Form 1 SOT Program Data Points Form

OMB NO: 0970-XXXX

EXPIRATION DATE: XX/XX/XXXX

ACF Office of Refugee Resettlement: Services for Survivors of Torture

Program Data Points Form

Agency: Administration for Children and Families (ACF)/Office of Refugee Resettlement (ORR) Form: Survivors of Torture – Program Data Points (SOT-PDP)			Grantee Name: Grant Number: Point of Contact:			Reporting Period From: MM/DD/YYYY To: MM/DD/YYYY
Reporting: Submit annual program data with the second semi-annual report each year of the project period. Please use the narrative report to explain or highlight key program indicators and illustrate changes in outcome indicators. See the Program Data Points User Guide for more information: https://healtorture.org/content/office-refugee-resettlement
PROGRAM INDICATORS1
Data Point	Description	Indicators		No. of Clients Served	Data Validation Checks
01a	Active Caseload: Client count during reporting period	New primary New secondary Continuing primary Continuing secondary TOTAL ACTIVE CLIENT COUNT		_____ _____ _____ _____ _____	Please double check your math when adding up all new and continuing clients in the line indicating the total active client count.
01b	Closed Caseload: Client count during reporting period	New primary New secondary Continuing primary Continuing secondary TOTAL CLOSED CASE COUNT		_____ _____ _____ _____ _____	Please double check your math when adding up all new and continuing clients in the line indicating the total closed case count.
02	Age when first subjected to torture (Primary survivors only)	Under 5 years 5 – 17 years 18 – 44 years 45 – 64 years 65 years and over TOTAL		_____ _____ _____ _____ _____ _____	Add the number of new primary and continuing primary clients from DP01a to get the total number of active primary survivors: 01a. New primary: ______ + 01a. Continuing primary: ______ = _______ The total number of active primary survivors should be equal to the total ages reported to the left. If this is not the case, please check your entries for DP02. Total number of active primary survivors = ______ Total reported for DP02 = ______
Data Point	Description	Indicators		No. of Clients Served	Data Validation Checks
03	Type of torture suffered (Primary survivors only)	Asphyxiation Beating Burning Deprivation Electrical Forced postures Gender-based violence Kidnapping and disappearances Rape and sexual torture Sensory stress Severe humiliation Threats and psychological torture Witnessing torture of others Wounding/maiming Other: Please specify_________________ TOTAL		_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____	Compare the total number of active primary survivors to the total number of types of torture reported to the left: Total active primary survivors = ______ Total types of torture from DP03 = ______ The total number of types of torture from DP03 should be greater than or equal to the total number of active primary survivors. If this is not the case, please go back and check your entries for DP03.
04	Reason for torture (Primary survivors only)	Breakdown of authority/terror by non- state actors Ethnicity Nationality Religion Social group Clan/Tribe Gender Gender identity Sexual orientation Sociopolitical activism Other: Please specify_________________ TOTAL		_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____	Compare the total number of active primary survivors to the total number of reasons for torture reported to the left: Total active primary survivors = ______ Total reasons for torture from DP04 = ______ The total number of reasons for torture from DP04 should be greater than or equal to the total number of active primary survivors. If this is not the case, please go back and check your entries for DP04.

Data Point	Description	Indicators	No. of Clients Served	Data Validation Checks
05	Country where torture occurred (Primary survivors only)	Country 1: Country 2: Country 3: Country 4: … Unknown (Report all countries) TOTAL	_____ _____ _____ _____ _____ _____	Compare the total number of active primary survivors to the total number of countries reported to the left: Total active primary survivors = ______ Total countries from DP05 = ______ The total number of countries from DP05 should be greater than or equal to the total number of active primary survivors. If this is not the case, please go back and check your entries for DP05.
06	Client goal(s) at intake	Behavioral Housing Interpersonal/Social Legal Occupational/Educational Physical/Medical TOTAL	_____ _____ _____ _____ _____ _____ _____	Compare the total number of active clients (primary and secondary) from DP01a to the total number of goals reported to the left: Total active clients from DP01a = ______ Total goals from DP06 = ______ The total number of goals from DP06 should be greater than or equal to the total number of active clients (primary and secondary). If this is not the case, please go back and check your entries for DP06.
07	Gender	Female Male X (unspecified or another gender identity) TOTAL	_____ _____ _____ _____	Compare the total number of active clients (primary and secondary) from DP01a to the total number of genders reported to the left: Total active clients from DP01a = ______ Total genders from DP07 = ______ The total number of genders from DP07 should be equal to the total number of active clients. If this is not the case, please go back and check your entries for DP07.

Data Point	Description	Indicators	No. of Clients Served	Data Validation Checks
08	Immigration category/status at intake	Afghan Humanitarian Parolee Asylee (include derivatives) Asylum Applicant Refugee (include derivatives) Special Immigrant Juvenile (SIJ) Special Immigrant Visa Holder (SIV) Lawful Permanent Resident (LPR) Former refugee (include derivatives) Former asylee (include derivatives) Other former: Please specify___________ U.S. Citizen Former refugee (include derivatives) Former asylee (include derivatives) Other former: Please specify___________ U.S. born citizen Ukrainian Humanitarian Parolee Undocumented Unknown Other at intake: Please specify______________________ TOTAL	_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ ____ ____ _____ _____ _____ ____ _____ _____	Compare the total number of active clients (primary and secondary) from DP01a to the total number of categories/statuses reported to the left: Total active clients from DP01a = ______ Total categories/statuses from DP08 = ______ For the lines labeled “Lawful Permanent Resident (LPR)” and “U.S. Citizen,” please enter the subtotal of the lines below (former refugee, former asylee, other former, U.S. born citizen). When checking the total for immigration categories/statuses, be careful not to double count the LPR and U.S. Citizen subtotals and the categories beneath it. The total number of categories/statuses from DP08 should be equal to the total number of active clients. If this is not the case, please go back and check your entries for DP08.
09	Age at intake	Under 5 years 5 – 17 years 18 – 44 years 45 – 64 years 65 years and over TOTAL	_____ _____ _____ _____ _____ _____	Compare the total number of active clients (primary and secondary) served from DP01a to the total number of ages reported to the left: Total active clients from DP01a = ______ Total ages from DP09 = ______ The total number of ages from DP09 should be equal to the total number of active clients. If this is not the case, please go back and check your entries for D09.

Data Point	Description	Indicators	No. of Clients Served	Data Validation Checks
10	Education prior to arrival (For clients > 18 years of age at intake)	Less than 1 year 1-4 years 5-8 years 9-12 years 13-16 years More than 16 years TOTAL	_____ _____ _____ _____ _____ _____ ____	Add the following age categories together from DP09: 18 – 44 years = ______ 45 – 64 years = ______ 65 years and over = ______ This gives you the total number of clients ≥ 18 years at intake = ______ Compare the total number of clients ≥ 18 years of age at intake to the total from DP10 to the left. Total number of clients ≥ 18 years at intake = ______ Total education from DP10 = ______ The total reported in DP10 should be equal to the total number of clients 18 years or older at intake. If this is not the case, please go back and check your entries for D10.
11	Employment in the U.S. at intake (For clients > 18 years of age at intake)	No work authorization Unemployed and not seeking employment (e.g., students, elderly, disabled, and primary caregivers) Unemployed, work authorized, and seeking employment Employed with work authorization (PT/FT) TOTAL	_____ _____ _____ _____ _____	Compare the total number of clients ≥ 18 years of age at intake calculated above to the total number of employment categories reported to the left: Total clients ≥ 18 years of age at intake = ______ Total employment categories from DP11 = ______ The total number employment categories from DP11 should be equal to the total number of clients ≥ 18 years of age at intake. If this is not the case, please go back and check your entries for DP11.
12	Length of time in the U.S. at intake	Less than one year 1-5 years More than 5 years Unknown TOTAL	_____ _____ _____ _____ _____	Compare the total number of active clients (primary and secondary) served from DP01a to the total number of categories reported to the left: Total active clients from DP01a = ______ Total length of time in the U.S. at intake from DP12 = ______ The total number of categories from DP12 should be equal to the total number of active clients. If this is not the case, please go back and check your entries for DP12.

Data Point	Description	Indicators	No. of Clients Served	Data Validation Checks
13	Country of origin	Country 1: Country 2: Country 3: Country 4: … (Report all countries) TOTAL	_____ _____ _____ _____ _____	Compare the total number of active clients (primary and secondary) from DP01a to the total number of countries reported to the left: Total active clients from DP01a = ______ Total countries from DP13 = ______ The total number of countries from DP13 should be equal to the total number of active clients. If this is not the case, please go back and check your entries for DP13.
14	Ethnicity	Ethnicity 1: Ethnicity 2: Ethnicity 3: Ethnicity 4: …. Unknown (Report all ethnicities) TOTAL	_____ _____ _____ _____ _____ _____	Compare the total number of active clients (primary and secondary) from DP01a to the total number of ethnicities reported to the left: Total active clients from DP01a = ______ Total ethnicities from DP14 = ______ The total number of ethnicities from DP14 should be equal to the total number of active clients. If this is not the case, please go back and check your entries for DP14.
15	Religion	Buddhism Christianity Hinduism Islam Judaism None Unknown Other: Please specify______________________ TOTAL	_____ _____ _____ _____ _____ _____ _____ _____ _____	Compare the total number of active clients (primary and secondary) from DP01a to the total number of religions reported to the left: Total active clients from DP01a = ______ Total religions from DP15 = ______ The total number of religions from DP15 should be equal to the total number of active clients. If this is not the case, please go back and check your entries for DP15.

Data Point	Description	Indicators	No. of Clients Served	Data Validation Checks
16	Languages used	Language 1: Language 2: Language 3: Language 4: … (Report all languages used) TOTAL	_____ _____ _____ _____ _____	Compare the total number of active clients (primary and secondary) from DP01a to the total number of languages reported to the left: Total active clients from DP01a = ______ Total languages from DP16 = ______ The total number of languages from DP16 should be equal to the total number of active clients. If this is not the case, please go back and check your entries for DP16.
17	Clients served by service category	Behavioral Housing Interpersonal/Social Legal Occupational/Educational Physical/Medical TOTAL	_____ _____ _____ _____ _____ _____ _____	Compare the total number of active clients (primary and secondary) from DP01a to the total number of service categories reported to the left: Total active clients from DP01a = ______ Total service categories from DP17 = ______ The total number of service categories from DP17 should be greater than or equal to the total number of active clients. If this is not the case, please go back and check your entries for DP17.
18	Professionals/community members trained under SOT	Community Education Interpretation/translation Law Enforcement Legal Medical Mental health Social work Other: Please specify:______________________	_____ _____ _____ _____ _____ _____ _____ _____ _____	There are no data validation checks for this data point.

Data Point	Description	Indicators	No. of Clients Served	Data Validation Checks
19	Pro bono professional service hours donated to SOT program	Administrative, managerial, and other professional services Accounting, development, and grant writing Information technology and research Interpretation/Translation Legal Medical services Mental health services Social services Other: Please specify:______________________	Number of hours _____ _____ _____ _____ _____ _____ _____ _____ _____	There are no data validation checks for this data point.

OUTCOME INDICATORS2 Indicate the tool from which you have derived the client-level data you are reporting here in the aggregate: SOT-PWI-S Our Program Tool Case File Review Other: Please specify Complete all the boxes for each data point below to show aggregate changes in the level of need.
Data Point	Description	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
20.a New Clients	Legal (Immigration)	S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=
Data Point	Description	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
20.b Continuing Clients	Legal (Immigration)	S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=

Data Point	Description	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
21.a New Clients	Housing	S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=
Data Point	Description	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
21.b Continuing Clients	Housing	S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=

Data Point	Description	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
22.a New Clients	Employment	S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=
Data Point	Description	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
22.b Continuing Clients	Employment	S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=

Data Point	Description	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
23.a New Clients	Physical Health	S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=
23.b Continuing Clients	Physical Health	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
		S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=

Data Point	Description	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
24.a New Clients	Mental Health	S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=
24.b Continuing Clients	Mental Health	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
		S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=

Data Point	Description	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
25.a New Clients	Access to community resources	S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=
25.b Continuing Clients	Access to community resources	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
		S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=

Data Point	Description	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
26.a New Clients	U.S.-Based Support Systems	S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=
26.b Continuing Clients	U.S.-Based Support Systems	Level of Need		END
				1 In Crisis	2 Vulnerable	3 Stable	4 Safe
		S T A R T	1 In Crisis N=
			2 Vulnerable N=
			3 Stable N=
			4 Safe N=

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

The purpose of this information collection is to collect demographic, programmatic, and outcome data in order to learn more about the population being served, the types of services they receive, and the effectiveness of those services. Public reporting burden for this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (Funding Announcement: HHS-2022-ACF-ORR-ZT-0051). This collection of information is required to retain a benefit (Torture Victims Relief Act of 1998, Pub. L. 105-320). If you have any comments on this collection of information, please contact the Administration for Children and Families, Office of Refugee Resettlement, Division of Refugee Health, 330 C Street, SW, 5th Floor, Washington, DC 20201 or email [email protected]. 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. The OMB number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX.

1 Refer to the Program Data Points User Guide for all definitions

2 Use the Survivor of Torture Psychosocial Well-being Index (Short Version) (SOT-PWI-S) © 2016 Hodges-Wu & Zajicek-Farber to aggregate the data for these indicators. (See User Guide, Appendix A)

Program Data Points pg. 1