Form 1 STATE PERFORMANCE REPORT

PERFORMANCE PROGRESS REPORT

SF-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

OMB Approval Number: