ARCHIVED - Family Violence Shelter and Prevention Project Annual Report

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Form Instructions

DCI# 455955.GCIMS (2015-2016)

Privacy Act Statement:

This statement explains the purposes for the collection and use of personal information. Only information needed to respond to program requirements will be requested. Collection and use of personal information is in accordance with the Privacy Act. In some cases, information may be disclosed without your consent pursuant to subsection 8(2) of the Privacy Act. The collection and use of personal information for this Family Violence Prevention Sub-Program within Social Development is derived from the Department of Indian Affairs and Northern Development Act, R.S.C., 1985, c. I-6, as well as from annual Appropriation Acts granting authority to the Government to spend funds on programs. We will use personal information for assessing and determining eligibility for the administration of the program to which you are applying, and for reporting on aggregated results. We share the personal information you give us with those as outlined in the AANDC PPU 210 detailed at  Info Source. The information collected will be retained for a period of five years, then sent to Library and Archives Canada. As stated in the Privacy Act, you have the right to access the personal information you give us and request changes to incorrect information.  Contact your  regional office to notify us about incorrect information, or contact the AANDC Public Enquiries by phone at 1 (800) 567-9604 for general enquires. For more information on privacy issues and the Privacy Act in general, you can consult the Privacy Commissioner at 1 (800) 282-1376.

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

1(a) Identification Information

Reporting for:

FVPP Shelter Funding Prevention Project Funding Both

The Prevention Project Was Delivered:

On-Reserve Off-Reserve

Recipient Name

Recipient Number

Shelter Name

Prevention Project Name

Prevention Project Actual Cost:

1(b) Partnerships

  Type of Partnerships and Funding Shelter and
Prevention Project
  Shelter Funding and/or
Collaboration
Prevention Project Funding and/or Collaboration
Band

Tribal Councils

Aboriginal Community Organizations

Child and Family Services Agencies

Schools

Other Federal
Department (Specify):

Provincial
Department (Specify):

Municipality

Addiction Treatment Centres

Health Services

Police/RCMP

Charitable/Not-For-Profit Organizations

Volunteers

Other (Specify):

Community Plan/Needs Assessment

Did you complete a community plan or a needs assessment?

Shelter Yes No

Prevention Yes No

If you responded "Yes" to the above question, describe how the activities reported are linked to the community plan or the needs assessment.

Engagement With Communities

Describe how you inform communities about your programs and services, and how you report on the results of your activities to the community.

1(c) Shelter Services

Shelter Services
(Select a maximum of 5 services only)
Main Services Offered
(Prioritize from 1 to 5)
Unavailable Services
(Select those that apply)
Accompaniment  

Advocacy/Referral to Other Services/Programs  

Child Care  

Children's Programs  

Collaboration at the Community Level  

Community Education and Awareness Raising  

Crisis Intervention  

Crisis Line  

Counselling  

Drop In  

Follow-Up/Aftercare  

Housing Information/Procedures  

Individual Case Planning  

Legal Issues  

Transportation  

Referrals for Men's Programming (Outside the Shelter)  

Women's Programs  

Other (Specify)  

1(d) Prevention Activities

For shelters: Describe the prevention activities that were delivered with shelter funding for this year.

For prevention projects: Describe the prevention activities that were delivered with prevention project funding for this year. Explain how different or similar these activities were compared to the prevention project proposal.

1(e) Results and Challenges

Describe the results of your shelter and/or prevention project (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 Report)

2(a) Shelter Staff

Shelter Staff (Full Time Equivalent Positions) Quantity
Director(s)
Assistant Director(s)
Administrative Assistant(s)
Crisis Care Worker(s)
Outreach Worker(s)
Family Counsellor(s)
Child and Youth Worker(s)
Housekeeper(s)
Child Care Worker(s)
Security Worker(s)
Total of Full Time Equivalents
Volunteers
Other (Specify)

2(b) Shelter Use

Shelter Use Quantity
Number of First Nation Communities Served
Number of Bedroom/Unit Nights
Number of Crisis Calls Received
Number of Turn-aways
Number of Referrals From:
Self Referral
Police/RCMP
Clinic/Hospital
Mental Health Programs
Addictions Programs
Second Stage Housing
Schools
Other (Specify)

2(c) Shelter Clientele

Shelter Clientele Quantity
Total number of First Nation women (ordinarily resident on-Reserve) served  
Total number of Métis and Inuit women (living on-Reserve) served  
Total number of Aboriginal women (living off-Reserve) served  
Total number of non-Aboriginal women (living on-Reserve or off-Reserve) served  
Total number of women served  
Total number of women served with voluntary self-identified disability(ies)  
Total number of girls (age 17 and under)  
Total number of boys (age 17 and under)  

 

Age of Women Served Quantity
Less than 18 accessing service without parent  
18 - 24 years old  
25 - 34 years old  
35 - 44 years old  
45 - 54 years old  
55 - 64 years old  
65 years old and over  
Unknown age  

 

Age of Girls Served Quantity
0 - 4 years old  
5 - 9 years old  
10 - 14 years old  
15 - 17 years old  
Unknown age  

 

Age of Boys Served Quantity
0 - 4 years old  
5 - 9 years old  
10 - 14 years old  
15 - 17 years old  
Unknown age  

 

Length of Stay Quantity
Under 1 week  
1 to 2 weeks  
2 to 3 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  
Unknown  

 

Other Achievements Due to Shelter Services (During Shelter Stay) Quantity
Total number of women who started to search for a job  
Total number of women who found employment  
Total number of women who applied for Income Assistance  
Total number of women who enrolled in training or school  
Total number of women who began legal procedures to obtain child(ren) custody  
Total number of women who found short-term housing  
Total number of women who found second stage/transitional housing  
Total number of women who found long-term housing  
Total number of women who reported the violence to the police or RCMP  
Total number of women who started an addictions program (by shelter referral)  
Total number of children who returned to school (due to shelter programming for children)  

Section 3 (to be completed for Prevention Project Reports)

3(a) Delivery Method of Prevention Activities

 

Delivery Method of Prevention Activities Number of Sessions Total Number of Participants - All Sessions
Seminar/Workshop    
Healing Circle    
Cultural Camp    
Traditional Healing    
Elder Teaching    
Other (Specify)    

3(b) Prevention Project Target Demographic

Age of Women Age of Men Age of Girls Age of Boys
18 - 24 years old 18 - 24 years old 0 - 4 years old 0 - 4 years old
25 - 34 years old 25 - 34 years old 5 - 9 years old 5 - 9 years old
35 - 44 years old 35 - 44 years old 10 - 14 years old 10 - 14 years old
45 - 54 years old 45 - 54 years old 15 - 17 years old 15 - 17 years old
55 - 64 years old 55 - 64 years old    
65 years old and over 65 years old and over    

Families

Other (Specify):

3(c) Measuring Project Success

Was a survey, participant feedback or self-evaluation of the prevention project completed? Yes No Not Applicable

If "Yes", describe what the results of this survey, participant feedback or self-evaluation were.

If "Yes", specify how the survey, participant feedback or self-evaluation contributed to your prevention plan.

Contact

Authorization:

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

Given Name

Family Name

Title

Date (YYYYMMDD)

 

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