Form 1 PA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

ADMINISTRATION FOR CHILDREN AND FAMILIES

Program Office:	Administration on Children, Youth and Families (ACYF), Family and Youth Services Bureau (FYSB)
Program Announcement Number:	HHS-2009-ACF-ACYF-FVPS-XXXX
Announcement Title:	Family Violence Prevention and Services/Grants for Domestic Violence Shelters and Related Assistance/Grants to States
CFDA Number:	93.671
Due Date for Applications:	(Insert date 30 days from date of publication in the Federal Register)

Executive Summary: This announcement governs the proposed award of mandatory grants under the Family Violence Prevention and Services Act (FVPSA) to States (including Territories and Insular Areas) and Tribes. The purpose of these grants is to assist States in establishing, maintaining, and expanding programs and projects to prevent family violence (i.e. domestic violence) and to provide immediate shelter and related assistance for victims of domestic violence and their dependents (42 U.S.C. 10401).

This announcement sets forth the application requirements, the application process, and other administrative and fiscal requirements for grants in Fiscal Year (FY) 2009. Starting in FY 2009, applications should cover FYs 2009, 2010 and 2011 (see Section II, Funds Available, Length of Project Period).

I. DESCRIPTION

Legislative Authority: The Family Violence Prevention and Services Act (42 U.S.C. 10401 et. seq.).

Background

The purpose of this legislation is to assist States and Indian Tribes, Tribal organizations, and non-profit private organizations approved by an Indian Tribe in supporting the establishment, maintenance, and expansion of programs and projects to prevent incidents of family violence and to provide immediate shelter and related assistance for victims of family violence and their dependents that meet the needs of all victims, including those in marginalized communities (42 U.S.C. 10401).

During FY 2008, 52 grants were made to States. 202 grants were made to Indian Tribes, Tribal organizations, and non-profit private organizations approved by Indian Tribes. The Department of Health and Human Services (HHS) also made 53 family violence prevention grant awards to non-profit State Domestic Violence Coalitions.

The National Domestic Violence Hotline (Hotline) is supported by FVPSA to ensure that everyone has access to information and emergency assistance wherever and whenever it is needed. The Hotline is a 24-hour, toll-free service that provides crisis assistance, counseling, and local shelter referrals for people across the country who need assistance. Hotline counselors also are available for non-English speaking persons and for people who are hearing-impaired. The Hotline number is 1-800-799-SAFE (7233); the TTY number for the hearing-impaired is 1-800-787-3224.

Annual State Administrators Grantee Meeting

The annual grantee meeting for the State FVPSA Administrators is a training and technical assistance activity and FVPSA State Administrators are expected to attend. Subsequent correspondence will advise the State FVPSA Administrators of the date, time and location of their grantee meeting.

Client Confidentiality

FVPSA programs must establish or implement policies and protocols for maintaining the safety and confidentiality of the adult victims of domestic violence and their children whom they serve.  It is essential that the confidentiality of individuals receiving FVPSA services be protected.  Consequently, when providing statistical data on program activities and program services, individual identifiers of client records will not be used by the State or other FVPSA grantees or subgrantees. The address or location of any FVPSA-supported shelter facility will, except with written authorization of the person or persons responsible for the operation of such shelter, not be made public and the confidentiality of records pertaining to any individual provided domestic violence services by any FVPSA-supported program will be strictly maintained (42 U.S.C. 10402(a)(2)(E)).

Confidentiality requirements have been strengthened and clarified with the passage of the Violence Against Women and Department of Justice Reauthorization Act of 2005 (Public Law 109-162).  In the interest of establishing a consistent Federal standard for domestic violence programs, HHS follows the confidentiality provisions and definition of “personally identifying information” in sections 40002(b)(2) and 40002(a)(18) of the Violence Against Women Act of 1994 (42 U.S.C. 13925(b)(2) and 42 U.S.C. 13925(a)(18)) as a more detailed guidance for grantees about how to comply with the FVPSA confidentiality statute, and requires FVPSA-funded programs to comply with the VAWA confidentiality provisions. Included in the confidentiality provisions are grant conditions regarding the disclosure of personally identifying information, confidentiality, information sharing, and when release of information is compelled.

In FY 2009 guidance, the FVPSA Program requires that grantees only collect unduplicated data for each program, and that information not be unduplicated across programs or statewide. No client-level data may be shared with a third party, regardless of encryption, hashing or other data security measures, without a written, time-limited release as described in section 40002(b)(2) of the Violence Against Women Act of 1994 (42 U.S.C. 13925(b)(2)).

The Importance of Coordinated and Accessible Services

The impacts of domestic violence may include physical injury and death of primary or secondary victims, psychological trauma, isolation from family and friends, harm to children living with a parent or caretaker who is either experiencing or perpetrating domestic violence, increased fear, reduced mobility, damaged credit, employment and financial stability, homelessness, substance abuse, chronic illnesses and a host of other health and related mental health consequences.

Coordination and collaboration among victim services providers, community-based, culturally specific service providers, housing providers and homeless services providers, the police, prosecutors, the courts, child welfare services, employers and business, medical and mental health service providers, and Federal, State, and local public official and agencies is needed to provide more responsive and effective services to victims of domestic violence and their families. It is essential that community service providers, including those serving or representing marginalized communities, are involved in the design and improvement of intervention and prevention activities.

To help bring about a more effective response to the problem of domestic violence, HHS urges the designated State agencies receiving funds under this grant announcement to coordinate activities funded under this grant with other new and existing resources for the prevention of domestic violence and related issues.

To serve victims most in need and to comply with Federal law, services must be widely accessible. Services must not discriminate on the basis of age, handicap, sex, race, color, national origin or religion (42 U.S.C. 10406). HHS Office for Civil Rights provides guidance to grantees in complying with these requirements. Please see http://www.hhs.gov/ocr/immigration/bifsltr.html for HHS Office of Civil Rights guidance on serving immigrant victims.

Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794) forbids organizations and employers from excluding or denying individuals with disabilities an equal opportunity to receive program benefits and services. Organizations may not establish eligibility criteria for receipt of services or participation in programs or activities that screen out or tend to screen out individuals with disabilities, unless such criteria are necessary to meet the objectives of the program. Under this law, individuals with disabilities are defined as persons with a physical or mental impairment which substantially limits one or more major life activities. Some examples of impairments which may substantially limit major life activities, even with the help of medication or aids/devices, are: AIDS, alcoholism, blindness or visual impairment, cancer, deafness or hearing impairment, diabetes, drug addiction, heart disease, and mental illness.

Please see http://www.hhs.gov/ocr/discrimdisab.html for HHS Office of Civil Rights guidance on the Americans with Disabilities Act and the Rehabilitation Act of 1973. Services must also be provided on a voluntary basis; receipt of shelter or housing must not be conditioned on participation in supportive services.

National Data Collection and Outcomes Measurement

In collaboration with partners at State FVPSA programs, State Domestic Violence Coalitions (Coalitions), Tribes and Tribal organizations, the National Resource Center on Domestic Violence, and experts on both data collection and domestic violence prevention and intervention issues, the FVPSA Program continues to develop informative, succinct, and non-burdensome reporting formats that safely measure quantifiable outputs and outcomes. During FY 2007, the FVPSA Program revised and defined the program services reporting components for recipients of FVPSA State Formula Grant funds. Throughout FY 2008, grantee workshops, teleconferences, and information memoranda provided further guidance on performance reporting requirements for these grantees. In FY 2009, the FVPSA Program is requiring States and their subgrantees, and Tribal grantees to use standardized reporting forms to facilitate the collection of uniform, aggregate data on FVPSA-supported program services and client outcomes, as described in Section VI.

Definitions

States should use the following definitions in carrying out their programs. The definitions are found in 42 U.S.C. 10421.

Family Violence: Any act or threatened act of violence, including any forceful detention of an individual, which: (a) results or threatens to result in physical injury; and (b) is committed by a person against another individual (including an elderly person) to whom such person is or was related by blood or marriage or otherwise legally related or with whom such person is or was lawfully residing. In this program announcement, domestic violence and family violence are used interchangeably. Domestic violence is defined in 42 U.S.C. 13925(a)(6).

Shelter: The provision of temporary refuge and related assistance in compliance with applicable State law and regulation governing the provision, on a regular basis, of shelter, safe homes, meals, and related assistance to victims of family violence and their dependents.

Related assistance: The provision of direct assistance to victims of family violence and their dependents for the purpose of preventing further violence, helping such victims to gain access to civil and criminal courts and other community services, facilitating the efforts of such victims to make decisions concerning their lives in the interest of safety, and assisting such victims in healing from the effects of the violence. Related assistance includes:

1. Prevention services such as outreach and prevention services for victims and their children, assistance for children who witness domestic violence, employment training, parenting and other educational services for victims and their children, preventive health services within domestic violence programs (including services promoting nutrition, disease prevention, exercise, and prevention of substance abuse), domestic violence prevention programs for school-age children, family violence public awareness campaigns, and violence prevention counseling services to abusers;

2. Counseling with respect to family violence, counseling or other supportive services provided by peers individually or in groups, and referral to community social services;

3. Transportation and technical assistance with respect to obtaining financial assistance under Federal and State programs, and referrals for appropriate health-care services (including alcohol and drug abuse treatment), but shall not include reimbursement for any health-care services;

4. Legal advocacy to provide victims with information and assistance through the civil and criminal courts, and legal assistance;

5. Children’s counseling and support services, and child care services for children who are victims of family violence or the dependents of such victims, and children who witness domestic violence.

II. FUNDS AVAILABLE

In accordance with 42 U.S.C. 10409(b), in FY 2009 through FY 2011, HHS will make available for grants to designated State agencies 70 percent of the amount appropriated under 42 U.S.C. 10409(a)(1), which is not reserved under 42 U.S.C. 10409(a)(2). In separate announcements, HHS will allocate 10 percent of the foregoing appropriation to Tribes and Tribal organizations for the establishment and operation of shelters, safe houses, and the provision of related services; and 10 percent to the State Domestic Violence Coalitions to continue their work within the domestic violence community by providing technical assistance and training, and advocacy services, among other activities, with local domestic violence programs and to encourage appropriate responses to domestic violence within the States.

State Allocation

FVPSA grants to the States, the District of Columbia, and the Commonwealth of Puerto Rico are based on a population formula. Each State grant shall be $600,000 with the remaining funds allotted to each State on the same ratio as the population of the State to the population of all States (42 U.S.C. 10403(a)(2)). State populations are determined on the basis of the most recent census data available to the Secretary of HHS, and the Secretary shall use for such purpose, if available, the annual current interim census data produced by the Secretary of Commerce pursuant to 13 U.S.C. 181 (42 U.S.C. 10403(b)).

For the purpose of computing allotments, the statute provides that Guam, American Samoa, the Virgin Islands, and the Northern Mariana Islands will each receive grants of not less than one-eighth of one percent of the amounts appropriated (42 U.S.C. 10403(a)(1)).

Length of Project Periods

The project period under this program announcement continues to be 24 months for each FY award. However, applications submitted by States now cover funding for FY 2009 and FY 2011. In other words, States apply for three years of grant funds in this one application, but they still have the same amount of time – two years per grant award – to spend the funds. States will not be required to submit additional applications for the years FY 2010 through FY 2011 unless there are material changes made to the program. Therefore, States must address their anticipated activities not only for the FY 2009 project period; i.e., October 2009 through September 2011, but also for the project periods covered by FYs 2010 through 2011; i.e., October 2010 through September 2012. States will have the opportunity to amend their applications for each of the fiscal years FY 2010 and FY 2011 if their anticipated activities materially change. This change does not affect the amount of the grant award or the timing of the grant award, only the application process.

Expenditure Period

FVPSA funds may be used for expenditures on and after October 1 of each fiscal year for which they are granted, and will be available for expenditure through September 30 of the following fiscal year; i.e., FY 2009 funds may be used for expenditures from October 1, 2008, through September 30, 2010.

Re-allotted funds, if any, are available for expenditure until the end of the fiscal year following the fiscal year that the funds became available for re-allotment. FY 2009 grant funds that are made available to the States through re-allotment, under 42 U.S.C. 10403(d), must be expended by the State no later than September 30, 2010.

III. ELIGIBILITY

“States” as defined in section 320 of FVPSA are eligible to apply for funds. The term “State” means each of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, American Samoa, the Virgin Islands, and the Commonwealth of the Northern Mariana Islands.

In the past, Guam, the Virgin Islands, the Commonwealth of the Northern Mariana Islands, and American Samoa have applied for funds as a part of their consolidated grant under the Social Services Block grant. These jurisdictions need not submit an application under this program announcement if they choose to have their allotment included as part of a consolidated grant application.

Additional Information on Eligibility

D-U-N-S Requirement

All applicants must have a D&B Data Universal Numbering System (D-U-N-S) number.  On June 27, 2003, the Office of Management and Budget (OMB) published in the Federal Register a new Federal policy applicable to all Federal grant applicants.  The policy requires Federal grant applicants to provide a D-U-N-S number when applying for Federal grants or cooperative agreements on or after October 1, 2003.  The D-U-N-S number will be required whether an applicant is submitting a paper application or using the government-wide electronic portal, www.Grants.gov.   A D-U-N-S number will be required for every application for a new award or renewal/continuation of an award, including applications or plans under formula, entitlement, and block grant programs, submitted on or after October 1, 2003.

Please ensure that the applicant’s organization has a D-U-N-S number.  To acquire a D-U-N-S number at no cost call the dedicated toll-free D-U-N-S number request line at 1-866-705-5711 or request a number online at http://www.dnb.com.

IV. APPLICATION REQUIREMENTS

The Paperwork Reduction Act of 1995 (P.L. 104-13)

Public reporting burden for this collection of information is estimated to average ten hours per response, including the time for reviewing instructions, gathering and maintaining the data needed and reviewing the collection information.

The project description is approved under the Office of Management and Budget (OMB) control number XXXX-XXXX, which expires October 31, XXXX. 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.

Content of Application Submission

The State’s application must be submitted by the Chief Executive of the State and signed by the Chief Executive Officer or the Chief Program Official designated as responsible for the administration of FVPSA.

Each application must contain the following information or documentation:

1. The name of the State agency, the name and contact information for the Chief Program Official designated as responsible for the administration of funds under FVPSA and coordination of related programs within the State, and the name and contact information for a contact person if different from the Chief Program Official (42 U.S.C. 10402(a)(2)(D)).

2. A plan describing in detail how the needs of underserved populations will be met (42 U.S.C. 10402(a)(2)(C)). “Underserved populations” include populations underserved because of geographic location (such as rural isolation), underserved racial and ethnic populations, populations underserved because of special needs (such as language barriers, disabilities, immigration status, or age), and any other population determined to be underserved by the State planning process or the Secretary of HHS (42 U.S.C. 13925(a)(32)).

1. Identify which populations in the State are underserved, describe those that are being targeted for outreach and services, and provide a brief explanation of why you have selected those populations were selected to receive outreach and services.

2. Describe the outreach plan, including the domestic violence training to be provided, the means for providing technical assistance and support, and the leadership role played by those representing and serving the underserved populations in question.

3. Describe the specific services to be provided or enhanced, such as new shelters or services, improved access to shelters or services, or new services for underserved populations such as victims from communities of color, immigrant victims, or victims with disabilities, etc.

4. Describe the public information component of the State’s outreach program: the elements of your program that are used to explain domestic violence, the most effective and safe ways to seek help, tools to identify available resources, etc.

3. Provide a complete description of the process and procedures used to involve the State Domestic Violence Coalition, knowledgeable individuals, and interested organizations, including those serving or representing marginalized communities, in the State planning process, and provide assurances that the State grantee is in compliance with the requirements of 42 U.S.C. 10402(a)(2)(C).

4. Provide complete documentation of consultation with and participation of the State Domestic Violence Coalition in the administration and distribution of FVPSA grants and grant funds awarded to the State as required by 42 U.S.C. 10410(a)(5) and 42 U.S.C. 10402(a)(2)(C)).

5. Provide complete documentation of policies, procedures and protocols that ensure individual identifiers of client records will not be used when providing statistical data on program activities and program services, that the confidentiality of records pertaining to any individual provided domestic violence prevention or treatment services by any FVPSA-supported program will be strictly maintained, and the address or location of any FVPSA-supported shelter will not be made public without the written authorization of the person or persons responsible for the operation of such shelter (42 U.S.C. 10402(a)(2)(E)).

6. Describe the plan to assure an equitable distribution of grants and grant funds within the State and between urban and rural areas within such State (42 U.S.C. 10402(a)(2)(C)).

7. Include a description of how the State plans to use the grant funds; a description of the target populations; the number of shelters to be funded; the number of non-residential programs to be funded; the services the State will provide; and the expected results from the use of the grant funds (42 U.S.C. 10402(a)(2)).

8. Provide a copy of the law or procedures, such as a process for obtaining an order of protection, that the State has implemented for the eviction of an abusive spouse from a shared household (42 U.S.C. 10402(a)(2)(F)).

Assurances

Each application must provide the assurances in Appendix A.

Certifications

All applications must submit or comply with the required certifications found in the Appendices as follows:

Anti-Lobbying Certification and Disclosure Form (See Appendix B): Applicants must furnish prior to award an executed copy of the Standard Form (SF) LLL, Certification Regarding Lobbying, when applying for an award in excess of $100,000. Applicants who have used non-Federal funds for lobbying activities in connection with receiving assistance under this announcement shall complete a disclosure form, if applicable, with their applications (approved by OMB under control number 0348-0046). Applicants should sign and return the certification with their application.

Certification Regarding Environmental Tobacco Smoke (See Appendix C): Applicants and subgrantees must understand they will be held accountable for the smoking prohibition included within P.L. 103-227, Title XII Environmental Tobacco Smoke (also known as the Pro Children Act of 1994). A copy of the Federal Register notice which implements the smoking prohibition is included with the forms. By signing and submitting the application, applicants are accepting and agreeing to all terms and conditions of the certification.

Certification Regarding Drug-Free Workplace Requirements (See Appendix D): The signature on the application by the chief program official attests to the applicant’s intent to comply with the Drug-Free Workplace requirements and compliance with the Debarment Certification. By signing and submitting the application, applicants are accepting and agreeing to all terms and conditions of the certification.

These certifications can be found at www.acf.hhs.gov/programs/ofs/forms.htm.

Notification Under Executive Order 12372

For States, this program is covered under Executive Order 12372, “Intergovernmental Review of Federal Programs,” for State plan consolidation and implication only -- 45 Code of Federal Regulations (CFR) 100.12. The review and comment provisions of the Executive Order and Part 100 do not apply.

Applications should be sent to:

Family Violence Prevention and Services Program

Family and Youth Services Bureau

Administration on Children, Youth and Families

Administration for Children and Families

Attention: Edna James and Shannon Gaskins

1250 Maryland Avenue, S.W., Suite 800

Washington, DC 20024

V. APPROVAL/DISAPPROVAL OF A STATE APPLICATION

The Secretary of HHS will approve any application that meets the requirements of FVPSA and this announcement and will not disapprove any such application except after reasonable notice of the Secretary’s intention to disapprove has been provided to the applicant and after a six-month period providing an opportunity for the applicant to correct any deficiencies. The notice of intention to disapprove will be provided to the applicant within 45 days of the date of the application.

VI. REPORTING REQUIREMENTS

Performance Reports

Section 42 U.S.C. 10402(a)(4) requires that States file a Program Performance Report (SF-PPR) with HHS describing the activities carried out, and inclusion of an assessment of the effectiveness of those activities in achieving the purposes of the grant (see Appendix E). 42 U.S.C. 10402(a)(5) requires that the State file a report that contains a description of the activities carried out with funds expended for State administrative costs.

A section of this performance report must be completed by each grantee or sub-grantee that performed the direct services contemplated in the State’s application certifying performance of such services. State grantees should compile performance reports into a comprehensive report for submission.

The Performance Report must include the following data elements and narrative examples of the services that were provided:

Funding – The total amount of the FVPSA grant funds awarded. Total amount of State administrative costs. Total number of subgrants awarded. Total domestic violence program budgets for programs that received FVPSA subgrants. The number of domestic violence programs with residential facilities funded. The number of non-residential programs funded.

Volunteers – The total number of volunteers working in FVPSA-supported programs; total volunteer hours.

Narrative Questions – For services or activities in the State supported in whole or in part by FVPSA funding, provide examples or summaries that describe:

• Stories concerning individual clients, services, or community or Statewide initiatives;

• Activities that the FVPSA grant allows grantees to do that they wouldn’t be able to do without this funding.

• Efforts to identify and meet the needs of underserved populations, including populations underserved because of ethnic, racial, cultural, or language diversity or geographic isolation. Include the ongoing challenges in addressing these needs.

• Significant prevention activities conducted during the program year.

• Any additional information that the grantee would like to share about the State’s FVPSA-supported domestic violence programs and their effectiveness, the unmet needs of victims in the State and what would be required to meet those needs, or service trends that are emerging in their communities.

People Served –

• An unduplicated count (unduplicated by program but not across state) of non-residential clients who are women, men, children, and youth who are intimate partner violence victims

• An unduplicated count (unduplicated by program but not across state) of residential clients, including the number of shelter nights, for women, men, children, and youth who are intimate partner violence victims

Demographics – For Unduplicated Clients, include the following demographic categories:

• Race/Ethnicity: Black or African American; American Indian/Alaska Native; Asian; Hispanic or Latino; Native Hawaiian/Other Pacific Islander; White; Unknown/Other

• Gender: Female; Male; or Not Specified

• Age: 0-17; 18-24; 25-59; 60+; Unknown

Residential Services –

• Total shelter nights

• Number of unmet requests for shelter

Related Services and Assistance – List the related services and assistance provided to victims and their family members by indicating the number of hours and or number of service contacts in each of the following categories:

• Crisis/hotline calls (number of calls)

• Supportive Counseling and Advocacy: Individual and Group

• Children’s Services

• Supportive Counseling and Advocacy: Individual and Group

• Children’s Activities: Individual and Group

• Batterer Intervention Services (if funded through FVPSA): Individual and Group

Community Education and Public Awareness – Report the number of presentations and participants that attended presentations/training for:

• Adults/General Population

• Youth Targeted

• Community Awareness Activities (Number of events only)

Outcome Data – Report results from FVPSA outcome surveys:

• Total number of domestic violence survivors who have more strategies for enhancing their safety, and total number completing safety outcome survey; and,

• Total number of domestic violence survivors who have more knowledge about community resources, and total number completing resource outcome survey.

Performance Reports for the States are due on an annual basis at the end of the calendar year (December 29). Performance Reports should be sent to:

Family Violence Prevention and Services Program

Family and Youth Services Bureau

Administration on Children, Youth and Families

Administration for Children and Families

Attention: Edna James and Shannon Gaskins

1250 Maryland Avenue, S.W., Suite 800

Washington, DC 20024

Please note that section 42 U.S.C. 10402(a)(4) of FVPSA requires HHS to suspend funding for an approved application if any State applicant fails to submit an annual Performance Report or if the funds are expended for purposes other than those set forth under this announcement.

Financial Status Reports

Grantees must submit annual Financial Status Reports. The first SF-269A is due December 29, 2009. The final SF-269A is due December 29, 2010. SF-269A can be found at http://www.whitehouse.gov/omb/grants/grants_forms.html.

Completed reports may be mailed to:

Frederick Griefer

Division of Mandatory Grants

Office of Grants Management

Administration for Children and Families

370 L’Enfant Promenade, S.W.

6^th Floor

Washington, DC 20447

Grantees have the option of submitting their reports online through the Online Data Collection (OLDC) system at the following address: https://extranet.acf.hhs.gov/ssi

Failure to submit reports on time may be a basis for withholding grant funds, suspension or termination of the grant. All funds reported as unobligated after the obligation period will be recouped.

VII. ADMINISTRATIVE AND NATIONAL POLICY REQUIREMENTS

Grantees are subject to the requirements in 45 CFR Part 74 (non-governmental) or 45 CFR Part 92 (governmental).

Direct Federal grants, sub-award funds, or contracts under this ACF program shall not be used to support inherently religious activities such as religious instruction, worship, or proselytization. Therefore, organizations must take steps to separate, in time or location, their inherently religious activities from the services funded under this program.   Regulations pertaining to the Equal Treatment for Faith-Based Organizations, which includes the prohibition against Federal funding of inherently religious activities, can be found at the HHS web site at http://www.hhs.gov/fbci/waisgate21.pdf.

A faith-based organization receiving HHS funds retains its independence from Federal, State, and local governments and may continue to carry out its mission, including the definition, practice, and expression of its religious beliefs.  For example, a faith-based organization may use space in its facilities to provide secular programs or services funded with Federal funds without removing religious art, icons, scriptures, or other religious symbols.  In addition, a faith-based organization that receives Federal funds retains its authority over its internal governance, and it may retain religious terms in its organization’s name, select its board members on a religious basis, and include religious references in its organization’s mission statements and other governing documents in accordance with program requirements, statutes, and other applicable requirements governing the conduct of HHS funded activities.

Faith-based and community organizations may reference the “Guidance to Faith-Based and Community Organizations on Partnering with the Federal Government” at http://www.whitehouse.gov/government/fbci/guidance/index.html.

HHS Grants Policy Statement

The HHS Grants Policy Statement (GPS) is the Department of Human Services new single policy guide for discretionary grants and cooperative agreements.  Unlike previous HHS policy documents, the GPS is intended to be shared with and used by grantees.  It became effective October 1, 2006 and is applicable to all Operating Divisions (OPDIVS), such as ACF, except the National Institutes of Health (NIH).  The GPS covers basic grant processes, standard terms and conditions and points of contact as well as important OPDIV-specific requirements.  Appendices include a glossary of terms and a list of standard abbreviations for ease of reference.  The GPS may be accessed as http:///www.acf.hhs.gov/grants/grants_resources.html.

VIII. OTHER INFORMATION

FOR FURTHER INFORMATION CONTACT: Edna James at (202) 205-7750 or e-mail at Edna.James@acf.hhs.gov, or Shannon Gaskins at (202) 205-7891 or e-mail at Shannon.Gaskins@acf.hhs.gov.

Date: ______________________ ________________________________

Joan E. Ohl, Commissioner

Administration on Children, Youth and Families

Appendices – Required Assurances and Certifications:

A. Assurances

B. Anti-Lobbying and Disclosure

C. Environmental Tobacco Smoke

D. Drug-Free Workplace Requirements

E. Performance Progress Report (SF-PPR)

Appendix A

ASSURANCES OF COMPLIANCE WITH GRANT REQUIREMENTS

The undersigned certifies that:

1. Grant funds under FVPSA will be distributed to local public agencies and non-profit private organizations (including religious and charitable organizations and voluntary associations) for programs and projects within the State to prevent incidents of family violence and to provide immediate shelter and related assistance for victims of family violence and their dependents in order to prevent future violent incidents (42 U.S.C. 10402(a)(2)(A)).

2. Not less than 70 percent of the funds distributed shall be used for immediate shelter and related assistance, as defined in 42 U.S.C. 10421(4) and (5), to victims of family violence and their dependents and not less than 25 percent of the funds distributed shall be used to provide related assistance as defined in 42 U.S.C. 10421(5) (42 U.S.C. 10402(g)).

3. Not more than five percent of the funds will be used for State administrative costs (42 U.S.C. 10402(a)(2)(B)(i)).

4. In distributing the funds, the States will give special emphasis to the support of community-based projects of demonstrated effectiveness carried out by non-profit, private organizations, particularly for those projects where the primary purpose is to operate shelters for victims of family violence and their dependents and those which provide counseling, advocacy, and self-help services to victims and their children (42 U.S.C. 10402(a)(2)(B)(ii)).

5. The State grantee is in compliance with the requirements of 42 U.S.C. 10402(a)(2)(C), as described in this program announcement (Program Announcement Number HHS-2009-ACF-ACYF-FVPS-XXX) under Section IV, Application Requirements, Content of Application Submission, paragraphs (2), (3), (4), and (6).

6. Grants funded by the States will meet the matching requirements in 42 U.S.C. 10402(f); i.e., not less than 20 percent of the total funds provided for a project under 42 U.S.C. 110 with respect to an existing program, and with respect to an entity intending to operate a new program under 42 U.S.C. 110, not less than 35 percent. The local share will be cash or in-kind, and the local share will not include any Federal funds provided under any authority other than this chapter (42 U.S.C. 10402(f)).

7. Grant funds made available under this program by the State will not be used as direct payment to any victim or dependent of a victim of family violence (42 U.S.C. 10402(d)).

8. No income eligibility standard will be imposed on individuals receiving assistance or services supported with funds appropriated to carry out FVPSA (42 U.S.C. 10402(e)).

9. The address or location of any shelter or facility assisted under FVPSA will not be made public, except with the written authorization of the person or persons responsible for the operations of such shelter (42 U.S.C. 10402(a)(2)(E)).

10. The applicant will comply with FVPSA confidentiality requirements and has established policies, procedures and protocols that ensure individual identifiers of client records will not be used when providing statistical data on program activities and program services and that the confidentiality of records pertaining to any individual provided domestic violence prevention or treatment services by any FVPSA-supported program will be strictly maintained (42 U.S.C. 10402(a)(2)(E)).

11. All grants, programs or other activities funded by the State in whole or in part with funds made available under FVPSA will prohibit discrimination on the basis of age, handicap, sex, race, color, national origin or religion (42 U.S.C. 10406).

12. Funds made available under the FVPSA will be used to supplement and not supplant other Federal, State and local public funds expended to provide services and activities that promote the purposes of the FVPSA (42 U.S.C. 10402 (a)(4).

____________________________________________

Signature

____________________________________________
Title

____________________________________________
Organization

Appendix B

CERTIFICATION REGARDING LOBBYING

Certification for Contracts, Grants, Loans, and Cooperative Agreements

The undersigned certifies, to the best of his or her knowledge and belief, that:

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Statement for Loan Guarantees and Loan Insurance

The undersigned states, to the best of his or her knowledge and belief, that::

If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions. Submission of this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

____________________________________________

Signature

____________________________________________
Title

____________________________________________
Organization

Appendix C

CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE

Public Law 103227, Part C Environmental Tobacco Smoke, also known as the Pro Children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor routinely owned or leased or contracted for by an entity and used routinely or regularly for provision of health, day care, education, or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law does not apply to children’s services provided in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1000 per day and/or the imposition of an administrative compliance order on the responsible entity. By signing and submitting this application the applicant/grantee certifies that it will comply with the requirements of the Act.

The applicant/grantee further agrees that it will require the language of this certification be included in any subawards which contain provisions for the children’s services and that all subgrantees shall certify accordingly.

Appendix D

CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS

This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988: 45 CFR Part 76, Subpart, F. Sections 76.630(c) and (d)(2) and 76.645(a)(1) and (b) provide that a Federal agency may designate a central receipt point for STATE-WIDE AND STATE AGENCY-WIDE certifications, and for notification of criminal drug convictions. For the Department of Health and Human Services, the central point is: Division of Grants Management and Oversight, Office of Management and Acquisition, Department of Health and Human Services, Room 517-D, 200 Independence Avenue, SW Washington, DC 20201.

Certification Regarding Drug-Free Workplace Requirements

(Instructions for Certification)

1. By signing and/or submitting this application or grant agreement, the grantee is providing the certification set out below.

2. The certification set out below is a material representation of fact upon which reliance is placed when the agency awards the grant. If it is later determined that the grantee knowingly rendered a false certification, or otherwise violates the requirements of the Drug-Free Workplace Act, the agency, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act.

3. For grantees other than individuals, Alternate I applies.

4. For grantees who are individuals, Alternate II applies.

5. Workplaces under grants, for grantees other than individuals, need not be identified on the certification. If known, they may be identified in the grant application. If the grantee does not identify the workplaces at the time of application, or upon award, if there is no application, the grantee must keep the identity of the workplace(s) on file in its office and make the information available for Federal inspection. Failure to identify all known workplaces constitutes a violation of the grantee’s drug-free workplace requirements.

6. Workplace identifications must include the actual address of buildings (or parts of buildings) or other sites where work under the grant takes place. Categorical descriptions may be used (e.g., all vehicles of a mass transit authority or State highway department while in operation, State employees in each local unemployment office, performers in concert halls or radio studios).

7. If the workplace identified to the agency changes during the performance of the grant, the grantee shall inform the agency of the change(s), if it previously identified the workplaces in question (see paragraph five).

8. Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common rule apply to this certification. Grantees’ attention is called, in particular, to the following definitions from these rules:
   
   Controlled substance means a controlled substance in Schedules I through V of the Controlled Substances Act (21 U.S.C. 812) and as further defined by regulation (21 CFR 1308.11 through 1308.15);
   
   Conviction means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or both, by any judicial body charged with the responsibility to determine violations of the Federal or State criminal drug statutes;
   
   Criminal drug statute means a Federal or non-Federal criminal statute involving the manufacture, distribution, dispensing, use, or possession of any controlled substance;
   
   Employee means the employee of a grantee directly engaged in the performance of work under a grant, including: (i) All direct charge employees; (ii) All indirect charge employees unless their impact or involvement is insignificant to the performance of the grant; and, (iii) Temporary personnel and consultants who are directly engaged in the performance of work under the grant and who are on the grantee’s payroll. This definition does not include workers not on the payroll of the grantee (e.g., volunteers, even if used to meet a matching requirement; consultants or independent contractors not on the grantee’s payroll; or employees of subrecipients or subcontractors in covered workplaces).
   
   

Certification Regarding Drug-Free Workplace Requirements

Alternate I. (Grantees Other Than Individuals)

The grantee certifies that it will or will continue to provide a drug-free workplace by:

(1) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the grantee’s workplace and specifying the actions that will be taken against employees for violation of such prohibition;

(2) Establishing an ongoing drug-free awareness program to inform employees about –

(a) The dangers of drug abuse in the workplace;

(b) The grantee’s policy of maintaining a drug-free workplace;

(c) Any available drug counseling, rehabilitation, and employee assistance programs; and

(d) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;

(3) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph (a);

(4) Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant, the employee will –

(a) Abide by the terms of the statement; and

(b) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction;

(5) Notifying the agency in writing, within 10 calendar days after receiving notice under paragraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant activity the convicted employee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant;

(6) Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d)(2), with respect to any employee who is so convicted –

(a) Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or

(b) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency;

(7) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e) and (f).

The grantee may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant:

Place of Performance (Street address, city, county, state, zip code)

                                                                                                                                

                                                                                                                                

Check if there are workplaces on file that are not identified here.

Alternate II. (Grantees Who Are Individuals)

1. The grantee certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant;

2. If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant activity, he or she will report the conviction, in writing, within 10 calendar days of the conviction, to every grant officer or other designee, unless the Federal agency designates a central point for the receipt of such notices. When notice is made to such a central point, it shall include the identification number(s) of each affected grant.

   
   

S

Appendix E

F-PPR

Family Violence Prevention and Services Program

Family and Youth Services Bureau/Administration for Children and Families

U.S. Department of Health and Human Services

State Grant Report

					Page	of Pages
1. Federal Agency and Organization Element to Which Report is Submitted FVPSP/FYSB/ACYF/ACF/HHS		2a. Total FVPSA Funds Awarded 2b. Total Amount of State Administrative Costs			3a. DUNS Number
					3b. EIN
4. Recipient Organization (Name and Complete Address Including Zip Code)					5a. Total Number of Subgrants Awarded 5b. # Shelter Programs Funded with Residential Facilities 5c. # Non-Residential Domestic Violence Programs Funded
6. Project Reporting Period
Start Date: (Month, Day, Year)	End Date: (Month, Day, Year)
Note: Information on FVPSA grants/funds awarded should include any funds awarded by the state during the federal fiscal year reporting period. For example, during the past federal fiscal year (Oct- Sep), the State made awards to subgrantees in July. The State should report on the grants and funds awarded in July and any other funds awarded during the federal fiscal year reporting period. The State’s aggregate report of services provided by FVPSA subgrantees should include all services/grant activities that occurred throughout the federal fiscal year reporting period (Oct – Sep).
7. Other Attachments (Performance Progress Report with aggregated subgrantee information for the State/ Territory)
8. Certification: I certify to the best of my knowledge and belief that this report is correct and complete for performance of activities for the purposes set forth in the award documents.
9a. Typed or Printed Name and Title of Authorized Certifying Official			9c. Telephone (area code, number and extension)
			9d. Email Address
9b. Signature of Authorized Certifying Official			9e. Date Report Submitted (Month, Day, Year)
			10. Agency Use Only

Family Violence Prevention and Services Program

Family and Youth Services Bureau/Administration for Children and Families

U.S. Department of Health and Human Services

Subgrantee Information

			Page		of Pages
1. Federal Agency and Organization Element to Which Report is Submitted FVPSP/FYSB/ACYF/ACF/HHS	2a. Total Domestic Violence Budget 2b. FVPSA Grant Amount		3a. # of Shelter Programs with Residential Facilities
			3b. # of Non-Residential Domestic Violence Programs
4. Recipient Organization (Name and complete address including zip code)
5. Project/Grant Period				6. Number of Volunteers
Start Date: (Month, Day, Year)	End Date: (Month, Day, Year)			7. Number of Volunteer Hours
8. Performance Narrative (attach performance narrative as instructed by the awarding Federal Agency) For services supported in whole or in part by your FVPSA grant, share a story about a client, service or community initiative. What does the FVPSA grant allow you to do that you wouldn’t be able to do without this funding? Describe, if applicable, any efforts supported in whole or in part by your FVPSA grant in meeting the needs of underserved populations in your community, including populations underserved because of ethnic, racial, cultural or language diversity or geographic isolation. Describe any ongoing challenges. Describe significant prevention and outreach activities, supported in whole or in part by your FVPSA grant, during the program year. (Optional) Provide any additional information that you would like us to know about your FVPSA-supported domestic violence program and its effectiveness, the unmet needs of victims in your community and what would be required to meet them, or service trends that are emerging in your community.
9. Other Attachments (attach other documents as needed or as instructed by the awarding Federal Agency)
10. Certification: I certify to the best of my knowledge and belief that this report is correct and complete for performance of activities for the purposes set forth in the award documents.
11a. Typed or Printed Name and Title of Authorized Certifying Official		11c. Telephone (area code, number and extension)
		11d. Email Address
11b. Signature of Authorized Certifying Official		11e. Date Report Submitted (Month, Day, Year)
		12. Agency Use Only

SF-PPR-D

Table of Activity Results

Page

of Pages

1. Federal Agency and Organization Element to Which Report is Submitted FVPSP/FYSB/ACYF/ACF/HHS

2. Name of Recipient Organization

3a. DUNS

4. Reporting Period End Date (Month, Day, Year)

3b. EIN

Section A—People Served (Unduplicated) Indicate the number of all clients served by gender, ethnicity, and age. Do not include clients served only in Batterers Intervention Services; count them in Section E.

Residential

Women

Men

Children

Youth IPV Victim

FV-A-100

Unduplicated Count of Clients Served

Non-Residential

Women

Men

Children

Youth IPV Victim

FV-A-200

Unduplicated Count of Clients Served

Race

Black or African American

American Indian/ Alaska Native

Asian

Hispanic or Latino

Native Hawaiian/ Other Pacific Islander

White

Unknown/ Other

FV-A-300

Clients

Gender

Female

Male

Not Specified

FV-A-400

Clients

Age

0-17

18-24

25-59

60+

Unknown

FV-A-500

Clients

Section B—Residential Services Indicate the number of shelter nights for each person that arrives and is provided a shelter bed. Count the # of people housed X the number of nights.

FV-B-100

Shelter Nights

FV-B-200

Unmet Requests for Shelter

SF-PPR-D

Page

of Pages

1. Federal Agency and Organization Element to Which Report is Submitted FVPSP/FYSB/ACYF/ACF/HHS

2. Name of Recipient Organization

3a. DUNS Number

3b. EIN Number

4. Reporting Period End Date (Month, Day, Year)

Section C—Related Services and Assistance for Adults Indicate the number of service contacts and/or hours provided regardless of length. For states using time increments, report total hours in “Number of Hours” column provided.

3b. EIN

Crisis/Hotline Calls

Total Calls

FV-C-100

Crisis/Hotline Calls

Supportive Counseling & Advocacy

Number of Service Contacts

Number of Hours

FV-C-200

Individual Supportive Counseling & Advocacy

FV-C-201

Group Supportive Counseling & Advocacy

Section D—Related Services and Assistance for Children Indicate the number of service contacts and/or hours provided regardless of length. For states using time increments, report total hours in “Number of Hours” column provided.

Supportive Counseling & Advocacy

Number of Hours

Number of Service Contacts

FV-D-100

Individual

FV-D-101

Group

Activities for Children & Youth

Number of Hours

Number of Service Contacts

FV-D-200

Individual Activities

FV-D-201

Group Activities

Section E—Batterer Intervention Services Indicate the number of service contacts and/or hours provided. Report only if these services are funded by FVPSA.

Intervention/Counseling Services

Number of Clients

Number of Service Contacts

Number of Hours

FV-E-100

Individual Counseling

FV-E-101

Group Counseling

Section F—Community Education and Public Awareness Indicate the total number of training and community education presentations. Indicate the total number of individuals attending.

Community Education

Number of Presentations

Number of Participants

FV-F-100

Adults/General Population

FV-F-101

Youth Targeted

Community Awareness Activities

Number of Activities

FV-F-200

Awareness Activities

SF-PPR-D

					Page			of Pages
1. Federal Agency and Organization Element to Which Report is Submitted FVPSP/FYSB/ACYF/ACF/HHS			2. Name of Recipient Organization	3a. DUNS Number	3b. EIN Number			4. Reporting Period End Date (Month, Day, Year)
Section G—Service Outcome DATA For each program area from which you collected outcome data, indicate how many surveys were completed and how many YES responses you received to each of the outcome questions (resources and safety).
	Survey Type	Number of Surveys Competed		Number of Yes Responses to Resource Outcome		Number of Yes Responses to Safety Outcome
FV-G-101	Shelter Survey
FV-G-102	Support Services and Advocacy Survey
FV-G-103	Counseling Survey
FV-G-104	Support Group Survey
FV-G-105	TOTAL

42