Form 1 Client Characteristics and Enrollment Form

Domestic Victims of Human Trafficking (DVHT) Program Data

OMB 0970-0542_Revised DVHT Performance Indicators_10.17.22

Client Characteristics and Program Entry

OMB: 0970-0542

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Domestic Victims of Human Trafficking (DVHT) Performance Indicators

The Domestic Victims of Human Trafficking (DVHT) Program is inclusive of two distinct programs: the Domestic Victims of Human Trafficking and Services Outreach Program (DVHT-SO) and the Demonstration Grants to Strengthen the Response to Victims of Human Trafficking in Native Communities Program (VHT-NC). The data collection instruments are intended to collect information for both DVHT programs.

DVHT award recipients must provide the following program performance indicator data to OTIP on a quarterly and annual basis, as indicated. Award recipients will be provided with the following information when requesting data:

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to gather data on the grant program to assess program performance, inform evaluation efforts, tailor technical assistance for recipients, respond to inquiries from stakeholders, and inform policy and program development. Public reporting burden for this collection of information is estimated to average XX hours per grant recipient, 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 U.S.C. 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. The OMB # is 0970-0542 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Vera Soto, Office on Trafficking in Persons, by email at Vera.Soto@acf.hhs.gov.

Quarterly Reports

Victim Assistance – Client Characteristics and Program Entry (Public reporting burden for this collection of information is estimated to average 0.75 hours per grant recipient)

  • Intake Date

  • Referral Date

  • Referral Source

    • Child Protective Services/Child Welfare

    • Court

    • District Attorney/State's Attorney/Victim Assistance

    • Defense Attorney/Public Defender/Legal Aid

    • Domestic Violence Agency/Shelter

    • Educator/Teacher/School

    • Employer

    • Family Member/Guardian

    • Friend/Peer/Acquaintance

    • Health Care Provider

    • Housing Assistance Agency/Shelter

    • Juvenile Justice

    • Law Enforcement

    • National Human Trafficking Hotline (NHTH)

    • Other National Hotline

    • Psychiatric Treatment Facility

    • State/Local Hotline

    • Religious Organization

    • Self

    • Other (specify)

  • Type of Trafficking

    • Sex

    • Labor

    • Sex and Labor

    • Unknown

  • Does the client have family members receiving services from grant recipient?

    • Yes

    • No

  • Grant Eligibility Status

    • Pre-Certified Foreign National

    • Certified Foreign National

    • U.S. Citizen/Lawful Permanent Resident

  • Country of Origin

  • Age

  • Gender Identity

    • Male

    • Female

    • Transgender Male

    • Transgender Female

    • Client uses a different term (specify)

    • Unknown

    • Prefer not to answer

  • Does the client identify as 2SLGBTQIA+?

    • Yes

    • No

    • Unknown

  • Does the client have a disability?

    • Ambulatory Difficulty

    • Cognitive Difficulty

    • Hearing Difficulty

    • Self-Care Difficulty

    • Vision Difficulty

  • Race/Ethnicity

    • American Indian or Alaska Native

    • Asian

    • Black or African American

    • Native Hawaiian or Other Pacific Islander

    • White

    • Hispanic or Latino

    • Other (specify)

    • Unknown

  • Living Situation at Intake

    • Emergency Housing

    • Institutional Housing

    • No Housing/Place not meant for habitation

    • Permanent Housing

    • Transitional Housing

    • Unknown

  • If client is a minor, are they enrolled in school?

    • Yes

    • No

  • Location of Services

    • State/Territory

    • Remote

  • Location of Trafficking

    • State/Territory

    • Country

  • Exploitation Industry/Venue

    • Agriculture/Field Labor

    • Auto-Mechanic/Auto-Shop/Car Repair

    • Arts/Entertainment

    • Bar/Cantina/Nightclub

    • Begging/Peddling

    • Carnival

    • Carpentry/Woodworking

    • Cobbling

    • Commercial Cleaning

    • Commercial Sex

    • Construction

    • Domestic Work

    • Elder Care

    • Escort Services

    • Factories/Manufacturing

    • Fishing

    • Forced Criminal Activities

    • Forestry/Logging

    • Garment/Textiles

    • Herding/Livestock

    • Health/Beauty

    • Health Care

    • Herding Livestock/Animal Husbandry

    • Hotel/Hospitality

    • Illicit Massage/Health

    • Landscaping

    • Mining/Quarrying

    • Other (specify)

    • Personal Sexual Servitude

    • Production of Child Sexual Abuse Material (CSAM)

    • Recreation/Sports

    • Religious Institution

    • Restaurant/Food Service

    • Retail Sales

    • Stripping/Dancing

    • Transportation

    • Traveling Sales Crew

    • Waste Management/Recycling

    • Not Reported

  • Commercial Sex Venue

    • Commercial Space-Based

    • Institution-Based

    • Technology-Based

    • Outdoor/Street-Based

    • Residence-Based

    • Not Reported

Victim Assistance – Barriers to Service Delivery (Public reporting burden for this collection of information is estimated to average 0.167 hours per grant recipient)

  • Feelings of No Support and Isolation

  • Ineffective Coordination with Federal Agencies

  • Ineffective Coordination with Local Agencies

  • Lack of Adequate Funding

  • Lack of Adequate Resources

  • Lack of Adequate Training

  • Lack of Cooperation of Client

  • Lack of Formal Rules and Regulations

  • Lack of In-House Procedures

  • Lack of Knowledge of Victims’ Rights

  • Language Concerns

  • Public Health Concerns

  • Safety Concerns

  • Victims’ Legal Status

  • Other Services (specify)

  • None

Victim Assistance – Client Case Closure (Public reporting burden for this collection of information is estimated to average 0.167 hours per grant recipient)

  • Case Closure Date

  • Reason for Case Closure

    • Client relocated

    • Client unable to meet program expectations

    • Determined not eligible

    • Incarcerated and out of contact with program

    • Lost contact

    • No longer in need of services

    • Time limitations of the program

    • Transfer to another service program

    • Other (specify)

  • Living Situation Upon Case Closing

    • Emergency Housing

    • Institutional Housing

    • No Housing/Place not meant for habitation

    • Permanent Housing

    • Transitional Housing

    • Unknown

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

    • Yes

    • No

Victim Outreach (Public reporting burden for this collection of information is estimated to average 0.3 hours per grant recipient)

  • Number of outreach activities conducted

  • Outreach Settings

    • Agricultural Settings

    • Casinos

    • Commercial Establishments

    • Consulates

    • Court-Based Settings

    • Day Labor Settings

    • Detention Settings

    • Digital: Social Media

    • Digital: Other

    • Education Settings

    • Factories

    • Health Care Settings

    • Homeless Encampments

    • Hotel/Hospitality Settings

    • Massage Parlors

    • Shelter Settings

    • Street Settings

    • Strip Clubs

    • Youth Care Settings

    • Other (specify)

  • Target Population(s)

    • 2SLGBTQIA+ Populations

    • Alaska Native/Indigenous Populations

    • Asian American/Pacific Islander Populations

    • Black Populations

    • Boys and Men

    • Direct Care Workers

    • Hispanic or Latino Populations

    • People with Disabilities

    • People who Live in Rural Communities

    • Religious Minority Populations

    • Runaway Homeless Youth Populations

  • Number of Victims Identified

Training (Public reporting burden for this collection of information is estimated to average 0.5 hours per grant recipient)

  • Number of trainings conducted by Topic

    • Grant Management Training Topic

      • Building a Community Referral Network and Partnership Building

      • Data Collection, Management, and Reporting

      • Introduction to Grant Program and Onboarding

      • Outreach Strategies

      • Program Policy, Protocol, and Administration

    • Service Delivery and Access Topic

      • Approaches, Strategies, and Special Considerations for Working with Victims (e.g. Trauma Informed Care)

      • Available Services/Benefits and Strategies for Self Sufficiency

      • HHS Certification, Eligibility, and Other HHS Resources

      • How to Access Legal Services and Remedies

      • Human Trafficking 101: Definition, Types, Laws, and Indicators

      • Other

  • Number of Individuals Trained by Type of Audience Member

    • Behavioral Health

    • Child Welfare

    • Education

    • Faith-Based

    • Government

    • Health Care

    • Housing

    • Law Enforcement

    • Legal

    • Private Sector

    • Public Health

    • Social Services

    • Students (Higher Education)

    • Tribal

    • Other

Subrecipient Enrollment (Public reporting burden for this collection of information is estimated to average 0.167 hours per grant recipient)

  • Name of Subrecipient Organization

  • Location of Subrecipient Organization

    • City

    • State

  • Type of Subrecipient Organization

    • Advocacy

    • Behavioral Health

    • Child Welfare

    • Education

    • Employment

    • Faith Based

    • Government

    • Health Care

    • Housing

    • Law Enforcement

    • Legal

    • Other Criminal Justice

    • Private Sector

    • Public Health

    • School (K-12)

    • Service Provider

    • Other (specify)

  • Number of Subrecipient Service Sites

  • Services Provided by Subrecipient

    • Basic Necessities

    • Case Management

    • Child Care

    • Crisis Intervention

    • Education Assistance

    • Employment Assistance

    • Family Reunification

    • Financial Assistance

    • Healthcare

    • Housing/Shelter Services

    • Interpreter/Translator

    • Legal Advocacy and Services

    • Life Skills

    • Mental/Behavioral Health Services

    • Medical Services

    • Peer-to-Peer Support/Mentoring

    • Safety Planning Services

    • Substance Use Assessment/Treatment

    • Traditional Healing/Cultural Practices

    • Transportation

    • Victim Advocacy

    • Other Services (specify)

    • None

    • Unknown

  • Enrollment Date

  • Exit Date



Annual Performance Indicator Report

Victim Assistance – Client Service Use and Delivery (Public reporting burden for this collection of information is estimated to average 0.25 hours per grant recipient)

  • Services Received

    • Basic Necessities

    • Case Management

    • Child Care

    • Crisis Intervention

    • Education Assistance

    • Employment Assistance

    • Family Reunification

    • Financial Assistance

    • Healthcare

    • Housing/Shelter Services

    • Interpreter/Translator Services

    • Legal Advocacy and Services

    • Life Skills

    • Mental/Behavioral Health Services

    • Peer-to-Peer Support/Mentoring

    • Safety Planning Services

    • Substance Use Assessment/Treatment

    • Traditional Healing/Cultural Practices

    • Transportation

    • Victim Advocacy

    • Other Services (specify)

    • None

    • Unknown

  • Benefits Received

    • Child Care Subsidy

    • General Assistance

    • Medicaid

    • Refugee Cash Assistance

    • Refugee Medical Assistance

    • Refugee Social Services

    • Section 8/Permanent Housing Assistance

    • SNAP (Food Stamps)

    • State-specific Health Benefits

    • Social Security Disability (SSI or SSDI)

    • Temporary Assistance for Needy Families

    • Unemployment Insurance

    • WIC

    • Other (specify)

    • None

    • Unknown


Categories of Assistance (Public reporting burden for this collection of information is estimated to average 0.75 hours per grant recipient)

  • Total number of clients who received services under each category of assistance

  • Total dollars spent on each category of assistance

  • Percentage of recipient’s budget spent on each category of assistance

  • Total grant recipient budget for project

    • Basic Necessities

    • Case Management

    • Childcare

    • Crisis Intervention

    • Education Assistance

    • Employment Assistance

    • Family Reunification

    • Financial Assistance

    • Healthcare

    • Housing/Shelter Services

    • Interpreter/Translator

    • Legal Advocacy and Services

    • Life Skills

    • Mental/Behavioral Health Services

    • Peer-to-Peer Support and Mentoring

    • Safety Planning Services

    • Substance Use Assessment/Treatment

    • Traditional Healing/Cultural Practices

    • Transportation

    • Victim Advocacy

    • Other Services

    • None


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AuthorKimberly Casey
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File Created2022-10-21

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