Form 1122-0022 Progress Reporting form for SASP subgrantees

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

U.S. Department of Justice
Office on Violence Against Women
ANNUAL PROGRESS REPORT FOR
Sexual Assault Services
Formula Grant Program
Brief Instructions: This form must be completed for all Sexual Assault Services Formula Grant Program
(SASP Program) subgrants received. The grant administrator or coordinator must ensure that the form is
fully completed.
All subgrantees should read each section to determine which questions they must answer, based on the
staffing and activities supported under this subgrant during the current reporting period. Subsection A1 and
sections B, D, and E must be completed by all subgrantees. In subsection A2 and section C, subgrantees
must answer an initial question about whether they engaged in certain activities during the current reporting period. If the response is yes, then the subgrantee must complete that section or subsection. If the
response is no, the rest of that section or subsection is skipped.
For example, if you are an agency providing victim services using a SASP Program-funded advocate,
you would complete A1, A2, B, D, and E (and answer “no” in C, if you did not use SASP Program funds to
develop, revise, or distribute informational materials).
The activities of volunteers or interns should be reported if they were coordinated or supervised by SASP
Program-funded staff or if SASP 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 A:
A1:
A2:
Section B:
Section C:
Section D:
Section E:

SECTION
General Information
Grant Information
Staff Information
Purpose Areas
Informational Materials
Victim Services
Narrative

Page Number
1
1
2
3
4
5
12

Sexual Assault Services Formula Grant Program Annual Progress Report • Office on Violence Against Women

SECTION

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

A1

GENERAL INFORMATION
Grant Information

All subgrantees must complete this subsection.

1.

Date of report

(format date with 6 digits - 01/31/09)

2.

Current reporting period

January 1-December 31

3.

Subgrantee name

4.

Subgrant number(s) for each subgrant award under which activities were supported during the
current reporting period
(List the numbers for all subgrants supporting activities during the current reporting period.)

5.

Type of funded organization
(Check the one answer that best describes the organization receiving the SASP Program subgrant.)

(Year)

Community-based organization
Dual program (sexual assault and domestic violence)
Sexual assault/dual coalition
Sexual assault program
Tribal coalition
Tribal sexual assault program
Other (specify):
5a. Is this a faith-based organization?
Yes

No

5b. Does the funded organization receive its subgrant from a State or Territory Sexual Assault
Coalition?
Yes
6.

No

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

MI

Last name

Agency/organization name
Address
City

State

Telephone

Facsimile

Zip code

E-mail
7.

Does this grant specifically address Alaska Native/American Indian tribal populations?
(Check yes if your SASP Program subgrant focuses on tribal populations, and indicate which tribes or nations you serve or intend to serve.)
Yes

No

If yes, which tribes/nations:

Sexual Assault Services Formula Grant Program Annual Progress Report • 1 • Office on Violence Against Women

SECTION

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

A2

Staff Information

Were your SASP Program funds used to fund staff positions during the current reporting period?
Check yes if SASP Program funds were used to pay staff, including part-time staff and contractors.
Yes—answer question 8
No—skip to section B
8.

Staff
(Report the total number of full-time equivalent (FTE) staff funded by the SASP Program grant during the current reporting period. Report staff by the 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 advocate in October who was 100% funded with SASP Program
funds, you would report that as .25 FTE. Report all FTEs in decimals, not percentages. One FTE is equal to
2,080 hours—40 hours per week x 52 weeks. See separate instructions for examples of how to calculate
FTEs.)

Staff

FTE(s)

Administrator (fiscal manager, executive director)
Children’s advocate
Counselor
Legal advocate (does not include attorney or paralegal)
Outreach worker
Program coordinator (training coordinator, volunteer coordinator, hotline coordinator, victim services coordinator)
Support staff (bookkeeper, accountant, administrative assistant)
Translator/interpreter
Victim advocate (non-governmental)
Other (specify):
TOTAL

Sexual Assault Services Formula Grant Program Annual Progress Report • 2 • Office on Violence Against Women

0

SECTION

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

9.

B

PURPOSE AREAS

All subgrantees must complete this section.

Statutory purpose areas
(Check all purpose areas that apply to activities supported with SASP Program funds during the current
reporting period.)

Check ALL
that apply

14p11

Purpose areas
24-hour hotline services providing crisis intervention and referral
Accompaniment and advocacy through medical, criminal justice, and social support systems,
including medical facilities, police, and court proceedings
Crisis intervention, short-term individual and group support services, and comprehensive
service coordination and supervision to assist sexual assault victims and family or household
members
Information and referral to assist the sexual assault victim and family or household members
Community-based, linguistically and culturally specific services and support mechanisms, including outreach activities for underserved communities
The development and distribution of materials on issues related to the services described
above

Sexual Assault Services Formula Grant Program Annual Progress Report • 3 • Office on Violence Against Women

SECTION

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

C

INFORMATIONAL MATERIALS

Were your SASP Program funds used to develop, substantially revise, or distribute informational materials regarding services provided by the funded organization during the current reporting period?
Check yes if SASP Program-funded staff developed, substantially revised, or distributed such materials
or if SASP Program funds directly supported the development, revision, or distribution of such materials.
Yes—answer question 10
No—skip to section D
10. Use of SASP Program funds for development, substantial revision, or distribution of informational
materials
(Report the number of materials developed, substantially revised, or distributed with SASP Program funds
during the current reporting period that describe or promote the services provided by the funded organization. Do not report materials or products designed to train professionals or educate victims about the
dynamics of sexual assault or other issues related to sexual assault. Report the number of new materials
developed or substantially revised during the current reporting period; the title/topic and intended audience
for each type of material developed, revised, or distributed; and the number of materials used or distributed.
If materials were created in or translated into a language other than English, including Braille, indicate the
language. Report on materials that were newly developed or revised during the current reporting period
whether or not they were used or distributed, and on materials that were previously developed or revised and
used or distributed during the current reporting period. Do not report the number of materials printed or
copied; only report the number developed or revised—in most cases that number will be one for each informational item described —and/or the number used or distributed. See separate instructions for examples of
how to report under “developed or revised” and “used or distributed.”)

Materials

Number
developed or
revised

Title/topic

Intended
audience

Number
used or
distributed

Other
languages

Outreach
material
(brochures,
pamphlets,
information
packets, posters, tv/radio/
other media
spots, etc.)
Promotional
products
(wallet cards,
key rings,
whistles, etc.)
Website
(indicate the
number of
page views
in the number used or
distributed
column)
Other
(specify):

Sexual Assault Services Formula Grant Program Annual Progress Report • 4 • Office on Violence Against Women

SECTION

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

D

VICTIM SERVICES

All subgrantees must complete this section.

Count only victims/survivors served and victim services/activities provided by SASP Program-funded
staff or supported with SASP Program funds.
11. Number of primary 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 was directed. Do not report secondary victims here.)
Primary victims/survivors

TOTAL

A. Served: Victims/survivors who received the service(s) they requested, if those
services were funded by your SASP Program subgrant
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 SASP Program subgrant
TOTAL SERVED AND PARTIALLY SERVED (11A + 11B)

0

C. Victims/survivors seeking services who were not served: Victims/survivors
who sought grant-funded service(s) and did not receive the grant-funded services
they were seeking, if those services were funded by your SASP Program subgrant
12. Number of secondary victims served
Please do not answer this question without referring to the separate instructions for further explanation and
for examples of how and when to report secondary victims. (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 secondary victim who received services during the current reporting period should be counted only once. For
purposes of this question, secondary victims are those who are indirectly affected by the sexual assault—
e.g., children, siblings, spouses or intimate partners, grandparents, other affected relatives, friends, neighbors, etc.—except for the perpetrator of such victimization. Secondary victims do not need to be connected
with a primary victim who is receiving services.)
Secondary victims
Secondary victims who received service(s) funded by your SASP Program
subgrant

TOTAL
0

Sexual Assault Services Formula Grant Program Annual Progress Report • 5 • Office on Violence Against Women

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

13. Reasons that the primary 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
Insufficient/lack of culturally appropriate services
Insufficient/lack of language capacity (including sign language)
Insufficient/lack of services for victims/survivors who are D/deaf or hard of hearing
Insufficient/lack of services for victims/survivors with disabilities
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 with mental health issues
Services inappropriate or inadequate for victims/survivors with substance abuse issues
Services not appropriate for victim/survivor
Transportation
Other (specify):

Sexual Assault Services Formula Grant Program Annual Progress Report • 6 • Office on Violence Against Women

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

14. Demographics of primary victims/survivors served or partially served

(Based on the primary victims/survivors reported in 11A and 11B, 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 11A and 11B. However, the total
number of victims/survivors reported under Race/ethnicity should not be less than the total number of
victims/survivors reported in 11A and 11B. 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
11A and 11B. 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 11A and

0

11B.)

Gender

Number of
victims/survivors

Female
Male
Unknown
TOTAL GENDER (should equal 0, the sum of 11A and 11B.)
Age

0

Number of
victims/survivors

0-6
7-12
13-17
18-24
25-59
60 +
Unknown
TOTAL AGE (should equal 0, the sum of 11A and 11B.)
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

Sexual Assault Services Formula Grant Program Annual Progress Report • 7 • Office on Violence Against Women

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

15. Victims/survivors’ relationships to offender by victimization
(For those primary victims/survivors reported as served and partially served in 11A and 11B, report the
victim/survivor’s relationship to the offender. If a victim/survivor was victimized by more than one
perpetrator, count the victim/survivor in all categories that apply. The total number of relationships
must be at least 0. Do not report relationships to offender for secondary victims.)

Victim/survivor’s relationship to offender

Number of victim/survivor
relationships

Current or former spouse or intimate partner
Other family or household member (son/daughter, stepson/daughter,
sibling, etc.)
Dating relationship
Acquaintance (neighbor, employee, co-worker, student, schoolmate, etc.)
Stranger
Relationship unknown
TOTAL

0

Sexual Assault Services Formula Grant Program Annual Progress Report • 8 • Office on Violence Against Women

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

16. Victim services

(Report the number of primary victims/survivors from 11A and 11B who received SASP Program-funded

(Report the number of primary victims/survivors from 11A and 11B who received SASP Culturally
servicesProgram-funded
during the current
reporting
period.
Count
each victim/survivor
once type
for each
type of that
service
Specific
services.
Count
each
victim/survivor
only onceonly
for each
of service
that
victim/survivor
received
during
the
current
reporting
period;
do
not
report
the
number
of
times
that
servictim received during the current reporting period; do not report the number of times that service
was
vice
was
provided
to
the
victim/survivor.
The
total
for
each
type
of
service
should
not
be
higher
than
[insert
provided to the victim. The total for each type of service should not be higher than 0, the total of 11A
total11B.
of 11A
total of 11A
and receiving
11B. Do not
report in
secondary
victims receiving services in this
and
Doand
not 11B],
reportthe
secondary
victims
services
this question.)

question.)

Type of service

Number of victims/
survivors
served

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.)
Counseling services/support group (Short-term 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; advocacy with probation/parole/
corrections; supporting victims/survivors through sex offender management process; 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 counseling (Actions designed to assist a victim/survivor in obtaining employment, e.g., coaching on career options, skills training, job searches,
resume-writing, marketing, job interviews, and preservation of employment)
Financial counseling (Actions designed to assist a victim/survivor with issues
related to improving credit, retiring debt, setting up bank accounts, managing
household finances, negotiating with lenders or landlords, developing budgets,
managing financial assets, making major purchases such as a home or auto,
filing tax returns, etc.)
Hospital/clinic/other medical response (Accompanying a victim/survivor to, or
meeting a victim/survivor at a hospital, clinic, or medical office)
Job training (Providing training in specific employment-related skills to a victim/
survivor, e.g., on computer literacy)
Language services (Interpretation, translation)
Material assistance (Providing victims/survivors with clothing, food, personal
items, etc.)
Transportation (Provision of transportation, either directly or through bus passes,
taxi fares, or other means of transportation)
Victim/survivor advocacy (Actions designed to help the victim/survivor obtain
needed support, resources, or services including employment, housing, shelter
services, health care, victims’ compensation, school/education, etc.)
Other (specify):

Sexual Assault Services Formula Grant Program Annual Progress Report • 9 • Office on Violence Against Women

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

17. Hotline calls/information and referral

(Report the number of hotline calls received from primary victims/survivors, and the total number of hotline
calls received, on phone lines paid for with SASP Program funds or answered by SASP Program-funded staff,
during the current reporting period. Primary victims/survivors whose calls are reported here should not be
reported as victims served in question 11 unless they also received at least one of the services listed in question 16, Victim 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 16. 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 16, see separate instructions.)
Number of calls/requests
from primary
victims/survivors

Total number of
calls/requests

Hotline calls (Crisis or information and referral calls
received by an agency’s hotline or office telephone)
Walk-in information and referrals
Web-based information and referrals

18. Outreach to victims/survivors (Report the number of unsolicited letters, phone calls, or visits to victims/

survivors of specific incidents of sexual assault identified in police reports or court documents, informing
them of services and/or providing information about the criminal justice system. Report only SASP Program-funded outreach activities. Victims/survivors who are the recipients of these notification/outreach activities should not be reported as victims/survivors served in question 11 unless they also received at least
one of the services reported in question 16, Victim services. Victims/survivors who receive services such as
advocacy over the telephone should be reported in question 16.)

Number of outreach
activities to
victims/survivors
Outreach to victims/survivors (unsolicited letters,
phone calls, or visits.)

19. Protection/restraining orders

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

Protection orders

Temporary orders

Final orders

Number requested
Number granted

Sexual Assault Services Formula Grant Program Annual Progress Report • 10 • Office on Violence Against Women

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

20. (Optional) Additional information
(Use the space below to discuss the effectiveness of victim services funded or supported by your SASP Program subgrant 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 SASP funding, was able to provide medical accompaniment to an increased number of sexual
assault survivors. This resulted in a higher percentage of survivors also seeking additional support services.) (Maximum 2,000 characters)

Sexual Assault Services Formula Grant Program Annual Progress Report • 11 • Office on Violence Against Women

SECTION

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

E

NARRATIVE

All grantees must answer questions 21 and 22.
Please limit your responses to the space provided (8,000 characters) for each question.
21. What do you see as the most significant areas of remaining need, with regard to improving services to victims/survivors of sexual assault, increasing victims/survivors safety, and enhancing
community response (including offender accountability for sex offenders)?
(Consider geographic regions, underserved populations, service delivery systems, and challenges and
barriers unique to your jurisdiction.) Page 13.
22. What has SASP Program funding allowed you to do that you could not do prior to receiving this
funding? (e.g., expand services to include criminal justice advocacy; expand coordination and crossreferrals with sexual assault agencies in your community) Page 15.
Questions 23 and 24 are optional.
Please limit your responses to the space provided (8,000 characters) for each question.
23. Provide any additional information that you would like us to know about your SASP Program subgrant and/or the effectiveness of your grant.
(If you have any other data or information that you have not already reported in answer to previous
questions that demonstrate the effectiveness of your SASP Program-funded program please provide it
below.) Page 17.
24. Provide any additional information that you would like us to know about the data submitted.
(If you have any information that could be helpful in understanding the data you have submitted in
this report, please answer this question. For example, if you reported staff—e.g., victim advocates—but
did not report any corresponding victim services, you may explain why; or if you did not report either
staff or activities during the reporting period, please explain.) Page 19.

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.

Sexual Assault Services Formula Grant Program Annual Progress Report • 12 • Office on Violence Against Women

Back to Instructions

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

What do you see as the most significant areas of remaining need, with regard to improving services to victims/survivors of sexual assault, increasing victims/survivors safety, and enhancing community response
(including offender accountability for sex offenders)? Question #21

Sexual Assault Services Formula Grant Program Annual Progress Report • 13 • Office on Violence Against Women

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

What do you see as the most significant areas of remaining need, with regard to improving services to victims/survivors of sexual assault, increasing victims/survivors safety, and enhancing community response
(including offender accountability for sex offenders)? Question #21 (cont.)
Back to Instructions

Sexual Assault Services Formula Grant Program Annual Progress Report • 14 • Office on Violence Against Women

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

What has SASP Program funding allowed you to do that you could not do prior to receiving this funding?
Question #22
Back to Instructions

Sexual Assault Services Formula Grant Program Annual Progress Report • 15 • Office on Violence Against Women

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

What has SASP Program funding allowed you to do that you could not do prior to receiving this funding?
Back to Instructions
Question #22 (cont.)

Sexual Assault Services Formula Grant Program Annual Progress Report • 16 • Office on Violence Against Women

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

Provide any additional information that you would like us to know about your SASP Program subgrant and/or
the effectiveness of your grant. Question #23
Back to Instructions

Sexual Assault Services Formula Grant Program Annual Progress Report • 17 • Office on Violence Against Women

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

Provide any additional information that you would like us to know about your SASP Program subgrant and/or
Back to Instructions
the effectiveness of your grant. Question #23 (cont.)

Sexual Assault Services Formula Grant Program Annual Progress Report • 18 • Office on Violence Against Women

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

Provide any additional information that you would like us to know about the data submitted.
Back to Instructions
Question #24

Sexual Assault Services Formula Grant Program Annual Progress Report • 19 • Office on Violence Against Women

OMB Clearance # 1122-0022
Expiration Date: 2/29/2016

Provide any additional information that you would like us to know about the data submitted.
Question #24 (cont.)
Back to Instructions

Sexual Assault Services Formula Grant Program Annual Progress Report • 20 • Office on Violence Against Women

Validate