Form 3 Client Case Closure Form

OMB Control Number: 0970-0467
Expiration Date: 11/30/2018

Trafficking Victim Assistance Program Grantee
Client Case Closure Form
This form should only be submitted if a case closed during the reporting period.
Grantee
Reporting Period Start Date

Reporting Period End Date

Client Identifier
Reason for Case Closing (Check all that apply)

Report Type

Date on which case closed
Employment Status upon Case Closing

No longer in need of services

Employed, Full Time

Lost contact

Employed, Part Time

Incarcerated and out of contact with program

Employed, Seasonal/Sporadic

Client relocated

Enrolled in Job Training

Time limitations of the program

Unemployed, Looking for Work

Transfer to another service program

Unemployed, Unable to Work

Determined not eligible

Unemployed, Not Looking for Work

Client unable to meet program expectations

Unknown

Other
Living Situation upon Case Closing

Did the client obtain Continued Presence or a T-Visa?

Did the client obtain HHS Certification or Eligibility?

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

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average .167 hours per response, including the time for reviewing instructions,
gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number.