CA/Division of Program and Policy
c/o P.O. Box 47986
Seattle, WA 98146-7986 / Quarterly Program Summary, Match
and Financial Report
VOCA Grant Programs
Report Timeframe
Victims of Crime Act (VOCA) programs receiving funding for services from the Department of Social and Health Services, Children’s Administration, Division of Program and Policy, are required to submit a Quarterly Program Summary, Match and Financial Report by the 15th day following the end of each quarter. The Quarterly Report information is used to track demographic, service and compliance data required by state and federal fund sources.

Contractor: Contract No.:

Quarter Reported: 1 2 3 4Period Covered:

A. Quarterly Program Summary

1. Statistical information for new individuals served this quarter:

A. Demographics
African/African-American / Birth - 5
Asian/Pacific Islander / 6-11
Caucasian / 12-17
Hispanic/Latina / 18-21
Native Am/AK Native / 22-44
Unknown / 45-54
Other (specify): / 55-69
70+
Unknown
Total / Total
B. Indicate below the number of new victims served by type of victimization. Indicate the number of primary and secondary victims served by VOCA-funded projects during the grant period. Each victim should be counted only once, i.e., a victim of a series of domestic violence assaults should be counted more than once only as a result of separate and unrelated crimes.
Child physical abuse / Adults sexually abused as children
Child sexual abuse / Survivors of homicide victims
DUI/DWI crashes / Robbery
Domestic violence / Assault
Adult sexual assault / Other (specify)
Elder abuse
Total
C. Indicate below the number of new victims who received the following services: (See definitions (p. 4) for each service and select the one(s) which most closely correlate to the services provided).
Crisis counseling / Emergency financial assistance
Follow-up contact / Emergency legal services/advocacy
Therapy or counseling / Compensation claims
Group treatment/support / Personal advocacy
Shelter/safehome / Telephone I&R
In-person I&R / Crisis “hotline” calls
Legal advocacy / Other (specify)
Total

2. For this quarter, describe your program’s progress in meeting EACH of the goals and activities outlined in the contract Statement of Work.

B. Quarterly Match Report

Volunteer Hours / Hours/Rate / Cash Donation / Amount
e.g.: 3 project volunteers / 45 @ $10/hr / $450 / e.g.: United Way / $23,000
Subtotal / Subtotal
Equip., supplies, facility space / Value / Transportation/Other / Value
e.g.: Donated office supplies / $750 / e.g.: Field trip/children’s group / $150
Subtotal / Subtotal
Summary / Value Subtotal
Volunteer Hours
Cash Donation
Equip, supplies, etc.
Transportation/Other
Total Value of Match

C. Quarterly Financial Report

Month / Salary / Benefits / Consult. / Space / Travel / Training / Equip. / Supplies / Tel/Com / Other / Balance
Budget
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Balance

Submit this report electronically to:

Susan Hannibal

DSHS/CA/Program & Policy

Fax: (206) 923-4899

Questions? (206) 923-4910 V/TDD

VOCAREPORT.FORMS.3.DOC

10/01

Instructions and Definitions

The information requested on this Quarterly Program Summary, Match, and Financial Reports form is required from agencies receiving federal Victims of Crime Act (VOCA) victim assistance funds.

A. Quarterly Program Summary: The data asked in question 1(A) and (B) should be completed for each new primary and secondary victim who receives face-to-face services during the quarter being reported. Each victim should be counted only once. Question 1(C) should record all services provided to each primary and secondary victim served during the quarter. The definitions for each type of service are listed below. While it may be difficult to determine where a particular service fits in the definitions provided, use your best judgment. You should record only those services provided under, and allowed by, this Contract. Question 2 provides information on the progress of the funded project.

B. Quarterly Match Report: Programs should generally identify the source, and specific amount of qualified match for the quarter. Examples are reflected on the form. The subtotal value from each match source should be noted, with the total match value recorded in the appropriate box. Program match can be in the form of hard (cash) or soft (in-kind). Programs must maintain detailed records that clearly show the source, amount, and timing of all matching contributions. Match must not be from federal funds. Questions regarding match should be directed to the VOCA grant administrator.

C. Quarterly Financial Report: Programs should report monthly program expenditures on a quarterly basis. Questions regarding allowable contract costs should be directed to the DSHS Program Manager.

Definitions for Question 1(C), p. 1:

1. Crisis counseling refers to in-person crisis intervention, emotional support, and guidance and counseling provided by advocates, counselors, mental health professionals, or peers. Such counseling may occur at the scene of the crime, immediately after a crime, or be provided on an on-going basis.

2. Follow-up contact refers to in-person contacts, telephone contacts, and written communications with victims to offer emotional support, provide empathetic listening, check on a victim’s progress, etc.

3. Therapy or counseling refers to intensive professional psychological and/or psychiatric treatment for individuals, couples, and family members related to counseling to provide emotional support in crises arising from the occurrence of a crime.

4. Group treatment/support refers to the coordination and provision of supportive group activities and includes self-help, peer, social support, etc.

5. Shelter/safehome refers to offering short and long term housing and related support services to victims and families following victimization.

6. Information/referral (in-person) refers to in-person contacts with victims during which time services and available support are identified.

7. Legal Advocacy refers to support, assistance, and advocacy provided to victims at any stage of the legal process, to include post-sentencing services and support.

8. Emergency financial assistance refers to cash outlays for transportation, food, clothing, emergency housing, etc.

9. Emergency legal services/ advocacy refers to filing restraining or protection orders, elder abuse petitions, child abuse petitions, and obtaining emergency custody/visitation rights when actions are directly connected to domestic violence cases, but does not include criminal prosecution or the employment of attorneys for non-emergency purposes, civil suits, etc.

10. Compensation claims includes making the victim aware of the availability of crime victim compensation, assisting the victim in completing the required forms, gathering the needed documentation, etc. It may also include follow-up contact with the victim compensation agency on behalf of the victim.

11. Personal advocacy refers to assisting victims in securing rights, remedies, and services from other agencies; locating emergency financial assistance, intervening with employers, creditors, and others on behalf of the victim; assisting in filing for losses covered by public and private insurance programs including worker’s compensation, unemployment benefits, welfare, etc; accompanying the victim to the hospital, etc.

12. Information/referral (telephone) refers to contacts with victims during which time services and available support are identified. This does not include calls during which counseling is the primary function of the telephone call.

13. Crisis “hotline” calls refers to telephone crisis intervention on the agency’s “hotline.”

14. Other refers to other VOCA allowable services and activities not listed.