Form 3 Client Case Closure Form

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

Domestic Victims of Human Trafficking Grantee
Client Case Closure Form
This form should only be submitted if a case closed during the reporting period.
Grantee
Reporting Period Start Date

Reporting Period End Date

Client Identifier
Reason for Case Closing (Check all that apply)

Report Type

Date on which case closed
Employment Status upon Case Closing

No longer in need of services

Employed, Full Time

Lost contact, missing persons report filed

Employed, Part Time

Lost contact, no missing persons report filed

Employed, Seasonal/Sporadic

Incarcerated and out of contact with program

Enrolled in Job Training

Client is deceased

Unemployed, Looking for Work

Client relocated

Unemployed, Unable to Work

Time limitations of the program

Unemployed, Not Looking for Work

Transfer to another service program

Unknown

Determined not eligible
Client unable to meet program expectations
Other

Living Situation upon Case Closing

Did the client receive a referral for continued
case management services?

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN:
Through this information collection, ACF is gathering data on the grant program to assess program performance, inform evaluation, tailor technical
assistance, report to stakeholders, and inform policy and program development. Public reporting burden for this collection of information is estimated to
average .167 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of
information. This collection of information is required to retain a benefit (22 USC 7105, Trafficking Victims Protection Act). An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless
it displays a currently valid OMB control number. If you have any comments on this collection of information, please contact Flavia Keenan-Guerra, Office
on Trafficking in Persons, by email at Flavia.Keenan-Guerra@acf.hhs.gov.