Category 3 Measures (2 measures)

Pregnancy Assistance Fund (PAF) Performance Measures Collection

0990-0416_Attachment E_Form_Category 3_PAF PM Renewal_0990_0416

Category 3 Measures (2 measures)

OMB: 0990-0416

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OMB#: 0990-0416

Exp. Date: xx/xx/xxxx

Attachment E

Category 3 Form: Grantee Programs Only (Grantees who are Working with Women who have Experienced Stalking, Sexual Assault, or Intimate Partner Violence.)

Note: The target population is defined by legislation as expectant and parenting females who are victims of stalking, sexual assault, or Intimate Partner Violence


3.0 How many eligible participants received at least one activity?

Indicate the total number in each category below.

a) Expectant female teens (19 years and younger)

b) Parenting teen mothers (19 years and younger )

c) Expectant women (20 years and older)

d) Parenting women (20 years and older)

e) Children (of expectant or parenting participants [reported in a to d] above)

3.1 How many individuals from government, private non-profit, and other agencies serving victims of stalking, sexual assault, and IPV received training on violence against expectant and parenting teens and women?

3.2 How many expectant and parenting female participants who are victims of IPV, sexual violence, sexual assault, or stalking received any of the following services directly through the program?

Indicate the number in each category below.

a) Supportive social services (e.g., individual or group counseling)

b) Accompaniment services (e.g., assisting, representing, and accompanying women during court proceedings)

c) Intervention services (e.g., referral to 24 hour telephone hotline services for police protection and referral to shelters)


According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0416. The time required to complete this information collection is estimated to average 3 hours per respondent, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer


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AuthorTara Rice
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