Form 1 Tribal PPR

PERFORMANCE PROGRESS REPORT (PPR)
Family Violence Prevention and Services Program (FVPSP) / Family and Youth Services Bureau (FYSB) /
Administration on Children, Youth and Families (ACYF) / Administration for Children and Families (ACF) /
U.S. Department of Health and Human Services (HHS)
Tribal Grant Report Cover Page
Page
of
pages
1. Federal Agency and Organization Element
to Which Report is Submitted

2. Federal Grant or Other Identifying
Number Assigned by Federal Agency

3a. DUNS Number
3b. EIN

FVPSP/FYSB/ACYF/ACF/HHS
4. Recipient Organization (Name and Complete Address Including Zip Code)

5. Recipient Identifying Number or
Account Number

,
6. Project Reporting Period
Start Date: (Month, Day, Year)

7. Reporting Period End
Date
End Date: (Month, Day, Year)

(Month, Day, Year)

Yes
No

8. Final Report?
9. Report Frequency
annual
quarterly

semi-annual
other

10. Performance Narrative
Attach a separate document with the labeled responses to each of the elements in Section H.

11. Other Attachments

12. 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

1

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PERFORMANCE PROGRESS REPORT (PPR)
Family Violence Prevention Services Program Performance Report

Tribal Grantee Program Information
Page
of 0 pages
1. Federal Agency and Organization Element
to Which Report is Submitted

2. Federal Grant or Other Identifying
Number Assigned by Federal Agency

3a. DUNS Number
3b. EIN

FVPSP/FYSB/ACYF/ACF/HHS
Section A – General Program Information
Label

Information Requested

A-01

Total domestic violence program budget

A-02

FVPSA grant amount

A-03

Number of shelter facilities

A-04

Number of non-shelter service sites

A-05

Number of volunteers

A-06

Number of volunteer hours

Response

Explanation (optional)

Section B—People Served (Unduplicated)
Include all victims served. Do not include clients served only in Batterers Intervention Services; count them in Section F.
Shelter
(including safe homes)

B-01

2

Children

Youth
IPV
Victim

Women

Men

Not
Specified

Children

Youth
IPV
Victim

Black or
African
American

American
Indian/
Alaska
Native

Asian

0-17

18-24

25-59

Native
Unknown/
Hawaiian/
Hispanic
Other
White
Other
or Latino
Pacific
Islander

Clients
Age

B-04

Not
Specified

Unduplicated Count of
Clients Served

Race/Ethnicity

B-03

Men

Unduplicated Count of
Clients Served
Non-Shelter
(supportive services
only)

B-02

Women

60+

Unknown

Clients

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PERFORMANCE PROGRESS REPORT (PPR)

Tribal Grantee Program Information (continued)
Page
of 0 pages
1. Federal Agency and Organization Element
to Which Report is Submitted

2. Federal Grant or Other Identifying
Number Assigned by Federal Agency

3a. DUNS Number
3b. EIN

FVPSP/FYSB/ACYF/ACF/HHS

Section C—Shelter Services
Indicate the number of shelter nights for each person that arrives and is provided a bed, including on-site shelter, safe
home or hotel room. Count the # of people housed times the number of nights.
C-01

Shelter Nights

C-02

Unmet Requests for Shelter

Section D—Supportive Services for Adults
Indicate the number of service contacts provided regardless of length.
Crisis/Hotline Calls
D-01

Total Calls

Crisis/Hotline Calls
Supportive Counseling
& Advocacy

D-02

Individual Supportive
Counseling & Advocacy

D-03

Group Supportive
Counseling & Advocacy

Number of Service
Contacts

Section E—Supportive Services for Children
Indicate the number of service contacts provided regardless of length.
Supportive Counseling
& Advocacy
E-01

Individual

E-02

Group
Activities for Children
& Youth

E-03

Individual Activities

E-04

Group Activities

3

Number of Service
Contacts

Number of Service
Contacts

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PERFORMANCE PROGRESS REPORT (PPR)

Tribal Grantee Program Information (continued)
Page
of 0 pages
1. Federal Agency and Organization Element
to Which Report is Submitted

2. Federal Grant or Other Identifying
Number Assigned by Federal Agency

3a. DUNS Number
3b. EIN

FVPSP/FYSB/ACYF/ACF/HHS
Section F—Batterer Intervention Services
Report only if these services are funded by FVPSA.
Gender

F-01

Female

Not
Specified

0-17

18-24

25-59

Unduplicated Count of
Clients Receiving
Batterer Intervention
Services
Age

F-02

Male

60+

Unknown

Batterer Intervention
Clients
Intervention/
Counseling Services

F-03

Individual Counseling

F-04

Group Counseling

Number
of
Service
Contacts

Section G—Community Education and Public Awareness
Indicate the total number of training and community education presentations and the total number of individuals
attending.
Community
Education
G-01

Adults/General
Population

G-02

Youth Targeted
Community
Awareness Activities

G-03

4

Number of
Presentations

Number of
Participants

Number of
Activities

Awareness Activities

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PERFORMANCE PROGRESS REPORT (PPR)

Tribal Grantee Program Information (continued)
Page
of 0 pages
1. Federal Agency and Organization Element
to Which Report is Submitted

2. Federal Grant or Other Identifying
Number Assigned by Federal Agency

3a. DUNS Number
3b. EIN

FVPSP/FYSB/ACYF/ACF/HHS

Section H—Narrative Responses
Attach a separate document with the labeled responses to each of the below elements.
H-01

For services supported in whole or in part by your FVPSA grant, share
a story about a client, service or community initiative.

H-02

What does the FVPSA grant allow you to do that you wouldn’t be able
to do without this funding?

H-03

Describe any efforts to meet the unique needs of your community and
any ongoing challenges in meeting those needs, i.e., tribal shelters not
available, accessibility of transportation, services for adolescents.

H-04

Describe significant prevention and outreach activities, supported in
whole or in part by your FVPSA grant, during the program year.

H-05

Provide information on the evaluation of the effectiveness of your
domestic violence programming

H-06

(Optional) Provide any additional information that you would like us to
know about your FVPSA-supported domestic violence program, i.e.,
the unmet needs of victims in your community, other funding sources
used for programming or service trends that are emerging in your
community.

5

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PERFORMANCE PROGRESS REPORT (PPR)

Instructions for Completion of the Performance Progress Report

Instructions for Cover Page
Item

Data Element

Instructions

1.

Federal Agency and
Organizational Element to Which
Report is Submitted

Enter the name of the awarding Federal agency and organizational
element identified in the award document or otherwise instructed by the
agency. The organizational element is a sub-agency within an awarding
Federal agency.

2.

Federal Grant or Other Identifying
Number Assigned by the
awarding Federal agency

Enter the grant/award number contained in the award document.

3a.

DUNS Number

Enter the recipient organization's Data Universal Numbering System
(DUNS) number or Central Contract Registry extended DUNS number.

3b.

EIN

Enter the recipient organization's Employer Identification Number (EIN)
provided by the Internal Revenue Service.

4.

Recipient Organization

Enter the name of recipient organization and complete address, including
ZIP code.

5.

Recipient Account Number or
Account Number

Enter the account number or any other identifying number assigned by the
recipient to the award. This number is strictly for the recipient's use only
and is not required by the awarding Federal agency.

6.

Project/Grant Period

Enter the federal fiscal year covered by this performance progress report.

7.

Reporting Period End Date

Enter the ending date of the reporting period.

8.

Final Report

Mark appropriate box. Check “yes” only if this is the final report for the
project/grant period specified in Box 6.

9.

Report or Frequency

Select “annual” for report frequency.

10.

Performance Narrative

Attach a separate document with the labeled responses to each of the
elements in Section H.

11.

Other Attachments

None required.

12a.

Certification – Name

Type or print the name and title of the Authorized Certifying Official.

12b.

Certification - Signature

The Authorized Certifying Official should sign here.

12c.

Certification – Phone

Enter the area code, phone number and extension of the Authorized
Certifying Official.

12d.

Certification – Email

Enter the email address of the Authorized Certifying Official.

12e.

Certification – Date

Enter the date (month, day, year) the report is submitted.

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PERFORMANCE PROGRESS REPORT (PPR)

Instructions for Section A – General Program Information
Item

Data
Element

Instructions

This report is a compilation of all of the domestic violence services provided for victims of domestic violence and their
dependents – whether or not the service is provided with FVPSA funds. In consultation with FVPSA state
administrators, tribal program coordinators and coalition representatives, it was determined that this report would
include a count of all domestic violence services provided through FVPSA-funded programs, including those supported
through other funding sources. In order to accurately report the proportion of services supported through FVPSA
funding, grantees are required to report the total domestic violence budget (A-01) and the FVPSA grant amount (A-02).
These figures are used to determine the percentage of the program budget /services funded through FVPSA. It is
imperative that the total domestic violence program budget (A-01) are accurate numbers.
This is the sum of the total annual budget for the domestic violence program. Report the total
budget that is used to provide the services to victims included in this report, This number could
include additional funding from other sources or it may be the same as the FVPSA grant amount
listed in A-02.

A-01

Total
Domestic
Violence
Program
Budget

A-02

FVPSA
Grant
Amount

List total amount of FVPSA grant received within this fiscal year.

A-03

Number of
Shelter
Facilities

List the total number of shelter facilities providing immediate housing to victims of domestic
violence and their children managed by the tribal domestic violence program. This number
should not include safe homes, motels or shelter beds provided by other programs.

A-04

Non-Shelter
Services
Sites

List the total number of service sites (i.e., office locations) where a program provides nonresidential services. This may include the coordination of shelter for victims through hotels and
safe homes where there is not a tribal shelter facility. This number should be one (1) if the
program has a single program site with no tribal shelter facility. If a program maintains satellite
locations, they should be counted here, i.e., one main office and two satellite offices should be
reported as three (3) sites. This is not a count of the number of hotels and safe homes used.

A-05

Volunteers

Count number of individuals from all areas, including programmatic (i.e., advocacy, and
transportation) and administrative services (i.e., board members and data entry).

A-06

Volunteer
Hours

Count total time rounded to nearest hour.

For example, the total program budget would include all funding sources, i.e., FVPSA dollars
and state dollars to provide shelter to victims. Grant dollars set aside to provide separate
services to sexual assault victims would not be included here. In addition, a domestic violence
program that is located within a larger social service agency would only include its budget for
domestic violence programming. For example, a local domestic violence program that receives
$50,000 in FVPSA funds, $20,000 from the state for DV services and $10,000 from a private
funder would report $80,000 as its total domestic violence program budget.

Instructions for Section B – People Served
Item

Data Element

Instructions

If the grantee has concerns that providing the data below will allow a report reader to personally identify a victim, then
use the boxes for “not specified” or “unknown” for that client’s data.

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PERFORMANCE PROGRESS REPORT (PPR)
Item

Data Element
Shelter
(including safe
homes)

B-01

B-02

B-03

B-04

Instructions
Number of new domestic violence victims (clients) seen for the first time during this
reporting period who received shelter services (including a shelter facility managed by the
tribal program, safe home or hotel). Clients should be counted once regardless of the
number of times served during the fiscal year. Clients who received shelter should only
be counted in this element and not counted in B-02 even though they may have received
non-shelter services also. Clients who were referred to another domestic violence shelter
program should not be counted here. Count will be within tribal program only and not
unduplicated across programs statewide.

Non-Shelter
(supportive
services only)

Clients who received only non-shelter services should be counted in this category.
Exclude clients served only by Batterer Intervention Programs (they are counted in Sec.
E) and those served by a hotline only. Count should be within program only and not
unduplicated across programs statewide.

Youth IPV
Victim

Count the number of youth under the age of 18 who were identified as victims of intimate
partner violence (IPV). This number is a subset of the total number of children served.
For example, a program served 100 children & youth of which 8 identified as Youth IPV
Victims. Report as Children & Youth – 100; Youth IPV Victim – 8 which means the 8
Youth IPV Victims are counted in both fields. Child abuse cases do not count as IPV
victims.

Race/Ethnicity

Report the race and/or ethnicity of the clients served, including children and youth.
Clients may self-identify in more than one category, i.e., American Indian and Black.
Therefore, the total number may exceed the total number in B-01 plus B-02.

Age

Report the ages of the clients served, including children and youth. These demographic
totals should equal the program’s numbers totaled in B-01 plus B-02. For example, if the
program served 30 women, 62 children and 2 men, the total for all the ages should add up
to 94.

Instructions for Section C –Shelter Services
Item

Data Element

Instructions
Indicate the number of shelter nights for each person who arrives and is provided a bed,
including on-site shelter, safe home or hotel room. Include victims of domestic violence
and their dependents. Count the number of people housed times the number of nights.
For example, a victim and her 3 children stay in the shelter or safe house for 5 nights – 4
people x 5 nights = 20 shelter nights.

C-01

Shelter Nights
Shelter includes onsite shelter managed by the tribal domestic violence program,
program-sponsored hotel rooms and safe homes (residences of volunteers who offer their
private homes for short-term crisis situations) or other temporary housing that your
program arranges. Nights that a victims stays in a shelter (i.e., a shelter in a nearby
county) not managed by your tribal program should not be counted.

C-02

8

Unmet Requests
for Shelter

Count the number of unmet requests for shelter due to program shelter, safe homes or
sponsored hotel rooms being at capacity or unavailable. Count the adult victims of
domestic violence only. This count should not include individuals who were not served
because their needs were inappropriate for the services of your program, i.e.,
homelessness not related to domestic violence. Count the total number of times requests
for shelter were declined, even if the program provided other services.

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PERFORMANCE PROGRESS REPORT (PPR)

Instructions for Section D – Supportive Services for Adults
Item

D-01

D-02

Data Element

Crisis/Hotline
Calls

Individual

Instructions
Calls received on any agency line that relate to an individual or family in need of some kind
of service. A tribal program does not have to have a dedicated hotline to count these calls.
Count all calls including repeat callers and calls from third parties. Do not count donations,
general information about program or violence issues unrelated to a specific individual or
family, calls from the media, etc.
Count the total number of service contacts provided regardless of length. A contact could
be a thirty minute counseling session in shelter or several hours to accompany a survivor
to court. Do not count brief encounters such as distribution of toiletries, giving out a survey
to complete, etc.
Supportive services are services such as crisis intervention, safety planning, individual
counseling, educational services, legal advocacy, personal advocacy, housing advocacy,
medical advocacy, information/referral, transportation and home visits.

D-03

Group

Count the total number of sessions for each individual in attendance at the group. For
example, 5 support groups with 10 individuals at each = 50 service contacts. Some
examples of groups are support groups or psycho-educational groups.

Instructions for Section E – Supportive Services for Children
Item

Data Element

Instructions

Supportive Counseling/Advocacy for Children & Youth

E-01

E-02

Individual

Count total number of service contacts with children under the age of 18. These
supportive services provided to children may be crisis intervention, safety planning,
individual counseling or educational services. For example, if an advocate meets 3
different times with a client to have a safety planning session, drive to an
appointment and provide crisis counseling, then the count would be 3 service
contacts.

Group

Count the total number of sessions for each individual in attendance at the group.
For example, 4 groups with 8 individuals at each = 32 service contacts. Some
examples of groups are support groups for children who are exposed to domestic
violence or art therapy groups.

Activities for Children & Youth
Counts in this section are non-IPV related services provided.
E-03

Individual

Count total number of service contacts with children that fall outside of child
advocacy including contacts such as mentoring or recreational opportunities.

E-04

Group

Count the total number of service contacts that fall outside of child advocacy
including recreational activities, child care, etc. For example, a field trip to a park for
4 children residing in shelter = 4 service contacts.

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PERFORMANCE PROGRESS REPORT (PPR)

Instructions for Section F – Batterer Intervention Services
Item

Data Element

Instructions

Batterer intervention services include a provision of sessions based on a specific model of intervention designed to
address accountability for abusive behavior including re-education programs for those who abuse their intimate
partners.
Report in this section only if these services are funded by FVPSA.

F-01

Unduplicated Count of
Clients Receiving
Batterer Intervention
Services

Number of new clients seen for the first time during this reporting period who
received batterer intervention services (either individual or group services) using
FVPSA funds. Clients should be counted once regardless of the number of times
served during the fiscal year.

F-02

Age

Report the ages of the clients served in batterer intervention, including youth. These
demographic totals should equal the totals for F-01.

F-03

Individual

Count the total number of service contacts with clients who received batterer
intervention services. For example, if a provider meets with a client 12 separate
times to provide a series of counseling sessions, then that is 12 service contacts.

Group

Count the total number of service contacts with clients who received group batterer
intervention services. For example, if a support group was held with 12 clients that
met for 24 weeks, then the number of service contacts would be 12 times 24 to equal
288.

F-04

Instructions for Section G – Community Education and Public Awareness
Item

G-01

Data Element
Adults/ General
Population

Instructions
Count the total number of presentations or trainings about domestic violence and/or
services related to victims of domestic violence and their children. In addition, count
the number of individuals in attendance. Some examples may be a training for health
professionals or a workshop for tribal leaders. Include all presentations for a mixedage audience.

G-02

Youth Targeted

Count the total number of presentations or trainings about domestic violence, dating
violence, healthy relationships or available services for victims. In addition, count the
number of individuals in attendance. Some examples may be a presentation to youth
in school on healthy relationships or a workshop for youth at a Safety Day event.

G-03

Public Awareness
Activities

Report any domestic violence-focused information forums where domestic violence
information is distributed, yet an exact count of audience can not be obtained, such
as a press conference, booth at a health fair or a Pow Wow.

Instructions for Section H – Narrative Responses
Item
H-01
through
H-06

10

Data Element
Narrative Responses

Instructions
Attach a separate document with the labeled responses to each of the listed
elements (H-01 through H-06) on the form.

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