Document
Form 1 Proposed Reviesed Survey for 2015
ICR 201507-0970-001 · OMB 0970-0204 · Object 56967001.
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0970-0204 can be found here:
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| Grantee and/or Sub-Grantee Agency Profile | Summary of State AV Program Data | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Grantee and/or Sub-Grantee Information | Service Provided &Client Participation (Values M (Mandatory), V (Voluntary) B (Both) | U, R, B | Client Referral Source | Client Information | Child Support Cases (Optional) | Marital Status | Race/Ethnicity | Annual Income | Services Provided | Frequency of Service ( Hours) (Optional) | Outcome#1-Parenting Time (Required) | Outcome#2 - Knowledge of Effective Co-Parenting Strategies (Optional) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Name of Grantee and/or Sub-Grantee | Title of AV Program | Contact Name | Address Line 1 | City | State | Zip | Grant Amount | Grant Period From Date | Grant Period To Date | Mediation | Development of Parenting Plan | Counseling | Parent Education | Neutral Drop-off/Pick-up | Supervised Visitation | Visitation Enforcement | Geographic Area Served | Self | Court | Child Support Agency | Domestic Violence Agency | Child Protection Agency | Other | Data Not Reported | NCP Father | CP Father | NCP Mother | CP Mother | Grandparent/Legal Guardian | Number of Children in Common | NCP Father | CP Father | NCP Mother | CP Mother | Grandparent/Legal Guardian | Never Married to Each Other | Married to Each Other | Separated From Each Other | Divorced From Each Other | Data Not Reported | American Indian or Alaska Native | Asian | Black or African American | Hispanic or Latino | Native Hawaiian or Other Pacific Islander | White | Two or More Races | Other | Data Not Reported | Less than $10,000 | $10,000 to $19,999 | $20,000 to $29,999 | $30,000 to $39,999 | $40,000 & Above | Data Not Reported | Mediation | Development of Parenting Plan | Counseling | Parent Education | Neutral Drop-off/Pick-up | Supervised Visitation | Visitation Enforcement | Mediation | Development of Parenting Plan | Counseling | Parent Education | Neutral Drop-Off/Pick-Up | Supervised Visitation | Visitation Enforcement | NCP Fathers | NCP Mothers | NCP Fathers | CP Fathers | NCP Mothers | CP Mothers |
| File Type | application/vnd.ms-excel |
| File Title | AV Proposed Revised Survey |
| File Modified | 2015-04-13 |
| File Created | 2006-09-16 |