Form 1 Tribal Performace Report

PERFORMANCE PROGRESS REPORT

SF-PPR

Family Violence Prevention & Services Program

Family & Youth Services Bureau/Administration for Children and Families

U.S. Department of Health and Human Services

Native American Tribal Programs

				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. DUNS Number
				3b. EIN
4. Recipient Organization (Name and Complete Address Including Zip Code)				5a. # of Shelter Programs with Residential Facilities 5b. # of Non-Residential Domestic Violence Programs
6. Project/Grant Period				7. Number of Volunteers
Start Date: (Month, Day, Year)	End Date: (Month, Day, Year)			8. Number of Volunteer Hours
9. 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 your 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 to meet the unique needs of your community and any on-going challenges in meeting these needs. For example: Tribal shelters not available; accessibility of non-native shelters; transportation; teen services; etc. 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.
10. Other Attachments (attach other documents as needed or as instructed by the awarding Federal Agency)
11. 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.
12a. Typed or Printed Name and Title of Authorized Certifying Official		12c. Telephone (area code, number and extension)
		12d. Email Address
12b. Signature of Authorized Certifying Official		12e. Date Report Submitted (Month, Day, Year)
		13. Agency Use Only

SF-PPR-D

Table of Activity Results

						Page
1. Federal Agency and Organization Element to Which Report is Submitted FVPSP/FYSB/ACYF/ACF/HHS		2. Name of Recipient Organization			3a. DUNS
					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 service contacts and/or hours provided regardless of length. For Tribal programs using time increments, report total hours in “Number of Hours” column.
FV-B-100	Shelter Nights
FV-B-200	Unmet Request 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

3b. EIN

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

Crisis/Hotline Calls

Total Calls

FV-C-100

Crisis/Hotline Calls

Supportive Counseling

Number of Hours

Number of Service Contacts

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 Tribal programs using time increments, report total hours in “Number of Hours” column provided.

Supportive Counseling

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

FV-D-201

Group

Section E—Batterer Intervention Services Indicate the number of hours and/or service contacts 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

FV-E-101

Group

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

OMB Approval Number: