ARCHIVED - Family Violence Shelter and Prevention Project Annual Report

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Form Instructions

DCI# (2014-2015)

Privacy Act Statement

The information you provide in this document is collected under the authority of the Department of Indian Affairs and Northern Development Act for the purpose of assessing performance, allocating funds, and in determining, if applicable, eligibility for reimbursement. Information on individuals is used by Aboriginal Affairs and Northern Development Canada's Family Violence Prevention Program employees who need to know the information in order to respond to your request and/or the program requirements. We do not share the personal information with other federal government departments. The personal information will be kept for a period of five years after which it will be sent to archives. Individuals have the right to the protection of and access to their personal information under the Privacy Act. The information collected is described under the Treasury Board Personal Information Bank INA SEP 502 which is detailed at InfoSource.

Section 1 (to be completed for Shelter and/or Prevention Project Reports)

1(a) Identification Information

Reporting for:

Recipient Name

Recipient Number

Shelter Name

Prevention Project Name

Brief Project Description

1(b) Partnerships and Community Type of Partnerships and Funding  
  Shelter Prevention Project
  Funding and/or Collaboration Funding and/or Collaboration
_ Other Federal Department (Specify):    
_ Band    
_ Tribal Councils    
_ Province    
_ Municipality    
_ Aboriginal Community Organizations    
_ Child and Family Services Agencies    
_ Addiction Treatment Centres    
_ Health Services    
_ Schools    
_ Police/RCMP    
_ Charitable/Not-For-Profit Organizations    
_ Volunteers    
_ Other (Specify):    

Community Priority

Do your activities support a specific community priority?



If you responded "Yes" to the above question, specify the priority or priorities being addressed.

Engagement With Communities
Describe how you inform communities about your programs and services and how you report on results to the community.

1(c) Services Offered in Shelter (Select All That Apply) - Shelter
Advocacy/Referral to Other Services/Programs
Child Care
Children's Programs
Crisis Intervention
Crisis Line
Drop In
Housing Information/Procedures
Legal Issues
Needs Assessments

1(d) Prevention Activities With Shelter And/Or Prevention Project Funding (Up To 5 Priorities)

Treatment/Intervention - Shelter - Prevention Project
Mental Health/Illness
Suicide Intervention

Culturally Sensitive Services - Shelter - Prevention Project
Elder And/Or Traditional Teachings
Family Healing
Healing Circles And/Or Traditional Healing
Inner Healing
Residential School Survivor Support

Awareness Shelter - Prevention - Project
Alternatives to Violence
Anger Management
Characteristics of Abuser
Cycle of Violence
Men's Programs
Research Projects
Safety Planning

Self-Development - Shelter - Prevention Project
Financial Management Skills
Healthy Parenting
Healthy Relationship
Healthy Sexuality
Life Skills
Social Skills Development
Other (Specify):

1(e) Results and Challenges
Describe your shelter's and/or prevention project's results (as per your work plan), successes and/or challenges for this year.

What can be improved to achieve desired results for shelter operations and/or this prevention project?

Section 2 (to be completed for Shelter Reports)

2(a) Shelter Staff (Full Time Equivalent Positions) - Quantity

Assistant Director(s)
Administrative Assistant(s)
Crisis Care Worker(s)
Outreach Worker(s)
Family Counsellor(s)
Child and Youth Worker(s)
Child Care Worker(s)
Security Worker(s)
Total of Full Time Equivalents
Other (Specify)

2(b) Shelter Use - Quantity

Number of First Nation Communities Served
Number of Beds Nights
Number of Crisis Calls Received
Number of Referrals From:
Self Referral
Mental Health Programs
Addictions Programs
Second Stage Housing
Other (Specify)

2(c) Shelter Clientele - Quantity

Total Number of Women Served
Total Number of First Nation Women (Ordinarily Resident On-Reserve) Served
Total Number of Women Served (Off-Reserve)
Total Number of Non-Aboriginal Women
Total Number of Single Women
Total Number of Women Served with Voluntary Self-Identified Disability(ies)
Total Number of Children (Age 18 And Under)

Age of Women Served - Quantity
16 - 29 Years Old
30 - 54 Years Old
55 Years Old and Above
Unknown Age

Length of Stay - Quantity
Under 1 Week
1 to 2 Weeks
3 to 4 Weeks
More Than 4 Weeks

Frequency of Shelter Stays (Recurrence Rates) - Quantity
No Previous Stays in the Last 12 Months
1 Previous Stay in the Last 12 Months
2 to 4 Previous Stays in the Last 12 Months
5 or More Previous Stays in the Last 12 Months

Post-Shelter Housing - Quantity
Return Home
Friends or Family
Second State/Transitional Housing
Other (Specify)

Section 3 (to be completed for Prevention Project Reports)

3(a) Delivery Method of Prevention Activities - Number of Sessions - Number of Participants
Healing Circle and/or Traditional Healing
Cultural Camp
Elder and/or Traditional Teaching(s)
Other (Specify)

3(b) Prevention Project Target Demographic
Other (Specify):

3(c) Evaluation
Was an evaluation of the prevention project completed?

Did the evaluation conclude the project was:

The information provided is accurate to the best of my knowledge.

Given Name

Family Name



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