Form 1 Family Violence Prevention Service Program Disaster Info

OMB Control Number: 0970-0476

Expiration Date: xx/xx/xxxx

Family and Youth Services Bureau (FYSB)

Family Violence Prevention and Services Program (FVPSP)

Disaster Information Collection Form

Summary: When a disaster or emergency event occurs, ACF’s Watch Desk (OHSEPR-WatchDesk@acf.hhs.gov) will contact the designated point of contact for FVPSP (predetermined by FVPSP Director or designee). The Watch Desk will provide an Advisory about the event that will include what happened and where. The Advisory will include a Request for Information. The Request for Information will routinely ask the same questions, which appear below. The FVPSP point of contact (with help from the impacted grantee POC, if necessary) is requested to answer the questions within a specified amount of time (generally 4 hours), based on whatever information is available at that time, via email to the Watch Desk. If information is not available within the allotted time, please indicate that and when new information comes in during the days following the initial request, the FVPSP point of contact will send an update to the Watch Desk.

FVPSP Disaster Information Request for Information

Today’s Date: Click here to enter a date.

RESPONSE (72 hours post-disaster impact)

1. Have there been any requests for assistance related to the disaster from State Administrators, Tribes/Tribal organizations, State Coalitions, or Resource Centers comprising the Domestic Violence Resource Network (DVRN)?

☐ NO

☐ YES

(If yes, please explain.)

Click here to enter text.

2. Have any domestic violence shelters been evacuated due to damage, power loss, or other disaster-related reasons?

☐ NO (skip question 3)

☐ YES (continue to question 3)

3. Are sheltered residents and their dependents being served in an alternate shelter location?

☐ NO

☐ YES

Click here to enter text.

4. Do State Coalition members, partners, or other stakeholders report increases in requests for assistance?

☐ NO

☐ YES

(If yes, what is the increase and how is the increase measured?)

Click here to enter text.

5. COMMENTS, if any: Click here to enter text.

RECOVERY (estimated 30 days up to a year post-disaster impact)

6. Have there been any requests for assistance related to the disaster from State Administrators, Tribes/Tribal organizations, State Coalitions, or Resource Centers comprising the DVRN?

☐ NO

☐ YES

(If yes, please explain.)

Click here to enter text.

7. Do State Coalition members, partners, or other stakeholders report increases in requests for assistance?

☐ NO

☐ YES

(If yes, what is the increase and how is the increase measured?)

Click here to enter text.

8. Do State Coalitions, State Administrators, Tribes/Tribal organizations, or the DVRN report capacity shortfalls, increased difficulty finding housing for survivors to leave the shelter, or other disaster-related difficulties serving survivors?

☐ NO

☐ YES

(If yes, please describe the impacts.)

Click here to enter text.

9. Has there been an increase in the number of calls to the National Domestic Violence Hotline from States, Tribes, and Territories affected by the disaster?

☐ NO

☐ YES

(If yes, what is the difference (in number, i.e. +100 calls, -200 calls, …)?)

Click here to enter text.

10. Are there any reports from State Coalitions, State Administrators, Tribes/Tribal organizations, or the DVRN to suggest increased incidences of domestic violence since the disaster?

☐ NO

☐ YES

(If yes, please explain.)

Click here to enter text.

11. COMMENTS, if any: Click here to enter text.

Public reporting burden of this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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.

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