental health organization
Prosecutor’s office
Sexual assault coalition
Sexual assault program
Tribal government
Tribal organization
Other (specify):

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Pilot
Site

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14. Technical assistance received during planning and development
(Report the number of site visits and consultations received from TA provider.)
Technical assistance: A wide variety of activities designed to facilitate individual or agency change in
some systematic manner by providing expertise to solve a problem.

Technical assistance

Number of site
visits conducted by
OVW TA provider

Number of
consultations
conducted by OVW
TA provider

Accessibility
Accessible communication
Collaboration charter
Focus groups and interviews
Focus memo
Needs assessment plan and tools
Needs assessment report
Strategic plan
MOU partners
TOTAL

0

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0

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15. (Optional) Additional information

(Use the space below to discuss the effectiveness of your planning and development activities funded or supported by your Disability Program grant and to provide any additional information you would like to share about
planning and development activities beyond what you have provided in the data above. An example might include
how the collaboration has been enhanced, or how the capacity of the organizations involved in the collaborative
has been improved.) (Maximum - 2000 characters)

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C2

Training

Were your Disability Program funds used to provide training during the current reporting period?
Check yes if Disability Program funded staff provided training, or if grant funds directly supported training.
(Note: This section applies only to grantees who are in the implementation phase of their grant.)

Yes - answer questions 16-19
No - skip to C3
For the purposes of this reporting form, training means providing information on sexual assault, domestic violence,
dating violence, and/or stalking that enables a person to improve her/his response to victims/survivors with disabilities
as it relates to her/his role in the system. Education means providing general information that will increase awareness
and knowledge about sexual assault, domestic violence, dating violence, and/or stalking against people with disabilities.
In this subsection, report information on training.

16. Training events provided
(Report the total number of training events provided during the current reporting period that were either provided
by Disability Program-funded staff or directly supported by Disability Program funds. Also report the total number
of training events for which interpretive services were provided. Staff development training provided to Disability
Program-funded staff or cross-training provided to MOU partners should not be counted.)

Total number of training events provided
Total number of training events for which interpretive services were provided
17. Number of people trained
(Report the number of people trained by Disability Program-funded staff or with Disability Program funds during
the current reporting period.)
People trained
Adult protective services staff
ASL interpreters

People trained

Number

Legal services staff (does not include
attorneys)

Attorneys/law students

Mental health professionals

Court personnel (judges, clerks)

Personal care attendants

Deaf organization

Prosecutors

Disability organization staff (non-governmental, non-residential)

Residential or institutional staff

Disability rights organization staff (P&A, UCP,
NAMI)
Domestic violence program staff
Dual sexual assault and domestic violence
program staff
Faith-based organization staff

Sexual assault nurse examiners/sexual
assault forensic examiners
Sexual assault program staff
Social services organization staff (nongovernmental homeless shelter, food bank)
Transportation providers

Government agency staff (INS, Social Security, TANF, DHS)

Tribal government/agency staff

Health professionals (excluding sexual assault forensic examiners)

Victim-witness specialists

Job training program staff (vocational rehabilitation, occupational training)
Law enforcement officers

Number

Tribal organization staff

Volunteers
Other (specify):
TOTAL

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18. Training topics
(Check appropriate boxes to indicate all topics covered in training events provided by your Disability Program
funds during the current reporting period.)
Sexual assault, domestic violence, dating
Criminal justice issues
violence, and/or stalking
Child custody issues
Caregiver abuse overview, dynamics, and services
Criminal codes specific to violence against women
with disabilities
Confidentiality
Forensic evidence collection and victims/survivors
Dating violence overview, dynamics, and services
with disabilities
Domestic violence overview, dynamics, and serHate crimes against people with disabilities
vices
Identification and arrest of primary aggressor
Mandatory reporting requirements for violence
against women with disabilities
Interpreters in the criminal justice process
Public benefits (TANF, disability, food stamps, SSI)
Investigation of violence against women with
disabilities
Safety planning for victims/survivors with disabilities
Judicial response to violence against women with
disabilities
Sexual assault overview, dynamics, and services
Law enforcement response to violence against
Stalking overview, dynamics, and services
women with disabilities
Trauma informed response
Prosecution response to violence against women
Other (specify):
with disabilities
Protection orders and women with disabilities
Disabilities and accessibility
(including full faith and credit)
Accessibility
Women with disabilities as witnesses
Accessible policies, programs, or employment
Other (specify):
Americans with Disabilities Act
Assistive technology and devices
Issues specific to victims/survivors with
disabilities who:
Cost effective ways to accommodate victims/
survivors with disabilities
are American Indian or Alaska Native
Disability rights and laws
are Asian
Disability rights (P-A) organizations
are black or African American
Effective communication with individuals with
are elderly
disabilities
are Hispanic or Latino
Guardianship issues
are homeless or living in poverty
Information on blindness or low vision
are immigrants, refugees, or asylum seekers
Information on cognitive disabilities
are isolated or institutionalized
Information on Deafness or hard of hearing
are lesbian, gay, bisexual, transgender, or intersex
Information on developmental disabilities
are Native Hawaiian or other Pacific Islander
Information on medical disabilities and chronic
have substance abuse issues
illness
live in rural areas
Information on mental illness
Other (specify):
Information on physical disabilities
Interpreter services
Outreach to victims/survivors with disabilities
Physical, attitudinal, and programmatic barriers to
accessibility
Recognizing and responding to violence against
women with disabilities
Resources for victims/survivors with disabilities
(local, state, federal, or tribal)
Technology as a safety issue
TTY, Assistive Listening Devices (ALD), and relay
services
Other (specify):

Health care
Recognizing and responding to victims/survivors
with disabilities
Forensic evidence collection for victims/survivors
with disabilities
Institutional care issues for victims/survivors with
disabilities (includes residential or institutional)
Other (specify):

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19. (Optional) Additional information
(Use the space below to discuss the effectiveness of training activities funded or supported by your Disability Program grant and to provide any additional information you would like to share about your training activities beyond
what you have provided in the data above. Examples might include how a training on accessibility changed service delivery practice in a specific way, or how a training on domestic and/or sexual violence has allowed employees to respond appropriately when a disclosure is made.) (Maximum - 2000 characters)

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C3

Education

Were your Disability Program funds used to provide education during the current reporting period?

Check yes if Disability Program-funded staff provided education, or if grant funds directly supported education.
(Note: This section applies only to grantees who are in the implementation phase of their grant.)

Yes - answer questions 20-23
No - skip to C4
For the purposes of this reporting form, education means providing general information that will increase awareness
and knowledge about sexual assault, domestic violence, dating violence, and/or stalking against people with disabilities. Training means providing information on sexual assault, domestic violence, dating violence and/or stalking that
enables a person to improve her/his response to victims/survivors with disabilities as it relates to her/his role in the
system. In this subsection, report information on education activities.

20. Number of education events
(Report the total number of education events provided during the current reporting period that were either
provided by Disability Program-funded staff or directly supported by Disability Program funds. Also report the
total number of education events for which interpretive services were provided.)

Total number of education events provided
Total number of education events for which interpretive services were provided
21. People educated with Disability Program funds

(Report the number of people educated during the current reporting period.)

People attending event

Number

Community businesses (retail stores, pharmacies)
Community groups
Deaf individuals
Faith-based groups
Parents/guardians of individuals with disabilities
People with disabilities
Transportation providers
Other (specify):
TOTAL

0

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22. Education topics

(Check appropriate boxes to indicate all topics covered in education events provided by your Disability Program
funds during the current reporting period.)

Sexual assault, domestic violence, dating violence, and/or stalking against women with disabilities
Accessibility
Caregiver abuse overview, dynamics, and services
Community resources for victims/survivors with disabilities
Dating violence overview, dynamics, and services
Domestic violence overview, dynamics, and services
Overview of violence against women with disabilities
Physical and attitudinal barriers to accessibility
Recognizing and responding to violence against women with disabilities
Sexual assault overview, dynamics, and services
Sexual exploitation overview, dynamics, and services
Stalking overview, dynamics, and services
Other (specify):
Appropriate response to victims/survivors with disabilities who:
are blind or have low vision
are Deaf or hard of hearing
have cognitive disabilities
have developmental disabilities
have medical disabilities or chronic illness
have mental illness
have a physical disability
live in residential or institutional facilities
Other (specify):

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23. (Optional) Additional information

(Use the space below to discuss the effectiveness of education activities funded or supported by your Disability
Program grant and to provide any additional information you would like to share about your education activities
beyond what you have provided in the data above. Examples might include staffing a joint table at public events,
or staff wanting further information on disability and Deaf issues or on violence against women.) (Maximum 2000 characters)

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C4

Policies

Were your Disability Program funds used to develop, substantially revise, or implement policies or
protocols during the current reporting period?

Check yes if Disability Program-funded staff developed, substantially revised, or implemented policies or protocols or if Disability Program funds were used to directly support the development or implementation of policies or
protocols.
(Note: This section applies only to grantees who are in the implementation phase of their grant.)

Yes - answer questions 24-25
No - skip to C5
24. Types of policies and/or protocols developed, substantially revised, or implemented during the current reporting period
(Check all types of policies or protocols developed, substantially revised, or implemented with Disability Program
funds during the current reporting period. In the victim services area, use the SA column for policies and/or protocols addressing sexual assault, the DV/dating violence column for those addressing domestic violence and/or
dating violence, the stalking column for those addressing stalking, and the disability column for those addressing
disability.)

Victim services
SA

DV/
Stalking Disability
Dating
Violence

Accessibility
Accessible communications (ASL interpreters/communication devices)
Appropriate response to victims/survivors who have disabilities
Confidentiality
Mandatory reporting
Mandatory training standards for staff and volunteers
Staff, board, and/or volunteers represent the diversity of your service
area
Trauma informed practice
Other (specify):
Law enforcement
Accessibility
Accessible communications (ASL interpreters/communication devices)
Appropriate response to victims/survivors who have disabilities
Identifying primary aggressor/discouraging dual arrest
Immediate access to protection order information
Mandatory training on sexual assault, domestic violence, dating violence and/or stalking
Pro-arrest/mandatory arrest
Protection order enforcement (including full faith and credit)
Providing information to victims/survivors about victim services
Other (specify):

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Prosecution
Accessibility
Accessible communications (ASL interpreters/communication devices)
Appropriate response to victims/survivors who have disabilities
Mandatory training on sexual assault, domestic violence, dating violence and/or stalking
Vertical prosecution
Victim witness notification
Violation of protection orders
Other (specify):
Court
Accessibility
Accessible communications (ASL interpreters/communication devices)
Appropriate response to victims/survivors who have disabilities
Immediate access to obtaining protection orders
Mandatory training on sexual assault, domestic violence, dating violence and/or stalking
Procedures for courtroom security
Other (specify):

Health care
Accessible communications (ASL interpreters/communication devices)
Advocate response to emergency room
Appropriate response to victims/survivors who have disabilities
Forensic exams not billed to victim/survivor
Mandatory training on sexual assault, domestic violence, dating violence and/or stalking
Routine screening and referrals for sexual assault, domestic violence, dating violence and/or
stalking
Other (specify):

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25. (Optional) Additional information

(Use the space below to discuss the effectiveness of policies you have developed or implemented that were
funded or supported by your Disability Program grant and to provide any additional information you would like to
share about your activities relating to the developing, revising, or implementing of policies beyond what you have
provided in the data above. An example might include working with project partners to ensure that organizational
policies are responsive to the needs of victims with disabilities and Deaf victims.) (Maximum - 2000 characters)

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C5

Technical Assistance

Were your Disability Program funds used to provide technical assistance during the current reporting
period?

Check yes if Disability Program-funded staff provided technical assistance, or if grant funds directly supported
technical assistance.
(Note: This section applies only to grantees who are in the implementation phase of their grant.)
Yes - answer questions 26-29
No - skip to C6

26. Technical assistance
(Report the total number of technical assistance activities provided with Disability Program funds during the
current reporting period, indicating whether they were site visits to conduct accessibility assessments or
other consultations. Consultations may include in-person, telephone, electronic, or other types of contact.
Each contact should be counted as one activity.)
Technical assistance: A wide variety of activities designed to facilitate individual or agency change in some
systematic manner by providing expertise to solve a problem. Examples of technical assistance activities include
clarifying legislative and policy implementation and/or standards of service, technology consultations, and assistance with problem-solving.
People receiving technical assistance

Number of
accessibility assessment site
visits

Number of
other technical assistance
consultations

Adult protective services staff
Community advocacy organization staff (Disability Rights, UCP, NAMI)
Court personnel (judges, clerks)
Deaf organization
Disability organization staff (non-governmental, non-residential)
Domestic violence program staff
Dual sexual assault and domestic violence program staff
Faith-based organization staff
Government agency staff (INS, Social Security, TANF, DHS)
Health professionals (excluding sexual assault forensic examiners)
Independent living center staff
Interpreters
Job training program staff (vocational rehabilitation, occupational training)
Law enforcement officers
Mental health professionals
Prosecutors
Residential or institutional staff
Sexual assault forensic examiners
Sexual assault program staff
Social services organization staff (homeless shelter, food pantry)
Transportation providers
Tribal government/agency staff
Other (specify):
TOTAL

0
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27. Topics of technical assistance
(Check appropriate boxes to indicate all topics covered in technical assistance provided with Disability Program
funds during the current reporting period.)

Accessibility assessment (physical, programmatic, attitudinal)
Accessible communication (ASL interpreters/communication devices)
Accessible materials
Assistive technology and devices
Caregiver abuse
Collaboration and cross-training for responding to victims/survivors with disabilities
Cost-effective compliance with ADA
Court response to violence against women with disabilities
Culturally appropriate services for victims/survivors with disabilities
Dating violence experienced by women with disabilities
Disability organizations’ response to violence against women with disabilities
Disability services and resources
Disclosure, confidentiality, and safety
Domestic violence experienced by women with disabilities
Guardianship and power of attorney issues
Health care response to violence against women with disabilities
Interviewing techniques
Issues regarding victims/survivors living in residential or institutional facilities
Law enforcement response to violence against women with disabilities
Outreach to victims/survivors with disabilities
Personal safety planning for victims/survivors with disabilities
Prosecution response to violence against women with disabilities
Requirements of the Americans with Disabilities Act and other anti-discrimination laws
Responding to violence against victims/survivors who live in residential or institutional facilities
Responding to violence against women who are blind or have low vision
Responding to violence against women who are D/deaf or hard of hearing
Responding to violence against women with cognitive disabilities
Responding to violence against women with developmental disabilities
Responding to violence against women with medical disabilities and chronic illness
Responding to violence against women with mental illness
Responding to violence against women with physical disabilities
Service animals and accessibility
Sexual assault experienced by women with disabilities
Stalking experienced by women with disabilities
Technology as a safety issue
TTY, ALD and relay services
Victim services response to violence against women with disabilities
Other (specify):

28. Organizational policies and technical assistance
(As a result of the technical assistance provided with Disability Program funds, how many organizations developed, revised, and/or implemented polices regarding accessibility and/or services for women with disabilities?)

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29. (Optional) Additional Information
(Use the space below to discuss the effectiveness of technical assistance activities funded or supported
by your Disability Program grant and to provide any additional information you would like to share about
your technical assistance activities beyond what you have provided in the data above. Examples might
include conducting an accessibility audit, responsiveness assessment, or providing information/training
on adaptive communication.) (Maximum - 2000 characters)

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C6

Coordinated Community Response

Were your Disability Program funds used for coordinated community response during the current
reporting period?

Check yes if you have Disability Program funds and you are in the implementation phase. Only those grantees who
received Disability Program funds and who are in the implementation phase will answer question 30.

Yes - answer question 30
No - skip to C7
30. Coordinated community response activities
(Check the appropriate boxes to indicate the agencies or organizations, even if they are not a memorandum of
understanding [MOU] partner, that you engaged in development, revision, or implementation of training and/
or education with; and/or collaborated with during the current reporting period. In the last column, indicate the
agencies or organizations with which you have an MOU for purposes of the Disability Program Grant.)

Agency/organization

Development,
revision, and/or
implementation
of training and/
or education

Collaboration

MOU partner

Adult protective services
Community advocacy organization (Disability Rights,
UCP, NAMI)
Court
Deaf organization
Disability organization (non-governmental,
non-residential)
Domestic violence program
Dual sexual assault and domestic violence program
Faith-based organization
Government agency (INS, Social Security, TAN, DHS)
Health organization (excluding sexual assault forensic
examiners)
Job training program staff (vocational rehabilitation,
occupational training)
Law enforcement
Legal organization (legal services, bar association)
Mental health organization
Prosecutors
Residential or institutional
Sexual assault forensic examiners
Sexual assault program
Social services organization (homeless shelter, food
pantry)
Tribal government/agency
Other (specify):

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31. (Optional) Additional Information
(Use the space below to discuss the effectiveness of coordinated community response activities funded
or supported by your Disability Program grant and to provide any additional information you would like to
share about your coordinated community response activities beyond what you have provided in the data
above. Examples might include developing elements of the collaboration charter, exploring the intersection of violence against individuals with disabilities as a multi-disciplinary team, identifying common
areas/issues of concern, and working toward a solution that is equally beneficial to all parties involved,
etc.) (Maximum - 2000 characters)

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C7

Product Development

Were your Disability Program funds used to develop, substantially revise, and/or distribute products
during the current reporting period?
Check yes if Disability Program funds supported the development, substantial revision, and/or distribution of
products.
(Note: This section applies only to grantees who are in the implementation phase of their grant.)

Yes - answer question 32
No - skip to section D
32. Use of Disability Program funds for product development, substantial revision, and/or distribution
(Report the number of products developed, substantially revised or distributed with Disability Program funds during the current reporting period. Report the number of new products developed or substantially revised during
the current reporting period; the title/topic and intended audience for of each product developed, revised, and/or
distributed; and the number of products used and/or distributed. The description of the product should include
the title, topic, and intended audience. If a product was created in or adapted into an alternative format indicate
the format. Report on products that were newly developed during the current reporting period whether or not
they were used or distributed, and on products that were previously developed and were used and/or distributed
during the current reporting period.)

Products

Number
developed
or revised

Title/topic

Intended
audience

Number
used or
distributed

Alternative
format

Brochures

Manuals

Training
curricula

Training
materials

Other
(specify):

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D

VICTIM SERVICES

Were your Disability Program funds used to provide victim services to victims/survivors during the
current reporting period?
Check yes if Disability Program-funded staff provided victim services or if Disability Program funds were used to
support victim services during the current reporting period. Report all victims/survivors served and victim services provided with Disability Program funds, whether by a victim services agency or victim services within law
enforcement, prosecution, or the court system.
(Note: This section applies only to grantees who are in the implementation phase of their grant.)

Yes - answer questions 33-39
No - skip to section E
33. Number of victims/survivors served, partially served, and victims/survivors seeking services who
were not served

Please do not answer this question without referring to the separate instructions for further explanation and examples of how to distinguish among these categories. (Report the following, to the best of your ability, as an unduplicated count for each category during the current reporting period. This means that each victim/survivor who
was seeking or who received services during the current reporting period should be counted only once in that
reporting period. For purposes of this question, victims/survivors are those against whom the sexual assault, domestic violence, dating violence, and/or stalking was directed. If the victim/survivor experienced more than one
victimization, that person should be counted only once under the primary victimization. Do not report secondary
victims here.)

Sexual
Assault
A. Served: Victims/survivors who received the service(s) they requested,
if those services were funded by your
Disability Program grant
B. Partially served: Victims/survivors
who received some service(s), but not all
of the services they requested, if those
services were funded by your Disability
Program grant
TOTAL SERVED and PARTIALLY SERVED
(33A + 33B)
C. Victims/survivors seeking services
who were not served: Victims/survivors
who sought services and did not receive
the service(s) they were seeking, if those
services were funded by your Disability
Program grant

Domestic violence/
dating violence

Stalking

TOTAL

0

0

0

0

0

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34. Reasons that victims/survivors seeking services were not served or were partially served
(Check all that apply.)

Reasons not served or partially served
Conflict of interest
Did not meet statutory requirements
Hours of operation
Lack of child care
Program reached capacity
Program rules not acceptable to victim/survivor
Program unable to provide service due to limited resources/priority-setting
Services inappropriate or inadequate for victims/survivors who are D/deaf or hard of
hearing
Services inappropriate or inadequate for victims/survivors who have disabilities
Services inappropriate or inadequate for victims/survivors with mental health issues
Services inappropriate or inadequate for victims/survivors with substance abuse issues
Services not available for victims/survivors accompanied by male adolescents
Services not appropriate for victim/survivor
Transportation
Other (specify):

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35. Demographics of victims/survivors served or partially served
(Based on the victims/survivors reported in 33A and 33B, report the total numbers for all that apply. Because
victims/survivors may identify in more than one category of race/ethnicity, the total for Race/Ethnicity may
exceed the total number of victims/survivors reported in 33A and 33B. However, the total number of victims/
survivors reported under Race/ethnicity should not be less than the total number of victims/survivors reported
in 33A and 33B. The total number of victims/survivors reported under “Gender” and the total number reported
under “Age” should equal the total number of victims/survivors reported in 33A and 33B. Those victims for whom
gender, age, and/or race/ethnicity are not known should be reported in the “unknown” category. Do not report
demographics for secondary victims.)

Race/ethnicity (Victims/survivors should not be counted more than once in
either the category “American Indian or Alaska Native” or in the category
“Native Hawaiian or other Pacific Islander.”)

Number of victims/
survivors

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Unknown
TOTAL RACE/ETHNICITY (should not be less than

0 , the sum of 33A and 33B)

0

Number of victims/
survivors

Gender
Female
Male
Unknown
TOTAL GENDER (should equal

0 , the sum of 33A and 33B)

0

Number of victims/
survivors

Age
0-12
13-17
18-24
25-59
60+
Unknown
TOTAL AGE (should equal

0 , the sum of 33A and 33B)

Other demographics

0

Number of victims/
survivors

People with disabilities
People who are D/deaf or hard of hearing
People with limited English proficiency
People who are immigrants/refugees/asylum seekers
People who live in rural areas

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36. Victims/survivors’ relationship to offender by victimization
(For those victims/survivors reported as served and partially served in 33A and 33B, report the victim/survivor’s
relationship to the offender by type of victimization. If a victim/survivor experienced more than one type of victimization and/or was victimized by more than one perpetrator, count the victim/survivor in all categories that ap0 ; the total number
ply. The total number of relationships in the sexual assault column must be at least
0 ; and the total number in the stalking
in the domestic violence/dating violence column must be at least
0 .)
column must be at least

Victim/Survivor’s relationship to offender

Number of victim/survivor relationships
by victimization
Sexual
Domestic violence/
Stalking
assault
dating violence

Current or former spouse or intimate partner
Other family or household member
Dating relationship
Acquaintance (neighbor, employee, co-worker,
student, schoolmate, etc.)
Stranger
Recipient of personal care service
Relationship unknown
TOTAL

0

0

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37A. Victim services
(Report the number of victims/survivors from 33A and 33B who received Disability Program-funded services.
Count each victim/survivor only once for each type of service that the victim received during the current reporting
period; do not report the number of times that a service was provided to the victim. The total for each type of ser0 , the total of 33A and 33B. Shelter services should be reported in
vice should not be higher than
question 37B. Do not report secondary victims receiving services in this question.)

Type of service

Number of
victims/survivors
served

Case management
Civil legal advocacy/court accompaniment (Assisting a victim/survivor with civil
legal issues, including preparing paperwork for a protection order and accompanying victim/survivor to a protection order hearing, administrative hearing,
or other civil court proceeding. Does not include advocacy by attorneys and/or
paralegals.)
Civil legal assistance (Civil legal services provided by an attorney and/or a
paralegal)
Counseling/support group (Individual or group counseling or support provided
by a volunteer, peer, or professional)
Criminal justice advocacy/court accompaniment (Assisting a victim/survivor
with criminal legal issues including notifying the victim/survivor of case status,
hearing dates, plea agreements, and sentencing terms; preparing paperwork
such as victim impact statements; accompanying a victim/survivor to a criminal court proceeding or law enforcement interview; and all other advocacy
within the criminal justice system)
Crisis intervention (Crisis intervention is a 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.)
Employment (Job training, coaching, supported or sheltered employment)
Forensic exam (Exam conducted by a sexual assault nurse examiner or by a
sexual assault forensic examiner)
Hospital/clinic/other medical response (Accompanying a victim survivor to or
meeting a victim/survivor at a hospital, clinic, or medical office)
Language services (Interpretation, translation)
Long-term care (Assisting a victim/survivor with daily needs)
Peer support services (Services provided by a self-advocate)
Personal planning (Assisting a victim/survivor with goal-setting and developing
plans to accomplish identified goals)
Respite (Short-term care provided to a victim/survivor to relieve the primary
caregiver[s])
Transportation
Victim/survivor advocacy (Actions designed to assist the victim/survivor in obtaining support, resources, or services, including employment, housing, shelter
services, health care, victim’s compensation, etc.)
Other (specify):

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37B. Shelter services

(Report the number of victims/survivors and accompanying family members who received emergency shelter
and/or transitional housing provided with Disability Program funds during the current reporting period. This
should be an unduplicated count for both victims/survivors and for family members. This means that each victim/survivor and each family member who received shelter services during the current reporting period should
be counted only once. Report the total number of bed nights provided in emergency shelter and/or transitional
housing to victims/survivors and family members. The number of bed nights is computed by multiplying the number of victims and family members by the number of nights they stayed in the shelter. The number of bed nights
will typically be significantly higher than the number of victims and family members. For example, one victim and
her three children all stayed in the shelter for 10 nights. The number of bed nights would be 4 x 10, or 40.)

Shelter service

Number of victims/
survivors

Number of family
members

Number of bed
nights

Emergency shelter
Transitional housing
37C. Hotline calls
(Report the number of hotline calls received from primary victims, and the total number of hotline calls received,
on phone lines paid for with Disability Program funds or answered by Disability Program-funded staff, during
the current reporting period. Victims/survivors whose calls are reported here should not be reported as victims
served in question 33 unless they also received at least one of the services listed in question 37A Victim services
or question 37B Shelter services. Victims/survivors who receive services such as crisis intervention or victim
advocacy over the telephone, in addition to basic hotline information and/or referrals, should also be reported
in question 37A. Hotline calls that include victim advocacy or crisis intervention services are those that require
more time than the average call and involve a more intensive focus on the immediate needs and situation of the
victim. For examples of when to report only the hotline call and when to report both the hotline call and a service
or services in question 37A, see separate instructions.)

Type of service

Number of calls from
victims/survivors

Total number
of calls

Hotline calls (crisis or information and referral calls
received by an agency’s hotline or office telephone)
37D. Victim-witness notification/outreach to victims/survivors

(Report the number of unsolicited letters, phone calls, or visits to victims/survivors of specific incidents of sexual
assault, domestic violence, dating violence, and/or stalking identified in police reports or court documents, informing them of services and/or providing information about the criminal justice system. Victims who are the
recipients of these notification/outreach activities should not be reported as victims served in question 33 unless
they also received at least one of the services reported in question 37A Victim services or question 37B Shelter
services. Victims who receive services such as criminal justice advocacy over the telephone should be reported
in question 37A.)

Type of service

Number of notification/outreach
activities to victims/survivors

Victim-witness notification/outreach to victims/survivors
(unsolicited letters, phone calls, or visits)

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38. Protection orders

(Report the total number of temporary and/or final protection orders requested and granted for which Disability
Program-funded victim services staff provided assistance to victims/survivors during the current reporting period.
These orders may also be referred to as protection from abuse, protection from harassment or anti-harassment
orders, restraining orders, or no-contact or stay-away orders.)

Sexual assault protection orders

Temporary orders

Final orders

Temporary orders

Final orders

Temporary orders

Final orders

Number requested
Number granted
Domestic violence/dating violence protection orders
Number requested
Number granted
Stalking protection orders
Number requested
Number granted

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39. (Optional) Additional information
(Use the space below to discuss the effectiveness of victim services funded or supported by your Disability Program grant and to provide any additional information you would like to share about your victim services activities
beyond what you have provided in the data above. An example might include that your agency, as a result of
Disability Program funding, was able to provide medical accompaniment to an increased percentage of sexual
assault survivors. This resulted in a higher percentage of victims also seeking additional support services.)
(Maximum - 2000 characters)

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E

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NARRATIVE

All grantees must answer question 40.
Please limit your responses to the space provided.
40. Report on the status of your Disability Program grant goals and objectives for the current reporting
period.

(Report on the status of the goals and objectives for your Disability Program grant as of the end of the current
reporting period, as they were identified in your grant proposal, or as they have been added or revised. Indicate
whether the activities related to your objectives for the current reporting period have been completed, are in progress, are delayed, or have been revised. Comment on your successes and challenges, and provide any additional
explanation you feel is necessary for us to understand what you have or have not accomplished relative to your
goals and objectives. If you have not accomplished objectives that should have been accomplished during the
current reporting period, you must provide an explanation.) Page 33.

All grantees must answer questions 41 and 42 on an annual basis. Submit this information on the
January to June reporting form only.
Please limit your responses to the space provided. (8,000 characters)
41. What do you see as the most significant areas of remaining need, with regard to obstacles faced by
individuals with disabilities?
(For example, we need more training of disability organization staff about violence against women with disabilities; we struggle with negative community attitudes towards victims/survivors with mental illness.) Page 36.

42. What has Disability Program funding allowed you to do that you could not do prior to receiving this
funding?
(For example, we were able to train all victim service agencies in the state on the use of TTYs.) Page 38.

Questions 43 and 44 are optional.
Please limit your responses to the space provided. (8,000 characters)
43. Provide any additional information that you would like us to know about your Disability Program
grant and/or the effectiveness of your grant.
(If you have other data or information regarding the effectiveness of your Disability Program grant that would
more fully or accurately reflect your grant activities than the data you have been asked to provide on this form,
answer this question. If you have not already done so elsewhere on this form, you may want to report on changes
in accessibility of services for victims/survivors with disabilities; development, revision, or implementation of policies in your own agency; the sustainability of the grant activities; and/or positive or negative unintended consequences, i.e. changed grantee’s own policies.) Page 40.

44. Provide any additional information that you would like us to know about the data submitted.
(If you have information that could be helpful in understanding the data you have submitted in this report, please
answer this question. For example, if you submitted two different progress reports for the same reporting period,
you may explain how the data was apportioned to each report; or if your Disability Program funds supported staffe.g., victim advocates, law enforcement officers, etc. - but you did not report any corresponding victim services
or law enforcement activities, you may explain why; or if you did not use program funds to support either staff or
activities during the reporting period, please explain how program funds were used, if you have not already done
so.) Page 42.

Public Reporting Burden

Paperwork Reduction Act Notice. Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. We try to create forms and instructions that
are accurate, can be easily understood, and which impose the least possible burden on you to provide us with information. The estimated average time to complete and file this form is 60 minutes per form. If you have comments regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the Office on Violence
Against Women, U.S. Department of Justice, 800 K Street, NW, Washington, DC 20531.

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Back to Instructions

Report on the status of your Disability Program grant goals and objectives for current reporting period.
Question #40
Status
Goals/Objectives (1,750 characters)

Key Activities (1,750 characters)

Comments (500 characters)

Status
Goals/Objectives

Key Activities

Comments

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Back to Instructions

Report on the status of your Disability Program grant goals and objectives for current reporting period.
Question #40 (cont.)
Status
Goals/Objectives

Key Activities

Comments

Status
Goals/Objectives

Key Activities

Comments

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Back to Instructions

Report on the status of your Disability Program grant goals and objectives for current reporting period.
Question #40 (cont. 2)
Status
Goals/Objectives

Key Activities

Comments

Status
Goals/Objectives

Key Activities

Comments

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What do you see as the most significant areas of remaining need, with regard to obstacles faced by individuals with disabilities?
Question #41

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What do you see as the most significant areas of remaining need, with regard to obstacles faced by individuals with disabilities?
Question #41 (cont.)

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What has Disability Program funding allowed you to do that you could not do prior to receiving this funding?
Question #42

Disability Program Semi-annual Progress Report • 38 • Office on Violence Against Women
THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

Back to Instructions

OMB Clearance # 1122-0012
Expiration Date: 08/31/2015

What has Disability Program funding allowed you to do that you could not do prior to receiving this funding?
Question #42 (cont.)

Disability Program Semi-annual Progress Report • 39 • Office on Violence Against Women
THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

Back to Instructions

OMB Clearance # 1122-0012
Expiration Date: 08/31/2015

Provide any additional information that you would like us to know about your Disability Program grant and/or
the effectiveness of your grant.
Question #43

Disability Program Semi-annual Progress Report • 40 • Office on Violence Against Women
THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

Back to Instructions

OMB Clearance # 1122-0012
Expiration Date: 08/31/2015

Provide any additional information that you would like us to know about your Disability Program grant and/or
the effectiveness of your grant.
Question #43 (cont.)

Disability Program Semi-annual Progress Report • 41 • Office on Violence Against Women
THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

Back to Instructions

OMB Clearance # 1122-0012
Expiration Date: 08/31/2015

Provide any additional information that you would like us to know about the data submitted.
Question #44

Disability Program Semi-annual Progress Report • 42 • Office on Violence Against Women
THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

Back to Instructions

OMB Clearance # 1122-0012
Expiration Date: 08/31/2015

Provide any additional information that you would like us to know about the data submitted.
Question #44 (cont.)

Disability Program Semi-annual Progress Report • 43 • Office on Violence Against Women
THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.

Validate

THIS IS A SAMPLE GMS FORM. DO NOT USE THIS FORM TO SUBMIT YOUR FINAL DATA TO OVW.