VOCA DATA COLLECTION FORM

(Optional)

Client Name: Date Opened:
Relationship to victim: Date Closed:
Staff Assigned: ______
Type of Crime (one only):
o Child Abuse/Sexual
o Child Abuse/Physical
o Domestic Violence
o Adult Sexual Assault
o Adult/Molested as Child /
o Elder Abuse
o Drunk Driving
o Survivor of Homicide Victim
o Assault/ /
o Robbery
o Other Violent Personal Injury
o Property Crime
o Other/Unknown
______
Sex: o Male / o Female / o Unknown
Age:
Date of Birth:
o 0 - 12
o 13 - 17 / o 18 - 29
o 30 - 44
o 45 - 64 / o 65 +
o Unknown
National Origin: Ethnicity
o White (non-Hispanic)
o African-American
o Hispanic / o Am. Indian/Alaskan
o Asian/Pacific Islander / o Other:
o Unknown
Disabled: o Describe:
Service
Crisis Counseling
Follow-up Contact
Therapy
Group Treatment/Support
Crisis Hotline
Shelter / Safe House
Information and Referral
Criminal Justice Support
Emerg. Financial Assistance
Emerg. Legal Advocacy
Crime Victim Comp.
Personal Advocacy
Other:


Monthly VOCA Statistics

Month of: ______VOCA Subgrant No: ______

Staff: ______

New / On-going / New / On-going
Type of Crime / Client Demographics
Child Sexual Abuse / Sex: Male
Child Physical Abuse / Female
Domestic Violence / Age: 0 - 12
Adult Sexual Assault / 13 - 17
Adults Molested Children / 18 - 29
Elder Abuse / 30 - 44
Drunk Driving / 45 - 64
Surv/ of Homicide Victim / 65 +
Assault
Robbery / National Origin
Other Violent Crime / White (non-Hispanci)
Property Crime / African-American
Other/Unknown / Hispanic
Total Unduplicated / Native American/Alaskan
Asian/Pacific Islander
Disabled Clients / Other/Unknown
Services
Crisis Counseling / Criminal Justice Support
Follow-up Contact / Emerg. Financial Ass't
Group Treatment/Support / Emerg. Legal Advocacy
Therapy / Crime Victim Comp.
Crisis Hotline / Personal Advocacy
Shelter/Safe House / Other
Information & referral / Telephone I & R (calls)