Form for Grantees Funding Attorney General Office

Form Approved

OMB No. 0990-0460

Exp. Date XX/XX/20XX

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 0990-0460. The time required to complete this information collection is estimated to average 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete 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

Form for PAF Grantees States Providing Funding to Attorney General Offices

These Questions are only required for those grantees who are implementing comprehensive violence prevention services as defined by the Pregnancy Assistance Fund Funding Opportunity Announcement.

1. If grantee provided funding to its State Attorney General or functional equivalent for tribes, how many eligible pregnant participants received each of the services below:

Intervention services (such as a 24-hour hotline for police protection and referrals to shelters) _____

Accompaniment services:

Assisting, representing, and accompanying an eligible pregnant participant in seeking judicial relief for child support, child custody, restraining orders, and restitution for harm to persons and property _____

Filing criminal charges) _____

Supportive social services:

Transitional or permanent housing _____

Vocational counseling _____

Mental health services _____

Individual or group counseling aimed at preventing domestic violence, sexual violence, sexual assault, or stalking _____

2. If grantee provided funding to its State Attorney General or functional equivalent for tribes, how many State, tribal, territorial, or local governments, law enforcement agencies, or courts received technical assistance and/or training on the topics below?

The identification of eligible pregnant participants experiencing domestic violence, sexual violence, sexual assault, or stalking _____

The assessment of the immediate and short-term safety of such a pregnant participant, the evaluation of the impact of the violence or stalking on the pregnant participant’s health, and the assistance of the pregnant woman in developing a plan aimed at preventing further domestic violence, sexual violence, sexual assault, or stalking _____

The maintenance of complete medical or forensic records (including the documentation of any examination, treatment given, and referrals made, recording the location and nature of the pregnant participant’s injuries, and the establishment of mechanisms to ensure the privacy and confidentiality of those medical records _____

The identification and referral of the pregnant participant to appropriate public and private nonprofit entities that provide intervention services, accompaniment, and supportive social services _____

3. If grantee provided funding to its State Attorney General or functional equivalent for tribes, how many professionals working in legal, social service and health care settings, nonprofit organizations, or faith-based organizations received technical assistance and/or training on the topics below?

The identification of eligible pregnant participants experiencing domestic violence, sexual violence, sexual assault, or stalking _____

The assessment of the immediate and short-term safety of such a pregnant participant, the evaluation of the impact of the violence or stalking on the pregnant participant’s health, and the assistance of the pregnant participant in developing a plan aimed at preventing further domestic violence, sexual violence, sexual assault, or stalking _____

The maintenance of complete medical or forensic records (including the documentation of any examination, treatment given, and referrals made, recording the location and nature of the pregnant women’s injuries, and the establishment of mechanisms to ensure the privacy and confidentiality of those medical records _____

The identification and referral of the pregnant participant to appropriate public and private nonprofit entities that provide intervention services, accompaniment, and supportive social services _____