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OMB Control Number: 0970-0490
Expiration date: 03/31/2026
Program
Data Points (PDP) Form
OFFICE OF REFUGEE RESETTLEMENT
Division of Refugee Health
Support for Trauma-Affected Refugees
(STAR)
Agency:
Administration for Children and Families (ACF)/Office of Refugee
Resettlement (ORR)
Form:
Support for Trauma-Affected Refugees (STAR)
|
Grant
Recipient 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
(PPR) each year of the project period. Please use the narrative
portion of the PPR to explain or highlight key program indicators
and illustrate trends in outcome indicators. Please see the PDP
User Guide for more information.
|
PAPERWORK REDUCTION ACT (PRA) OF 1995 (Public Law 104-13) STATEMENT
OF PUBLIC BURDEN: The purpose of this information collection is to
measure how the STAR program is achieving the goal of sustained
psychosocial well-being of ORR-eligible clients whose experience of
trauma is impeding their ability to function effectively at home,
school, work and/or in social settings. Public reporting burden for
this collection of information is estimated to average 15 hours per
grantee, including the time for reviewing instructions, gathering and
maintaining the data needed, and reviewing the collection of
information. This collection of information is required to retain a
benefit (Immigration and Nationality Act (INA)). An agency may not
conduct or sponsor, and a person is not required to respond to, a
collection of information subject to the requirements of the PRA of
1995, unless it displays a currently valid OMB control number. If you
have any comments on this collection of information, please contact
Maggie Barnard at [email protected].
Assessment
Area 1: Core Service Delivery
Section
1: Aggregate Client Demographics
|
Enter
aggregate
data for indicators 1-7 for all new and continuing clients served
during the reporting period.
|
1a.
Client Count
___New
client
___Continuing
client
___Closed
client
|
1b.
Family composition (aggregate):
___
Family unit enrolled in STAR
___
Single enrollment from a family unit
___
Single
|
2.
Sexual orientation (client self-identification) (aggregate):
___
Bisexual
___
Gay or Lesbian
___
Straight/Heterosexual
___
Unknown
___
Other: Specify_____
___
N/A: Client under age 11
|
3.
Client language of preference (aggregate):
___
Language 1:
___
Language 2:
___
Language 3:
___
Language 4: …
|
4.
Employment status in the U.S. at intake (aggregate):
___
Unemployed and not seeking employment
___
Unemployed and seeking employment
___
Employed part-time
___
Employed full-time
|
5.
Immigration category/status at intake (aggregate):
___
Afghan Humanitarian Parolee
___ Afghan Individual with SI/SQ
Parole (aka Afghan Special Immigrant Parolee)
___
Afghan Individual with Special Immigrant Conditional Permanent
Residence (SI CPR)
___
Amerasian
___
Asylee
___
Cuban and Haitian Entrant
___
Iraqi and Afghan Special Immigrant Visa Holder (SIV)
___
Legal Permanent Resident (LPR)
___
Refugee
___
Special Immigrant Juvenile (SIJ)
___
Ukrainian Humanitarian Parolee
___ Victim of human
trafficking
___
Other at intake:
Please
specify________________
|
6.
Length of time in the U.S. at intake:
___
<1 year
___
1-2 years
___
3-5 years
|
7.
Type of trauma exposure
(aggregate - include all that apply):
___
Physical violence
___
Psychological violence
___
Sexual violence
___
Deprivation of basic needs
___
Forced labor
___
Domestic violence/abuse
___
Gender-based violence
___
Threats
___
Kidnapping or disappearances
___
Environmental/community
exposure
___
Other
|
Section
2: Individual Client Demographics and Outcomes
|
Complete
data points 8-14 for EACH enrolled client
|
Date
client enrolled in STAR program: __________________________
|
Date
client case closed (if applicable): __________________________
|
Age
at intake (Select
one):
Under
5 years
5
– 17 years
18
– 24 years
25
- 44 years
45
– 64 years
65
years and over
|
Gender
identity (Select
one):
Female
Male
Nonbinary
Transgender
Unknown
Other:
Specify_____
|
Country
of origin (select one):
Country
1:
Country
2:
Country
3:
Country
4: …
|
Activities/services
client received to date (select
all that apply):
MENTAL
HEALTH AND PSYCHOSOCIAL SUPPORT
PHYSICAL
HEALTH
Medical
services
Other:
Specify______
SOCIOECONOMIC
Childcare
services
Emergency
assistance
Employment
services
Housing
services
Vocation/education
Other:
Specify_____
|
Section
2: Individual Client Demographics and Outcomes (cont.):
Safety
& Wellness Benchmarks
|
ORR
requires quarterly assessments of each client using the Safety &
Wellness Benchmarks. Enter the score for EACH client in the
following categories.
Indicate
the client’s Safety & Wellness Benchmarks score at
intake and during their most recent assessment. If the client
has not been enrolled long enough to receive a second
assessment, please leave ‘most recent score’ blank.
For continuing clients, use their intake score from when they
entered the program, and their most recent score during this
reporting period. Assess all enrolled clients quarterly and/or
at case closure, whichever is sooner.
For
adults (ages 18+): Enter the client’s Mental Health,
Relationship Safety, and Self-Efficacy score
For
children and youth (under age 18): Enter the client’s
Mental Health and Relationship Safety score
|
14a.
Mental Health
Score
at Intake (select
one):
-
Most
Recent Score (most
recent quarter or case closure – select one):
-
|
14d.
Relationship Safety
Score
at Intake (select
one):
-
Most
Recent Score (most
recent quarter or case closure – select one):
-
|
14g.
Self-Efficacy – adults only
Score
at Intake (select
one):
-
Most
Recent Score (most
recent quarter or case closure – select one):
-
|
Assessment
Area 2: Capacity Building
Complete
Assessment Area 2: Capacity Building data points 15-16 using
aggregate
data for the reporting period.
|
Professional
training areas for staff
___
Interpretation/translation
___
Mental health
___
Physical/Medical health
___
Social services
___
Family-specific interventions
___
Other: Specify_____
|
Community-facing
trainings (by profession/audience type)
___
Community (general)
___
Educators
___
Interpreters/translators
___
Law enforcement
___
Medical providers
___
Mental health providers
___
Social workers (non-clinical)
___
Other: Please specify:_______________
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Subedi, Parangkush (ACF) |
File Modified | 0000-00-00 |
File Created | 2025-05-29 |