Fvpsa State Grant Program Announcement

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 nonprofit 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

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Health and Human Services (HHS) also made 53 family violence prevention grant awards to nonprofit 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,

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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 clientlevel 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)).

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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

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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,

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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 FVPSAsupported 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).

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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

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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.

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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,

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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.

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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.

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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:

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(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)).

(a) 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.

(b) 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.

(c) 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

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populations such as victims from communities of color, immigrant victims, or victims
with disabilities, etc.

(d) 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

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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

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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 nonFederal 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.

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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

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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:

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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.

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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

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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.

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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:

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Frederick Griefer
Division of Mandatory Grants
Office of Grants Management
Administration for Children and Families
370 L’Enfant Promenade, S.W.
6th 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

24

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

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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

26

C. Environmental Tobacco Smoke
D. Drug-Free Workplace Requirements
E. Performance Progress Report (SF-PPR)

27

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 communitybased 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

28

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-2009ACF-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 inkind, 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)).

29

(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).

30

____________________________________________
Signature

____________________________________________
Title

____________________________________________
Organization

31

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.

32

(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.

33

____________________________________________
Signature

____________________________________________
Title

____________________________________________
Organization

34

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.

35

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.

36

(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

37

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).

38

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);

39

(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

40

(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;

41

(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.

42

PERFORMANCE PROGRESS REPORT
Appendix E
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

1. Federal Agency and Organization Element
to Which Report is Submitted

2a. Total FVPSA Funds Awarded
2b. Total Amount of State
Administrative Costs

FVPSP/FYSB/ACYF/ACF/HHS

4. Recipient Organization (Name and Complete Address Including Zip Code)

of
Pages
3a. DUNS Number
3b. EIN

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

OMB Approval Number:

PERFORMANCE PROGRESS REPORT
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
1. Federal Agency and Organization Element to
Which Report is Submitted

2a. Total Domestic Violence Budget

FVPSP/FYSB/ACYF/ACF/HHS

2b. FVPSA Grant Amount

of
Pages
3a. # of Shelter Programs
with Residential Facilities
3b. # of Non-Residential
Domestic Violence Programs

4. Recipient Organization (Name and complete address including zip code)

6. Number of Volunteers

5. Project/Grant Period
Start Date: (Month, Day, Year)

8. Performance Narrative

End Date: (Month, Day, Year)

7. Number of Volunteer Hours

(attach performance narrative as instructed by the awarding Federal Agency)

a) For services supported in whole or in part by your FVPSA grant, share a story about a client, service or
community initiative.
b) What does the FVPSA grant allow you to do that you wouldn’t be able to do without this funding?
c) 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.
d) Describe significant prevention and outreach activities, supported in whole or in part by your FVPSA grant,
during the program year.
e) (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

OMB Approval Number:

PERFORMANCE PROGRESS REPORT
SF-PPR-D
Table of Activity Results
Page
1. Federal Agency and Organization
Element to Which Report is Submitted

2. Name of Recipient
Organization

3a. DUNS

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

3b. EIN
FVPSP/FYSB/ACYF/ACF/HHS

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

FV-A-100

Women

Men

Children

Youth IPV
Victim

Women

Men

Children

Youth IPV
Victim

Black or
African
American

American
Indian/
Alaska
Native

Asian

Hispanic
or Latino

Native
Hawaiian/
Other
Pacific
Islander

Gender

Female

Male

Not
Specified

Age

0-17

18-24

25-59

60+

Unknown

Unduplicated Count of
Clients Served
Non-Residential

FV-A-200

Unduplicated Count of
Clients Served
Race

FV-A-300

FV-A-400

FV-A-500

White

Clients

Clients
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

OMB Approval Number:

Unknown/
Other

PERFORMANCE PROGRESS REPORT
SF-PPR-D
1. Federal Agency and Organization
Element to Which Report is Submitted

2. Name of Recipient
Organization

Page
3b. EIN Number

3a. DUNS
Number

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

FVPSP/FYSB/ACYF/ACF/HHS

Section C—Related Services and Assistance for Adults
Indicate the number of service contacts and/or hours provided regardless of length.
report total hours in “Number of Hours” column provided.
Crisis/Hotline Calls

FV-C-100

Total
Calls

Crisis/Hotline Calls
Supportive Counseling
& Advocacy

FV-C-200

Individual Supportive
Counseling & Advocacy

FV-C-201

Group Supportive
Counseling & Advocacy

Number of
Service
Contacts

Number of Hours

Section D—Related Services and Assistance for Children
Indicate the number of service contacts and/or hours provided regardless of length.
report total hours in “Number of Hours” column provided.
Supportive Counseling
& Advocacy
FV-D-100

Individual

FV-D-101

Group
Activities for Children &
Youth

FV-D-200

For states using time increments,

Number of
Hours

Number of
Service Contacts

Number of
Hours

Number of
Service Contacts

For states using time increments,

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
FV-E-100

Individual Counseling

FV-E-101

Group Counseling

Number of
Clients

Number of
Service Contacts

Number
of Hours

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
FV-F-100

Adults/General Population

FV-F-101

Youth Targeted
Community Awareness
Activities

FV-F-200

Number of
Presentations

Number of
Participants

Number of
Activities

Awareness Activities

OMB Approval Number:

PERFORMANCE PROGRESS REPORT
SF-PPR-D
1. Federal Agency and Organization
Element to Which Report is Submitted

2. Name of Recipient
Organization

3a. DUNS
Number

Page
3b. EIN Number

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

FVPSP/FYSB/ACYF/ACF/HHS

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

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

Number of Surveys Competed

Number of Yes
Responses to
Resource Outcome

Number of
Yes
Responses to
Safety
Outcome

OMB Approval Number: