SASIC PDP Form

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OFFICE OF REFUGEE RESETTLEMENT
Services to Afghan Survivors Impacted by Combat 
Program Data Points Form
Agency: Administration for Children and Families (ACF)/Office of Refugee Resettlement (ORR)
Form: Services to Afghan Survivors Impacted by Combat – Program Data Points (SASIC-PDP)
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 each year of the project period. Please use the narrative report to explain or highlight key program indicators and illustrate changes in outcome indicators.      
PROGRAM INDICATORS
Data Point
Description
Indicators
No. of Clients Served

01
Client count during reporting period
Total active client count
    • New clients
    • Continuing clients
Clients who exited the program

____
____
____
____



02


Age at intake

Under 5 years 
5 – 17 years
18 – 44 years 
45 – 64 years 
65 years and over

_____
_____
_____
_____
_____


03


Sex
Female
Male


_____
_____
_____
_____

04

Length of time in the U.S. at intake
≤ 1 year
>1 year
Unknown

_____
_____
_____






05a


Type of combat exposure/ experience of trauma 
(Primary survivors only)

(Primary survivors: Individuals who directly experienced or were directly affected by a traumatic event/s).


Participated in combat
Sustained physical injury
Physical violence 
Psychological violence
Sexual violence
Deprivation of basic needs
Forced labor
Kidnapping or disappearances 
Environmental/community exposure to combat and trauma
Other: Specify_____

_____
_____
_____
_____
_____
_____
_____
_____
_____
_____










Data Point
Description
Indicators
No. of Clients Served




05b

Type of combat exposure/experience of trauma
(Secondary survivors only)

(Secondary survivors: Individuals indirectly affected by a traumatic event(s) because of their close relationship with primary survivors)

  Spouse 
  Child 
  Caregiver
  Parent
  Other: Specify_____





_____
_____
_____
_____
_____





06





Self-report of either prior service with the Afghan military or provision of support to the U.S. or Afghan government 

(Primary survivors only)


Served with the Afghan military
 
Supported the U.S. or Afghan government 

Other: Specify_____


_____

_____

_____





07


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


_____
_____
_____
_____
_____
_____








08







Immigration category/status
at intake
Afghan Refugee
Afghan Asylee
 Afghan Special Immigrant    
    Visa (SIV) holder
Afghan Individuals with SI/SQ  
    Parole (aka Afghan Special  
    Immigrant Parolee)
Afghan Individuals with Special 
    Immigrant Conditional 
    Permanent Residence (SI CPR)
Afghan Humanitarian Parolee
Unknown Status
Other: Specify_____

_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____



09
Employment in the U.S. at intake

 (For clients > 18 years of age at intake)

Unemployed and not seeking employment (e.g., older adult, disabled, and primary caregivers) 
Employed part-time
Employed full time
Student

_____

_____
_____

_____






Data Point
Description
Indicators
No. of Clients Served

10

Clients served by overall service category

Mental health
Physical health
Social services
_____
_____
_____






11





Service-related program activities  
Individual therapy
Family therapy
Group therapy 
Primary/specialty medical services
Community support
Employment services
Housing services
Language/Interpretation services
Vocational/education referrals
Other: Specify_____

_____
_____
_____
_____
_____
_____
_____
_____
_____



12a


Professional training areas for staff
Interpretation/translation
Mental health
Medical health
Social services
Other: Specify_____

_____
_____
_____
_____
_____



12b


Professional training areas for community
      
Interpretation/translation
Mental health
Medical health
Social services
Other: Specify_____

_____
_____
_____
_____
_____


























OUTCOME INDICATORS
    • Complete data points 13 14 and 15 below for each service your program offers to show aggregate change in the level of risk.
    • Please specify the duration of services for clients included in this section:
       -------1 year         -------2 years     ------3 years            
    • Please provide the number of clients served in the following categories:
        ◦ Clients who were enrolled in the previous program year   ---------
        ◦ Clients who were enrolled in the current program year     ----------
Data Point
Description

Risk Level
END




13





Mental Health Services
(N=)

1
In Crisis
2
Vulnerable
3
Stable
4
Safe






START
1
In Crisis







2
Vulnerable







3
Stable







4
Safe




Data Point
Description

Risk Level
END




14




Physical Health Services
(N=)

1
In Crisis
2
Vulnerable
3
Stable
4
Safe






START
1
In Crisis







2
Vulnerable







3
Stable







4
Safe




Data Point
Description

Risk Level
END




15





Social Services
(N=)

1
In Crisis
2
Vulnerable
3
Stable
4
Safe






START
1
In Crisis







2
Vulnerable







3
Stable







4
Safe




PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN:  The purpose of this information collection is to monitor SASIC grant recipients activities.  Public reporting burden for this collection of information is estimated to average 5 hours per grantee, 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 under INA § 412(c)(1)(A), 8 U.S.C. 1522(c)(1)(A).  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 Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number.  The OMB # is 0970-0490 and the expiration date is XX/XX/XXXX.  If you have any comments on this collection of information, please contact Francine White at [email protected].