PERFORMANCE MEASURES COLLECTION FORM Program name:

County:

Mo(s)/yr.:

For questions #1 to #6, count the number of new, unduplicated eligible participants served during this reporting period that have NOT been previously counted in this federal fiscal year (August 1, 2015 to July 31, 2016.) For each demographic category, use how the participant self-identifies and “unknown/not specified” if the participant does not want to give that information. For questions #7 to #14, please answer as instructed. Questions #15 and #16 are optional to answer. Footnotes and endnotes contain service definitions and information about updates to this form.i 1. In this reporting period, how many new, unduplicated eligible participants received at least one of the services categorized in Question #6? (This is an unduplicated count. Count each eligible participant only once during the federal fiscal year.)ii Performance question Expectant female teens (ages 19 or younger) Parenting female teens (ages 19 or younger) Expectant women (20 years or older) Parenting women (20 years or older) Unknown/not-specified:

Number

2. What are the specific ages of the participants counted in Question #1?iii Performance question 12 years or younger 13 years old 14 years old 15 years old 16 years old 17 years old 18 years old 19 years old

1

Number

Performance question 20-24 years old 25-29 years old 30-35 years old 36-40 years old 41-50 years old 51 to 65 years old 66 years old or older Age unknown/not-specified

Number

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PERFORMANCE MEASURES COLLECTION FORM

3. How many children of the participants counted in Question #1 were served?iv

4. What is the race of the participants counted in Question #1? Performance question Asian Black or African American American Indian and Alaska Native Native Hawaiian and other Pacific Islander White More than one race Unknown/not specified

Number

5. What is the ethnicity of the participants counted in Question #1? Performance question Hispanic/Latino Not Hispanic/Latino Unknown/not specified

Number

See endnote v

2

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PERFORMANCE MEASURES COLLECTION FORM 6. How many participants counted in Question #1 received one or more of the following services directly from the advocate? (Identify and count each category of service only once during the federal fiscal year (August 1, 2015 to July 31, 2016) for each new, unduplicated eligible participant counted in Question #1. For example, the advocate may provide several types of supportive social services to the participant during federal fiscal year. Nevertheless, count “supportive social services” only once during the federal fiscal year for each new, unduplicated participant that is served. There is an opportunity to list which types of supportive social services were provided in the semi-annual and annual Progress Reports.) Performance question Supportive social services1 Accompaniment services2 Intervention services3

Number

1

The Office of Adolescent Health defines the term “supportive social services” as transitional and permanent housing, vocational counseling, and individual and group counseling aimed at preventing domestic violence, sexual violence, sexual assault, or stalking. CVSD further expands the definition for “supportive social services’ to include support groups provided by the Safer Futures advocate, assistance securing transitional or permanent housing, child care referral and support, parenting skills information, healthy relationships information, home visitation, information and referral by phone or in-person, follow up services by phone or in-person and emergency assistance (concrete supports such as food, housing, clothing, furniture, or child care paid for with emergency assistance funds). 2

The Office of Adolescent Health defines the term ”accompaniment” as assisting, representing, and accompanying a woman in seeking judicial relief for child support, child custody, restraining orders, and restitution for harm to persons and property, and in filing criminal charges, and may include the payment of court costs and reasonable attorney and witness fees associated therewith. CVSD further expands the definition for “accompaniment services” to include accompanying a survivor to any appointment with another provider. 3

The Office of Adolescent Health defines the term “intervention services” as, with respect to domestic violence, sexual violence, sexual assault, or stalking, 24-hour telephone hotline services for police protection and referral to shelters. CVSD further expands the definition for “intervention services” to include crisis response provided in-person or by phone, assistance finding temporary shelter and safety planning. 3 DM #5888292 (DOJ CVSD)

PERFORMANCE MEASURES COLLECTION FORM 7. In this reporting period, how many extended family members of the participants counted in Question #1 received at least one service from the advocate? (This is an unduplicated count. Count each extended family member only once for the federal fiscal year.) Performance question Parent or guardian of the expectant or parenting female teen or woman Grandparent of the expectant or parenting female teen or woman Spouse of the expectant or parenting female teen or woman Partner of the expectant or parenting female teen or woman Other (Specify: )

Number

8. How many extended family members counted in Question #7 received one or more of the following services directly from the advocate? (Identify and count each service only once during the federal fiscal year for each extended family member counted in Question #7. Count these services in the same way that services for Question #6 are counted.) Performance question Supportive social services Accompaniment services Intervention services

Number

9. How many extended family members counted in Question #7 were referred by the advocate to other services? Please report the total number: Please describe the types of services to which extended family members were referred:vi

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PERFORMANCE MEASURES COLLECTION FORM 10. In this reporting period, how many referrals did the Safer Futures project staff receive from another partner, program or provider?

Performance question – Referred from? 1. 2. 3. 4. 5. 6. 7.

Number

Healthcare provider Public Health Child Welfarevii Social service program DVSA program staff Self-referred Other, please specify:

11. In this reporting period, how many referrals did the Safer Futures project staff make on behalf of the participant to another partner, program or provider?

Performance question - Referred to? 1. 2. 3. 4. 5. 6.

5

Number

Healthcare provider Public Health Child Welfare Social service program DVSA program staff Other, please specify:

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PERFORMANCE MEASURES COLLECTION FORM 12. In this reporting period, how many consultations did the Safer Futures project staff offer to other staff, partners or providers? (Count consultations for each situation/person that is discussed.)

Performance question - Consultations with whom? 1. 2. 3. 4. 5. 6.

Number

Healthcare provider Public Health staff Child Welfare staff Social service provider DVSA program staff Other, please specify:

13. In this reporting period, how many trainings were provided by Safer Futures project staff? How many individuals were in attendance? (Please provide a description of the trainings that were provided in the Six-Month Progress Report.)

Performance question - Trainings provided for whom? 1. 2. 3. 4. 5. 6. 7. 8.

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Number of Trainings

Number in Attendance

Healthcare providers Public Health staff Child Welfare staff Social service providers DVSA program staff Community members Participants Other, please specify:

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PERFORMANCE MEASURES COLLECTION FORM 14. How many participant surveys were distributed to eligible participants? Please report the total number:

OPTIONALviii 15. How many participants received ongoing services this month (and are already counted as new participants in a previous month)? (Only count those participants receiving ongoing services during federal fiscal year August 1, 2015 to July 31, 2016.) Performance question

Number

Adults (20+ years of age) Teens (13–19 years of age)

16. How many ongoing participants counted in Question #15 received any of the following services directly from the advocate? (Identify and count each service once per ongoing participant for the month.) Performance question Supportive social services Accompaniment services Intervention services

Number

i

The Safer Futures performance measures collection form was updated on 11/12/15. The following endnotes describe the changes that were made to the form. The “children (of expectant or parenting female teens/women)” category was eliminated from the list of eligible participants under Question #1. iii The “20 years old” age category was eliminated from Question #2. iv Question #3 was added. Grantees must still count the number of children of eligible participants. Grantees are no longer required to collect demographic data such as race, ethnicity or age for these children. v Grantees are no longer required to collect data as to whether participants speak or do not speak English. vi Grantees are now asked to describe what types of referrals they made for participants’ extended family members. vii An option for Child Welfare has been added to Questions #10, #11, #12, and #13. viii An option has been added for Grantees who wish to report on the number of ongoing participants they served and the services they provided. ii

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