Illinois Department of Human Services
Division of Family and Community Services
Bureau of Domestic Violence and Sexual Assault

Domestic Violence Shelter & Services RFA

Released March 12, 2014

DATA AND DEMOGRAPHICS FORM (OUTPUTS) - Existing and Projected

Domestic Violence Program Service Numbers

Insert your FY13 accomplishments - July 2012 through June 2013, FY14 6 months accomplishments - July 2013 through December 2013, and FY15 projections - July 2014 through June 2015 in the table. Data must reflect total outputs of your domestic violence program. If there have been significant changes in program data or significant changes are expected, please use the space provided on this form to explain those differences. If more space is needed to explain differences in data, you may exceed the space on the form.

1.  Number of Individual Clients

Clients FY13 Actual FY14 Progress (July-December) FY15 Projected
Adults Children Adults Children Adults Children
Clients Receiving Emergency Shelter (on or off site) 
Clients Receiving Transitional Housing
Nonresidential Clients (no shelter/no transitional housing - walk in clients)
TOTAL ALL CLIENT TYPES

Explain significant changes:

2.  Client Demographics - REPORT IN PERCENTS (%)

SEX FY13 Actual FY14 Progress (July-December) FY15 Projected
Adults Children Adults Children Adults Children
Female
Male
AGE FY13 Actual FY14 Progress (July-December) FY15 Projected
0-5
6-11
12-17
18-29
30-39
40-49
50-59
60+
Unreported
ETHNICITY FY13 Actual FY14 Progress (July-December) FY15 Projected
Adults Children Adults Children Adults Children
Hispanic/Latino
Non-Hispanic/Latino
Unreported
RACE FY13 Actual FY14 Progress (July-December) FY15 Projected
Adults Children Adults Children Adults Children
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Biracial
Unreported

Explain significant changes:

3.  Number of On-site Shelter/Transitional Housing beds

Emergency and Transitional Bed Space FY13 Actual FY14 Progress (July-December) FY15 Projected
On Site Emergency Shelter Beds
Transitional/Second Stage Beds

4.  Shelter Nights

Nights of On and Off Site Emergency Shelter FY13 Actual FY14 Progress (July-December) FY15 Projected
Adults
Children

Explain significant changes:

5.  Number of Hotline Calls

Hotline Calls FY13 Actual FY14 Progress (July-December) FY15 Projected
Hotline - Clients/Non-Clients Victims
Information and Referral

Explain significant changes:

6.  Direct Service Hours

DIRECT CLIENT SERVICE HOURS FY13 Actual FY14 Progress (July-December) FY15 Projected
Client Type Clients Hrs Clients Hrs Clients Hrs
Counseling Hours and Clients Adults
Children
Support Group Hours and Clients Adults
Children
Advocacy and Other Services (list services included for instructional purposes) Adults
Children
Legal Advocacy Adults
Children

Explain significant changes:

7. Order of Protection Assistance Provided

ORDER OF PROTECTION ASSISTANCE FY13 Actual FY14 Progress (July-December) FY15 Projected
Victims receiving OP Assistance
Emergency OPS you assisted with
Interim and Plenary OPS you assisted with

Explain significant changes:

8. Public Education/Awareness

PUBLIC AWARENESS FY13 Actual FY14 Progress (July-December) FY15 Projected
Presentations
Hours
Participants

Explain significant changes: