SECTION I - GENERAL INFORMATION

SUBGRANTEE CURRENT SUBGRANT NUMBER PROGRAM/PROJECT NAME PERSON COMPLETING FORM TELEPHONE NUMBER EMAIL REPORTING PERIOD DUE DATE VER.3.10

Section IIA - Victims by Category of Victimization (New Victims)

COUNTY OR COUNTIES SERVED CHILD PHYSICAL ABUSE CHILD SEXUAL ABUSE DOMESTIC VIOLENCE DV HOTLINE SEXUAL ASSAULT SA HOTLINE ELDER ABUSE ADULTS MOLESTED AS CHIDREN

COUNTY OR COUNTIES SERVED

Section IIC - Victims by Category of Victimization

CHILD PHYSICAL ABUSE CHILD SEXUAL ABUSE DV Hotline DOMESTIC VIOLENCE SEXUAL ASSAULT SA Hotline ELDER ABUSE

ADULTS MOLESTED AS CHIDREN

Section III - Victims by Type of Service Received (New Victims)

COUNTY OR COUNTIES SERVED In-Person Crisis Counseling Telephone Hotline Crisis Counseling Group Treatment Telephone In-Person Contact/ Information/ Information & Safe Shelter Referral Referral

Follow-Up

Therapy

ctims)
COUNTY OR COUNTIES SERVED Emergency Financial Assistance

Section III - Victims by Type of Service Received (New Victims)

Emergency Legal Advocacy Other Emergency Assistance Criminal Justice Support/ Advocacy1 Personal Advocacy Assistance in Filing Victims' Compensation Assistance w/ Applying for TANF, Medicaid, etc. NonEmergency Legal Advocacy

d (New Victims)

Other

Section IV - Total Units of Services Delivered

COUNTY OR COUNTIES SERVED In-Person Crisis Counseling Telephone Hotline Crisis Counseling Group Treatment Telephone In-Person Contact/ Information/ Information & Referral Referral

Follow-Up

Therapy

Safe Shelter

Section IV - Total Services Delivered

COUNTY OR COUNTIES SERVED Emergency Financial Assistance Emergency Legal Advocacy Other Emergency Assistance Criminal Justice Support/ Advocacy1 Personal Advocacy Assistance in Filing Victims' Compensation Assistance w/ Applying for TANF NonEmergency Legal Advocacy

Other